global realities demand a new emphasis_freeman_5.3.12
TRANSCRIPT
Reality of Community Health Needs Are We Meeting These?
by Paul Freeman ([email protected])
A synthesis of these needs versus what we are providing
Source: United Nations Population Division, World Population Prospects, The 2008 Revision.
World Population Growth Is Almost Entirely Concentrated in the World's
Poorer Countries.World Population (in Billions): 1950-2050
Urban PopulationPercent
29
15 17
53
47
37 37
76
55
42
74
85
54
61
82
World Africa Asia Latin Americaand the
Caribbean
MoreDeveloped
Regions
1950 2000 2030
Source: United Nations, World Urbanization Prospects: The 2003 Revision (medium scenario), 2004.
Trends in Urbanization, by Region
Much of growth in midsized cities/towns not just megacities
World Urbanization Prospects, the 2009 Revision
Urban and rural population by development regions (in millions)
Source: United Nations, Department of Economic and Social Affairs,2010
World Urbanization Prospects, the 2009 Revision
Urban and rural population by city size class (in millions)
Intra-Urban and Urban-Rural Variation in IMR and U5MR: Nairobi, Kenya
Location IMR (per 1,000 live
births)
U5MR(deaths per
1,000 children)
% prevalence of diarrhea in children
under 3
Kenya, nationwide 74 112 3
Rural Kenya 76 113 3
Urban Kenya, excluding Nairobi 57 84 2
Nairobi – all areas 39 62 3
High income area <10 <15 --
Informal settlements 91 151 11
---Kibera settlement 106 187 10
---Embakasi settlement 164 254 9
Source: Patel, Ronak, Burke, Thomas. (2009). Urbanization – An humanitarian disaster. New England Journal of Medicine, Vol. 361, No. 8, p741-743. Original source: Population and health dynamics in Nairobi’s informal settlements: Report of the Nairobi Cross-sectional Slums Survey (NCSS) 2000. Nairobi: African Population and Health Research Center, 2002.
Urban Causes of Child Mortality are Similar to Rural: Kenya
Source: The burden of disease among residents of Nairobi's informal settlements. APHRC No. 1, 2008, Policy Brief.
Pneumonia, Diarrheal Diseases, and still births* account
for nearly 60% of the mortality in children under
five in these slums.
*This study took place in two urban slums, Korogocho and Viwandani, with a population of about 56,000 persons.
Top five causes of premature mortality among children under the age of five years ranked by percentage contribution to the total years of life lost (YLL) in the Nairobi DSS (2003-2005)
Causes YLL % YLL
Rank
Pneumonia 3463 22.8 1
Diarrhoeal Diseases 2969 19.5 2
Stillbirths 2480 16.3 3
Malnutrition and Anaemia 1275 8.4 4
Birth Injury and/or Asphyxia
661 4.3 5
Source: Ezeh, Alex. Population Growth, Poverty & RH: Revisiting The Urban Advantage. African Population and Health Research Center. Presented at the Foundation Presidents Meeting, Population and Reproductive Health, in Seattle, WA. 10 Jan. 2008.
Natural Increase is the Major Cause of Urban Population Growth
Mental Health
• Widespread needs all common manifestations,
• depression, including child neglect and failure to provide normal nurturing,
• partner abuse, discrimination
• PTSD,
• poor self efficacy
Further Adult
• HIV/AIDS• NCD – esp diabetes eg. 8,000,000 known
in Bangladesh. • Note relationship childhood intrauterine
malnutrition and Adult NCDs (Barker Effect)
• Substances- Tobacco, Drugs, Alcohol etc• => Need for integrated “Health in a
Person”.
Scaling up Project Lessons Requires
Health System Strengthening
Source: D.Silimperi MSH
New Urban Health Paradigm*
• Recognizes multiple causations• Includes both social and economic determinants• Incorporates concepts of inequity and social capital• Considers the city as a whole• Integrates social science, epidemiology, public health,
urban planning and policy
• Takes into account the pluralism of providers
• Builds multi-sector partnerships
• *Trudy Harpham, ICUH 2008
Illustrative Evidence-based Urban Research Agenda to Reach MDGs 4 and 5
• Expand information base on the “urban poor”
• Undertake systematic studies of urban morbidity and mortality
• Cost and evaluate integrated urban MNCH package delivery
• Document quality of care • Evaluate diverse incentives and
payment with regard to outcome• Evaluate public-private health
partnerships• Evaluate how best to implement
CBPHC and involve community
Reality Check
• While all above needed for referral upwards and to support community workers resource limitations and costs are such that
• Communities need to have an active role in their own health.
CBPHC for common childhood illness works
• We now have good evidence that many common health • problems can be addressed by CHW’s in community but• how can we motivate, retain • and get them to practice well• at affordable cost?
• Modern technology will help but ??? Cost for billions of people living on <$2/day,
• ?motivation to use correctly • ? maintenance
Pink “Drive”
• Three Basic Human Drives:• Biological: Hunger, thirst and copulation• Extrinsic reward: Reward and
punishment delivered by the environment for behaving in certain ways (Carrot & Stick)---commonly used
• Intrinsic reward: The joy/satisfaction of completing a task motivates its completion.
Limitations of Extrinsic Reward
• Good for unrelenting, routine, mechanical, or boring tasks but not for quality & commitment can: crush creativity, encourage cheating, shortcuts, unethical behavior, foster short-term
• What happens when the incentive system goes away if it is not local & is determined by funding that is external to the local community?
