Community Based Primary Health Care The Answer to Addressing Child Mortality

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Community Based Primary Health CareThe Answer to
Addressing Child Mortality

• Paul Freeman
• Chairman CBPHC-WG APHA

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Content Overview

• The need OVCs
• What is CBPHC
• Evidence of What works
• Examples OVC programs

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Where We Stand on Child Survival U5MR declined ¼
between 1990 2006
Source. UNICEF
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Global distribution of cause-specific mortality
among children under five
Undernutrition is implicated in up to 50 of all
deaths of children under five
Source World Health Organization and UNICEF
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Where We Stand on Malnutrition South Asia and
Africa have highest levels
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Where We Stand on HIV/AIDS Sub-Saharan Africa
accounts for 90 of paediatric HIV infections
Source UNICEF
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Orphans Vulnerable Children

• Orphans SubSahara Africa
• 30.9 Million 1990
• 48 Million 2005
• 53 Million 2010 30 due AIDS
  gt12 of all children
• AIDS related At risk for
• schooling, food security, HIV
• 0-3 yrs old whoes mother dies are 3.9 times
  more likely to die in 1yr
• 0-5 yrs 16 of all orphans -gtphysical,
  nurturing needs greatest
• 12-17yrs 50 of all OVCs 66 of double orphans
• The closer to biological family-better care,
  schooling

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Selective primary health care and trends in
immunization rates since 1980
Source UNICEF
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Low Utilization of Health Facilities
sick children who were taken first to a health
facility
Source Arifeen S, Paryio G, Schellenberg J et al
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Overall Conclusions of Multi-country
Facility-Based IMCI Evaluation

• IMCI improves quality of care
• IMCI does not increase overall costs
• Either for providers or out-of-pocket
• IMCI dramatically reduces cost per child managed
  correctly
• IMCI is the gold standard for facility care of
  children aged 7 days 5 years

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Overall Conclusions of Facility-Based IMCI
Evaluation (cont.)

• IMCI can have an impact on mortality and
  nutrition
• But this requires
• Strengthening health systems
• Reaching out to the community
• IMCI was least likely to be implemented well
  where it was needed most
• IMCI did not expand to areas of greatest need and
  there was no prioritization given to these areas

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How about sickness care?

• From 70 90 of all sickness care takes place
  in the home
• Household members, especially mothers
• make the primary diagnoses of illnesses
• assess the severity and likely outcomes
• select among available providers and treatment
  options
• procure and administer treatments

WHO, World Health Report 2002. Reducing Risks,
Promoting Healthy Life Slide Source Henry
Moseley
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Why CBPHC?Lessons Learned from a hundred years

• Scaling-up will not be achieved through
  facility-based and outreach services alone
  Community Partnerships are central to achieving
  coverage, creating demand and achieving
  sustainability.
• Ensuring a continuum of care by delivering
  integrated packages of health, nutrition, HIV,
  water and sanitation interventions will be
  critical to achieving maximal impact on maternal,
  newborn and child survival.
• Strengthening of health-systems for outcomes
  combines the strength of selective/vertical
  approaches and comprehensive/horizontal
  approaches to scaling up evidence-based,
  high-impact intervention packages and practices,
  while removing system-wide bottlenecks to health
  care provision and usage.
• (Source R.Knippenburg UNICEF)

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What Is CBPHC?

• CBPHC is a process through which health programs
  and communities work together to improve health
  and control disease.
• CBPHC includes the promotion of key behaviors at
  the household level as well as the provision of
  health care and health services OUTSIDE of static
  facilities at the community level.
• CBPHC can (and of course should) connect to
  existing health services, health programs, and
  health care provided at static facilities
  (including health centers and hospitals) and be
  closely integrated with them.

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What is CBPHC? (cont.)

