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Systematic Review of the Effectiveness of CommunityBased Primary Health Care in Improving Child Heal

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Title: Systematic Review of the Effectiveness of CommunityBased Primary Health Care in Improving Child Heal


1
Systematic Review of the Effectiveness of
Community-Based Primary Health Care in Improving
Child Health The Contribution of the
Faith-Based Community
  • Henry Perry, Co-Chair, Review Task Force and Carl
    Taylor Professor for Equity and Empowerment
  • Future Generations

2
Outline
  • The review itself
  • Findings of the review
  • Contribution of individuals and organizations
    with a strong faith-based perspective to the
    evidence base
  • Conclusions

3
Key Questions of the Review
  • How strong is the evidence that CBPHC can improve
    child health?
  • What conditions/program elements must be in place
    for CBPHC to be effective?
  • How important are partnerships between
    communities and health systems?
  • Does CBPHC promote equity and is it
    cost-effective?

4
Definition of CBPHC
  • Activities, interventions, programs that take
    place in the community outside of health
    facilities (but possibly in partnership with
    health facilities)
  • Includes selective and comprehensive approaches
    as well as top-down and bottom-up approaches
  • Includes non-health interventions (e.g.,
    micro-credit, education, womens empowerment,
    societal factors)

5
Outline of Report
  • Evidence concerning individual interventions
  • Evidence concerning integrated approaches
  • Cross-cutting themes
  • Limits of health facilities for reducing
    mortality,
  • CHWs, etc.
  • Major programmatic approaches
  • Selective vs comprehensive PHC Bamako
    Initiative, SEED-SCALE, Care Groups, etc.

6
Evidence for Specific Interventions
7
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8
Key Interventions
  • Community-based diagnosis and treatment of
    childhood pneumonia
  • Insecticide-treated bednets
  • Home-based neonatal care
  • Handwashing (reduces rates of childhood diarrhea
    AND pneumonia)

9
Key Interventions (cont.)
  • Cleanliness (including handwashing and keeping
    house and yard clear of human and animal feces)
  • Exclusive breastfeeding and consumption of
    potable water (at point of use)
  • Immunizations, vitamin A essential, and ORT
  • Family planning, womens empowerment, cash
    transfers, micro-credit, overall social/political
    environment each contribute

10
Major Findings and Recommendations
11
Contextual Factors Enhancing Intervention
Effectiveness
  • Integrated community-based approaches are
    powerful and cost-effective strategies for
    reducing child mortality WHEN
  • Proven interventions are employed
  • Strong technical and professional leadership
    present
  • Strong monitoring and evaluation and operations
    research present
  • Strong outreach components down to the household
    level are present
  • Strong supervisory systems present especially
    for lower-level workers
  • Functioning health systems with referral systems
    (including referral hospital care) present
  • The health system interacts with the community
    and community-level workers with respect and
    treats them as partners
  • Long-term financial, technical and professional
    support (gt 5 years) present

12
Overall Findings
  • The evidence for the efficacy of specific CBPHC
    interventions in improving child health is
    strong, and CBPHC deserves a stronger role in
    programming
  • We need a stronger evidence base for the
    mortality impact of packages of interventions at
    scale in routine field settings (effectiveness
    studies)
  • There are few studies of the influence of
    community partnerships and community empowerment
    in improving outcomes, but those which do exist
    are compelling

13
Overall Findings (cont.)
  • The emerging evidence on the effectiveness of
    home-based neonatal care is very exciting, but
    effectiveness studies are needed at scale,
    especially when neonatal interventions are
    integrated with a broader package of
    interventions
  • Lack of studies from Africa except for malaria
    interventions
  • Need more effectiveness studies at scale of
    programs integrating reproductive and child health

14
Overall Findings (cont.)
  • More emphasis on CBPHC needed to accelerate
    progress in reaching MDG4, especially in high
    mortality settings, where health systems are weak
    (only 16 of the 68 countries with 97 of global
    under-5 deaths are on target)
  • More efforts are needed to involve the community
    as a partner in order to help programs reach
    their full potential
  • Ongoing rigorous monitoring and evaluation of
    impact on under-5 mortality will be critical for
    long-term effectiveness at scale

15
Figure 1. A Conceptual Framework for Planning,
Implementing and Evaluating the Effectiveness of
Proven Technical Interventions in Routine Field
Situations at Scale
16
Expert Review Panel Recommendations for Promoting
Community Empowerment for Improved Child Health
  • Establish a foundation of values to shift power
    to the community and to support processes to
    build community capacity through giving
    communities authority to supervise or control
    certain aspects of government health services and
    through programs such as the promotion of womens
    empowerment, micro-credit, and conditional cash
    transfers.

17
Expert Review Panel Recommendations (cont.)
  • Create a delivery system culture which is
    respectful of and collaborative with community
    members
  • Create bi-directional information and
    communication flows
  • Create bi-directional linkages between the
    district health system and communities which
    can help everyone be accountable for their
    performance

18
  • Final report will be out at the end of the summer
    or early fall

19
Sustained Impact of Integrated Programs on
Under-5 Mortality
  • Matlab (Bangladesh)
  • Hopital Albert Schweitzer (Haiti)
  • Jamkhed (India)
  • SEARCH (India)

20
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22
Significance of the Narangwal Project
  • One of the few field research projects which
    treated the community as a partner and resource
    rather than a target and placed rights of
    villagers over scientific objectives
  • First use of rapid breathing and chest in-drawing
    as a community-based method for diagnosing
    childhood pneumonia (suggested by the villagers)
  • First demonstration of the effectiveness of
    antibiotics in reducing mortality from childhood
    pneumonia

