Title: KEY PUBLIC HEALTH ACTIONS TO REVITALISE PRIMARY HEALTH CARE AND ADDRESS GLOBAL HEALTH INEQUITIES
1KEY PUBLIC HEALTH ACTIONS TO REVITALISE PRIMARY
HEALTH CARE AND ADDRESS GLOBAL HEALTH INEQUITIES
- David Sanders
- School of Public HealthUniversity of the Western
Cape - Member of Global Coordinating Commission
- Peoples Health Movement
A WHO Collaborating Centre for Research and
Training in Human Resources for Health
2Outline of Presentation
- Health trends in the era of Primary Health Care -
1980 to 2004 with special emphasis on Africas
health situation - Impact of globalisation, health sector reform and
HIV/AIDS on poverty, health determinants,
health systems and human resources for health - The role of Public Health. Examples of key
actions to improve access to and quality of
health care AND address the determinants of
ill-health.
3 AFRICA and SOUTH ASIAS CRISISMortality 1 - 4
year olds
Territory size shows the proportion of all deaths
of children aged over 1 year and under 5 years
old, that occurred there in 2002.
www.worldmapper.org
4 AFRICA and SOUTH ASIAS CRISIS TB cases
Territory size shows the proportion ofworldwide
tuberculosis cases found there.
www.worldmapper.org
5Despite successes, growing inequalities in global
health
6Growing inequalities in child health within
countries
7What are the key Basic Causes of Global Health
Inequities and Africas Health Crisis?
-
- HIV/AIDS
- Increasing poverty and inequality worsened by
inequitable globalisation -
- and selective PHC and inappropriate health
sector reform - .. result in slow progress and reversals.
8Global HIV prevalence
- 40 million people around the world live with HIV
- more than the population of Poland. - Nearly two-thirds of them live in Sub-Saharan
Africa, where in the two hardest hit countries
HIV prevalence is almost 40.
The AIDS debate, BBC News
9External debt
- Between 1970 and 2002, African countries borrowed
540 billion from foreign sources, paid back 550
billion (in principal and interest), but still
owe 295 billion (UNCTAD 2004) - Africa spends more on debt servicing each year
than on health and education
10imposed and unfair trade
11Unfair Trade
- ..drawing the poorest countries into the global
economy is the surest way to address their
fundamental aspirations -
(G8 Communiqué, Genoa, July 22, 2001) -
- BUT many developing countries have destroyed
domestic economic sectors, such as textiles and
clothing in Zambia (Jeter 2002) and poultry in
Ghana (Atarah 2005), by lowering trade barriers
and accepting the resulting social dislocations
as the price of global integration - .
12- Transnational corporations .have flourished as
trade liberalization has broadened and deepened.
The revenues of Wal-Mart, BP, Exxon Mobil, and
Royal Dutch/Shell Group all rank above the GDP of
countries such as Indonesia, Norway, Saudi
Arabia, and South Africa (EMCONET, 2007). - The combination of binding trade agreements ..
and increasing corporate power and capital
mobility have arguably diminished individual
countries capacities to ensure that economic
activity contributes to health equity, or at
least does not undermine it.
13The result unequal growth of wealth between
countries
14 AFRICA and SOUTH ASIAS CRISIS GDP wealth
Territory size shows the proportion of worldwide
wealth, that is Gross Domestic Product based on
exchange rates with the US, that is found there.
www.worldmapper.org
15..and growth of poverty
- In spite of decades of global economic growth,
the numbers of people living in poverty have grown
16- According to the World Banks most recent
figures, in sub-Saharan Africa 313 million
people, or almost half the population, live below
a standardized poverty line of 1/day or less
(Chen and Ravallion 2004). - Sub-Saharan Africa is the only region of the
world in which the number of people living in
extreme poverty has increased indeed, almost
doubling between 1981 and 2001.
17Why should a Japanese cow enjoy a higher income
than an African citizen?
