Welcome everyone to, the lectures for the, 2nd week of our course. We're going to begin with, a lecture, which is a continuation of, last weeks lecture. And as I said before, this, was originally recorded as part of a lecture on primary healthcare from, the course I teach here at Johns Hopkins on Introduction to International Health. And so, this is Section B, of that initial lecture, An Introduction to International Health, is called, What is Primary Health Care? So as an attempt to, describe in some depth, the concept of primary health care is, it has come to be understood in the field of global health. And then following this lecture, we're going to have a very special experience by listening to Carl Taylor in a lecture that he recorded prior to his death, which is his own definition of primary health care as well and what he considers to be the roots of primary health care. So we hope you enjoy this. The term, primary healthcare, in reality, means many things to many different people. Some of the meanings of this, word primary health care, are derived on the term primary. Primary health care has, really 2 parts, 1 is the term primary, the other is the term health care. But by primary, to some people, it means first contact with the health system. Which is certainly understandable. Some people refer to it as meaning basic, very elementary, the very fundamentals of health care, and this leads some people to sometimes say that this basic health care is poor quality health care, inadequate health care, and therefore isn't really appropriate if we're looking for a high quality standard for people on the world. Some people refer to the word primary as meaning essential. In that sense, I think we could think of some activities that are not commonly thought of as primary health care to be primary health care. And in that sense, essential and emergency surgery. I think could very easily be thought of as part of primary health care. And increasingly, people are already using that concept of, basic and essential surgery as needing to be considered as a part of primary health care. And then there's the sense of primary as meaning first causes, and by that I mean the multi-sectoral influences on health that go far beyond medical care. We're talking about education, nutrition, water and sanitation, among other things. And then we have this trouble understanding what we mean by health care, the dilemma between preventive and curative services, the biomedical disease orientation, in which the patient is the passive recipient of medical services versus the concept of creating conditions and environments that are healthy or that promote health, very different kinds of concepts. And then as I mentioned before as well, health is a social phenomenon whose determinants cannot be neatly separated from other social and other economic determinants. And then the whole behavioral side of health, the importance of programs to promote healthy behaviors is certainly a fundamental part of health care. But it's not commonly thought of as part of the health care process so much in developed countries, but it's clearly important in very poor countries. So we have this issue in which I think for many people primary healthcare is what I call an ambiguous mental model. It's the unconscious concepts that flow around a set of words that we're not always well aware of. One of the interesting parts of all this, to me, is the, concept of the household production of health. Which isn't widely recognized but it's the, basic notion that mothers are the most important health care providers in the world because of the influence that they have on the health of their children, which is very much Alma-Ata kind of concept and opposed to the idea that it's health systems and doctors in the hospital that produce health. And then there is a whole new flow of activities and ideas that flow around community based primary health care that I will get to in a minute as well. Activities that take place, outside of health facilities, with strong engagement in the communities. I like this slide that came from an article by a friend of mine, Jack Bryant, in which, primary health care, is such a fundamental part of healthsystems, thinking. But unfortunately, for a lot people involved in health systems, they don't really see primary health care as a fundamental basic element, of what a health system should be. This is a set of diagrams that I put together myself, when I was living in Bangladesh that, I think helps me and my thinking about the way we can conceptualize where primary health care fits into the health care model. In the top, we have on the left the various levels of curative medical services from primary care to secondary care and tertiary care, and the term primary care there is more the medical notion of it. But then we have public health services to the right, which have a continuum going from community oriented, to services oriented, to disease oriented. And as you move towards the center on this diagram, we have an increasing emphasis on community oriented approaches and responsiveness to local community health needs. And that general approach is shown also And the bottom, but not from the medical side as much as it is to the more intersectoral approach to improving health, thinking about centralized top-down approaches to the left, to more decentralized bottom-up approaches toward the center, in a somewhat kind of philosophical way, but not quite as medically oriented. When I lived in Bangladesh, I wrote a · , book which I am very proud, of called Health Role in Bangladesh. Lessons in primary Health Care for the 21st century. I was able to track down a fairly accurate notion of where the government expenditures for health went and you can see that in Bangladesh, at that time, the late 1990's they spent less than 20% of their budget on primary health care. And approximatley 2/3 of it on hospital care. I think this is typical, for many developing countries, in which primary healthcare has not, been the, major focus on