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

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Title: 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.

13
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
15
..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
20
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.

21
Evidence base for PHC
  • Pre Alma Ata
  • Work of McKeown and later Szreter demonstrated
    importance of socioeconomic, environmental and
    POLITICAL factors

22
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23
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24
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

25
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
28
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)

29
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

30
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

31
  • 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
33
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
35
GHPs, established1974-2003, (overall)

36
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)
37
  • Impact of GHIs on country health systems

38
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
39

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
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
41
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42
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

43
Slide 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

45
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46
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

48
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.

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.

50
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
51
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

52
Priority 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)

54
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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)

56
More focus on Health Systems Research to improve
coverage and quality of care
Priority Actions Needed (2)


57
How well are researchers presently meeting the
challenge?
58
Research steps in the development and evaluation
of public health interventions
De Zoysa et al, Bull WHO 1998, 76127-133
59
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

60
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
62
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

63
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
66
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

67
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
68
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

71
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
73
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
74
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
75
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.

76
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.

77
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

79
79
62
61
62
57
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.

87
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88
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

94
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95
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

103
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104
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105
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
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