KEY PUBLIC HEALTH ACTIONS TO REVITALISE PRIMARY HEALTH CARE AND ADDRESS GLOBAL HEALTH INEQUITIES

1
KEY 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

2
Outline 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
5
Despite successes, growing inequalities in global
health
6
Growing inequalities in child health within
countries
7
What 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.

8
Global 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
9
External 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

10
imposed and unfair trade
11
Unfair 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.

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The 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
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..and growth of poverty

• In spite of decades of global economic growth,
  the numbers of people living in poverty have grown

16

• ..and growth of poverty

• 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.

17
Why should a Japanese cow enjoy a higher income
than an African citizen?
18
Health Policy Trends and their Impact on the
Health System
19
WHO/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
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Primary 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.

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Evidence base for PHC

• Pre Alma Ata
• Work of McKeown and later Szreter demonstrated
  importance of socioeconomic, environmental and
  POLITICAL factors

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A 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

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EXAMPLE Comprehensive management of diarrhoea
26

• Selective PHC is reinforced by the current
  emphasis on economic efficiency

27
Cost-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
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CEA 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)

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Health 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

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Access 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

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• The changing donor funding architecture and
  the emergence of Global Health Partnerships
  have reinforced selective, technocratic and
  vertical approaches

32
What 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
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Categories 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
34
Categories 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
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GHPs, established1974-2003, (overall)

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Total 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)
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• Impact of GHIs on country health systems

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Donor 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
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AIDS 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
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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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In 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

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Slide Date October 03
Global Immunization 1980-2002, DTP3
coverage global coverage at 75 in 2002
Source WHO/UNICEF estimates, 2003
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• The case for revitalising CPHC and the role of
  Public Health

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Achievements 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.

47
The 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

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Promotive 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.

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• 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.

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Enhancing 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
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Capacity 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

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Priority Actions Needed (1)

• Address social determinants of (ill) health

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• 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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• 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)

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More focus on Health Systems Research to improve
coverage and quality of care
Priority Actions Needed (2)


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How well are researchers presently meeting the
challenge?
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Research steps in the development and evaluation
of public health interventions
De Zoysa et al, Bull WHO 1998, 76127-133
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AN 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

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STUDY 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

61
Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
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CASE 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

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Implementation Cycle
Advocacy
Policy
Evaluation
Capacity Development
Teambuilding
Implementation and Management
Situational Assessment
Planning
Analysis
64
WHO 10-STEPS PROTOCOL Nutrition component of
hospital level IMCI
65
Comparison of recommended and actual
practices
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WHO 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

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Evaluation 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
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CHANGES 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
69
Priority Actions Needed (3)

• Advocate for improved access and coverage,
  especially at primary and community levels

70
How many child deaths could be prevented per year
with proven interventions?

• 63 of child deaths
• More than 6 million deaths

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Why 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

72
IMCI pneumonia case management (Tanzania)
Coverage child actually receives the intervention
Source Jones et al, Lancet 2003, 362 65-71
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Towards 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
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Towards 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
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Why 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.

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Evidence 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.

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Factors 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
78
Priority Actions Needed (4)

• Improving access and extending coverage of health
  care
• Catalysing social action to address environmental
  and social determinants

79
Chhattisgarh, India
80
Mitanin 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

81
Mitanin 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

82
Key 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

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84
Anti-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

85
They 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
86
When 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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They did not allow the contractors to take away
the wood
They fought against pressure from police and
administration
89
They forced Central Government to institute an
Enquiry
90
Mitanin 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

92
PEOPLES 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
93
PEOPLES 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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Indias 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

96
Mokhada 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
97
National 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

98
Community 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

99
Some 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

100
Pictorial tool for community data collection
101
Public hearing at Health centre by Peoples
organisation involved in monitoring
102
International 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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Priority Actions Needed (5)

• Expand Public Health Education and make it more
  applied and relevant to addressing health
  inequities

106
Key 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.
107
Educational 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

108
Research, Education and Training Products.
109
Conclusions

• 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