This course explores why primary health care is central for achieving Health for All. It provides examples of how primary health care has been instrumental in approaching this goal in selected populations and how the principles of primary health care can guide future policies and actions. Two of the most inspiring, least understood, and most often derided terms in global health discourse are “Health for All” and “Primary Health Care.” In this course, we will explore these terms in the context of global health, their origins and meanings, the principles upon which they rest, and examples of how these principles have been implemented at both small and large scale. We will also explore some ultra-low-cost approaches to Health for All through primary health care, and the promise that primary health care holds for eventually achieving Health for All. Each module of this course consists of approximately one hour or lecture, approximately one hour of additional readings or video presentations, and two additional hours devoted to studying for each of the quizzes, writing and evaluating two short peer-review assignments, and participating in the discussion forums. Developed in collaboration with Johns Hopkins Open Education Lab.
BRAC, Bangladesh, Nepal and Beyond
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Health for All Through Primary Health Care
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Approaches to Implementing Primary Health Care in Resource-Constrained Settings
Implementation of primary health care is challenging work, particularly when resources are in short supply. In this module, we'll examine some of the challenges and opportunities and look at some real-life examples. A short review quiz follows the lesson.
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Dr. Henry Perry, MD, PhD, MPHSenior Scientist, International Health
Bloomberg School of Public Health
Welcome back, everybody. We're coming down the home stretch now, this is kind of a
long lecture and since I have apologized for it, but still I think there's a lot of
important and interesting information here. We're going to turn now to a very
interesting program that has many dimensions that's run by a very famous NGO
now that I'm sure many of you have heard of called BRAC. This was originally named
BRAC as an acronym for the Bangladesh Rule Advancement Committee, an NGO that started
in Bangladesh about 3 decades ago after a severe typhoon destroyed a lot of the
coastline of Bangladesh. But now, the term BRAC refers to a different set of words
which is Building Resources Across Communities. Because BRAC is no longer
working just in Bangladesh, and it's no longer working just in rural areas. Two
recent monographs give a great insight into the programs that we don't have time
to spend now talking about in the level of detail that I would like to. But, the book
Freedom from Want has been published recently by Ian Smillie. And this a story
of the whole BRAC organization from beginning up until recent times it's a
very interesting narrative, has a lot of personal antidotes in it. But the health
programs of BRAC, which are only one small part of the overall organization are
described in some detail in this volume published in Bangladesh about BRAC. But
you could obtain through the internet if you would like to. BRAC is a
multi-sectoral organization that addresses a mini elements that contribute to the
poverty of the population. It's focused essentially on women and local women's
organizations that they refer to as village organizations. BRAC has
approximately 110 million women in these organizations in the country of
Bangladesh, which now has approximately 160 million people. So, you get some sense
of the vastness of scope of this organization just in Bangladesh alone. And
it's now spread to quite a few other countries as well. But the basic notion is
a very simple one and that women's groups a re established with the help of a paid
supervisor and these womens groups have 10, 15, 20 women in it, and they become
savings groups, among other things. So they're involved in contributions of very
small amounts of money at the time they meet, 25, 50 cents. But, at the same time,
the women in these organizations, they obtain special training in some specific
aspect of development. It could be in health, it could be in nutrition, it could
be in small crafts, it could be in income generating activities like dairy
production or chicken production. here we're going to limit our discussion to the
health aspects of BRAC. And so, within the village organization, one or more of the
members may choose to obtain training as a community health worker, which in
Bangladesh they call Shasthya Shebikas. And, so the members of the village
organization that want to obtain this training, they go off to a training center
that BRAC has. And over a 6 month or so period they learn a lot of essential
health care messages and practices. They learned how to actually treat common
simple illnesses, and they come back with the capacity to provide simple services in
the village. And this actually has some interesting CBIO characteristics because
they visit every household, and they also provide a lot of preventative and curative
services. In this next slide, you see a picture of a Shasthya Shebika who is
generally a woman who is married, 25 years of age or older. And she's going household
to household with preventive healthcare messages and with basic curative care
capability. She normally has around 250 households for which she is responsible.
Here, you see a picture of a BRAC village organization in its regular monthly
meeting. They frequently have educational messages they discuss. The person in the
bottom right hand corner whose back is to us is the paid supervisor from BRAC who
travels around and visits with these groups as they meet every two weeks or so.