18Health Policy Trends and their Impact on the
Health System
19WHO/UNICEF Alma Ata Conference (1978)
Alma Ata, the capital of Kazakhstan, now called
Almaty Site of the 1978 WHO/UNICEF conference
Health for All by the Year 2000
20Primary Health Care is more than health services
- The concept of PHC had strong sociopolitical
implications. It explicitly outlined a strategy
which would respond more equitably, appropriately
and effectively to basic health care needs and
ALSO address the underlying social, economic and
political causes (determinants) of poor health.
21Evidence base for PHC
- Pre Alma Ata
- Work of McKeown and later Szreter demonstrated
importance of socioeconomic, environmental and
POLITICAL factors
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24A Split in the PHC Movement
- In 1980s, a focus on cost-effective technologies
and a neglect of social and environmental
determinants and processes led to substitution of
selective for comprehensive primary health
care (PHC) e.g. UNICEF Child Survival and
Development Revolution - Growth Monitoring
- Oral Rehydration Therapy
- Breast Feeding
- Immunisation
25EXAMPLE Comprehensive management of diarrhoea
26- Selective PHC is reinforced by the current
emphasis on economic efficiency
27Cost-effectiveness analysis has focused only on
certain measurable interventions and proposed
limited packages of care reminiscent of
selective PHC..
Health sector reform Quest for efficiency
IN MANY COUNTRIES A BASIC PACKAGE IS AVAILABLE
THROUGH THE PUBLIC SECTOR WHILE MORE
COMPREHENSIVE SERVICES ARE AVAILABLE FOR THOSE
WITH PRIVATE INSURANCE
28CEA does not evaluate the effectiveness of
broader interventions that may result in health
improvement through numerous direct and indirect
mechanisms
- Cost-effectiveness analyses have shown
improved water supply and sanitation to be costly
ways of improving peoples health. . encouraging
people to wash their hands and making soap
available have reduced the incidence of
diarrhoeal disease by 32 to 43... (Commission
on Macroeconomics and Health,2001/02)
29Health sector reform Quest for efficiency
cont.- The move from equity and
comprehensiveness to efficiency and selectiveness
leads to
- A return to vertical programmes
- Fragmentation of health services
- Neglect of SDH, erosion of intersectoral work and
community health infrastructures
30Access to water and hygienic sanitation
- Only 44 percent of rural SSA ie 60 percent of SSA
population, has access to adequate water supplies
and good sanitation in 2004 - Over the period 1990 2004, the number of people
without access to drinking water increased by 23
and those without sanitation increased by over
30
31- The changing donor funding architecture and
the emergence of Global Health Partnerships
have reinforced selective, technocratic and
vertical approaches
32What is new about GHPs/GHIs?
- New actors
- in addition to country governments (donor /-
recipient), notably Philanthropy (e.g. Gates),
Pharma and Civil Society (e.g. NGOs) - New global governance mechanisms
- outside of, or transcending, traditional
multilateral bodies (WHO, World Bank, UN agencies)
Brugha 2007
33Categories and Purposes of GHIs
- Product (drug or vaccine) development (33)
-
- 2. Increase access to health products (26)
- 3.Health service strengthening (9)
-
- 4.Public education advocacy (8)
Brugha 2007
34Categories and Purposes of GHIs
- 5.Global Coordinating mechanisms including
funding vehicles (11) - Eg The Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM), Global Alliance for Vaccines
and Immunization (GAVI Alliance), Roll Back
Malaria Global Partnership (RBM), Stop TB
Partnership (Stop TB)
Brugha 2007
35GHPs, established1974-2003, (overall)
36Total annual resources available for
AIDS 1986?2005
8297
Signing 2001 UN Declaration of Commitment on
HIV/AIDS (UNGASS )
World Bank MAP launch
UNAIDS
Less than US 1 million
1623
Global Fund
292
257
212
59
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
Notes 1 1986-2000 figures are for
international funds only 2 Domestic funds are
included from 2001 onwards
i 1996-2005 data Extracted from 2006 Report
on the global AIDS epidemic (UNAIDS, 2006) ii
1986-1993 data AIDS in the World II. Edited by
Jonathan Mann and Daniel J. M. Tarantola (1996)
37- Impact of GHIs on country health systems
38Donor practices 5 highest burdens for LMICs
- 1. donor driven priorities and systems
- 2. difficulties with donor procedures
- 3. uncoordinated donor practices
- 4. excessive demands on government time
- 5. delays in disbursements
- survey of 11 recipient countries cited in
- Guidelines for harmonising donor practices for
effective aid delivery OECD Development
Assistance Committee, 2003
Brugha 2007
39AIDS and Aid may both disrupt health systems
In 2000, Tanzania was preparing 2,400 quarterly
reports on separate aid-funded projects and
hosted 1,000 donor visit meetings a year.
