Welcome back everybody, this is Henry Perry again. In this lecture, I want to
spend some time talking about some of the programmatic issues. And progress and
challenges in the actual implementation of primary care programs, and we'll build on
some of the concepts and principles that we discussed in the previous lecture. So
after talking about some of the programmatic challenges that face primary
health care I want to mention some of the noteworthy programs, at least from my
standpoint. Of course, there's so many that we could talk about but I wanted to
highlight a few of these. some of these I have had some personal relationship with
either through my friendship with people who have operated these programs or
through my own experience of living in Haiti and living in Bangladesh. And then
after we review these, we'll think about some possible ways forward for
strengthening these kids of programs in high-mortality, resource-constrained
settings. As I said in the initial introduction to this course, at the outset
on the video, the challenges that are facing. The world, in terms of health and
disparities in health and the magnitude of the problems that should be easily
solvable with the available resources and know-how, are astounding. And just to
review a few of those again, let me point out what I'm sure that most of you know
and I stated this earlier, but at the present time about 6.8 million children
are estimated to be dying around the world and the overwhelming majority of these
deaths are from readily preventable or treatable causes. The number is declining
and that's the great news but the tragic side of this is that even though the
number is declining There should be a much smaller number of children dying than
there currently are. And in addition to the children who are born live who are
dying around the world, we're also beginning to pay increasing amounts of
attention to stillbirths. These are fetuses who are essentially at term. And,
mostly due to complications in the process of childbi rth, these fetuses are born
dead and they're fully capable of life. And with better attention to the medical
care of the mother. At the time of delivery and attention to the care of the
newborn, if the child is born without breathing, a very large of these deaths
could be averted and the current estimate is there is about 4 billion still births
and so, increasingly, we will be giving attention to what can be done, at the
local level, through primary health care processes and in particular. In the
community, in the home, where facilities aren't available and this is a rapidly
emerging area with global health. In addition, to the large number of
preventable or treatable deaths of children and still births, we still have
an unconsciously large number of deaths of women, during their pregnancy. During time
of childbirth, mostly. The current estimate is there are about 300 to 500,000
of these deaths occurring each year. The numbers have been declining slowly. But
again, this is an uncountable number of deaths of women. Because virtually, all of
these deaths are readily treatable, or Preventable with very basic medical care.
And then, the other tragic side of the maternal care issue, is the very large
number of women who develop long term chronic morbidities related to child birth
as a result of inappropriate or inadequate, or lack of basic medical care.
The most tragic of these of course is the so-called obstetric fistula. The
vesicovaginal or recto-vaginal fistula that is result of prolonged labor, where
the tissues And the vagina become necrotic as result of lack of blood flow because of
pressure from the baby's head. And we're increasingly aware of this tragic
complication and more and more efforts are being made to identify. Women who have
this condition because in developing countries they become outcasts, and lead a
life that's really subhuman. And so, this is the most severe of the morbidity
conditions among women who have a complication childbirth. But there're many
other ones too, which we don't have time to go into. So, improving care for
children and mothers through. Primary health care approaches is terrible
important for reducing this number. We also know that millions of people around
the world are still lacking access to testing and treatment for HIV/AIDS. And
also access to basic services to prevent and control TB and malaria. And to treat
cases of tuberculosis and malaria. And the role of both selective approaches to
primary health care, and more comprehensive approaches. And primary
health care to address this problem is terribly important. We don't have time to
go into the real technical side of this, but it's obviously an important issue for
selective primary health care But we're particularly interested in this course to
think about and talk about how comprehensive primary health care can be
effective in impressing disease priorities, but at the same time address
broader needs and concerns that people have. And then finally we all know that
billions of people are lacking ready access to other basic healthcare services
beyond these particular Priorities and of particular notice as well as the lack that
billions of people have to clean water and sanitation and essential nutrients in, in
the Al-Matar conception of primary health care addressing these issues is a
fundamental part of the framework. And so many places health facilities are still
far away and, even if they're not far away, they're often too expensive for the
capabilities of very poor families. And they're still often providing care that
