Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long-term mortality impact

Enablers and barriers of community health programs for improved equity and universal coverage of primary health care services: A scoping review

BACKGROUND

Community health programs (CHPs) are integral components of primary health care (PHC) systems and support the delivery of primary care and allied health and nursing care services. CHPs are necessary platforms for delivering health services toward universal health coverage (UHC). There are limited prior studies on comprehensive evidence synthesis on how CHPs strengthen community health systems for the demand and supply of PHC services. Therefore, this scoping review synthesized existing evidence on the interlinkage between CHPs and the community health system and beyond for delivering and utilising PHC services toward UHC.

METHODS

We conducted a scoping review of research articles on CHPs. We identified research articles in six databases (PubMed/Medline, CINAHL, Scopus, Cochrane, Web of Science, and Embase) and Google Scholar using search terms under three concepts: CHPs, PHC, and UHC. Of the 3836 records identified, 1407 duplicates were removed, and 2346 were removed based on titles and abstracts. A total of 83 articles were eligible for the full-text review; of them, 18 articles were removed with reasons, and the other 16 were included through hand search. Themes were identified and explained using Sacks and colleagues' "Beyond the Building Block" framework.

RESULTS

A total of 81 studies were included in the final review. Studies described CHPs as foundations for community health system readiness for PHC services, including decentralization in the health sector, community-controlled governance, resource mobilization, ensuring health commodities (e.g., through community pharmacies), and information evidence. These foundational inputs mediate the actions of CHPs by partnership with community organizations and health workforces (e.g., community health workers). CHPs contributed to improved access to health services by providing health services in public health emergencies, affordable and comprehensive care, and modifying social determinants of health.

CONCLUSIONS

CHPs are platforms for implementing and delivering PHC services close to communities. They help to modify social determinants of health, promote health and wellbeing, reduce care costs, prevent disease progression, and reduce hospitalisation rates. CHPs are integral parts of community health systems and require investment to improve access to PHC services. Gaps and challenges of CHPs include inadequate funding, limited engagement of the private sector, poor quality of health services, and limited focus on non-communicable diseases (NCDs). Further implementation research is needed to mitigate the burden of NCDs. Health systems efforts focus on increasing resources (e.g., financial and human) required in CHPs to ensure the quality of PHC services provided through CHPs toward better service access, and reaching the unreached and achieve equity and universality of PHC services.

Assessment of the compliance with minimum quality standards by public primary healthcare facilities in Nigeria

Achieving universal health coverage (UHC) and the Sustainable Development Goals (SDG) by 2030 relies on the delivery of quality healthcare services through effective primary healthcare (PHC) systems. This necessitates robust infrastructure, adequately skilled health workers and the availability of essential medicines and commodities. Despite the critical role of minimum standards in benchmarking PHC quality, no global consensus on these standards exists. Nigeria has established minimum standards to enhance healthcare accessibility and quality, including the Revised Ward Health System Strategy (RWHSS) by the National Primary Health Care Development Agency (NPHCDA). This paper outlines the evolution of PHC minimum standards in Nigeria, evaluates compliance with RWHSS standards across all public PHC facilities, and examines the implications for ongoing PHC revitalization efforts. The study used a cross-sectional descriptive design to assess compliance across 25 736 public PHC facilities in Nigeria. Data collection involved a national survey using a standardized assessment tool focussing on infrastructure, staffing, essential medicines and service delivery. Compliance with RWHSS minimum standards was found to be below 50% across all facilities, with median compliance scores of 40.7%. Outreach posts had a median compliance of 32.6%, level 1 facilities 31.5% and level 2+ facilities 50.9%. Key findings revealed major gaps in health infrastructure, human resources and availability of essential medicines and equipment. Compliance varied regionally, with the North-west showing the highest number of facilities but varied performance across standards. The lessons learned underscore the urgent need for targeted interventions and resource allocation to address the identified deficiencies. This study highlights the critical need for regular, comprehensive compliance assessments to guide policy-makers in identifying gaps and strengthening PHC systems in Nigeria. Recommendations include enhancing monitoring mechanisms, improving resource distribution and focussing on infrastructure and human resource development to meet UHC and SDG targets. Addressing these gaps is essential for advancing Nigeria's healthcare system and ensuring equitable, quality care for all.