Labonte, 2005, presentation to Nuffield Trust
40 Ethiopia Challenges Sustainability. HIV/AIDS
especially ART is donor dependentHIV Spending
(in Birr) by Source of Funds Donor Vs Government
(source HAPCO documents till 2005)
Banteyerga, 2007
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42In summary health status is stagnant or
declining and public health systems in Africa and
many Southern countries are weak and fragmented
- reversing previous gains in PHC implementation
43Slide Date October 03
Global Immunization 1980-2002, DTP3
coverage global coverage at 75 in 2002
Source WHO/UNICEF estimates, 2003
44- The case for revitalising CPHC and the role of
Public Health
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46Achievements of CPHC.
- In countries where CPHC has been implemented,
dramatic improvements occurred eg greatly
improved coverage, especially of MCH care and
particularly EPI, and steep declines in child
mortality - eg Brazil, Thailand, Iran, Cuba when political
commitment sustained.
47The Alma Ata Declaration notes that
-
- PHC addresses the main health problems in the
community, providing promotive, preventive,
curative and rehabilitative services
accordingly. - The PHC approach therefore includes
- clinical
- (curative, rehabilitative, and personal
preventive) - public health
- (preventive and promotive) components
48Promotive approach
- Addresses basic social, economic and political
causes of ill-health through advocacy and
lobbying government and policymakers, for
example, to ban smoking in public places, as well
as intersectoral interventions directed at
households or communities to improve water
supply, sanitation, housing etc.
49- Public Health is defined as
- what we as a society do collectively,
- to assure the conditions
- for people to be healthy
- Satcher D Higginbotham EH. The Public Health
Approach to Eliminating Disparities in Health,
American Journal of Public Health March 2008,
98(3) 400 - 403.
50Enhancing Capacity for Public Health Action
Increasing health inequity and decentralised
health services have dramatically increased need
for public health skills for policy, advocacy,
planning, programme design, implementation,
monitoring and evaluation
51Capacity development
- Capacity development is required at all levels of
the health sector - central management, who need skills in change
management, advocacy and stewardship - local managers and service providers (doctors,
nurses, mid-level workers) who need different
combinations of clinical and public health
skills - Training institutions, including universities,
training schools and units
52Priority Actions Needed (1)
- Address social determinants of (ill) health
53- CSDH notes that the dominant model of
development has resulted in health-harming
effects and is threatening the environment. - Growing car dependence, land-use change to
facilitate car use... have knock-on effects on
local air quality, greenhouse gas emission, and
physical inactivity (p. 4) - trade policy that actively encourages the
unfettered production, trade, and consumption of
foods high in fats and sugars to the detriment of
fruit and vegetable production is contradictory
to health policy (p 10)
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55- The health sector is a defender of health,
advocate of health equity, and negotiator for
broader societal objectives. It is important
therefore that ministers of health, supported by
the ministry, are strongly equipped to play such
a stewardship role within government . (p 111)
56More focus on Health Systems Research to improve
coverage and quality of care
Priority Actions Needed (2)
57How well are researchers presently meeting the
challenge?