are perceived by local people to be either unfriendly or they're perceived as being
unwelcome in the environment. we are making progress on these issues but still
there's a long ways to go. You may not have heard of one of my favorite articles
and it's cited from time to time and I have the reference for this at the end of
the PowerPoint here. Tudor Hart wrote in the Lancet, in 1971, a very interesting
article, which he calls, that Inverse Care Law and he talks about in the Br itish
case, how the best medical services are available to the people who need it the
least and the people who need health care services the most, have the worst medical
care. And of course we know that's even more true in so many other countries where
development is still very much in the early stages. I have taken this idea and
modified it. Into something of which is similar but slightly different, which I
call the reverse inverse care law. And that is those with the greatest health
needs are often those with least the access to health services and often
they're the portion of the population with the least motivation to improve their
health. And so this provides a particular challenge for health programs to reach
those in the greatest need with services that they are willing and interested in
making use of. Miriam Were was a student at Johns Hopkins School of Public Health
back in the 70's and she has become one of the great promoters of primary heath care
throughout Africa. And she more recently was the chair of the board of AMREF. At
the time that AMREF received the Gates Award in Global Health. And this statement
is from her acceptance speech, which I think also gives some sense of the
challenge that we all face in developing programs, in strengthening health
services, but this is from the standpoint of an African. She says that we are
convinced that if the development agenda had recognized the existing strengths of
the African people and had built on them, we would've gotten much further than with
the approach of treating African people as if all they have is ignorance to be gotten
rid of and presenting them with solutions with no bridges to their reality. This
statement, to a large degree I think, reflects the strong biomedicals with a top
down vertical approach that has permeated so much of development work in developing
countries. Although there certainly are plenty of exceptions to this. James Grant,
you may remember from the previous lecture, was the truly outstanding
executive director of UNICEF from 1980 to 1995. And he used to like to talk about
this dream product. And it will probably be pretty obvious to you when you read
this, what, exactly. This dream product is, but, I think this is a great example
of one of the many challenges facing programs and improvement of health through
programs. And that is our And ability still to convince mothers that appropriate
breast feeding is so vital for their children. Breast feeding is such an
obvious win, win situation for everybody in terms of the health of the child, the
convenience of the mother. The low cost, and so forth. But it's really surprising
that, in this first decade of the 21st century. We still have a situation where
so many women are not providing exclusive breast feeding during the 6 months of
life. And then providing appropriate, continued breast feeding after that, with
complimentary feeding. The figure that you see before you now coverage of
interventions varies across the continuum of care. This is a figure that has come
from a very important document called the countdown document that looks at where we
are. In the 68 countries we're in 7% of the worlds child and maternal deaths take
place. For the interventions that we know are effective in reducing deaths of
mother's and children, this graph shows the coverage of these services. In the 68
countries it's a little bit hard to see exactly what these interventions are and
if you look carefully you can probably make it out on the next slide you'll see
these interventions a little more clearly specified but what's important here is to
see that for The majority of these interventions. The coverage of these is
less than 50% in this priority population. The interventions that have the highest
coverage are primarily those related to the provision of immunizations, and
vitamin A supplementation. The other interventions which are critical are
harder to deliver. Because they require provision of services in the household on
a more continuous basis. Whereas, immunization s and vitamin A
supplementation are usually given in campaigns. Either through mobile clinics
and outreach services from a. A mobile team based at a fixed health center or
through national campaigns. This next figure enables you to see a little bit
more clearly what these specific interventions are. And we have them listed
here by the lowest level of coverage at the bottom all the way up to the highest
level of coverage at the top. And you can see here, as I was just mentioning before,
that The curvage level of immunizations and vitamin A's, roughly 80% or higher in
these priority countries but we have very important interventions that we know work
for priority. Conditions of mothers and children that have very low levels of
coverage. And so these include, for instance, the intermittent preventive
treatment of malaria among pregnant women. Insectiside treated nets. you see the.
Percentage of, mothers who are exclusively breastfeeding their child is only 28% and
only 32% of children are receiving antibiotics when they develop pneumonia.
So, you can see that we have an enormous way to go in terms of getting proven.