Shasthya Shebikas are the backbone of the BRAC health sy stem.
They're, I think about 80,000 of these community health workers in Bangladesh
now. And they carry out a broad variety of services you see here on the slide. They
are able to generate a small amount of money that is sufficient to motivate them
to continue their work, and they do this by selling essential drugs and other items
such as iodized salt, delivery kits, condoms, birth control pills, soap and so
forth at very low prices but at a price that is attractive to the person living in
the household, but a price that generates a profit for the Shasthya Shebika. Many of
these items were actually produced by BRAC and, at mass scale so the prices are very
inexpensive. And BRAC actually makes a small profit by selling these to the
Shasthya Shebika. Shasthya Shebikas are trained to diagnose and treat childhood
pneumonia, for example. So the levels of antibiotic treatment of childhood
pneumonia among the communities where BRAC is working is very high. They have very
well trained capabilities for treating diarrhea, and the nutritional support that
children with diarrhea need. They have a long history of promoting immunizations
and working with the government immunization program. They have a long
history of working at the village level to improve nutritional practices as well.
They have been involved in family planning work and support of pregnant women. And
BRAC has become famous for its TB program which is now on a massive scale throughout
the country. You see, on this next slide, the rapid growth of Shasthya Shebika, the
community health workers that has occurred in the last decade. In the previous slide,
with the photograph that Shasthya Shebika, you see her providing directly observe
treatment to a woman with tuberculosis, and this national TB program that BRAC
operates has become very effective because they have been able to screen symptomatic
patients at the local level. And once their diagnosis has been confirmed, then
the Shasthya Shebikas ensure that the patients receive their medicatio n on a
regular basic, up until the completion of the course of therapy. I will say a little
bit more about this in just a minute. BRAC's achievements in their 2009 annual
report are highlighted on this next page. And you get a sense of the extraordinary
scope of the primary healthcare programs that BRAC operates there. 100 million
people receiving essential healthcare services through the work of the Shasthya
Shebikas. We see that, for instance, the tuberculosis control program that BRAC
operates is reaching 86 million people. And you also see here that BRAC is
expanding its programs into the very poor urban population of Bangladesh, and as
well like expanding it's work in a substantial way into the promotion of
latrine installation and promotion of hygiene. Only in the last few years has
BRAC expanded beyond the country of Bangladesh, and you see here on this next
slide its, its extensive scope now into other countries of South Asia. Indo,
Indonesia as well as quite a few countries in Africa. It's interesting to note that
BRAC is now the largest NGO working in Afghanistan and it has programs in
England, The United States, as well as Haiti. Based on BRAC's history in
Bangladesh, I think we can expect that their methods will be successful based on
the early experience. And this will lead them to continue their rapid growth in the
other countries that they're expanding to. I think, within a small number of years
into the future, BRAC is going to be a global force for poverty alleviation and
also improvement of health through its primary healthcare programs. The BRAC Oral
Therapy Extension Program which was carried out during the decade of the 80s
was a famous prototype for their scaling up of other activities. And that example
BRAC decided to visit every home in the country of Bangladesh, which at that time
involved about 12 million homes. Oral therapy extension workers were trained
over a short period of time to visit households and these women taught mothers
how to prepare oral re-hydration thera py with sugar and salt available in the home.
And how to diagnose and treat children with diarrhea and to provide appropriate
nutritional support. And this had a very powerful impact nationally at that time,
when diarrhea was the leading cause of death among children in Bangladesh. I
mentioned a minute ago the TB program in Bangladesh, they have been able to achieve
90% completion rate of therapy and they have demonstrated in the districts where
BRAC has been active and working that the TB prevalences rate is only half that in
other areas where BRAC was not working. You see here a picture of sputum specimens
that were collected by the Shasthya Shebikas and then transferred to a
visiting supervisor who was transferring these sputum specimens onto a slide for
further examination under a microscope at the Central District Office where a
laboratory was based. And on the basis of this, finding positive patients received
antibiotic treatment from the Shasthya Shebika through the course of therapy.
