Future Generations (Perry)

This report summarises current research findings concerning the effectiveness of community-based primary health care (CBPHC) in improving the health of children in high-mortality, resource-poor settings around the world. It is based on what is described here as a growing recognition that programmes which reach beyond the walls of health care facilities and which involve the community as partners have a great potential for helping achieve Millennium Development Goal (MDG) number 4, which calls for a two-thirds reduction by the year 2015 in the mortality of children aged less than 5 years.

The review was carried out by a Task Force of the Working Group on CBPHC of the International Health Section of the American Public Health Association. The review covers much - but not all - of what is known at present about community-based approaches to improve the nutritional status of children; to improve perinatal and neonatal health; to prevent and treat childhood pneumonia, diarrhoea, and malaria; to expand coverage of immunisations; to promote handwashing and family planning; to prevent mother-to-child transmission (PMTCT) of HIV infection; and to improve child health through non-health interventions. The review also covers major programmatic achievements in child health during the past 25 years, cross-cutting themes (such as community health workers (CHWs), equity issues, health system issues, and the broader social determinants of health), and current and emerging programmatic approaches.

Overall, the findings of this review provide strong scientific support for the following 3 conclusions:

1. When proven interventions are implemented at the community level by local trained and well-supervised CHWs, coverage, impact, and equity can be favourably affected.
2. Under the right conditions, communities can become strong partners with established health delivery systems in improving the health of children.
3. Health programmes can more effectively and sustainably improve the health of children by mobilising the energy of local people for their own benefit.

"When these findings are linked to the philosophical and political principle that most people in the modern world share, namely that local people have the right to exercise control over their health care, a virtually incontrovertible argument emerges for giving priority to CBPHC in areas with high child mortality and severe resource constraints."

One way into understanding this claim is by looking at what conditions (including those within the local health system) facilitate the effectiveness of CBPHC and what community-based approaches appear to be most effective. The review found the following:

1. The first condition is for the health system to earn the trust and respect of the community. Trust, respect, and confidence arise when local people have reason to believe that the health system provides quality services (including treating its clients with respect) and has basic drugs and supplies.
2. Effectiveness depends on having a strong outreach system. Some of the interventions required to improve child health require technical expertise, drugs, vaccines, and equipment not available in communities.
3. Health systems need some type of CBW in order to implement many interventions and to reach those who need them. These workers must be appropriately trained and supported. If they are unpaid volunteers, they must have a limited set of tasks and not be expected to work more than a few hours a week.
4. A method of developing and maintaining contact with all homes and mothers is necessary in order to identify pregnant women and young children, to provide services in the home when possible, and to identify those in need of services which cannot be provided in the home. Routine systematic visitation of all homes by CBWs is a common approach to achieving this.
5. Community-based approaches are particularly relevant for interventions which involve behaviour change at the household level such as birthing practices, neonatal care practices, infant feeding practices, and hygiene.
6. When health systems are well-developed and under-5 mortality levels are low, then strengthening CBPHC may not provide as much additional benefit.
7. Compassionate and high-quality curative and referral care, including basic hospital and surgical care, lends credibility to the community-based work and the workers that provide it.

The review explored questions of equity, with the key finding being that the stronger the outreach services of a CBPHC programme, the more likely the programme will reach those who need the child survival interventions and the more likely the programme will reach those who are in the lowest wealth quintile. That is, "CBPHC approaches which provide services to all households can have a strongly positive equity impact."

A key focus of the review was on how programmes implementing CBPHC interventions were able to work with communities to achieve these results. Training CHWs, promoting partnerships between communities and health programmes, drawing on local resources for program support, and promoting community and women's empowerment were common features of successful CBPHC programmes. Top-down vertical approaches to implementing single interventions at the community level to improve child health can be very effective at scale, the review revealed. Immunisation coverage levels globally have increased from less than 5% in 1974 to 80% at present, and an estimated 3 million child deaths are being averted annually as a result of the immunisation programme.

One of the central findings from the review is that the existing evidence base regarding intervention efficacy and effectiveness rests primarily on studies of individual interventions provided in atypical field settings over relatively short periods of time, usually two years or less. The authors stress that there is a notable lack of studies of interventions in routine field settings at scale over longer periods of time, and they call for additional research. See pages 20-21 for detailed recommendations.

Despite this lack of evidence, the review was able to identify successful CBPHC programmes that have implemented a comprehensive set of interventions in a participatory manner over a period of 10 years or longer. Most of these programmes were on a much smaller scale (serving 2,000-300,000 people). These long-term programmes had a number of important shared characteristics: a broad array of primary health care services such as family planning and reproductive health, access to referral care at higher levels, utilisation of CHWs and support for them through strong training and supervision, routine systematic home visitation, a strong partnership between the health programme and the community, a strong level of community trust in the health programme, and treatment of clients with a high level of respect.

The conceptual framework in Figure 4 (on page 26 of the report), developed by the Expert Panel at its March 2008 meeting, emphasises the importance of strengthening community empowerment as well as the delivery system in order to improve child health. The framework emphasises the influence of both programmatic and community-related factors on the effectiveness, scalability, and sustainability of interventions. The authors identify the following activities through which communities can contribute to improving the effectiveness of child health interventions and that will at the same time be empowering for communities:

• Involving local leadership in mobilising a partnership between communities and "top-down" officials for planning and managing programme activities and resources;
• Clarifying respective value systems to help both health care workers and community members develop joint understanding and respect as they work together for benefits that are effective and equitable;
• Involving women's groups to provide peer-to-peer education and home-based care while also involving men and mothers-in-law in creative ways to encourage community action for healthy behaviour and appropriate health care utilisation;
• Adapting the health delivery system to local realities and culture, with integration of interventions and practices for maximising acceptability and efficiency;
• Enabling communities to collaborate with the health system - not just in the initial stages of implementation but in a continuing relationship so that families feel ownership of the process and together can establish a long-term partnership; and
• Registering vital events, identifying newborns who need to be enrolled in CBPHC services and programmes, and tracking under-5 mortality rates at the local level.

"The findings of this review highlight the need to focus greater attention and more resources on CBPHC for improving child health in high-mortality settings. There is great value in giving a stronger role to communities (and especially to mothers) for improving child health. Mothers and communities have a strong vested interest in the survival of children. Related to this is the need to create structures which make it possible and feasible to delegate certain technical responsibilities to well-trained and well-supervised CHWs, including identification of births for systematic referral for preventive interventions (such as immunization) and case management of neonatal sepsis, childhood pneumonia, and childhood malaria. Finally, independent assessments of large-scale program effectiveness in reducing under-5 mortality which are publicly available and which conform to international scientific standards are critical for continued improvements in program effectiveness."

Posting to CORE's Child Survival Community listserv, September 10 2009.