Effective interventions to children and mother's who really need these services.
When I was coming along, this monograph was published in 1980 and interestingly
enough at that time, Jim Grant was actually the director of the organization
that published this The Overseas Development Council. But Davidson , Janet
Wilcox, and Joe Ray, pulled together the world's experience on programs that
measure their impact on either the mortality of children, or on the
nutritional status of children. And they, at that time discovered only ten projects
that had undergone this level of review, and their conclusion at that time in 1980
was that we need to learn how to carry out these kinds of programs on a larger scale.
All of the. These projects were small projects in populations of 60,00 to 70,000
people. And so, over the last, three decades there has been some growing
experience about how to implem ent and evaluate programs that improve the health
of mothers and children. But still we have a lot of progress to continue to make in
this area as well. In 1993, the National Research Council pulled together this
extensive review of the effects of health programs on child mortality in sub-Saharan
Africa. This was edited by Ewbank and Gribble. And their conclusion almost two
decades ago was still very relevant today. The studies that they reviewed looked
primarily at the effects of single interventions and many of these studies
were from carefully controlled clinical trials and there were very few evaluations
of large scale programs Therefore they concluded that we cannot make strong
statements about the overall effectiveness of health programs in Africa. There are
very few studies of the effects of health centers and integrated programs on
mortality, and no studies that attempt to estimate the effectiveness of hospitals in
reducing population levels of mortality. This statement is just as current and
appropriate today as it was almost two decades ago So, given this reality, I
would like to share with you several examples of programs that have attempted
to do something about improving health and a. An important way is with demonstrated
outcomes as well. The first in these is the Jamkhed comprehensive rural health
project established in 1970 by Mabelle and Raj Arole who were students in our school.
And went back to their home country in India and stared a, small project
initially that has grown in stature and has gained wide spread admiration and
respect all around the world. In this next slide you see a recent photograph of Raj
Arole on the right with his mentor Carl Taylor the Chairman of the department for
many years and the founder of international health workage at John
Hopkins. Unfortunately, Roger Rolley's wife, Maybelle, died about ten years ago.
But here we see her in the next slide and their daughter Shobha on the right, who is
a physician and surgeon and also. Very much involved in lead ership for the
Jamkhed project. Now, there has been a lot of information written about Jamkhed. The
book that I showed in the first slide here, is one of the great classics of
global health. And readily available. And I strongly encourage you to read it if you
ever have the chance. But there also have been a lot of articles written about the
Jamkhed project. But what is important here is that the Aroles have developed a
whole approach, which they refer to as, comprehensive primary health care. That is
very much along the lines of the concept that we discussed as declared at Almata
and by that I mean that they've developed a program that is multi-sectoral that has
Strong activities in agriculture, nutrition, water, sanitation, as well as
medical care. And also has other components that vital to improving health
such as women's empowerment and promotion of income generation. , their whole
approach has really fostered on empowerment of women and empowerment of
communities. At the same time helping community health workers to Understand and
be able to respond to the acute healthcare needs of the community. An to provide
health education that will help these very poor people in rural villages of Jamkhed
in Maharashtra, India to improve their health. And in this graph here, you see
the dramatic decline in infant mortality that they have recorded for their work
going back to 1972. At that time, in 1972, there was enormous. malnutrition, there
was famine, lack of access to water. Very basic issues that had to be dealt with.
But as you see here, in this graph, which is from their book that was published in
1994, they were able to Obtained very low levels of infant mortality. Which have
continued on as you see in the next slide from more recent data from their project.
And I have here as well a comparison data for rural Maharashtra from the democratic
and health surveys that have been reported. And you can see how the infant
mortality rate in Jamkhed started out at a much higher level than was the c ase for
rural Maharashtra. And very quickly, fell to a. Level which was lower than that for
rural Maharahstra and has continued to decline and is now in the low 20s as an
infant mortality rate. quite an achievement for a rural area in a very
poor country. The next program I wanted to mention briefly is the hospital Albert
Schweitzer in Haiti. Where I had the privilege of working from 1999 until 2004.
