Reality of Community Health Needs Are We Meeting These?

by Paul Freeman (freemp@uw.edu)

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