Welcome everyone to this lecture for Week 3. And in this lecture, we'll be discussing in a general way approaches to implementing Primary Healthcare Programs and Resource Constraints Settings. What you would be hearing this week again are Lectures which I've given to our Introduction to international health course, which I teach now at Johns Hopkins. And in the first part of this lecture, we'll be reviewing some of the programmatic issues that exist as we think about how to implement primary health care. And we'll be presenting some of the early pioneering projects that really guided the way for a lot of programming that has come since. And I've had the great fortune of having personal contact with the people who started these programs, so it's a special privilege for me to be able to share that with you. In the second part of the lecture, we'll be talking about a very special strategy for implementing primary healthcare services, not in a real comprehensive way. But it's an ultra low cost way of working with communities to provide some very basic services that can save the lives of mothers and children and this is called the care group model. And we'll be talking about some of the projects that have implemented this care group model and how the model got started and some of the exciting results that the care group model has been able to achieve in a number of different countries around the world. And then finally, we'll be talking about my very favorite NGO in all the world BRAC and how it operates and implementing primary health care in a very comprehensive intersectoral way in Bolivia and it's expansion around the world. And then we will talk about Bangladesh a little more broadly as a country. Beyond what BRAC itself, is doing. And then we'll share a little bit about some of the, the exciting progress that Nepal has made all through primary health care programs. And some of the implications of all of this work for the world. So I hope you enjoy this weeks lecture and we look forward to moving forward down the road towards achieving health for all through primary health care. Thank you. So after talking about some of the problematic challenges that face primary health care. I want to mention some of the noteworthy programs at least from my standpoint of course there's so many that we could talk about. But I wanted to highlight a few of these some of these I have had some personal relationship with either through my friendship with people who have operated these programs or through my own experience living in Haiti and living in Bangladesh. And then after we review these we'll think about some possible ways forward for strengthening these kinds of programs and high mortality resource constraint settings. As I said in the initial introduction to this course on the outset of the video, the challenge is are facing the world in terms of health and disparities in health and the magnitude of the problems. Should be easily solvable with the available resources and know-how are astounding. And just to review a few of those again, let me point out what I'm sure that most of you know, and I stated this earlier, but at the present time about 6.8 million. Children are estimated to be dying around the world, and the overwhelming majority of these deaths are from readily preventable treatable causes. The number is declining and that’s the great news, but the tragic side of this is that even though the number is declining, there should be a much smaller number of children dying than there currently are. And in addition to the children who are born live who are dying around the world, we're also beginning to pay increasing amounts of attention to stillbirths. These are fetuses who were essentially at term. And mostly due to complication in the process of child birth these fetuses are born dead and they're fully capable of life and with better attention to the medical care of the mother. At the time of delivery and attention to the care of the newborn if the child is born without breathing. A very large proportion of these deaths could be averted, and the current estimate is there are about 4 million stillbirths. And so increasingly, we'll be giving attention to what can be done at the local level through primary health care processes. And in particular, in the community and the home where facilities aren't available and this is a rapidly emerging area of global health. In addition to the large number of readily preventable or treatable deaths of children and stillbirths, we still have an unconsciously large number of Deaths of women during their pregnancy, during time of childbirth. Mostly, the current estimate is that there are about 300 to 500,000 of these deaths occurring each year. The numbers have been declining slowly. But again, this is an unconscionable number of deaths of women because virtually all of these deaths are readily treatable or preventable with very basic medical care. And then the other tragic side of the maternal care issue is the very large number of women who develop long term chronic morbidities related to childbirth as a result of inappropriate or inadequate or lack of basic medical care. The most tragic of these, of course, is the so-called obstetric fistula, the vesicovaginal or rectovaginal fistula that is the result of prolonged labor, where the tissues and the vagina become necrotic as the result of lack of blood flow because of the pressure from the baby's head. And we're increasingly aware of this tragic complication and more and more efforts are being made to identify women who have this condition. Because in developing countries, they become outcasts and lead a, a life that's really subhuman. And so, this is the most severe of the morbidity conditions among women who have a complication in childbirth. But there are many other ones, too, which we don't have time