Albert Schweitzer was a very famous medical missionary who worked for some. 60
years in Gabon and West Africa and was a famous writer and theologian and
philosopher, as well as a very well known medical missionary. But he inspired the
people you see on the right here. Larimer and Gwen Mellon who, at midlife, decided
that they wanted to follow in Albert Schweitzer's footsteps, having read about
him in a Life Magazine article. So when they were 37 or so they changed their
lives. Larimer went to medical school and his wife became a medical technician, and
they moved to Haiti and started a hospital which they named in honor of Albert
Schweitzer. And in 1956, this hospital opened up and it was quite well-known
early on. The Mellons were very wealthy. They had money to invest in this and they
moved there and operated this hospital. But after 10 years of operation, they came
to realize that just hospital services by themselves were not going to make much of
a dent in terms of the overall needs of the population. And so they went back to
the United States, and looked for some public health expertise that could help
them in the public health side of this. And they found Warren and Gretchen
Berggren at the Harvard School of Public Health. Who would have been medical
missionaries in the Belgian Congo. And had decided to move out of hospital
care, and get into public health. And so, in 1967, the Berggrens came down to the
hospital Albert Schweitzer. And started a community health program to complement the
work of the hospital. And their mentor was a Harvard faculty member named John Wyon
whom you see in t he next slide, who back in the 50's. Had worked with Carl Taylor
and was very much involved in a, important study that was foundational for primary
health care work, which is called the CONA study, and was a building block for the
Narangwal project that Carl Taylor led back in the 60s in India, which we haven't
had time to discuss, but That we do discuss in our Case Studies and Primary
Healthcare course that you might consider taking. The Khanna study, among other
things, was the. First extensive assessment of the epidemiology of health
and fertility in a developing country, and it was a landmark study. But one of the
things that came out of this for John Wyon, who spent most of his career either.
providing field leadership for the study or writing up the results. One of the
important outcomes of all this was the potential of home visitation for providing
education to families. And for registering vital events. And this principle was
passed on to the when they went to the hospital. Albert Schweitzer, and with John
Wyon's support. The were able to develop a primary heath care program that involved a
visitation of all households, registration of vital events, and delivery of services,
to as near the household as possible. And that community health activity linked with
the availabilty of hospital services Led to the outcomes that you see in this next
slide. You see just like as in Jamkhed a very dramatic decline of undefined
mortality in the Haiti situation A large part of this decline was due to the very
successful immunization program against neonatal tentanus, by immunizing mothers
during their pregnancy, but you can see that Over a long period of time through
the maintenance of this community health, primary healthcare program at the hospital
Albert Schweitzer and it's service area there have been much lower, under 5
mortality rates then has been the case for Haiti. As a whole, or when more recent
data became available for rural Haiti. These levels are not as low as, , what
were achieved in Jahmked. But, of course, we all know that Haiti is a very difficult
place to work. With all of its political turmoil, and. Many other problems so the
fact that they were able to achieve this level for a long period of time and
sustain it, I think, is quite an achievement. Here you see, on the next
graph, a comparison of the coverage of key child survival interventions in the
Hospital Albert Schweitzer area. Compared to those that were measured for the
country as a whole and these changes in coverage represent some of the reasons for
why this mortality impact was achieved at the Hospital Albert Schweitzer. One of the
interesting things that we found when I was involved in this work is that there
were some prominent disparities of mortality within the Hospital Albert
Schweitzer service area. The country of Haiti has a lot of mountainous areas and
then it also has central plains where rivers run through and that's certainly
the case where the hospital Albert Schweitzer is. And so for the communities
that were living in the plains Which were near the hospital, the mortality rates
were only about half, or less, that of the mortality rates of children that lived in
the mountains, where the families were poor, more isolated, services were more
difficult to access. From the beginning the hospital Albert Schweitzer made
enormous efforts to extend coverage of these services out to the rural areas, but
in spite of these efforts, marked a mortality differential persistant, and so
I think it points to the great need within health programs to be aware of priority
groups, and to Invests additional efforts towards these priority groups, not just to
ensure that they have equal access as other better off groups have. As you can
see in this table of the health care resources of the Hospital Albert
Schweitzer compared to Haiti nationally. The number of, physicians actually, is