Creation of a globally informed and locally relevant KMC implementation model for population-impact in Amhara, Ethiopia

AIM

As part of a multi-country implementation trial, we tested a regionally specific model of kangaroo mother care (KMC). Effective KMC was defined as ≥8 h of newborn-caregiver skin-to-skin contact daily plus exclusive breast feeding. The study was designed to achieve ≥80+% effective KMC coverage at the population level.

METHODS

The Amhara KMC model was designed using global evidence, formative research in the region and input from government officials, clinicians, newborn families and global scientists. We optimised the initial model using continuous quality improvement with process feedback, outcome measurement and collaborative re-design. Outcomes from the evaluation period are reported.

RESULTS

At discharge, the final model resulted in a median of 16 h per day of skin-to-skin contact with 63% effective KMC coverage. Fifty-three percent sustained effective KMC to 7 days post-discharge.

CONCLUSIONS

It is possible to achieve high coverage (63%), high-quality KMC at public hospitals without prior KMC services using government-owned, multisectoral collaborative design. Targeted co-design, real-time data and customisation of KMC interventions with input from impacted stakeholders was critical in achieving high coverage and sustained quality.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 1. Introduction and project description

BACKGROUND

The Curamericas/Guatemala Maternal and Child Health Project, 2011-2015, was implemented in the Western Highlands of the Department of Huehuetenango, Guatemala. The Project utilized three participatory approaches in tandem: the Census-Based, Impact-Oriented (CBIO) Approach, the Care Group Approach, and the Community Birthing Center Approach. Together, these are referred to as the Expanded CBIO Approach (or CBIO+).

OBJECTIVE

This is the first article of a supplement that assesses the effectiveness of the Project's community-based service delivery platform that was integrated into the Guatemalan government's rural health care system and its special program for mothers and children called PEC (Programa de Extensión de Cobertura, or Extension of Coverage Program).

METHODS

We review and summarize the CBIO+ Approach and its development. We also describe the Project Area, the structure and implementation of the Project, and its context.

RESULTS

The CBIO+ Approach is the product of four decades of field work. The Project reached a population of 98,000 people, covering the entire municipalities of San Sebastián Coatán, Santa Eulalia, and San Miguel Acatán. After mapping all households in each community and registering all household members, the Project established 184 Care Groups, which were composed of 5-12 Care Group Volunteers who were each responsible for 10-15 households. Paid Care Group Promoters provided training in behavior change communication every two weeks to the Care Groups. Care Group Volunteers in turn passed this communication to the mothers in their assigned households and also reported back to the Care Group Promoters information about any births or deaths that they learned of during the previous two weeks as a result of their regular contact with their neighbors. At the outset of the Project, there was one Birthing Center in the Project Area, serving a small group of communities nearby. Two additional Birthing Centers began functioning as the Project was operating. The Birthing Centers encouraged the participation of traditional midwives (called comadronas) in the Project Area.

CONCLUSION

This article serves as an introduction to an assessment of the CBIO+ community-based, participatory approach as it was implemented by Curamericas/Guatemala in the Western Highlands of the Department of Huehuetenango, Guatemala. This article is the first of a series of articles in a supplement entitled Reducing Inequities in Maternal and Child Health in Rural Guatemala through the CBIO+ Approach of Curamericas.

Community Health Workers: what do international studies tell us?

Abstract This is a narrative review whose objective is to understand the state of the art of the literature on Community Health Worker (CHW) programs worldwide, identifying their nomenclatures, practices, training, and working conditions. The major concentration of CHW programs can still be found in low- and middle-income countries in Africa (18), Asia (12), and Latin America (05), with a few experiences in high-income countries in North America (02) and Oceania (01). In total, 38 experiences were cataloged, and the practices of care, surveillance, education, health communication, administrative practices, intersectoral articulation, and social mobilization were described. The levels and duration of CHW training were characterized, as were the different working conditions in each country. Much of the work is precarious, often voluntary and carried out by women. This review provided a comparative overview that can contribute to enrich the view of managers and decision-makers in contexts of the implementation, expansion, and reconfiguration of such programs.