to go into. So improving care for children and mothers through primary healthcare approaches is terribly important for reducing this number. We also know that millions of people around the world are still lacking access to testing and treatment for HIV/AIDS. And also asks us to basic services to prevent and control TB and malaria. And to treat cases of tuberculosis and malaria. And the role of both selective approach is to primary health care and more comprehensive approaches in primary health care to address this problem is terribly important. We don't have time to go into the real technical side of this but it's obviously an important issue for selective primary health care. But we are particularly astute in this course to think about and talk about how comprehensive primary health care can be effective in addressing disease priorities but at the same time address broader needs and concerns that people have. And then finally we all know that billions of people are lacking ready access to other basic healthcare services beyond these particular priorities. And of particular note as well as the lack that billions of people have to clean water and sanitation and essential nutrients in, in the Alma-Ata conception of primary health care. Addressing these issues is a fundamental part of the framework. In so many places, health facilities are still far away. And even if they are not far away. They're often, too expensive for the capabilities of very poor families. And they're still often providing care that are perceived by local people to be either unfriendly or they're perceived as being unwelcome in the environment. we are making progress on these issues, but still, there's a long ways to go. You may not have heard of one of my favorite articles and it's cited from time to time. and I have the reference for this at the end of the PowerPoint here. Tudor Hart wrote in the Lancet in 1971 a very interesting article which he calls the inverse care law and talks about in the British case how the the best medical services are available to people who need it the least. And the people who need health care services the most have the worst medical care, and of course we know that that's even more true in so many other countries where development is still very much in the early stages. I have taken this idea and modified it into something which is similar but slightly different which I call the reverse inverse care law. And that is, those with the greatest health needs are often those with the least access to health services. And often they're the portion of the population with the least motivation to improve their health. And so, this provides a particular challenge for, health programs, to reach those in the greatest need with services that, they are willing and interested in, making use of. Miriam Were was a student at Johns Hopkins School of Public Health back in the 70s and she has become one of the great promoters of primary healthcare througout Africa. And she more recently was the Chair of the Board of AMREF at the time that AMREF received the Gates award in global health. And this statement is from her acceptance speech, which I think also gives some sense of the challenge that we all face in developing programs, strengthening health services but this is from the standpoint of an African. she says that, we are convinced that if the development agenda had recognized the existing strengths in the African people and had built on them, we would have gotten much further than with the approach of treating African people as if all they have is ignorance to be gotten rid of and presenting them with solutions with no bridges to their reality. This statement, to a large degree, reflects the strong biomedical sort of top down vertical approach that it is permuted so much of developed work in developing countries although there is certainly are plenty exceptions to this. James Grant, you may remember from the previous lecture, was the truly outstanding Executive Director of UNICEF from 1980 to 1995. And he used to like to talk about this dream product, and it will probably be pretty obvious to you as you read this, what exactly this dream product is. But I think this is a great example of one of the many challenges facing programs and improvement of health through programs and that is our inability still to convince mothers that appropriate breast feeding is so vital for their children. Breast feeding is such an obvious, win win situation for everybody in terms of the health of the child, the convenience of the mother, the low cost and so forth. But it's really surprising that, in this first decade of the 21st century, we still have. A situation where so many women are not providing exclusive breastfeeding during the six months of life. And then providing appropriate, but continued breastfeeding after that with complimentary feeding. They figure that you see before you now coverage of interventions varies across the continuom of care. This is a figure that has come from a very important document, called the countdown document, that looks at where we are in the 68 countries, where 97% of the worlds child and maternal deaths take place. For the interventions that we know are effective in reducing death of mothers and children, this graph shows the coverage of these services in the 68 countries. It's a little bit hard to see exactly what these interventions are, and if you look carefully, you can probably make it out on the next slide. You'll see these interventions a little more clearly specified. But what's important here is to see that for the majority of these interventions, the coverage of these. Is less than 50% in this bird population. The interventions that have the highest coverage are primarily those related to the provision of immunization and Vitamin A supplementation. The other interventions