POST 00893E : COMMUNITY HEALTH PLANNING
Follow-up on Post 00888E
2 March 2006
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This posting contains two contributions. The first is from Robert
Steinglass (mailto:
[email protected] ) from ImmunizationBasics in
the United States. He shares information on another experience with
community involvement in health, that of the Uganda national immunization
programme, UNEPI.
The second contribution is again cross-posted from the network "The
Connection" (mailto:
[email protected] ). Dr. A.T. SEDDOH
(mailto:
[email protected]), External Relations and Governing Bodies,
WHO AFRO, Brazzaville, Republic of Congo, suggests the following view on
the community-based approaches to health with reference to the Nkwanta
model. He also informs us of integrated community-based interventions to
deliver lifesaving health service in hard-to-reach communities, the ACDS
in Africa.
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In the same vein as reported in Post 00888E recently on the Ghanaian
experience with Community involvement in its own health, let me share with
you some information on the Uganda UNEPI experience that many of you may
not be aware of.
To raise and sustain immunization coverage, the Uganda Ministry of Health,
with support from the BASICS Project, elected to pursue the Community
Problem Solving and Strategy Development (CPSSD) approach, which is
designed to help health workers learn to work with communities, understand
community perspectives about immunization services, and encourage
community support and participation in immunization delivery. The Ministry
produced three documents that summarize the approach, which is consistent
with the Reaching Every District (RED) strategy.
To access these documents, please go to the ImmunizationBasics site at :
http://www.immunizationbasics.jsi.com/Resources_Immunization.htm#Linking
There is no direct link for downloading. The documents are the first on
top of the list. They have also been added to the list of country
programme documents, under Uganda on the TechNet21 site at :
http://www.technet21.org/countryprog.html
In addition to these Uganda materials listed above, a short description of
the program with data showing the success of the intervention in Uganda to
lower drop-out rates, and a Powerpoint presentation on the topic can be
accessed at the following links.
http://www.technet21.org/pdf_file/UgandaCPSSDFinal.pdf
http://www.technet21.org/UgandaDropOut.ppt
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"It is exciting to see that the spirit of Alma Ata and the primary health
approach is being rekindled and indeed the debate on finding an
alternative system for improving human resources for health, given the
current precarious levels of health manpower, is now urgent. From that
perspective, the piece by Dr. J.K Awoonor is most interesting and sets up
a good platform to explore community-based approaches to health.
While acknowledging the potential of a Community-based approach to service
delivery, I am of the opinion that framework of the model of the
Community-based Health Planning and Services (CHPS) initiative discussed
requires more detailed review.
I have been a keen follower of the CHPS initiative in Ghana which as a
concept has a promise but may need further methodological and design
clarity. I would focus on a few observations with the hope that the
authors might provide further insight to promote experience sharing.
First, in their diagnosis, the authors bemoaned the previous affinity for
the health system to invest in health facilities but with dwindling human
resource levels, there appears to be a reintroduction of the same
facilities building philosophy but at a lower level. Secondly with CHPS
requiring the production of additional 6000 nurses, the call to increase
the production of these new Community health nurses using the facilities
that are already used for training general nurses probably does not
appreciate enough existing limitations and complexities of health human
resource production. Thus a static facilities approach will still face the
three challenges of human resources, service delivery policy as well as
design, infrastructure and logistics constraints that the CHPS concept faces.
The methods for the assessments are not quite clear and the conclusions
need further scientific rigour to be globally acceptable. For instance,
the assumption that the presence of a BCG scar is a significant proxy for
the probability that immunisations will be completed is difficult to
accept. The terms "CHPS and non-CHPS zones" pre-supposes a distinct
variation in design that is unique and assumes that the particular
characteristics of CHPS are significantly exclusive to these zones and in
no other areas.
Another experiment in Ghana is encapsulated in the Accelerated Child
Survival Strategies used in the country's Upper East Region which drew on
networks between Communities, community-based volunteers and the existing
sub-district and district health system and used the "marginal budgeting
bottle-neck tool" developed by UNICEF, WHO and World Bank. I recall the
results were quite good between 2001 and 2003.
There is definitely a need for clear guidance about the organisation,
rules and incentives that best help a health system to achieve its goals
within available resources. This, of course, depends on the value of past
investments and training programs as well as a systematic rejuvenation of
networks ensuring that the existing and new cadres of human resources are
custodians of the clients' interest, complemented with communities' own
resources - volunteers, private sector, CSOs etc.
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Every year nearly 11 million children under age five die from preventable
causes, with nearly 5 million of those deaths occurring in sub-Saharan
Africa. In order to reach the Millennium Development Goal of a two-thirds
reduction in child mortality by 2015, three million child deaths per year
will need to be averted in sub-Saharan Africa.
Funded by Canadian government, UNICEF developed a pilot project called The
Accelerated Child Survival and Development (ACSD) programme that is
designed to deliver a package of lifesaving health services to children in
hard-to-reach communities. ACSD was initiated in approximately 100
districts within 11 countries in West Africa beginning in 2002.
ACSD takes the most effective health interventions for children, newborns
and pregnant women and bundles them in an integrated, cost-effective
package. Interventions include immunizing children and pregnant women,
delivering life-saving micronutrients, encouraging breastfeeding,
supplying oral re-hydration salts for diarrhoea and providing bed nets to
protect children and women from malaria.
After three years of increasing coverage in basic health interventions,
UNICEF estimates that child deaths will have dropped by an average of 20
per cent across the 16 districts where the programme was fully
implemented, and by 10 per cent where it was partially applied.
After analysing what has worked in the pilot programme, UNICEF has set the
goal of expanding ACSD to cover many more African children. "We believe
that we can reach 60 per cent of children across sub-Saharan Africa by
2009 with these integrated community-based interventions...This will mean
saving the lives of an additional one million children every year in that
region alone," - UNICEF executive director Ann M. VENEMAN said at the
World Health Assembly, 16 May 2005, Geneva, Switzerland.
To learn more on ACSD's goals, challenges and solutions visit UNICEF site at:
http://www.unicef.org/health/index_childsurvival.html
Read "Integrated Approach to Child Survival Achieving Important Results,
UNICEF Finds
In Several West African Countries, 20% Drop in Death Rates Estimated" at:
http://www.fasid.or.jp/oda/pdf/handout_ban2_14.pdf
On the subject of ACSD in Ghana, attached please find the document
"Ghana's Ministry of Health adopts the UNICEF-supported Accelerated Child
Survival and Development approach as a major strategy for scaling up child
survival interventions nation-wide and for achieving the child survival MDG"
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