Overview
THE SITUATION
Basic health care is not present where it is most needed so we must have a model to bring health and welfare to the most marginalized and to the 1.2 billion people which the World Health Organization estimates do not have access to basic health services.
Community Based Health Care (CBHC) is one model with huge potential which in the view of many is going to become a major player in the health sector over the next 10 years.
Although hard evidence is difficult to obtain, many health workers estimate that about three out of four common health problems in resource poor communities can be prevented and treated by well-trained community health workers, working aloingside well informed community members.
WHAT ARE COMMUNITY HEALTH WORKERS?
This a definiton from the Lancet medical journal.
"Community health workers act as the first line of contact with the health system in most low and middle income countries- these are selected community members who are trained in general primary care functions, and the restricted evidence available suggests that these enhance the performance of community level programmes and are usually cost effective. Hongoro C McPake B How to bridge the gap in human resources for health Lancet 2004; 364:1451-8"
There is more about CHWs under the topic area Community Health Workers, selection and training.
WHAT IS COMMUNITY BASED HEALTH CARE?
Here is another quote from the Lancet which describes what we mean by CBHC.
"Working with and in close association to the many communities being served is the most important of all partnerships for public health practitioners. This partnership is essential; for building the long term community, and to negotiate their inclusion in health systems, and to demand the full range of health services…. But this partnership has long been neglected".
A paper from WHO Beaglehole et al Lancet 2004;363: 2084-6
CBHC is a process which means making basic health care accessible to everyone. This will change the face of the world’s most impoverished communities.
WHAT DO WE MEAN BY ACCESS?
Accessible health care is:
Near, friendly, affordable, culture-sensitive, competent , with reliable medical supplies.
To access health care you must be brave enough, rich enough, well enough, and near enough
If you are not brave- someone in your family or community must be brave for you
If you are not rich enough a family/community member must pay
If you are not well enough or near enough a family/community member must arrange transport
So health care needs to be within, or as near as possible, to the communities where people live. Would a sick mother be able to walk even 1 kilometer to a clinic on a hot day when she is not even sure if the clinic is open and life-giving supplies will be available? This same mother would be much more likely to walk a few hundered metres to see her own community health volunteer or better still to have been trained how to use 2 or 3 life saving medicines which she can keep in her own home, such as treatments for malaria and pneumonia.
CBHC- CONTINUING EVOLUTION
The world is changing and CBHC is changing with it. But it must be foundational to health systems.
Here are some of the core activities of CBHC as written down in 1978- at Alma Ata:
Education about prevailing health problems and the methods of preventing and controlling them
Promotion of food supply and proper nutrition
An adequate supply of safe water and basic sanitation
Maternal and child health needs, including family planning
Immunization against the major infectious diseases
Prevention and control of locally endemic diseases
Appropriate treatment of common diseases and injuries
Provision of essential medicines
But now we need to add some more: Here are some
1. Emerging non-communicable diseases such as:
* Diabetes, hypertension, strokes, heart attacks and cancer
* Mental health problems including addiction, suicide
* Smoking and alcohol related diseases
2. Increasing differences between the poorest and wealthiest within countries and communities
3. Disability including hearing impairment, blindness and injuries from wars, landmines and munitions
So somehow we have to take all these new priorities on board in our community based health programmes. In other words we must learn how to deal with as many of these new problems as possible at primary level so that solutions are accessible to as many people as possible.
CBHC- A TOOL TO REACH THE MILLENIUM DEVELOPMENT GOALS
Now talking about CBHC in the 21st century seems like such a big subject and a massively long period of time. So we are going to think ahead to the year 2015 and try to focus it down. 2015 is a key year because it is the target year when the Millennium Development Goals are supposed to be reached.
The Millenium Development Goals are an example on a massive scale of what are known as SMART objectives: Specific, Measurable, Achievable, Results Orientated and Time bound. We may not be able to achieve all these goals, but even if targets are missed the MDGs focus our minds and help us to maximize our efforts. See Further Study for dedtails.
CBHC: NEED TO BUILD ITS CAPACITY
Many CBHC programmes are small, isolated and unconnected, others are already an integral part of a national health system.
So CBHCs need:
* Linking up so they are not in isolation
* To have their capacity strengthened
* To be based on evidence where available and take on operational research
* To follow good practice
* To follow specific guidelines laid down by national andvertical health programmes
With an increasing number of effective CBHCs they can play a vital role in national health programmes by being the effective community base, without which no health programme can ever involve the local people or be sustainable.
Various organisations are helping to achieve these aims including the People’s Health Movement. Community Health Global Network is designed specifically but not exclusively to increase the effectives of faith based organisations worldwide, as they work with others to achieve these goals and look outwards beyond them.