Community Health Workers: what do international studies tell us?

This is a narrative review whose objective is to understand the state of the art of the literature on Community Health Worker (CHW) programs worldwide, identifying their nomenclatures, practices, training, and working conditions. The major concentration of CHW programs can still be found in low- and middle-income countries in Africa (18), Asia (12), and Latin America (05), with a few experiences in high-income countries in North America (02) and Oceania (01). In total, 38 experiences were cataloged, and the practices of care, surveillance, education, health communication, administrative practices, intersectoral articulation, and social mobilization were described. The levels and duration of CHW training were characterized, as were the different working conditions in each country. Much of the work is precarious, often voluntary and carried out by women. This review provided a comparative overview that can contribute to enrich the view of managers and decision-makers in contexts of the implementation, expansion, and reconfiguration of such programs.

Pediatric Cardiac Surgery in Ethiopia: A Single Center Experience in a Developing Country

Background

In developing countries, the diagnosis of congenital heart diseases (CHD) is growing as the availability of echocardiography is increasing with most diagnoses made after birth. However, the access to pediatric surgery is still low and is mainly done by global surgical campaigns rather than local surgeons. Ethiopia has trained its local surgeons, and this is expected to improve the care of children with CHD. We aimed to evaluate the experience of local pediatric CHD surgery and its outcome in a single-center in Ethiopia.

Methods

A hospital-based retrospective cohort study was done by including all patients with CHD and acquired heart disease in patients under the age of 18 operated at children's cardiac center in Addis Ababa Ethiopia. We set in-hospital mortality, 30-day mortality, and the prevalence of complications including major complications after cardiac surgery as the primary outcomes.

Results

A total of 76 children were operated. The mean age at the time of diagnosis and surgery was 4 (±5) and 7 (±5) years, respectively. Forty-one (54%) were female. Ninety five percent of the 76 operated children were with the diagnoses of congenital heart diseases while the rest (5%) with acquired heart disease. Of those with congenital heart disease, Patent ductus arteriosus (PDA) accounted for (33.3%), Ventricular septal defect (VSD) for 29.5% and Atrial Septal Defect (ASD) for 10% and Tetralogy of Fallot (TOF) for 5%. According to the RACS-1 category, 26 (35.1%) were in category 1, 33 (44.6%) were in category 2, 15 (20.3%) were in category 3 and none of the children were in category 4 and 5. In-hospital mortality was 2.6% whereas there was no patient who died within 30 days after discharge. Operative mortality was 2.6%.

Conclusions

Various types of lesions were treated in the hands of the local teams with VSD and PDA ligations as the commonest of all. The 30day mortality was within acceptable range and this outcome shows congenital and acquired heart diseases can be operated on in developing countries with good outcome despite the limited resources.

Geographic barriers to care persist at the community healthcare level: Evidence from rural Madagascar

Geographic distance is a critical barrier to healthcare access, particularly for rural communities with poor transportation infrastructure who rely on non-motorized transportation. There is broad consensus on the importance of community health workers (CHWs) to reduce the effects of geographic isolation on healthcare access. Due to a lack of fine-scale spatial data and individual patient records, little is known about the precise effects of CHWs on removing geographic barriers at this level of the healthcare system. Relying on a high-quality, crowd-sourced dataset that includes all paths and buildings in the area, we explored the impact of geographic distance from CHWs on the use of CHW services for children under 5 years in the rural district of Ifanadiana, southeastern Madagascar from 2018-2021. We then used this analysis to determine key features of an optimal geographic design of the CHW system, specifically optimizing a single CHW location or installing additional CHW sites. We found that consultation rates by CHWs decreased with increasing distance patients travel to the CHW by approximately 28.1% per km. The optimization exercise revealed that the majority of CHW sites (50/80) were already in an optimal location or shared an optimal location with a primary health clinic. Relocating the remaining CHW sites based on a geographic optimum was predicted to increase consultation rates by only 7.4%. On the other hand, adding a second CHW site was predicted to increase consultation rates by 31.5%, with a larger effect in more geographically dispersed catchments. Geographic distance remains a barrier at the level of the CHW, but optimizing CHW site location based on geography alone will not result in large gains in consultation rates. Rather, alternative strategies, such as the creation of additional CHW sites or the implementation of proactive care, should be considered.

