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.