funding. Although, many would argue that it's, got the greatest potential for imporving health. In terms of personal expeditures for health, you see that in Bangladesh, again similar to so many different developing countries, the overwhelming proportion of the small amount of money that's spent on health care is given directly to drug retail outlets for Purchases for drugs over the counter, very small amount of money for other activities. This is the annual World Health research from 2008 that I mentioned earlier, which promoted primary healthcare. And, the Lancet series, on Alma-Ata, that was published in 2008 as well. Both, in part, recognizing the importance of Alma-Ata in the growing recognition of the, need to give more attention to the concepts of Alma-Ata. I wanted to get into some, a little bit of detail about exactly, how Alma-Ata defined primary health care, but I also want to, focus briefly, on, some of the other variations of, primary health care as you see on this slide, Community-based primary health care, what I call CBIO, Census-based, Impact-Oriented approach, Care Groups and Participatory Women's Groups, and Community-oriented primary health care. The effect-relation of Ala-Ata, considered, primary healthcare to be essential healthcare, based on practical, scientifically sound and socially acceptable methods in technology, made university accessible to individuals in families and the community, through their full participation And at a cost that the community and country can afford. So in that sense, primary healthcare addresses the main problems of the community. It includes promotive, preventive, curative and rehabilitative services, so it certainly has the curative element built into it, but within the context of a whole. Range of broader activities. But it has this intra-sectoral element that's lacking from the biomedical model, specifically talks about the importance of food supply and nutrition. safe water, basic sanitation, maternal and child health, family planning, the public health approach of, prevention and control of locally endemic diseases. Treatment of common diseases and injuries, which is a priority for local people in provision of a central drug. Again, a local priority, but not necessarily a disease control priority. But it talks about these other sectors; agriculture, animal husbandry, food, education, and housing. And it also, gives great importance to engagement with the community. Maximum community and individual self-reliance and participation in planning, organization, operation and control of primary health care. Again, this is an example of the challenge to the more traditional medical model. The declaration of Alma-Ata goes on to say that these primary health care services need to be sustained and integrated into a functional and mutually supportive referral system. So it recognizes the need for hospital care, surgical services And the need for comprehensive care. But of course, it also states that we need to create services that countries themselves can afford. And it talks about the various levels of workers that are required to make primary health care work, all the way down to community workers, as well as traditional practitioners. Again, a challenge to the modern medical model, so to speak. But the creation of a health team. In order to be able to respond to the health needs of communities particularly, when resources are limited. So many people have referred to the three pillars of Alma-Ata, which were embedded in this definition, Equity, Community participation and Intersectoral development. Again, very different concepts from the medical model and from the notion of primary medical care. I want to say a few words about community based primary health care because this is becoming such an important new direction for primary healthcare. Of course, it was very much a part of the Alma-Ata concept, but the success of this and the enthusiam for it now is becoming quite exciting. And so I wanted to say a few words about this. Again community based is a term that means different things to different people. And when I think of it and I talk about it, I'm talking about services that take place outside of health facilities, but. In the eyes and the ears and the mind of many other people, they're thinking about services in which local people are engaged, in which they're readily accesible but they still could be facility based services, but that's not my concept of community based priority healthcare. I'm not saying that I'm right, and their wrong, but it's important to be clear, what we're talking about. So, through this approach, we're talking about provision of important services, outside of facilities, which again was part of the Narangwal Project. They were one of the early pioneers in this. But we are also talking about education, health promotion at the household level, which is a fundamental part of CBPHC. So you see here, this is a definition that I was involved in developing, it's very long and laborious, but it tries to as clearly as possible, define what we mean by CBPHC. And we did this because we were developing a review of the effectiveness of. Community based primary health care and improving child health so we needed to define what kinds of programs and documents qualified for our view, and which ones didn't. And so, I won't read this to you, but it gives you a sense of the effort that we took to clearly define what community based primary healthcare really is. But when you boil all this stand it basically involves any activity that takes place ouside of the health facility, that's focussed toward improving health, it could be well, very nearly focussed to vertical activity or could be more comprehensive approach and it could have conduction of health facility but it didn't have to, And so, that's the basis for what our review is all about. There's an interesting story about, integrated management of childhood illness, and how that links to primary healthcare. But, this started out as being almost entirely focused on