Currently, world regions differ greatly in their levels of urbanization. In more developed regions and in Latin America and the Caribbean, over 70 percent of the population is urban, whereas in Africa and Asia, under 40 percent of the population is urban. By 2030, however, the urban proportion of these two regions will exceed 50 percent. By 2030, roughly 60 percent of the world’s population will be living in urban areas.
[Slide 6] Although I will use only one example from Kenya and one from India, numerous other countries have confirmed significant intra-urban variation in mortality and access to proven MNCH interventions - Egypt, Ghana, Bangladesh and Pakistan to name a few. In Nairobi, there is a 9-10 fold increase in IMR and U5MR in the informal settlements when compared with Nairobi’s high income area. Of particular note – this striking difference is lost if we only look at the aggregate figure for Nairobi. And if we compare the rural Kenyan rates with urban Kenyan rates (or all areas of Nairobi), it appears that urban infants in Kenya have a distinctive advantage to their rural counterparts!
*In countries with a similar mortality pattern as Kenya, one in five children die within 28 days of birth. In Nairobi slums, around 33% (one in three) children die within 28 days. [Slide 9] Most importantly, as seen in this slide from Kenya (but corroborated in other developing countries in Africa and Asia), the most common causes of child mortality are the same as in rural settings, namely pneumonia and diarrhea. Thus, the crucial difference between urban and rural health lies not in the interventions themselves, but in the DELIVERY of the interventions…and frankly, in the l ack of an urban health system to ensure that healthcare reaches needy, urban poor children and women.
One of the things which struck me when preparing this session was the reality that many of the challenges and evidence gaps today have not changed much from those outlined 15- 20 years ago! In the interim, although many innovative solutions have been found, they have not been systematically applied at scale, with documented impact on health outcomes. Perhaps as a result, urban health investment has lagged. Meanwhile the magnitude of the problem has increased exponentially….so we truly have an urban crisis dawning in the century of the city. I believe one of the major deterrents to expansion and scale has been the lack of an effective urban health system. So let’s examine what we do know about health systems – and make an urban-rural comparison. To structure the comparison, I will use the main building blocks of health system strengthening shown here Slide 12]: Leadership, Management and Governance; Human Resources for Health; Health Information; Management of Medicines and Health Technologies; Healthcare Financing; and most importantly, Health Service Delivery. These building blocks are the same in both rural and urban health systems, and are critical to the development of an effective, sustainable health system. Over the next slides, I will describe some of the key urban-rural system differences.
New urban health paradigm In addition to the development of urban health systems, the evidence dictates that we must also implement a whole new paradigm for urban health -- as espoused by Trudy Harpham, one that : 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
[Slide 21] In order to achieve the MDGs we need to undertake research to : Expand the information base on “urban poor” families Systematic studies of urban morbidity and mortality Costing and evaluation of the delivery of integrated urban MNCH package(s) Documentation of urban quality of care Evaluation of diverse incentives and payment in terms of health impact and Evaluation of public-private health partnerships, again with a focus on health outcomes
Here’s the best proof I’ve seen of the effectiveness of Care Groups. On this slide, we have compared how child survival projects perform on 14 different RapidCATCH indicators. One of these is an impact indicator (underweight), but most are results-level behavioral indicators or coverage indicators. The bars show the amount of gap closure for each indicator. For example, if you started at 20% EBF and increased that to 40%, you would have closed 20 of 80 possible points – that 25% gap closure. Looking at gap closure is one of the best ways to compare performance across projects. The red bars show the average indicator gap closure for each of these indicators for 58 child survival projects NOT using CGs ending between 2003 and 2009. The white bars show the average indicator gap closure for each of these indicators for 9 Care Group projects. What do you note about the difference? Care Groups projects out-performed the average child survival project in terms of indicator gap closure on all indicators except HWWS where there was a slight non-significant difference. The average gap closure was in the 35-70% range for the nine Care Group projects as compared with 25-45% with all the other CSHGP projects. There were only 9 CG projects to compare, but the difference between those 9 projects and the 58 other projects is statistically-significant for EBF. So what this shows is that Care Groups are outperforming the other methods we generally use for behavior change. We are still looking for other similarities among more successful programs, but this is an important one.
Lest you think that these results are atypical, here’s a graph showing the estimated mortality reduction in 13 CSHGP-funded Car Group Projects in eight different countries. The average estimated reduction in under-five mortality was 30% in Care Group projects, and this is almost double what non-CG projects often achieve. Most of these are five year projects. I think this is compelling evidence that volunteer CHWs – coached and trained by paid CHWs – should have a place in national health systems.