• How often is the underlying assumption that the desired change- economic or social produced by incentives will be maintained valid?
Intrinsic Motivation
• Modern Psychology –says this is best to encourage creativity and retention
• Give people (e.g., CHWs) Autonomy … of task (what they do), time (when they do it), team (who they do it with) and technique (how they do it). (Except clinical treatment detail)
• Helping people to achieve Mastery. • Helping people to discover or act on THEIR
Purpose on their terms e.g. self image/growth, help family, community etc.
For all CHWs
• can focus on intrinsic reward
• need to provide basic training, supplies, consumables and supervision
• but only pay for those working many hours (> 8 per week) with advanced skills
Care Group experience as an example.
FH/Mozambique Care Group Model
Promoter #6
Promoter #3
Promoter #7
12 Leader Mothers
12 families12 families
12 families12 families12 families12 families12 families12 families
Promoter #5
Promoter #4
Promoters
(Paid CHWs)
Each Health Promoter educates and motivates 5 Care Groups. Each Care Group has 12 Care Group Volunteers (a.k.a., Leader Mothers)
12 families12 families
Promoter #2
Promoter #112 families
12 families
12 Leader Mothers
12 Leader Mothers
Each Care Group Volunteer educates and motivates pregnant women and mothers with children 0-23m of age in 12 households every two weeks. Children in households with children 24-59m are visited every six months.
Care Groups
With this model, one Health Promoter can cover 720 beneficiary households.
12 Leader Mothers
12 Leader Mothers
Evaluation of Care Groups
• Only Promoter is paid • Evaluation of above Mozambique project• 30% reduction in child mortality at $442 per life
saved by 65 paid CHWs & 4,100 Care Group Volunteers for 1.1M people. Good retention of workers (93%), maintenance of EPI coverage and ORS usage for diarrhea, on 4 year follow up post 5 yr long project. P.S. Also Social Capital building
Care Groups Outperform in Behavior Change:Indicator Gap Closure: CSHGP Care Group Projects
vs. Non-CG Project Averages
Indicator Gap Closure on Rapid Catch Indicators: Care Groups CSHGP Projects vs. Non-CG CSHGP Projects
32
4135
52
71
59
39
53 51
77
49
63
37
53
0
10
20
30
40
50
60
70
80
90
Underw
t
Birth Spa
cSBA TT2
EBF
CompFeed
AllVac
s
Measle
s ITN
Danger
Signs
IncFlui
ds
AIDSKno
w
HWWS
AllRap
id
RapidCATCH Indicator
Per
cent
All CSHGPs, 2003-2009 (n=58)
CSHGP using CareGroups (2003-2010,n=9)
Gap closure range for Care Group projects: ~35 – 70%(Avg = 57%)
Gap closure range in non-CG projects ~25 – 45% (Avg. = 37%)
Care Group Performance: Estimated Perc. Reduction in Child Death Rate (0-59m) in Thirteen CSHGP Care Group Projects in Eight Countries
(Bellagio Lives Saved Calculator Data)
23%
33%
48%41% 42%
32%28% 29%
14%
26%
12%
34%30%33%
0%
10%
20%
30%40%
50%
60%
ARC/Cam
bodia
WR/V
ur I
WR/V
ur II
WR/V
ur IV
FH/Moz
(Bell
agio)
WR/C
ambo
dia
WR/M
alawi
WR/M
alawi II
WR/R
wanda
Curam./G
uat
Plan/Ken
ya
SAWSO/Zambia
MTI/Libe
ria
Avg. C
are G
rp Proj
.
CSHGP Project
% R
ed. U
5MR
Series1
Other Examples Using Intrinsic Motivation
• Jamkhed approach- spread to large population –CHWs the main drivers of expansion. Emphasis on CHWs as part of community – not bottom rung in larger system.
• Ethiopian Health System- CHW system has contributed to improved < 5 mortality
• 88 /1000 live births in 2011 • compared to 123/1000 in 2005
Addressing Mental Health
• Evidenced based mental health care for displaced and traumatized populations
• Paul Bolton – use lowest level capable.• Possible approaches – cognitive therapy(No)
• xxxgroup therapy (Yes)• drug therapy (No) • Using iterative group therapy approaches
• Currently ? Moving into broad prevention.
Community Organizations
• Social Capital Building• These organizations can also be motivated using
INTRINSIC Motivation• & Appreciative Inquiry• to solve local problems practically using
• sustainable level of local resources
Skills we can help with• Building learning organizations• Community level use of objective data• Appreciative Inquiry & orientation to Intrinsic Motivation• Training of local facilitators-senior health workers
To meet real community situation
• Use methods that focus on community ownership and sustainability with limited outside help or direction
• Not community as bottom of system but partner– need to change community and our attitudes- we love technology and more complexity but ?? disempowers community-lower level HFs.
• Programs are executed differently--more successful/ sustainable if community owns them
• Strengthen community organizations• Technology- yes but ??? Community effects.
Components
• Internally motivated CHWs• Senior CHWs as local facilitators –of AI• supervisors• Community Learning Organizations• As far as practical local funding of health• Satisfactory lowest level Health Facilities• Motivators/facilitators from (MOH) outside
community visiting every few months