BRAC is an interesting example of how vertical and horizontal approaches can be
effectively linked. BRAC has very strong vertical programs for example the TB
program I just mentioned. But they also have strong horizontal approaches of
responding to the acute care needs that women and families in the communities have
and through the Shasthya Shebika there is a unifying agent who can link these
various activities into one. Very effective program that reaches every
household. The broad nature of responsibility of Shasthya Shebikas is
very interesting because in so many programs it seems very difficult for
community workers to take on such a role, but BRAC has clearly shown that this can
be done with proper training and supervision. But how to maintain a role
for a community worker, that is appropriate within the capability and
skills of the worker and the program, is certainly an important issue as we move
forward and think about how to expand these programs in needy areas. In my view,
BRAC is perhaps the world's best example of implementation of the principles of
primary health care as defined at Almont at scale. And by that, I mean the BRAC has
taken on a mulch-sectoral approach to health improvement that goes far beyond
simply the provision of medical and public health services, but also promotion of
education. And improvement of women's empowerment and so forth. BRAC, because of
its national scope and because it's serving 2/3 of the population of
Bangladesh, I think can very justifiably take some of the credit for the remarkable
success that Bangladesh has had as a country in improving child health back in
the 1980s and early 1990'. So, BRAC was very aggressive in its efforts to
collaborate with the government in improving immunization services. And this
was very successful in the BRAC areas but less successful in other areas. Its role
in promoting oral rehydration therapy in Bangladesh is well known, as I mentioned.
But also very important to note is that Bangladesh is one of only 19 of the 68
high-mortality countries that's currently on track to reach the millennium
development goal for children. And so, I think that this success is certainly due
to an important degree. It's hard to know just how much, but to an important degree,
as a result of these primary healthcare programs. But also, it's important to note
that there is growing evidence that simply improving the educational level of women
has an important role in reducing mortality. This study recently from the
Lancet indicates that approximately half of the decline in mortality globally of
children could be attributed to the improvement of educational levels of
women. And this has particularly importance for BRAC where they have had
enormous efforts to improve educational levels of children in the community level.
And in fact, BRAC, through these efforts operates the largest private school system
in the world. community schools for children who had not been attending the
public primary schools. And I don't have time to talk about this but it's a very
interesting element of BRAC's work that has important health implications. There
is also published data from BRAC which demonstrates the health impact of just the
non-health BRAC interventions, and this is a study that was published by Abbas
Bhuiyan and Mushtaq Chowdhury that you'll see in the bibliography at the end of the
PowerPoint here. But they were able to show that the women who participated in
BRAC's programs that did not include health, but their other development
programs. Their children had an improved mortality compared to women of similar
background who were not engaged in these programs and it's one of the few examples
of the health impact of non-health activities that is community development
work on health that I'm aware of. In this next slide, it looks like a mess but this
is a graph that was published in the New York Times. And what it is demonstrating
here is how the life expectancy in various countries around the world has improved as
the level of education. And that country has also improved, and what's notable here
is that Bangladesh and Nepal are two outliers in this graph of countries. And
they both showed dramatic improvements in life expectancy during a 10-year period of
time. But, they also showed dramatic improvements in levels of education as
well, and this is particularly true for Bangladesh. So, in summary I think BRAC
and Bangladesh both are very interesting example of how effective community based
primary healthcare can be, and the principle of home visitation, how that can
be applied at scale both through BRAC's programs as well as through other program
throughout Bangladesh. and the important role of NGOs in improving the health of
very poor populations and the importance of strong civic and community engagement,
which I think the Bangladesh example provides. I lived in Bangladesh from 1995
to 1999 and over that time, I became a great admirer of all the progress and the
programs that have been developed in Bangladesh. And they're all described in s
ome detail in this book here that's been published in Bangladesh, but is available
if you're interested. I'd like to move now to just a brief comments about Nepal,
which is also an interesting example, as I just said, about strong improvements in
health. But, with a strong community-based component that certainly has contribulated
to this. one recent review reported in the Lancet, led by Jon Rohde, found that there
has been no other low-income country in the world with an under-five mortality
rate greater than 100 in 1990 that has made more progress than Nepal has and
reduce in child mortality. And, I think it's generally accepted that the female
community health volunteers have played an important role in this. They've played a
very active role in insuring a high level of distribution of vitamin A tablets
throughout the country. And then, more recently, playing an important role in the
community-based treatment of pneumonia with marked gains and access to treatment
through their work. So, in addition to the important role that the female community
health volunteers have played in Nepal and their contributions towards this rapid