Impact of the Liberian National Community Health Assistant Program on childhood illness care in Grand Bassa County, Liberia

Liberia launched its National Community Health Assistant Program in 2016, which seeks to ensure that all people living 5 kilometers or farther from a health facility have access to trained, supplied, supervised, and paid community health workers (CHWs). This study aims to evaluate the impact of the national program following implementation in Grand Bassa County in 2018 using data from population-based surveys that included information on 1291 illness episodes. We measured before-to-after changes in care for childhood illness by qualified providers in a portion of the county that implemented in a first phase compared to those which had not yet implemented. We also assessed changes in whether children received oral rehydration therapy for diarrhea and malaria rapid diagnostic tests if they had a fever by a qualified provider (facility based or CHW). For these analyses, we used a difference-in-differences approach and adjusted for potential confounding using inverse probability of treatment weighting. We also assessed changes in the source from which care was received and examined changes by key dimensions of equity (distance from health facilities, maternal education, and household wealth). We found that care of childhood illness by a qualified provider increased by 60.3 percentage points (95%CI 44.7-76.0) more in intervention than comparison areas. Difference-in-differences for oral rehydration therapy and malaria rapid diagnostic tests were 37.6 (95%CI 19.5-55.8) and 38.5 (95%CI 19.9-57.0) percentage points, respectively. In intervention areas, care by a CHW increased from 0 to 81.6% and care from unqualified providers dropped. Increases in care by a qualified provider did not vary significantly by household wealth, remoteness, or maternal education. This evaluation found evidence that the Liberian National Community Health Assistant Program has increased access to effective care in rural Grand Bassa County. Improvements were approximately equal across three measured dimensions of marginalization.

Trends and outcomes in primary health care expenditures in low-income and middle-income countries, 2000-2017

Introduction

As the world responds to COVID-19 and aims for the Sustainable Development Goals, the potential for primary healthcare (PHC) is substantial, although the trends and effectiveness of PHC expenditure are unknown. We estimate PHC expenditure for each low-income and middle-income country between 2000 and 2017 and test which health outputs and outcomes were associated with PHC expenditure.

Methods

We used three data sources to estimate PHC expenditures: recently published health expenditure estimates for each low-income and middle-income country, which were constructed using 1662 country-reported National Health Accounts; proprietary data from IQVIA to estimate expenditure of prescribed pharmaceuticals for PHC; and household surveys and costing estimates to estimate inpatient vaginal delivery expenditures. We employed regression analyses to measure the association between PHC expenditures and 15 health outcomes and intermediate health outputs.

Results

PHC expenditures in low-income and middle-income countries increased between 2000 and 2017, from $41 per capita (95% uncertainty interval $33–$49) to $90 ($73–$105). Expenditures for low-income countries plateaued since 2014 at $17 per capita ($15–$19). As national income increased, the proportion of health expenditures on PHC generally decrease; however, the fraction of PHC expenditures spent via ambulatory care providers grew. Increases in the fraction of health expenditures on PHC was associated with lower maternal mortality rate (p value≤0.001), improved coverage of antenatal care visits (p value≤0.001), measles vaccination (p value≤0.001) and an increase in the Health Access and Quality index (p value≤0.05). PHC expenditure was not systematically associated with all-age mortality, communicable and non-communicable disease (NCD) burden.

Conclusion

PHC expenditures were associated with maternal and child health but were not associated with reduction in health burden for other key causes of disability, such as NCDs. To combat changing disease burdens, policy-makers and health professionals need to adapt primary healthcare to ensure continued impact on emerging health challenges.