facilites, and became a community activity Because of the lack of effectiveness of simply limiting this to facility-based services. It's very interesting that back in the late 80's and much of the 90's, IMCI was the major focus on WHO's activities And to a lesser degree UNICEF at improving child health, and it underwent a very rigorous evaluation, and because of its facility orientation it was shown to have no impact at all on mortality, and part of the reason for this is the limitation of health facilities and the The lack of access that people have to health facilities, because the effort that it takes to get there. This is a slide that came back from way back in the 1966, almost 50 years ago, which shows that The probability of a person attending a health facility drops off exponentially with their distance away from the facility, and we're still having trouble understanding this basic principle, that when facilities are few and far between, it's very unlikely that people are going to be able to make use of them, and that's still the case in very poor countries. And so, as a result of all of this, this whole approach to, developing child health care services in the community away from facilities, became very strong, and showed a very dramatic impact, and I'll get into some of this as we move along. So you see here that in 2004 the World Health Organization summarized the, very important influences that family in community practices again outside of heath facilities have on promoting child survival growth and development. So this was their review of the current. Evidence that focused on the importance of community based primary healthcare for child health. This is the review that I helped to lead again focusing on community based primary healthcare in child health. And in these slides that follow you see the very very large number of very important interventions that have been scientifically shown to improve health.It can be delieverd outside the facilities.So i am not going to go through these, But just for child health alone, the list is quite substantial. The, enthusiasm with which, these community based interventions have been, taken up, in very poor countries has been disappointing, but I think we are seeing, more recently Expanded interest and and rapid growth now, in many of these for instance the expansion of coverage of insecticide treated nets as making a dramatic difference in the reduction in cases of malaria just to give one small example. But recognizing the growing power of community based approach's to improve health, particularly child health, but, increasing in maternal, and I don't have time to talk about that now. But a number of exciting interventions are coming forth that are very powerful Can be delivered, at the community level, and I have mentioned family planning, but that is certainly a very important one that can be delivered at the community level. But this is a framework that came out of some of out work in which we tried to highlight the importance of community engagement, as well as the health care system, for impacting health and. The four major delivery processes for providing these interventions to the community level or home visitation participatory women's group, what we call community case management, which is diagnosis and treatment by community level workers. And then mobile clinics, which have been the traditional. Way in which imunizations have, been able to achieve their high levels of coverage. So again, I think these are all important as we think about primary health care. And I come back to this concept of John Wyon's that I mentioned earlier that so important. And I mention this here to move to this next framework, which I was involved in developing as well, which I think is a nice way of thinking about how we can use community based primary health care for diesease control programs, for basic services and for addressing the priority needs of communities through these 4 approaches. So, there's increasing interest in community engagement in health systems. That's coming slowly but the global fund to fight AIDS, Tuberculosis, and Malaria, recently has come out with a framework that highlights the need to consider communities and their interact with health systems as you see here. The Lancet has recently published an article, reviewing the importance of community health workers which are certainly a fundamental part of community based primary health care, and there's throwing enthusiasm for building up various types of community workers. Interestingly enough, after Alma-ata there was a strong push towards this direction, but with the failure of Alma-ata The whole concept of community workers fell out of favor as well, and there were many failures of community health worker programs at that time as well, so we're entering now after several decades a resurgence of interest in this and this slide shows a number of the different types of community level workers that are used around the world. Then the implementation of community based primary health care, and whether or not we can develop these programs and make them effective is certainly one of the key issues in global health today. The ways in which communities can be engaged in community based primary health care is another important issue, and again coming out of our review we see here A wide variety of different ways in which programs have interacted with communities in a way that has led to effective, programming for the benefit of children. Let me turn now to a somewhat different Kind of framework which I'm passionate about personally but is not widely known, and we call it the CBIO framework. It's not specifically a community based framework. it's a little more specific than the concept of primary healthcare at Alma-ata We call it the census based impact oriented approach and it grew out of my early days in the early 1980s working in Bolivia but with the support of John Wyon, and I mention that to bring that link back to those early primary healthcare concepts that permeate what