improvement in under-five mortality, I think it's fair also to point out the
importance of strong national leadership for the female community health volunteers
in Napal. And the strong logistics management and information systems that
were developed that did not go through the government system. It went outside of this
and a strong donor coordination that made all these successes possible in Nepal. And
I think these are important lessons for the future, too, is these large scale
community health programs become more widespread in developing countries. So,
let me close here with just a few final thoughts about moving forward with primary
health care, given the enormous needs that exist today in what continue to exists for
the foreseeable future in terms of women and children, particularly who are dying
from readily preventable or treatable conditions. Who, or who suffer from
chronic conditions that we know can either be prevented or treated. This saying that
you see on the slide here, doesn't provide you with detailed guidance about how to
move forward, but it does give a sense that we need to think about how to adapt
interventions and how to adapt processes to local realities, and they do vary so
much from place to place. And so building on the general knowledge level and the
general techniques and interventions but adapting them to the local level and
finding, as Carl Taylor says here, appropriate local solutions, is one
important ingredient for making these programs successful. The second thought
that might be helpful at this point as we think about moving forward is, the idea
that Cesar Victora shared at a meeting I attended several years ago. This statement
is offensive to some people because of its militaristic kind of tone, but still I
think the idea's important. he said we have the bullets but not the guns for a
second child survival revolution. And by that he meant, that we know what
interventions work, and those are the bullets, of course. But we don't really
know how to deliver those interventions in a way that achieve their intended effect.
And by that, I think he's really referring to the notion of how we can engage
communities. How can we develop implementation processes that are
effective and that are sustainable, and that can work at scale. There has recently
been a lot of discussion about the current status of the polio eradication program
around the world. And Bill Gates, in a recent video about this, he was referring
to the contribution that the smallpox eradication made to helping to build
momentum for the first child survival revolution, which as you remember, was led
by a Jim Grant and UNICEF back in the 80s. Bill Gates is now conveying the idea that
maybe the principles and the momentum from polio eradication, if that is in fact
effective, that, that can help to build momentum for what many people have been
hoping for, for a long time no w, which is the second child survival revolution. But,
one of the interesting things about the current polio eradication program is that
there are many community-based elements that feed into it which involve tracking
individual children, immunizing children in the home. And these basic ideas, I
think, are fundamental towards making child survival programs effective as I
have mentioned throughout this lecture, and in the previous lecture. So, how can
we tap into the, what some people refer to the explosive force of the community? I
have to believe that the community is a vastly under utilized resource. In public
health, we often think of the community as a target, but not as a resource for
efforts to improve health. And I think that we need to learn how to do this in
order to build the capability of our programs to reach those who need services
to, to improve their effectiveness. And as the case in Bangladesh demonstrates by
merging community energy, community resources with the work of NGO's and with
the resources and technical expertise that governments provide all of this together
can be the explosive force that can really make a tremendous difference in the lives
of mothers and children. And in reducing mortality from other important diseases
such as HIV, AIDS and, and tuberculosis and malaria. I think, that primary health
care was defined at Alma-Ata as a fundamental strategy for improving the
health of populations around the world. And we're still looking for ways to
appropriately link vertical and horizontal approaches. And I think, the BRAC example
is such an important one for doing this, although there are certainly other ones
out there, too. And I think that BRAC has pointed the way
towards linking health interventions with broader poverty alleviation efforts which
can be very powerful if implemented well. My final point is that, in looking to the
future, we need stronger evaluations of large scale priority health care programs.
And this article here, published by Jennifer Bryce, is the lead author who is
one of our faculty members at Hopkins, is a very important one because it was an
independent assessment of a very important UNICEF program that failed to achieve the
success that many people had hoped for. But it pointed out some of the important
reasons why this program did not have its intended effect. And they have to do, in
part, with CBIO principles that I have mentioned off and on. And one of these is
that the program did not address the epidemiological priorities as existed in
these high mortality areas in West Africa. I encourage you to read this article to
understand more of the details of this. But it's an important example of how we
need strong evaluations to assess program effectiveness, and then modify programs
based on the findings of these evaluations. So, we now finally have come
to the end of this lecture. The end of the PowerPoint has a number of references that
you might find of interest, if you want to pursue this area further. But I hope that
this lecture on primary health care has given you some new insights into the
importance of primary health care in the field of internaitonal health and its
potential for playing an ever stronger role in improving the health of
populations around the world.
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