• CBPHC also includes multi-sectoral approaches to
  health improvement beyond the provision of health
  services per se, including programs which seek to
  improve education, income, nutrition, living
  standards, and empowerment.
• CBPHC programs may or may not be in collaboration
  with governmental or private health care
  programs they may be either comprehensive in
  scope or highly selective and they may or may
  not be part of a program which includes the
  provision of services at fixed facilities.

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What Is CPBHC? (cont.)

• CBPHC includes the following three different
  types of activities
• (1) Communications with individuals, families
  and communities to improve key practices
• (2) Social mobilization and community
  involvement for planning, delivering and using
  health services
• (3) Provision of health care in the community,
  including preventive services (e.g.,
  immunizations) or curative services (e.g.,
  community-based treatment of pneumonia).

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A Continuum of Care in Time and Place
Source PMNCH (www.who.int/pmnch/about/continuum_o
f_care/en/index.htm), accessed 30 September 2007
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Technical Interventions Priority child survival
interventions for scale up

• Insecticide-treated materials and/or indoor
  residual spraying for malaria
• Malaria treatment
• Intermittent preventive therapy for malaria for
  pregnant women
• Exclusive breastfeeding promotion for first 6
  months
• Continued breastfeeding promotion until at least
  24 months
• Ready to use therapeutic foods for severely
  malnourished children
• Promotion of complementary feeding for children
  focused on 6 to 23 months
• Supplementary feeding for food-insecure families
  focused on 6 to 23 months

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Technical Interventions (cont.) Priority child
survival interventions for scale up

• Insecticide-treated materials and/or indoor
  residual spraying for malaria
• Malaria treatment
• Intermittent preventive therapy for malaria for
  pregnant women
• Exclusive breastfeeding promotion for first 6
  months
• Continued breastfeeding promotion until at least
  24 months
• Ready to use therapeutic foods for severely
  malnourished children
• Promotion of complementary feeding for children
  focused on 6 to 23 months
• Supplementary feeding for food-insecure families
  focused on 6 to 23 months

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Setting Stage for Successful Interventions

• Community partnerships in PHC
• Scaling up community partnerships, a continuum of
  care, effective health systems for outcomes
• Participative planning, implementation,
  monitoring evaluation
• Uniting for Child Survival
• Pivotal actions at the macro-level
• Planning, funding, cooperation

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Comprehensive needs OVCs

• Support for caregivers-extended family,
  communities
• Multisectoral core needs-physical/mental health,
  nutrition, education, material support, day/after
  school
• Commitment from government- policy, legislation,
  situational analysis, planning, monitoring,
  resources, accelerated evidence based prevention
  ARV access for all members of society.
• Child female led households special needs
• Meet needs without setting OVCs apart from rest
  of society
• Note also needs of children with chronically ill
  parents

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Bana ba Keletso Orphan Day Care Centre, urban
village Botswana

• Actively reaches out to orphaned children
• Preschool children cared for during the day
• Older children meals, skilled based activities,
  psychosocial counseling
• Family outreach program counseling and support
  through home visits.
• Comprehensive, quality but labor intensive, maybe
  hard to scale up, sets orphans apart.

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Ikamva Labantu Organization Cape Town South
Africa

• Decentralized
• Two outreach strategies identifies OVC through
  network of 250 creches by word of mouth request
  for assistance.
• Follow Up visits to OVC and families
• Support indirectly through creches
• -directly through home visits,
  material nutritional support, capacity building
  in home, access to government grants.
• Helps families to build resources in the long
  run, does not separate out OVCs as attend creches
  with other children, uses local structures, serve
  more children, cheaper, more easily scalable.

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FBOs can offer

• Christian unconditional love as basis towards
  building self love and efficacy
• Immunization against future trials
• Moving away from dependence towards building
  confidence in community participation and
  empowerment

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Conclusion

• Getting community commitment is an essential part
  of addressing child health if we are going to
  reach the most needy children achieve
  sustainable programs.
• This involvement should be in all phases of
  program planning, implementation and evaluation.