Evidence on the effectiveness of community-based primary health care in improving HIV/AIDS outcomes for mothers and children in low- and middle-income countries: Findings from a systematic review

BACKGROUND

The effectiveness of community-based primary health care (CBPHC) interventions in low- and middle-income countries (LMICs), especially for maternal, neonatal and child health, is well established. However, there has not been a systematic review of the literature on the effectiveness of CBPHC on HIV outcomes derived from rigorous assessments of primary studies. Using peer-reviewed studies of randomized interventions or those containing a specified control group and directly measuring clinical HIV outcomes, we provide evidence for the effectiveness of CBPHC on HIV outcomes for mothers and children in low- and middle-income countries (LMICs).

METHODS

Eligibility criteria included studies assessing the effectiveness of community-based HIV interventions with or without a facility-based component, or multiple integrated projects, with outcome measures defining an aspect of HIV health status such as the utilization of prevention or health care services, nutritional status, serious morbidity (including clinical measures of HIV progression) or mortality of children aged five or younger and pregnant women. Articles published through June 3, 2020 were identified by searching four databases. The type of community-based projects implemented, the implementors, and the implementation strategies of each program were identified and the impact on HIV-related outcomes assessed.

RESULTS

The search yielded 10 537 articles; 4881 underwent title and abstract screening after removing duplicates. Of these, 117 studies qualified for full-text screening; only 22 were included in the final analysis. Most studies showed that community-based interventions improved HIV prevention and treatment outcomes compared to facility-based approaches alone. Each study had at least one statistically significant HIV-related outcome; the non-significant outcomes found in six of the 22 studies were mostly not related to HIV programming. Most interventions were implemented by community health workers; other implementers were government workers, community members, or research staff. Strategies used included peer-to-peer education, psychosocial support, training of community champions, community-based follow-up care, home-based care, and integrated care.

CONCLUSIONS

CBPHC strategies are effective in improving population-based, HIV-related health outcomes for mothers and children, especially in combination with facility-based approaches. However, there is a need to assess the scalability of such interventions and integrate them into existing health systems to assess their impact on the HIV pandemic in more routine settings.

The Implications of Zinc Therapy in Combating the COVID-19 Global Pandemic

The global pandemic from COVID-19 infection has generated significant public health concerns, both health-wise and economically. There is no specific pharmacological antiviral therapeutic option to date available for COVID-19 management. Also, there is an urgent need to discover effective medicines, prevention, and control methods because of the harsh death toll from this novel coronavirus infection. Acute respiratory tract infections, significantly lower respiratory tract infections, and pneumonia are the primary cause of millions of deaths worldwide. The role of micronutrients, including trace elements, boosted the human immune system and was well established. Several vitamins such as vitamin A, B6, B12, C, D, E, and folate; microelement including zinc, iron, selenium, magnesium, and copper; omega-3 fatty acids as eicosapentaenoic acid and docosahexaenoic acid plays essential physiological roles in promoting the immune system. Furthermore, zinc is an indispensable microelement essential for a thorough enzymatic physiological process. It also helps regulate gene-transcription such as DNA replication, RNA transcription, cell division, and cell activation in the human biological system. Subsequently, zinc, together with natural scavenger cells and neutrophils, are also involved in developing cells responsible for regulating nonspecific immunity. The modern food habit often promotes zinc deficiency; as such, quite a few COVID-19 patients presented to hospitals were frequently diagnosed as zinc deficient. Earlier studies documented that zinc deficiency predisposes patients to a viral infection such as herpes simplex, common cold, hepatitis C, severe acute respiratory syndrome coronavirus (SARS-CoV-1), the human immunodeficiency virus (HIV) because of reducing antiviral immunity. This manuscript aimed to discuss the various roles played by zinc in the management of COVID-19 infection.

A Cluster-Randomized Trial to Test Sharing Histories as a Training Method for Community Health Workers in Peru

BACKGROUND

Community health workers (CHWs) are increasingly deployed to support mothers' adoption of healthy home practices in low- and middle-income countries. However, little is known regarding how best to train them for the capabilities and cultural competencies needed to support maternal health behavior change. We tested a CHW training method, Sharing Histories (SH), in which CHWs recount their own childbearing and childrearing experiences on which to build new learning.