which are critical, are harder to deliver because they require provision of services in the household on a more continuous basis. Whereas immunizations and Vitamin A supplementation, I usually give it in campaigns. Either through mobile clinics and outreach services from a mobile team based at a fixed health center or through national campaigns. This next figure enables you to see a little bit more clearly what these specific interventions are. And we have them listed here by the lowest level of coverage at the bottom all the way up to the highest level of coverage at the top. And you can see here, as I was just mentioning before, that the coverage level of immunizations and vitamin a is roughly 80% or higher in these priority countries. But we have very important interventions that we know work. For priority conditions of mothers and children that have very low levels of coverage. And so these include, for instance the intermittent preventive treatment of malaria among pregnant women, insecticide treated nets. you see the percentage of mothers who are exclusively breast feeding their child is only 28% and only 32% of children are receiving antibiotics when they develop pneumonia. So, you can see that we have an enormous way to go in terms of getting proven, effective interventions to children and mothers who I really need these services. When I was coming along, this monograph was published in 1980 and in, interestingly enough at that time Jim Grant was actually the director of the Organization that published this, the Overseas Development Counsel. But Davidson Gwatkin, Janet Wilcox and Joe Wray pulled together the world's experience on programs that measured their impact on either the mortality of children or all the nutritional status of children. And they, at that time, discovered only, ten projects that had undergone this level of review. And their conclusion at that time in 1820 was that we need to learn how to, carry out these kinds of programs on a larger scale. All of these projects were small projects. Some populations of 60 to 70,000 people. And so over the last three decades there has been some, a growing experience about how to implement and evaluate programs that improve the health of mothers and children. But still we have a lot of progress to continue to make new series as well. In 1993 the national research counsel pulled together this extensive review of the effects health programs on child mortality in Sub-Saharan, Africa. This was edited by Ewbank and Gribble. And their conclusion, almost two decades ago, is still very relevant today. The studies that they reviewed looked primarily at the effects of single interventions. And many of these studies were from carefully controlled clinical trials. And there were very few evaluations of large scale programs. Therefore they concluded that we cannot make strong statements about the overall effectiveness of health programs in Africa. There are very few studies of the effects of health centers and integrated programs on mortality, and no studies that attempt to estimate the effectiveness of hospitals in reducing population levels of mortality. This statement is just as current and appropriate today as it was almost two decades ago. So, given this reality, I would like to share with you several examples of programs that have attempted to do something about improving health and in important ways with demonstrated outcomes as well. The first of the, is the Jamkhed Comprehensive Rural Health Project established in 1970 by Mabelle and Raj Arole, who were students in our school, and went back to their home country in India and started a, a small project initially that has grown in stature and has gained widespread admiration and respect all around the world. In this next slide you see a recent photograph of Raj Arole on the right with his mentor Carl Taylor, the chairman of the department for many years and the founder of International Healthwork at Johns Hopkins. Unfortunately Raj Arole's wife, Mabelle, died about ten years ago. But here we see her in the next slide, and their daughter, Shobha, on the right who is a physician and surgeon, and also very much involved in leadership for the Jamkhed project now. There is been a lot of information written about Jamkhed. The book, that I showed in the first slide here is one of the great classics of global health and, readily available and I strongly encourage you to read it if you ever have the chance. But there also have been a lot of articles written about the Jamkhed project. But what is important here is that the Aroles have developed a whole approach which they refer to as comprehensive primary health care, that is very much along the lines of the concept that we discussed is declared at Alma-Ata. And by that, I mean that the they've developed a program that is multisectoral that has strong activities in agriculture, nutrition, water, sanitation. As well as medical care and also has other components that are vital for improving health such as women's empowerment and promotion of income generation. Um, [COUGH] their whole approach has really fostered on empowerment of women and empowerment of communities. At the same time helping community health workers to understand and be able to respond to the acute health care needs of the community and to provide health education that will help these really poor people and rule villages of Jamkhed in Maharashtra, India to improve their health. And in this graph here, you see the dramatic decline in infant mortality that they have recorded for their work going back to 1972. At that time in 1972, there was enormous malnutrition, there was famine, lack of access to water, very basic issues that had to be dealt with. But as you see here, in this graph, which is from their book which was published in 1994, they were able to obtain very low levels