The Community: strengthening the health system from the bottom up


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The Community: strengthening the health system from the bottom up

Dr. Adrian Hopkins, Director of the Mectizan Donation Programme

CORE Group Spring Meeting, Tuesday April 27, 2010

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The Community: strengthening the health system from the bottom up

  1. 1. The Community: strengthening the health system from the bottom up Dr Adrian Hopkins Director of the Mectizan Donation Programme
  2. 2. The patients perspective on health systems <ul><li>How can I get help when I get sick? </li></ul><ul><li>Will the staff at the health centre </li></ul><ul><ul><li>Receive me </li></ul></ul><ul><ul><li>Treat me properly </li></ul></ul><ul><ul><li>Have the drugs I need at a price I can afford </li></ul></ul>
  3. 3. The crushing burden of chronic disease <ul><li>Multiple infections gradually squeeze out energy, and reduce immunity </li></ul><ul><li>Reduced ability to work = loss of income </li></ul><ul><li>More resources are needed for Health Care </li></ul><ul><li>Morbidity is as important as mortality </li></ul>
  5. 5. The six building blocks of a Health System: aims and desirable attributes
  6. 6. WHO: The first building block <ul><li>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.   </li></ul>
  7. 7. 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
  8. 8. Onchocerciasis and the eye 300,000 people are blind and 0.5 million visually impaired 40,000 estimated new cases of blindness per year
  9. 9. Onchocerciasis and the skin <ul><li>Parasites in the skin cause major irritation </li></ul><ul><li>Chronic inflammation leads to permanent skin changes </li></ul>Typical “ Leopard skin” changes Skin lesions due to severe itching
  10. 10. Onchocerciasis and the brain <ul><li>There is dwarfism in Uganda shown to be related to onchocerciasis </li></ul><ul><li>There appears to be a relationship between certain types of epilepsy and severe onchocerciasis. ( some epilepsy is also improved after taking Mectizan®) </li></ul>
  11. 11. Mass Treatment with Ivermectin <ul><li>Mectizan® (ivermectin Merck) has been donated by Merck since 1987 “as much as is needed for as long as is needed. </li></ul><ul><li>Mectizan® is safe for mass distribution </li></ul><ul><li>Is effective as a once yearly dose. </li></ul><ul><li>Can be given using a simple dose calculation based on height. </li></ul><ul><li>Causes few side effects, except in highly infected people, during the first treatment round. </li></ul><ul><li>BUT it has to be taken for 20 years. </li></ul>
  12. 12. Mass treatment Strategies <ul><li>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 </li></ul><ul><li>Mobile teams are unsustainable over 15-25 years therefore a sustainable approach had to be developed </li></ul>
  13. 13. Community Directed Treatment with Ivermectin (CDTI) <ul><li>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 </li></ul><ul><li>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. </li></ul>
  14. 14. CDTI <ul><li>After suitable Information, Education and Communication (IEC) the communities </li></ul><ul><li>Choose a distributor for training </li></ul><ul><li>Do a census to calculate Mectizan requirements </li></ul><ul><li>Organise the collection of Mectizan from a Health Centre or other distribution point </li></ul><ul><li>Organise a distribution method, house to house, fixed point in village etc </li></ul><ul><li>Help the distributor calculate the dose and distribute the Mectizan </li></ul><ul><li>Note the treatment statistics and report to the health authorities </li></ul><ul><li>Participate in community supervision </li></ul><ul><li>After 5 years communities should be ready to continue treatment alone with minimal help and supervision from the P.H.C. services </li></ul><ul><li>Equally a mechanism is in place for mass distribution of other medicines </li></ul>
  15. 15. Treatment beyond the end of the road
  16. 16. And further
  17. 17. CDTI in Action in Burundi
  18. 18. CDTI Partnership in Southern Sudan <ul><li>A CDTI workshop for stakeholders was organised in Rumbek during the cease fire. </li></ul><ul><li>WHO, NGDOs, and Health Secretariat staff worked out policy issues together. </li></ul><ul><li>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. </li></ul>