METHODS

We conducted an embedded cluster-randomized trial in rural Peru in 18 matched clusters. Each cluster was a primary health facility catchment area. Government health staff trained female CHWs using SH (experimental clusters) or standard training methods (control clusters). All other training and system-strengthening interventions were equal between study arms. All CHWs conducted home visits with pregnant women and children aged 0-23 months to teach, monitor health practices and danger signs, and refer. The primary outcome was height-for-age (HAZ)<-2 Z-scores (stunting) in children aged 0-23 months. Household surveys were conducted at baseline (606 cases) and 4-year follow-up (606 cases).

RESULTS

Maternal and child characteristics were similar in both study arms at baseline and follow-up. Difference-in-differences analysis showed mean HAZ changes were not significantly different in experimental versus control clusters from baseline to endline (P=.469). However, in the subgroup of literate mothers, mean HAZ improved by 1.03 on the Z-score scale in experimental clusters compared to control clusters from baseline to endline (P=.059). Using generalized estimating equations, we demonstrated that stunting in children of mothers who were literate was significantly reduced (Beta=0.77; 95% confidence interval=0.23, 1.31; P<.01), adjusting for covariates.

CONCLUSION

Compared with standard training methods, SH may have improved the effectiveness of CHWs as change agents among literate mothers to reduce child stunting. Stunting experienced by the children of illiterate mothers may have involved unaddressed determinants of stunting.

Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study

BACKGROUND

The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up.

METHODS

The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis.

RESULTS

Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n = 13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation.

CONCLUSIONS

The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries.

STUDY REGISTRATION

ClinicalTrials.gov number NCT02726230.

Measures to strengthen primary health-care systems in low- and middle-income countries

Primary health care offers a cost–effective route to achieving universal health coverage (UHC). However, primary health-care systems are weak in many low- and middle-income countries and often fail to provide comprehensive, people-centred, integrated care. We analysed the primary health-care systems in 20 low- and middle-income countries using a semi-grounded approach. Options for strengthening primary health-care systems were identified by thematic content analysis. We found that: (i) despite the growing burden of noncommunicable disease, many low- and middle-income countries lacked funds for preventive services; (ii) community health workers were often under-resourced, poorly supported and lacked training; (iii) out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and (iv) health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in primary health care was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of primary health care. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. Policy-making should be supported by adequate resources for primary health-care implementation and government spending on primary health care should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of primary health-care management is also needed. Support from primary health-care systems is critical for progress towards UHC in the decade to 2030.

Communities, universal health coverage and primary health care

Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.

Association of primary care physician supply with maternal and child health in China: a national panel dataset, 2012-2017

Background

The Chinese government has been strengthening the primary care system since the launch of the New Healthcare System Reform in 2009. Among all endeavors, the most obvious and significant improvement lays in maternal and child health. This study was designed to explore the association of primary care physician supply with maternal and child health outcomes in China, and provide policy suggestions to the law makers.

Methods

Six-year panel dataset of 31 provinces in China from 2012 to 2017 was used to conduct the longitudinal ecological study. Linear fixed effects regression model was applied to explore the association of primary care physician supply with the metrics of maternal and child health outcomes while controlling for specialty care physician supply and socio-economic covariates. Stratified analysis was used to test whether this association varies across different regions in China.

Results

The number of primary care physicians per 10,000 population increased from 15.56 (95% CI: 13.66 to 17.47) to 16.08 (95% CI: 13.86 to 18.29) from 2012 to 2017. The increase of one primary care physician per 10,000 population was associated with 5.26 reduction in maternal mortality per 100,000 live births (95% CI: − 6.745 to − 3.774), 0.106% (95% CI: − 0.189 to − 0.023) decrease in low birth weight, and 0.419 decline (95% CI: − 0.564 to − 0.273) in perinatal mortality per 1000 live births while other variables were held constant. The association was particularly prominent in the less-developed western China compared to the developed eastern and central China.

Conclusion

The sufficient supply of primary care physician was associated with improved maternal and child health outcomes in China, especially in the less-developed western region. Policies on effective and proportional allocation of resources should be made and conducted to strengthen primary care system and eliminate geographical disparities.