58Research steps in the development and evaluation
of public health interventions
De Zoysa et al, Bull WHO 1998, 76127-133
59AN EXAMPLE OF EFFECTIVENESS RESEARCH MT. FRERE
HEALTH DISTRICT
- Eastern Cape Province, South Africa
- Former apartheid-era homeland
- Estimated Population 280,000
- Infant Mortality Rate 99/1000
- Under 5 Mortality Rate 108/1000
60STUDY SETTINGPAEDIATRIC WARDS
- Nurses have the main responsibility for
malnourished children - Per Ward
- 2-3 nurses and 1-2 nursing assistants on day
duty, and - 2 nurses on night duty
- 10-15 general paediatric beds and 5-6
malnutrition beds
61Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
62CASE FATALITY IN RURAL HOSPITALS
- PRE-INTERVENTION CFRs
- Mary Teresa 46 Sipetu 25
- Holy Cross 45 St Margarets
24 - St. Elizabeths 36 Taylor Bequest 21
- Mt. Ayliff 34 Greenville 15
- St. Patricks 30 Rietvlei 10
- Bambisana 28
63Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
64WHO 10-STEPS PROTOCOL Nutrition component of
hospital level IMCI
65 Comparison of recommended and actual
practices
66WHO 10-STEPS TRAINING Mt. Frere District,
Eastern Cape
- Training Implementation from March 98 to Aug 99
- Two formal training workshops for Paeds staff
- On-site facilitation by nurse-trainer
- Adaptation of protocols Now have Eastern
Cape Provincial Guidelines
67Evaluation of Implementation
- Major improvements
- Separate HEATED wards
- 3 hourly feedings with appropriate special
formulas and modified hospital meals - Increased administration of vitamins,
micronutrients and broad spectrum antibiotics - Improved management of diarrhea dehydration
with decreased use of IV hydration - Health education empowerment of mothers
- Problems still existed
- Intermittent supply problems for vitamins and
micro-nutrients - Power cuts no heat
- Poor discharge follow-up
- Staff shortage, of both doctors and nurses, and
resultant low morale and QOC
Ashworth et al, Lancet 2004 3631110-1115
68CHANGES IN CFRs IN RURAL HOSPITALS
Puoane et al, Health Policy and Planning, 2008
Ongoing research indicates leadership and
management at all levels are the key reasons for
the differences between well and poorly
performing hospitals
69Priority Actions Needed (3)
- Advocate for improved access and coverage,
especially at primary and community levels -
70How many child deaths could be prevented per year
with proven interventions?
- 63 of child deaths
- More than 6 million deaths
71Why should interventions be delivered in
community settings?
- Many deaths occur outside health facilities
- Currently the coverage of many effective
interventions is low well under 50 in many
cases and the quality of care is deficient in
many communities - Poor families are less likely to access
government health facilities than wealthier
families
72IMCI pneumonia case management (Tanzania)
Coverage child actually receives the intervention
Source Jones et al, Lancet 2003, 362 65-71
73Towards population impact
IMCI pneumonia case management (Tanzania)
Coverage under actual programme conditions
- Population effectiveness
- Intervention efficacy x
- Intervention availability x
- Diagnostic accuracy x
- Provider compliance x
- Patient compliance x
- Coverage
The HR factor
Tugwell framework applied to multi-country
evaluation data
Source Tugwell, J Chron Dis, 1985 38(4)339-51
74Towards population impact
IMCI pneumonia case management (Tanzania)
Coverage under improved programme conditions
- Population effectiveness
- Intervention efficacy x
- Intervention availability x
- Diagnostic accuracy x
- Provider compliance x
- Patient compliance x
- Coverage
19
Pneumonia mortality averted
The HR factor
Health workers are trained
90
Health workers assess child correctly
90
Health workers treat child correctly
90
Source Tugwell, J Chron Dis, 1985 38(4)339-51
75Why should interventions be delivered in
community settings?