less on a per capita basis. In the hospital Albert Schweitzer, service area
than it is for Haiti as a whole. And the number of hospital beds i s actually less
as well. But the real difference is shown in the number of nurses where they have
twice as many per capita, the number of auxiliary nurses where they have twice as
many per capita as Haiti as a whole. And in the larger number of health agents who
are the paid community health workers and the Very large number of volunteers called
monitrices, which really don't exist in other parts of Haiti. Now I wanted to move
on to another project, which again has cloose ties to Johns Hopkins. This is a
SEARCH. SEARCH is an acronym that stands for the Society of Education, Action, and
Research in Community Health. And this is now a world famous project that Has been
founded and led to this stay still by Abhay and Rani Bang. They were NPH
students here back in the '80s. And have carried the path breaking work in their
program there, which is in Maharashtra As well, just as the Jamkhed project is. But
they're about 12 hours away in terms of travel within Maharashtra. But again, you
see them with Carl Taylor, who was their mentor and their inspiration for their
work. And in both the Jamkhed and the SEARCH examples They were very much
inspired, not only by Carl Taylor and his vision, but by the Nuringal project that
Carl helped to establish in North India back in the 60's and early 70's. SEARCH is
the world's foremost example of the implementation of CBIO principles, so you
will recall from the previous lecture I talked about these. And, the reason I say
this is because Search on its own without ever reading or hearing about CBIO. But
through their relationship with Carl Taylor and Naringul and the general ideas
that were promoted there, they came to sense. The reaching out to every household
was terribly important, visiting every home on a regular basis was very
important, registering vital events through home visitation was very
important, and using this information to guide programming Was very important as
well. And also another fundamental CBIO principle is the importance of developing
a strong partnership with communities. And so SEARCH has done all of these things and
in the process of this They noted back in the 80's that pneumonia was such an
important cause of child death and, as a result of that, they developed a
community-based intervention to diagnose and treat pneumonia at the community
level. And their publication in the Lancet It is one of the great milestone of
primary healthcare in which they showed a dramatic decline in mortality based on the
diagnosis and treatment of pnemonia with community level workers. Then more
recently they have become quiet noted because Having us more or less solve the
problem of childhood pneumonia to the best of their ability in the circumstance in
which they work. They noted with their own vital events system that neonatal
mortality was such an important contributor to mortality.
So they set about to develop an intervention to reduce neonatal mortality.
And their home based neonatal program has now become a model for the rest of the
world. And has been Then replicated. And is setting the standard now for global
health around the world. But another example of CBIO principles that the have
implemented here is that it involves responsiveness to the community's
priorities. Which may not be epidemiological priorities. So in this
case, in their process of building a partnership at the community. They learned
that alcoholism was a strong priority, particularly of the women because so many
of the men, were abusing alcohol with instructive effects for themselves and
their families. So, search developed a very interesting approach to dealing with
alcoholism, which continues on to this day. So.
Search is like say the world's foremost example of the principles of CBIO that we
talked about in the previous lecture. This is just one small example of some of there
findings that, That arose from their work there. They have a search, a comparison
area along with their intervention area, and here are the findings of their
home-based neonatal care p rogram as it was reported through 2003. And you see the
impact of their home-based neonatal care program In the intervention area, the data
that you see here, the infant mortality rates not just neonatal mortality rate,
but since neonatal mortality was such an important component of infant mortality
rate. Then you can see the impact that this has had. I have been involved as I've
mentioned in the previous lecture with a review of the effectivness of community
based approaches in improving child health and if you look at The programs that have
had the longest and the most sustained impact on child health, they all have some
very interesting similarities that you see here. In this next table. They're all
involved with providing a broad range of services. They all have strong management
and support for program activities. They've all developed strong community
partnerships and community involvement. And they all have Developed a strong role
for community based workers. So, I think these principals are important, as we
think about developing programs that have long term effectiveness, addressing high
mortality settings. I think we will take a break here and we will move very shortly
into a slightly different kind of approach to providing primary health care services.