of infant mortality, which have continued on, as you see in the next slide from more recent data from their project. And I have here as well a comparison data for a rural Maharashtra from the demographic health surveys it have been reported and you can see how the infant mortality rate in Jamkhed have started up to much higher level than was the case for rural Maharashtra. And very quickly fell to a level which was lower than that for rural Maharashtra and has continued to decline and is now in the low 20s as an infant mortality rate. quite an achievement for a rural area in a very poor country. The next program I wanted to mention briefly is the Hospital Albert Schweitzer in Haiti. Where I had the privilege of working from 1999 until 2004. Albert Schweitzer was a very famous medical missionary who worked for some 60 years in Gabon in West Africa and was a famous writer. And theologian and philosopher, as well as very well known medical missionary. But he inspired people you see on the right here, Larimer and Gwen Mellon, with midlife side they want to follow in Albert Schweitzer's footsteps, having read about him in a life Magazine article, so when they were 37 or so, they changed their lives. Larry went to medical school and his wife became a medical technician and they moved to Haiti and started a hospital which they named in honor of Albert Schweitzer and in 1956 this hospital opened up. And it was quite well known early on the Mellon's were very wealthy. They had money to invest in this and they moved there and operated this hospital. But after 10 years of operation, they came to realize that just hospital services by themselves were not going to really make much a dent in terms of the overall needs of the population. And so they went back to the United States and looked for some public health expertise that could help them in the public health side of this. And they found Warren and Gretchen Berggren at the Harvard School of Public Health, who had been medical missionaries in the Belgian Congo. And had decided to moved out of hospital care and get into public health. And so, in 1967, the Berggrens came down to the hospital, Albert Schweitzer, and started a community health program to compliment the work of the hospital. And their mentor was a Harvard faculty member named John Wyon, whom you see in the next slide, who back in the 50s had worked with Carl Taylor and was very much involved in a, important study that was foundational for primary health care work which is called the Khanna study. And was a building block for the Narangwal project that Carl Taylor led back in the 60s in India which we haven't had time to discuss, but that we do discuss in our case studies in primary health care course, that you might consider taking. The Khanna study, among other things, was the first extensive assessment of the epidemiology of health and fertility in a developing country, and it was a landmark study, but one of the things that came out of this for John Wyon who spent most of his career either. providing field leadership for the study, or writing up the results. One of the important outcomes all of this was the potential of home visitation for providing education to families and for registering vital events. And this principle was passed onto the Berggren's when they went to the Hospital Albert Schweitzer, and with John Wyon's support the Berggren's were able to develop a primary health care program. That involved a visitation of all households registration of vital events in delivery of services to as near the household as possible. And that community health activity linked with the availability of hospital services led to the outcomes that you see in this next slide. You see just like as in Jamkhed, a very a dramatic decline of under five mortality. In the Haiti situation a large part of this decline was due to the very successful immunization program against neonatal tetanus by immunizing mothers during their pregnancy. But you can see that over a long period of time, through the maintenance of this community health, primary health care program at the Hospital Albert Schweitzer, and its service area. There have been much lower under under five mortality rates than has been the case for Haiti as a whole Or when more recent data became available for rural Haiti. These levels are not as low as what were achieved in job care but of course we all know that Haiti is a very difficult place to work with all of its political turmoil and many other problems. So the fact that they were able to achieve this level for a long period of time and sustained it I think is quite an achievement. Here you see on the next graph a comparison of the coverage of key child survival interventions in the Hospital Albert Schweitzer area compared to those that were measured for the country as the whole. And these changes in coverage represent some of the reasons for why this mortality impact was achieved at the Hospital Albert Schweitzer. One of the interesting things that we found when I was involved in this work is that there were some prominent disparities of mortality within the Hospital Albert Schweitzer service area. The country of Haiti has a lot of mountainous areas and it also has central plains where rivers flow through and that's certainly the case where the Hospital Albert Schweitzer is located. And so, for the communities that were living in the plains that were near the hospital, the mortality rates were only about a half or less that of the mortality rates of children who lived in the mountains where the families were poor or they were more isolated services were more difficult to access. From the beginning, the Hospital Albert Schweitzer made enormous efforts to extend coverage of these services out to the rural areas. But inspite of these efforts, marked mortality differentials persisted