Global Realities Demand a New Emphasis_Freeman_5.3.12
Reality of Community HealthNeeds Are We Meeting These? by Paul Freeman (firstname.lastname@example.org) A synthesis of these needs versus what we are providing
World Population Growth Is Almost Entirely Concentrated in the Worlds Poorer Countries.World Population (in Billions): 1950-2050Source: United Nations Population Division, World Population Prospects, The 2008 Revision.
Trends in Urbanization, by RegionUrban Population 85Percent 82 76 74 61 54 55 53 47 42 37 37 29 15 17 World Africa Asia Latin America More and the Developed Caribbean Regions 1950 2000 2030 Much of growth in midsized cities/towns not just megacitiesSource: United Nations, World Urbanization Prospects: The 2003 Revision (medium scenario), 2004.
World Urbanization Prospects, the 2009 RevisionUrban and rural population by development regions (in millions) Source: United Nations, Department of Economic and Social Affairs,2010
World Urbanization Prospects, the 2009 RevisionUrban and rural population by city size class (in millions)
Intra-Urban and Urban-Rural Variation in IMR and U5MR: Nairobi, Kenya Location IMR (per U5MR % prevalence of 1,000 live (deaths per diarrhea in children births) 1,000 under 3 children) 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 9Source: 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 HealthResearch Center, 2002.
Urban Causes of Child Mortality are Similar to Rural: Kenya 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 % Rank YLL Pneumonia, Pneumonia 3463 22.8 1 Diarrheal Diseases, and still births* account Diarrhoeal Diseases 2969 19.5 2 for nearly 60% of the Stillbirths 2480 16.3 3 mortality in children under Malnutrition and Anaemia 1275 8.4 4 five in these slums. Birth Injury and/or 661 4.3 5 Asphyxia *This study took place in two urban slums, Korogocho and Viwandani, with a population of about 56,000 persons.Source: The burden of disease among residents of Nairobis informal settlements. APHRC No. 1, 2008, Policy Brief.
Natural Increase is the Major Cause of Urban Population GrowthSource: Ezeh, Alex. Population Growth, Poverty & RH: Revisiting The Urban Advantage. African Population and Health Research Center. Presented at theFoundation Presidents Meeting, Population and Reproductive Health, in Seattle, WA. 10 Jan. 2008.
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 skillsCare Group experience as an example.
FH/Mozambique Care Group Model Each Health Promoter Each Care Group Volunteer educates and motivates 5 Care educates and motivates Groups. Each Care Group has pregnant women and mothers Promoters 12 Care Group Volunteers with children 0-23m of age in 12 (a.k.a., Leader Mothers) households every two weeks. (Paid CHWs) Children in households with Care children 24-59m are visited every Promoter #2 Groups six months. Promoter #1 Promoter #3 12 Leader Mothers 12 families 12 Leader Mothers 12 families 12 families Promoter #5 12 Leader Mothers 12 families 12 Leader Mothers Promoter #4 Promoter #6 12 families 12 Leader Mothers 12 families 12 families Promoter #7 12 families 12 families 12 families 12 families 12 familiesWith this model, one Health Promoter can cover 720 beneficiary households.
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 90 All CSHGPs, 2003- 2009 (n=58) 80 77 71 70 63 CSHGP using Care 59 60 53 53 Groups (2003-2010, 52 51 49 n=9) 50Percent 41 39 40 32 35 37 Gap closure 30 range in non-CG projects ~25 – 20 45% 10 (Avg. = 37%) 0 Gap closure N 2 F A t range for Care id ds S TT s s ow IT rw ed s ac EB SB s le ac gn W ap lui de Fe Sp Kn HW lV Si ea lR cF Un mp Al DS Group projects: er rth Al M In ng Co Bi AI Da RapidCATCH Indicator ~35 – 70% (Avg = 57%)
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) 60% 48% 50% 41% 42%% Red. U5MR 40% 33% 33% 32% 34% Series1 28% 29% 30% 26% 30% 23% 20% 14% 12% 10% 0% Gr eria /M R/V II R/ I (B r IV Rw i II /Z ya W ala i W /K t m o) ra nda R/ law W dia Ca TI/L ia j. R/ ia W ur SA an a FH W Vur ro Pl ./Gu R/ w SO en Ca gi M mb W bod V ib u bo W Ma pP R/ ella Cu a R/ a am m M /C re oz C AR W g. Av CSHGP Project
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 resourcesSkills 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