- An analysis of cost effective interventions for
saving newborn lives examined three different
delivery approaches outreach, family-community
and facility-based clinical care. -
- Outreach and family-community care in combination
at 90 coverage could result in an 18-37
reduction in mortality even before facility-based
care is strengthened.
76Evidence for impact and cost-effectiveness of
community health workers
- A meta-analysis of community-based trials of
pneumonia case management on mortality suggested
an overall reduction of 24 in neonates, infants,
and preschool children. -
- A trial in Tigray, Ethiopia, of training local
coordinators to teach mothers to give prompt home
antimalarials showed a 40 reduction in under-5
mortality.
77Factors influencing success of CHW programmes
- Selection
- Training
- Health system factors esp support supervision
- Community factors
- Political, macroeconomic and international
factors - Financial and non-financial incentives
Haines, Sanders et al, Lancet, 2007, Vol. 369,
pages 2121-2131
Lehmannn and Sanders, WHO, 2007,
http//www.who.int/hrh/documents/community_health_
workers.pdf
78Priority Actions Needed (4)
- Improving access and extending coverage of health
care - Catalysing social action to address environmental
and social determinants
79Chhattisgarh, India
80Mitanin Programme About 60000 Women as
Community level Health Volunteers To Support the
Public Health System Public Health Initiatives
in Chhattisgarh
- State Health Resource Centre, Chhattisgarh, India
81Mitanin Programme
- Started in 2002.
- A State-Civil Society joint initiative as a
result of a long consultation process. - Mitanin- the best friend- derived from the
friendship custom among indigenous communities - About 60,000 female CHVs selected and trained -
one per hamlet, covering about 250-300 population - Influenced design of national ASHA Scheme under
National Rural Health Mission
82Key Activities of Mitanins
- Antenatal care and prompt referral
- Day 1 essential neonatal care
- Regular Health Education, awareness through
women's groups - Identification and referral of malnourished
children - Mobilize community for public health services
- Early detection, first contact care and referral
of critical childhood illnesses - To act as community interfaces for health
related interventions - To lead the hamlet level health related
development.
83- IMR 2000-2006
- A comparison with Madhya Pradesh, the mother
state, and India
79
79
62
61
62
57
84Anti-Deforestation Agitation by CHWs
Chhattisgarh-India
- In Chhattisgarh
- Mitanins led opposition to state government plan
of felling and selling 40,000 hectares of dense
natural forests involving felling of 20 million
trees for timber - Mitanins mobilised women to oppose deforestation
policies of state as deforestation threatens
livelihoods and nutrition security of tribal
(indigenous) communities especially the women
85They organised anti-felling demonstrations
They mobilised Village Assemblies and Forest
Protection Committees (Formal mechanisms of local
self governance) to pass resolutions demanding a
stop to the felling
86When resolutions and demonstrations did not seem
to put an immediate stop to felling, they
snatched the axes and saws
- They chased the timber contractors away.
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88They did not allow the contractors to take away
the wood
They fought against pressure from police and
administration
89They forced Central Government to institute an
Enquiry
90Mitanin CHWs fight against deforestation
- Filed a Public Interest Litigation in State High
Court - Mitanins won the litigation, thus forcing the
Government to withdraw its deforestation
programmes in three districts of Chhattisgarh - Followed it up with national litigation in the
Supreme Court, which is now demanding an end to
all state sponsored deforestation programmes
91- Some examples of social mobilisation for
health, including by the Peoples Health Movement
92PEOPLES HEALTH MOVEMENT
- The Peoples Health Movement (PHM) is a large
global civil society network of health activists
supportive of the WHO policy of Health for All
and organised to combat the economic and
political causes of deepening inequalities in
health worldwide and revitalise the
implementation of WHOs strategy of Primary
Health Care.