and so I think it points to the great need within health programs to be aware of priority groups. And to invest additional efforts towards these priority groups, not just to ensure that they have equal access as other better off groups have. As you can see in this table of the health care resources at the Hospital Albert Schweitzer compared to Haiti nationally, the number of physicians actually is less on a per capita basis than the hospital Albert Schweitzer service area that is is for Haiti as a whole and the number of hospital beds is actually less as well. But the real difference is shown in the number of nurses where they have twice as many per capita. The number of auxiliary nurses where they have twice as many per capita as Haiti as a whole, and then the larger number health agents who are the paid community health workers and the very large number of volunteers called animatrices, which really don't exist in other parts of Haiti. Now, I wanted to move on to another project which again has close ties to Johns Hopkins. This is SEARCH. SEARCH is an acronym that stands for the Society for Education, Action, And Research in Community Health. And this is now a world famous project that has been founded and led to this day still by Abhay and Rani Bang. They were MPH students here back in the 80s, and they've carried out a path breaking of work in their program there, which is in Maharashtra as well just as the Jamkhed Project. But they're about 12 hours away in terms of travel within Maharashtra but again you see them with Carl Taylor, who was their mentor and their inspiration for their work. And in both the Jamkhed and the SEARCH examples, they were very much inspired not only by Carl Taylor and his vision. But by the Narangwal Project that Carl helped to establish in North India back in the sixties and early 70s. SEARCH is the world's foremost example of the implementation of CBIO principle. So you would recall from the previous lecture, I've talked about these and the reason I say you this is because SEARCH on it's on without ever reading or hearing about CBIO but through their relationship with Carl Taylor and Narangwal and the general ideas that were promoted there. They came to sense that reaching out to every household was terribly important, visiting every home on a regular basis was very important. Registering vital events through home visitation is very important and using this information to guide programming was very important as well. And also another fundamental CPIO principle is the importance of developing a strong partnership with community and so search is done all of these things and in the process of this. They noted back in the 80s that pneumonia was a such an important cause of child death, and as result of that they developed a community based intervention to diagnose and treat pneumonia the community level and their publication in the Lancet is one of the great milestones of primary healthcare. In which they showed a dramatic decline in mortality based on the diagnosis and treatment of pneumonia with community global workers. Then more recently, they have become quite noted because having this more or less solve the problem of childhood pneumonia to the best of their ability. And the circumstances in which they work they noted with their own vital events system that neonatal mortality was such an important contributor to under five mortality. So they set about to develop an intervention to reduce neonatal mortality and their home based neonatal program has now become a model for the rest of the world, and has been replicated and is setting the standard now for global health around the world. But another example of CBIO principles that the banks have implemented here is that it involves responsiveness to the community's priorities, which may not be epidemiological priorities. So in this case, in their process of building a partnership with the community, they learned that alcoholism was a strong priority, particularly of the women. Because so many of the men were abusing alcohol with destructive effects for themselves and their families. And so, SEARCH developed a very interesting approach to dealing with alcoholism, which, continues on to this day. So, SEARCH as I say, the world's foremost example of the principles of CBIO that we talked about in the previous lecture. This is just one small example of some of their findings that arose from their work there. They have, at SEARCH, a comparison area along with their intervention area, and here are their findings of their home-based neonatal care program as it was reported through 2003. And you see the impact of their home base neonatal care program, in the intervention area. The data that you see here are the infant mortality rates, not just the neonatal mortality rate. But, since neonatal, mortality was such a important component of infant mortality rate, then you can see the impact that this has had. I have been involved, as I mentioned in the previous lecture, with a review of the effectiveness of community based approaches in improving child health. And if you look at the programs that have had the longest and the most sustained impact on child health, they all have some very interesting similarities that you see here in this next table. There all involved with providing a broad range of services. They all have strong management and support for program activities. They've all developed strong community partnerships and community involvement. And they all have developed a strong role for community based workers. So I think these principles are important as we think about, developing programs that have long term effectiveness in addressing high mortality settings. I think we will take a break here and we will move very shortly into a slightly different kind of approach to providing primary health care services.