23
Significance of the Narangwal Project (cont.)
  • One of the few studies systematically comparing
    sets of integrated packages of services and
    integrating family planning, nutrition and health
    interventions, and clearly showing synergism
    (increased program effectiveness and
    cost-effectiveness) arising from integration
  • Provided the basis for Carl Taylors
    controversial child survival hypothesis which
    was disputed for many years but is now widely
    accepted
  • Served as an inspiration to James Grant and the
    first Child Survival Revolution, to the Aroles at
    Jamkhed (India), and to the Bangs at SEARCH in
    Gadchiroli (India)

24
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25
  • Carl Taylor -
  • The acknowledged leader of primary health care
    over the second half of the 20th century"
  • Jon Rohde, 2002

26
John Wyon Pioneer in Census-Based Child Survival
Programming
27
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28
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29
Matlab MCH-FP, Bangladesh, Field Site (100,000
people)
ICDDR,B, 1996 and 2007
30
Major Early Influences on Matlab
  • Henry Mosley
  • Carl Taylor and Shushum Bhatia

31
The Aroles at Jamkhed(rural Maharashtra, India)
with Carl Taylor
32
Community Dialogue and Information System at
Jamkhed
33
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34
Jamkhed (150,000 people)
Arole and Arole, 1994
(Major external evaluation of mortality impact
compared to surrounding villages currently
underway by researchers at the London School of
Economics and at the London School of Hygiene)
35
Hopital Albert Schweitzer
36
Hospital Albert Schweitzer, Haiti(150,000 people)
Perry et al., American Journal of Public Health,
2007
37
Dr. Albert Schweitzer in Lambarene
38
Albert Schweitzer with the Mellons
39
The Entrance to HAS in Deschapelles
40
Hôpital Albert Schweitzer Aerial View
41
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45
Father Bringing Newborn to Tie Umbilical Cord
46
Tetanus of the Newborn
47
  • Malnutrition and Tuberculosis

48
  • Tuberculosis of the Spine

49
Kwashiorkor
50
Kwashiorkor
51
Marasmus
52
Marasmus
53
Pediatric Ward A MotherAdministersOral
Rehydration Treatment to Her Child
54
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55
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57
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58
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59
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61
One of 9 Original Community Health Centers
62
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63
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64
Community Health Agents Immunizing Children in
the Community
65
Gwen and Larry Mellon Surveying
66
The Mellonswith the CaterpillarBuilding a
Road into the Mountains
67
Community Development Bringing Water to
Villages By Capping Fresh Mountain Springs and
Piping the Water to Newly Constructed
Fountains
68
Rows Of Fountains Making Clean Water
Accessible
69
On The Back of This Photograph in Larry
MellonsHandwriting First To Drink From The
Public Water Fountain In Desarmes.
70
Larry MellonAndNeighborsClearing
OldIrrigation Ditches
71
Valley Farmers Digging New Drainage Ditches
72
Dam Construction for Irrigation
73
Seedlings For Reforestation ProjectsWater
From A Watering Can
74
Cottage IndustriesLarry Mellon Buys Cotton
To MakeCloth And RugsAt The
HospitalsWeaving Center
75
Cotton ManBringing Balls Of Seeded And Spun
Cotton To TheWeaving Center
76
In Addition To WeavingCommunity DevelopmentHas
Fostered Works In CarpentryCarving Ceramics
IronworkPaintingMicro Enterprise AndSmall
Loan Programs
77
Gwen And Larry Mellon At Home In Haiti
78
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79
The Flute Always Draws an AudienceBut So Does
theCelloClarinetGuitarFrench
HornandAccordion
80
A Letter From Dr. Schweitzer
  • Larimer Mellon Died in 1989, Buried in
    Deschapelles

81
Gwen Grant MellonDied in 2000Buried in
Deschapelles
82
HAS Results 1956-1999
  • 18,000 lives of children lt 5 saved
  • 1 million years of life saved among children lt 5
  • 143 million spent (almost all Dr. Mellons own
    money)
  • Estimated cost 2,775 per life saved, 77 per
    DALY saved
  • Gwen Mellon We had so much fun doing it!
  • Answer of Why?to Larimer Mellon To follow
    Jesus

83
The Bangs at SEARCH in Gadchiroli (rural
Maharashtra, India) with Carl Taylor
84
SEARCH in Gadchiroli
85
Reductions in Infant Morality in Gadchiroli
86
Reductions in Neonatal Mortality in Gadchiroli
87
  • SEARCH as a faith-based organization
  • Ghandian communitarian social solidarity

88
The Care Group Model of World Relief
Mozambique, Rwanda, Cambodia, Mali
89
Care Group Model
WHE
WHE
WHE
WHE
WHE
A Care Group
WHE
WHE
WHE
WHE
WHE










4





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2
3
4
5
6
7
8
9
15
10
11
12
13
14
The total number of WHEs 2490
90
Handwashing Practices
Percentage of mothers who wash their hands before
food preparation, before feeding their children
before eating, or after defecation OA Original
Project Area EA Extension Project Area
91
Percentage of Children Who Received All
Immunizations
Children 12-23 months of age completely
vaccinated on day of survey
92
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93
Mortality Impact on Care Groups in Mozambique
(Edwards et al., Transactions of the Royal
Society of Medicine and Hygiene, 2007)
94
The Web of Influence
95
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97
Conclusions
  • Individuals with a strong Christian faith
    orientation, including individuals with an early
    experience in medical missions, have played an
    important role in the creation of the evidence
    base for CBPHC as an approach to improving child
    health
  • Faith-based organizations , including Christian
    organizations, have made important contributions
    to this evidence base as well

98
Full Report
  • Download at
  • http//www.apha.org/membergroups/sections/aphasect
    ions/intlhealth/cbphcw/news
  • Or email me henry_at_future.org
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