www.phmovement.org
93PEOPLES CHARTER FOR HEALTH
- A tool for advocacy
- Health as a Human Right
-
- Tackling the broader determinants of health
- Economic Challenges
- Social and political challenges
- Environmental challenges
- War, violence, conflict and natural disasters
- A people-centred health sector
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95Indias Right to Health care campaign
- Jan Swasthya Abhiyan (JSA) or Peoples Health
Movement launched a Right to Health care
campaign and NHRC conducted a series of Public
hearings on Health rights - Cases of denial of health care documented in
various regions based on a common proforma - Participatory surveys of Public health facilities
across some states, using a common checklist - This information fed into Peoples Health
Tribunals, involving hundreds of people, PHM
activists, health officials and expert panelists - Cases and survey findings collated at state level
for the National inquiry
96Mokhada Peoples Health Tribunal
9th Jan. 2004 Attended by over 700 mostly tribal
people. Thirteen cases of denial of health care
in public health centres and hospitals were
presented e.g. lack of care to a child with
pneumonia causing death, lack of prompt response
to gastroenteritis outbreak leading to deaths,
Out of these 13 testimonies, death occurred in
six cases
97National Public Hearingon Right to Health Care
- Attended by Central health minister, Chairperson,
member and officials of NHRC, apex health
officials of 22 states and over 100 JSA delegate - Led to declaration of a comprehensive National
Action Plan on the Right to Health by NHRC
98Community monitoring of Health services in India
- Promoting community ownership of Health services
and accountability - Information from community is systematically used
for improving and re-shaping health services and
activities
99Some tools for monitoring
- Village Health Register
- Village Health Calendar
- Guideline for information from Village group
discussion - Interview format for MO PHC / CHC
- Format for Exit interview (PHC / CHC)
- Documentation of testimony of denial of health
care - Guidelines for organising a Public hearing
100Pictorial tool for community data collection
101Public hearing at Health centre by Peoples
organisation involved in monitoring
102International Peoples Health University Courses
- Cuenca, 2005
- Bhopal, 2007
- Vancouver, 2007
- Atlanta, 2007
- Savar, 2007
- Jaipur, 2008
- Cairo, 2008
- Porto Alegre, September 2008
- Planned
- Greece
- Ghana
- Sri Lanka
- London
- Belen
- Rosario
- Bangalore
- Penang
- etc
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105Priority Actions Needed (5)
- Expand Public Health Education and make it more
applied and relevant to addressing health
inequities
106Key issues for public health training
- Need to train personnel from different
backgrounds to facilitate policy development and
implementation - Must incorporate the lessons of the New Public
Health and Comprehensive Primary Health Care - Short to medium term priority is to upskill those
already in the field - Needs to be as least disruptive, both to the
participants and the health services, as possible - Critically interrogate PH curriculum does one
size fit all? Eg Health Economics vs District
Budgeting Financing, Research Epidemiology vs
Monitoring Evaluation
Sanders et al, SAMJ, 2001, 9110, 823-829.
107Educational Strategies
- Based on assessed training needs
- Problem-oriented
- Adult education techniques
- Linked to systems development
- Distance learning materials
- Training guides
- Location should be as close to workplace as
possible - Training of teams
- Follow-up support
108Research, Education and Training Products.
109Conclusions
- Main actions required from Public Health
Community - CHALLENGE UNFAIR GLOBAL MACROECONOMIC REGIME
THROUGH EVIDENCE-BASED ADVOCACY AND SOCIAL
MOBILISATION - Challenge ill-considered health sector reforms
through research and advocacy - Advocate for investment in universal public
health systems - Act to address HRH crisis - ?compensation to
supplying countries - Advocate for increased investment in enhancing
capacity of and reorientating Southern
institutions (incl. equitable collaboration/partne
rships with Northern institutions) - Develop capacity through health systems and
equity-oriented research, practice-based and
problem-oriented training. - Improve quality of interventions and develop
well-managed comprehensive programmes - Involve other sectors and communities
- Rapidly (re)train CHWs
- Get involved in strengthening progressive civil
society