The Community: strengthening the health system from the bottom up

The Community: strengthening the health system from the bottom up Dr Adrian Hopkins Director of the Mectizan Donation Programme

The patients perspective on health systems
How can I get help when I get sick?
Will the staff at the health centre
Receive me
Treat me properly
Have the drugs I need at a price I can afford

The crushing burden of chronic disease
Multiple infections gradually squeeze out energy, and reduce immunity
Reduced ability to work = loss of income
More resources are needed for Health Care
Morbidity is as important as mortality

EVERYBODY’S BUSINESS STRENGTHENING HEALTH SYSTEMS TO IMPROVE HEALTH OUTCOMES WHO’S FRAMEWORK FOR ACTION

The six building blocks of a Health System: aims and desirable attributes

WHO: The first building block
Good health services are those which deliver effective, safe, quality personal and non-personal health interventions, to those who need them, when and where needed, with minimum waste of resources.

Onchocerciasis : Life cycle Adult filariae in nodules Microfilariae in skin Microfilariae in eyes and elsewhere in body Microfilariae ingested By black fly during bite Development of microfilariae in black fly Infective larvae in head of black fly Infective larvae injected with black fly bite Larvae develop into adults

Onchocerciasis and the eye 300,000 people are blind and 0.5 million visually impaired 40,000 estimated new cases of blindness per year

Onchocerciasis and the skin
Parasites in the skin cause major irritation
Chronic inflammation leads to permanent skin changes
Typical “ Leopard skin” changes Skin lesions due to severe itching

Onchocerciasis and the brain
There is dwarfism in Uganda shown to be related to onchocerciasis
There appears to be a relationship between certain types of epilepsy and severe onchocerciasis. ( some epilepsy is also improved after taking Mectizan®)

Mass Treatment with Ivermectin
Mectizan® (ivermectin Merck) has been donated by Merck since 1987 “as much as is needed for as long as is needed.
Mectizan® is safe for mass distribution
Is effective as a once yearly dose.
Can be given using a simple dose calculation based on height.
Causes few side effects, except in highly infected people, during the first treatment round.
BUT it has to be taken for 20 years.

Mass treatment Strategies
Most programmes at the beginning depended on some sort of mobile teams, visiting the communities, doing a community diagnosis, and then organising a mass treatment if required
Mobile teams are unsustainable over 15-25 years therefore a sustainable approach had to be developed

Community Directed Treatment with Ivermectin (CDTI)
It has been found that Communities once fully informed are capable of organising their own treatment. In fact communities once empowered not only organise but control and direct their treatment in what is called Community Directed Treatment
The educational role of the NGDO and health worker is to communicate the benefits of the programme to the community and then pass on programme management skills to community members.

CDTI
After suitable Information, Education and Communication (IEC) the communities
Choose a distributor for training
Do a census to calculate Mectizan requirements
Organise the collection of Mectizan from a Health Centre or other distribution point
Organise a distribution method, house to house, fixed point in village etc
Help the distributor calculate the dose and distribute the Mectizan
Note the treatment statistics and report to the health authorities
Participate in community supervision
After 5 years communities should be ready to continue treatment alone with minimal help and supervision from the P.H.C. services
Equally a mechanism is in place for mass distribution of other medicines

Treatment beyond the end of the road

And further

CDTI in Action in Burundi

CDTI Partnership in Southern Sudan
A CDTI workshop for stakeholders was organised in Rumbek during the cease fire.
WHO, NGDOs, and Health Secretariat staff worked out policy issues together.
Working conditions were not ideal but CDTI was planned for the whole of southern Sudan and is now operational and developing into an NTD programme.

Onchocerciasis Treatments Approved

Treatment requirements to 2020 < APOC >

Study on Community-directed Interventions
Main objective
To determine the extent to which the CDI process can be used for the integrated delivery of health interventions with different degrees of complexity
Specific objectives
Determine effectiveness and efficiency of CDI as compared to current systems
Identify critical factors that facilitate or hinder effective implementation and integration

Target P<0.001

RBM target P<0.001

RBM target P=0.014

RBM target P<0.001

APOC target P<0.001

Costs to the Health System District Level First Line Health Facility Level

Evolution of treatment with Mectizan® in the Americas 1989-2007 and Projection 2008-2015 NOTE: Projected figures from 2nd cycle of 2009-2015 are UTG(2) numbers based on 2008 treatment census data from the remaining foci under treatment in the Americas region Resolution XIV Issued Resolution XIV Expiration OEPA started

Lymphatic Filariasis (Elephantiasis)
Found in many African countries and in Asia

Global elimination programme Using combination of two drugs

Morbidity Control is also needed
Surgery is also required for hydrocoele
Simple care of the skin done in a CBR programme reduces febrile episodes

Lymphatic Filariasis Treatments approved

Other NTDs and distribution systems
Shistosomiasis; normally orientated to school children and school distribution systems
Soil transmitted helminths; normally targeting mothers and children
Trachoma; targeting mostly the whole community for MDA but adults for surgery
All are more effective when reinforced by the community but they must be integrated with care.

What is Integration
Your vision on integration depends on the lens you use.
It is not just giving out 3 tablets instead of one
It is not setting up a rapid delivery system which can exist as a parallel structure with government health services
Integration is the inclusion of all important health interventions in the minimum package of activities within the PHC system

Partnerships for NTDs
Ministry of Health ↔ Communities
Geneva Global via GNNTDC, APOC, CBM for financial support
Multiple partners for technical expertise and logistical support (SCI, WHO, APOC, CBM)
Drug donation (Merck/ MDP)

AXIOMS ON MEDICAL CARE
Patients should be treated as close to their homes as possible in the smallest, cheapest, most humbly staffed and most simply equipped unit that is capable of looking after them adequately.
Some form of medical care should be supplied to all the people all the time.
In respect of most of the common conditions there is little relationship between the cost and size of a medical unit and its therapeutic efficiency.
Medical care can be effective without being comprehensive.
Medical services should be organized from the bottom up and not from the top down,

AXIOMS ON MEDICAL CARE
The health needs of a community must be related to their wants.
In developing countries medical care requires the adaptation and development of its own particular methodology.
Medical care and the local culture are closely linked.
Medical care must be carefully adapted to the opportunities and limitations of the local culture.
Where possible medical services should do what they can to improve the non-medical aspects of a culture in the promotion of a 'better life' for the people.
(Maurice King 1966)

What is needed is a strong base Communities MoH Programme Specifics Reports Data Management Decentralisation Funds flow Drug distribution to Periphery Health Districts Policy And Technical Support

What is needed is a strong base or more input from communities Communities MoH Programme Specifics Health Districts Policy And Technical Support

Case Histories to conclude
Pimu Health Zone in DRC
Vaccination programmes were organised by the community
Health Centres were built and run by the community
MDA and hygiene were organised by the community
What was achieved in a small level in the early 1980s has been reinforced by the latest work in NTDs:
Once communities are empowered and work with the health system, good results can be achieved and health systems can be considerably strengthened at the periphery

Thank you

The Community: strengthening the health system from the bottom up

by jehill3 on Apr 28, 2010

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The Community: strengthening the health system from the bottom up — Presentation Transcript