we have here. So in CBIO we have a conceptual framework in which a practitioner is working with a population with the overarching goal to improve health and to show that we have in fact improved health, but it also recognizes that this can't be done unless a strong partnership between the practitioner. And the community has been established and you can't establish a strong partnership unless you have trust between the health system and the community, and in order to build trust the practitioner has to respond to community priorities. A very simple set of ideas, but often lacking so much in what we think of as health programming and public health. So you see here some steps that are embedded in this CBIO paradigm which involves defining the community, that is determining who's living there, where they're living. That's the census part of this. But making a community diagnosis, which involves the epidemiological priorities as well as the communities priorities, which could be very different kinds of Of things. John Wyatt is the, person who taught me this idea about epidemiological priorities, and I'm sure he learned it from John Gordon, if you remember from our initial lecture about founding figures in primary health care. John Wyatt always taught me that epidemiological priorities are the most serious, frequent, readily preventable, or treatable conditions in the The population where the program is being provided, and those require technical support to define. A community can't readily define those, but the community's priorities are what they conceive of in their own mind of course, and they don't require technical support so much. But by clarifying the epidemiological priorities, and the community priorities, then the program priorities became a merged, set of activities, that arise from those 2. And so the whole process, then builds from that. But epidemiological priorities require some way of contacting everybody in the community or perhaps set a minimally represented sample of the people in the community but in the way we have developed this we have built-in routine systematic visitation as a key action for developing trust of the community for delivering, For delivering services, but also for determining what the epidemiological priorities are, so I won't go into that further, but there are lot of programmes around the world that are increasingly using these ideas and I think it is going to continue to gain steam and people are developing these ideas on their own, that are we are having heard CBI or when I think through some real power, when I think the, Concepts are worth mentioning. Another different kind of primary health care, which is also very important now, is what I call participatory women's groups. And there's a special type of this called care groups that I've had engagement with that I thought I would just mention in, in the outset here. As you see on this slide here, a care group is a group of 10 or so women. And here, they're designated as WHE's. WHE means Women Health Educator. From program to program, different names are given to the women who make up a care group. It's the idea and the principle that's important here. But each one of the members of the care group, takes responsibility for 10 to 15 households, and the mothers and the children within that household. And over the course of a 2-week period or a 1 month period, she visits all of her 10 households with a specific message: wash your hands, after you go to the bathroom, for example. These are messages that have come out of the community based IMCI experience among others. The care group meets periodically, usually every 2 weeks or once a month with a paid low-level supervisor who herself has been taught this message. And then she carries it to the care group, and then the care group members carry it to each household. So its a way of achieving very high coverage at very subtle low cost process and the results have been very dramatic. Another interesting element of this, which I like very much which brings it to CBIO, is the common common practice in many of these programs to use these home visits is a way to record vital events which is a part of CBIO. So recording births and deaths and putting them back into the system is an important way of determining further you are making any progress with your program. A different approach to this use of volunteer women is shown here in a study from the Lansen where they did a randomized controlled trial of participatory women's groups in Nepal. And in this case these, were just volunteers from a village who met with a paid volunteer. And this was very empowerment-focused process where women were encouraged to talk among themselves, to understand their problems. And in the process, they also receive some education about maternal health issues and neonatal healthcare issues, which is what their study was about. But they were able to show fairly dramatic results in terms of improvement of neonatal mortality through this and even maternal mortality which was a big surprise to them. And these participatory women's groups only involved about a third of the community, and so they were spreading this information to the other people in the community to make the impact. And of course, the health impact was determined at the community level, not just among the people who attend these sessions. So finally, let me very briefly mention a different approach to primary health care, which has been very influential, particularly in the United States, but it started in South Africa with the Karks'. Sydney Kark and his wife, as shown here in the early publication in 1952. But it is an attempt to involve the community in primary health care, but to a less public health oriented concept, at least in my thinking. And this was the origin of what is in the United States referred to as the Community Health Center movement. But it's a little bit more of a medical model but still attempting to engage the community and involve the community, but not so much on public health principles.