  19. 19. Onchocerciasis Treatments Approved
  20. 20. Treatment requirements to 2020 < APOC >
  21. 21. Study on Community-directed Interventions <ul><li>Main objective </li></ul><ul><ul><li>To determine the extent to which the CDI process can be used for the integrated delivery of health interventions with different degrees of complexity </li></ul></ul><ul><li>Specific objectives </li></ul><ul><ul><li>Determine effectiveness and efficiency of CDI as compared to current systems </li></ul></ul><ul><ul><li>Identify critical factors that facilitate or hinder effective implementation and integration </li></ul></ul>
  22. 22. Target P<0.001
  23. 23. RBM target P<0.001
  24. 24. RBM target P<0.001
  25. 25. RBM target P=0.014
  26. 26. RBM target P<0.001
  27. 27. APOC target P<0.001
  28. 28. Costs to the Health System District Level First Line Health Facility Level
  29. 30. 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
  30. 31. Lymphatic Filariasis (Elephantiasis) <ul><li>Found in many African countries and in Asia </li></ul>
  31. 32. Global elimination programme Using combination of two drugs
  32. 33. Morbidity Control is also needed <ul><li>Surgery is also required for hydrocoele </li></ul><ul><li>Simple care of the skin done in a CBR programme reduces febrile episodes </li></ul>
  33. 34. Lymphatic Filariasis Treatments approved
  34. 35. Other NTDs and distribution systems <ul><li>Shistosomiasis; normally orientated to school children and school distribution systems </li></ul><ul><li>Soil transmitted helminths; normally targeting mothers and children </li></ul><ul><li>Trachoma; targeting mostly the whole community for MDA but adults for surgery </li></ul><ul><li>All are more effective when reinforced by the community but they must be integrated with care. </li></ul>
  35. 36. What is Integration <ul><li>Your vision on integration depends on the lens you use. </li></ul><ul><li>It is not just giving out 3 tablets instead of one </li></ul><ul><li>It is not setting up a rapid delivery system which can exist as a parallel structure with government health services </li></ul><ul><li>Integration is the inclusion of all important health interventions in the minimum package of activities within the PHC system </li></ul>
  36. 37. Partnerships for NTDs <ul><li>Ministry of Health ↔ Communities </li></ul><ul><li>Geneva Global via GNNTDC, APOC, CBM for financial support </li></ul><ul><li>Multiple partners for technical expertise and logistical support (SCI, WHO, APOC, CBM) </li></ul><ul><li>Drug donation (Merck/ MDP) </li></ul>
  37. 38. AXIOMS ON MEDICAL CARE <ul><li>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. </li></ul><ul><li>Some form of medical care should be supplied to all the people all the time. </li></ul><ul><li>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. </li></ul><ul><li>Medical care can be effective without being comprehensive. </li></ul><ul><li>Medical services should be organized from the bottom up and not from the top down, </li></ul>
  38. 39. AXIOMS ON MEDICAL CARE <ul><li>The health needs of a community must be related to their wants. </li></ul><ul><li>In developing countries medical care requires the adaptation and development of its own particular methodology. </li></ul><ul><li>Medical care and the local culture are closely linked. </li></ul><ul><li>Medical care must be carefully adapted to the opportunities and limitations of the local culture. </li></ul><ul><li>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. </li></ul><ul><li>(Maurice King 1966) </li></ul>
  39. 40. 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
  40. 41. What is needed is a strong base or more input from communities Communities MoH Programme Specifics Health Districts Policy And Technical Support
  41. 42. Case Histories to conclude <ul><li>Pimu Health Zone in DRC </li></ul><ul><ul><li>Vaccination programmes were organised by the community </li></ul></ul><ul><ul><li>Health Centres were built and run by the community </li></ul></ul><ul><ul><li>MDA and hygiene were organised by the community </li></ul></ul><ul><li>What was achieved in a small level in the early 1980s has been reinforced by the latest work in NTDs: </li></ul><ul><li>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 </li></ul>
  42. 43. Thank you