CBHC MUST LINK IN WITH NATIONAL HEALTH SYSTEMS
We must find a new model- of strengthening CBHC and integrating it into national health care systems.
How can this be one. These are just a few examples:
1. Government can contract out health care services to CBHCs and other NGOs, or civil society organisations.
2. These new players can work in partnership with the government.
3. Donor agencies can fund projects directly or through the government.
4. CBHCs can have direct links into UN agencies eg through partnership units
5. WHO can give technical support and draw up country and disease specific protocols and good-practice guidelines.
6. Advocacy for better services based on a human rights approach can put pressure on governments and the world community.
We must make sure that the CBHC movement does not just consist of programmes doing their best in isolated areas. It must be a linked-up movement which relates to and works closely with governments, following national health guidelines. This is not always easy or possible but it should be our goal. At the same time we must avoid being submerged or having the flame of our faith- our key motivation- blown out.
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Excerpt from setting up community Health programmes by Ted Lankester
WHERE ARE WE NOW
After a century of the most spectacular health advances in human history some of the world s poorest countries face rising death rates and falling life expectancy. Gains are being lost because of feeble health systems. On the front line we see overworked and overstressed health workers too few in numbers losing the fight with many collapsing under the strain. Lancet Vol 364 2004 Page 1984 More than one billion people one sixth of the world s population- live in extreme poverty lacking the safe water proper nutrition basic health care and social services needed to survive. Almost 11 million children die each year six million of them under 5 from preventable diseases 500 000 women per year do not survive pregnancy or childbirth and there are presently 40 million people living with HIV AIDS Press release WHO 2005 . This situation is completely unacceptable. We must be moved by the human suffering which underlies these figures and challenged to use our skills and knowledge to take effective action without delay. This website attempts to show some ways of doing this based on evidence good practice and experience from around the world and using the model of community based health care.
HOW CAN CBHC TACKLE POVERTY- THE ROOT CAUSE OF ILL HEALTH
Health workers soon come to realize that the diseases they see are usually symptoms of a much greater illness which affects their communities. Health planners call this The Social Determinants of Health and a great deal of research and action is focused on trying to understand these issues in more detail. For example the reason why under 5 mortality rates in children vary from 316 per 1000 live births in one country to 3 in another is in part a health care issue but largely depends on these social determinants What this really means is that most diseases in developing countries are a direct result of poverty. Poor people have little money little food or little power the rich consider them little people . They become used and abused by those who own more land and more money. Such exploitation is always found in association with poverty and both causes it and results from it. As health workers we must be aware of the forces which act against the poor and lock them into lifestyles of poverty. We must come to see how other forms of development which reduce poverty and exploitation may be even more important than the health programmes we help to bring about. We can look further and notice another thread which weaves its way through all the problems listed human corruptibility. This multiplies still further the problems facing the poor. Here are some examples Greed which brings about a wealthy minority at the expense of a poor majority Dishonesty where broken promises and pledges are most keenly felt by the poor Corruption where those unable to offer a bribe suffer the most and Pride where the rich and clever tend to despise the weak and poor so refusing to share their resources or help in time of need.
OUR APPROACH
In planning our attack on poverty and exploitation we must consciously resist becoming discouraged or intimidated. Anyone ?ghting poverty is liable to threats and opposition. We should simply see this as part of our job description. Here are some approaches we can follow 1. Understand the causes of poverty.This will help us to be more compassionate towards the community and more realistic in our planning. 2. Realise that although we can do little by ourselves we can do a great deal as we work together with others and form local national and global networks 3 See CBHC as a multiplication process not an addition process.If we merely treat patients this is an addition process. Someone has described it as trying to empty the ocean with a teaspoon. But if as health workers we teach others who teach others who teach others this is a multiplication process. It is like a stone which is set in motion at the top of a hill and which moves faster and faster the further it travels. 4. Start with the skills which we do have. Each community is rich in ideas skills and creative talent. These can be released as we empower and affirm community members. 5. Include community development in addition to health as soon as we are able. This may either mean expanding our own health programmes or linking the community with other agencies and experts. Agriculture forestry education adult literacy micro-finance appropriate technology improved housing urban renewal and housing co-operatives will have a far greater effect on improving the health of our communities than health interventions alone. 6. Encourage people to claim their rights under the laws of the country. There may be many promises on paper designed to help the poor but little happening in practice. We can help community members to claim the services and supplies which are due to them. 7. Alter traditional patterns of life as little as possible unless they are actually harmful. This becomes harder every year as globalization brings the promises of riches and glamour to those who will never afford them. 8. Resist injustice and show solidarity with the people where important principles are involved.
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Practices members have applied in their own situations
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This topic is convened by: |
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Dr Ted Lankester
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