Community Based Primary Health Care The Answer to Addressing Child Mortality Paul Freeman Chairman CBPHC-WG APHA

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

Where We Stand on Child Survival U5MR declined ¼ between 1990 & 2006 Source. UNICEF

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

Where We Stand on Malnutrition: South Asia and Africa have highest levels

Where We Stand on HIV/AIDS: Sub-Saharan Africa accounts for 90% of paediatric HIV infections Source: UNICEF

Orphans & Vulnerable Children Orphans SubSahara Africa 30.9 Million Million Million % due AIDS >12% 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 ->physical, nurturing needs greatest 12-17yrs 50% of all OVCs 66% of double orphans The closer to biological family-better care, schooling

Selective primary health care and trends in immunization rates since 1980 Source: UNICEF

9 Low Utilization of Health Facilities % sick children who were taken first to a health facility Source: Arifeen S, Paryio G, Schellenberg J et al

10 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

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

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 How about sickness care? WHO, World Health Report Reducing Risks, Promoting Healthy Life Slide Source Henry Moseley

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)

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.

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.

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). (3) Provision of health care in the community, including preventive services (e.g., immunizations) or curative services (e.g., community-based treatment of pneumonia).

A Continuum of Care in Time and Place Source: PMNCH ( accessed 30 September 2007www.who.int/pmnch/about/continuum_of_care/en/index.htm

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

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

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

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

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.

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.

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

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.