The association between the supply and utilization of community-based primary care and child health in a context of hospital-oriented healthcare system in urban districts of Guangdong, China: a panel dataset, 2014-2016

Background

Since 2009, the Chinese government has been reforming the healthcare system and has committed to reinforcing increased use of primary care. To date, however, the Chinese healthcare system is still heavily reliant on hospital-based specialty care. Studies consistently show an association between primary care and improved health outcomes, and the same association is also found among the disadvantaged population. Due to the “hukou” system, interprovincial migrants in the urban districts are put in a weak position and become the disadvantaged. Therefore, the aim of this study is to investigate whether greater supply and utilization of primary care was associated with reduced child mortality among the entire population and the interprovincial migrants in urban districts of Guangdong province, China.

Methods

An ecological study was conducted using a 3-year panel data with repeated measurements within urban districts in Guangdong province from 2014 to 2016, with 178 observations in total. Multilevel linear mixed effects models were applied to explore the associations.

Results

Higher visit proportion to primary care was associated with reductions in the infant mortality rate and the under-five mortality rate in both the entire population and the interprovincial migrants (p < 0.05) in the full models. The association between visit proportion to primary care and reduced neonatal mortality rate was significant among the entire population (p < 0.05) while it was insignificant among the interprovincial migrants (p > 0.05).

Conclusions

Our ecological study based in urban districts of Guangdong province found consistent associations between higher visit proportion to primary care and improvements in child health among the entire population and the interprovincial migrants, suggesting that China should continue to strengthen and develop the primary care system. The findings from China adds to the previously reported evidence on the association between primary care and improved health, especially that of the disadvantaged.

The Capacities of Primary Health Care in Hungary: A Problem Statement

In the establishment, development, and provision of equal access to the health care system, the operation of adequate primary health care is essential and has undergone significant transformation in the most developed countries over the past decades. The central and eastern European countries, including Hungary, are struggling with the disadvantages of the traditional model of primary health care, based on independent general practitioner and family paediatrician practices: the ability of the system is extremely limited to meet emerging needs and is facing a chronic human resource crisis. In the current study, the functions, legislation, and challenges of the Hungarian primary health care system, as well as the basic interrelations of the development of vacant general practitioner and family paediatrician districts were examined, and the government measures for the sake of solving the occurrence of the vacancy and improving access in the lagging areas. (The situation of the other fields of primary health care—e.g., dental care, child care officer care, etc.—was not subject of the analysis.). The basic characteristics of the vacant districts (type by supplied age group, bounding region, population size, length of vacancy) were primarily examined by the analysis of categorical and metric variables, with the use of cross-tabulation and nonparametric correlation, while the discovery of soft interrelations was supported by an expert interview conducted with the professionals of the Primary Health Care Department of the National Health Care Services Centre. In Hungary, the fundamentals of primary health care are made up of the individual practices of general practitioners and paediatricians, and there is a growing concern about the permanent vacancy of the districts, and the fact that the system is less suitable for meeting the needs of the population. The ever-increasing number of vacant general practitioner and family paediatrician districts due to the growing shortage of professionals because of aging and emigration poses the burden of substitution on the physicians in existing practices, that concerns the access of more than a half million people to health care, almost 70 percent of which live in settlements with a population less than 5000 inhabitants.

The Jamkhed Comprehensive Rural Health Project and the Alma-Ata Vision of Primary Health Care

The Jamkhed Comprehensive Rural Health Project (Jamkhed CRHP) was established in central India in 1970. The Jamkhed CRHP approach, developed by Rajanikant and Mabelle Arole, was instrumental in influencing the concepts and principles embedded in the 1978 Declaration of Alma-Ata. The Jamkhed CRHP pioneered provision of services close to people's homes, use of health teams (including community workers), community engagement, integration of services, and promotion of equity, all key elements of the declaration. The extraordinary contributions that the Jamkhed CRHP has made as it approaches its 50th anniversary need to be recognized as the world celebrates the 40th anniversary of the International Conference on Primary Health Care and the writing of the declaration. We describe the early influence of the Jamkhed CRHP on the declaration as well as the work at Jamkhed, its notable influence in improving the health of the people it has served and continues to serve, the remarkable contributions it has made to training people from around India and the world, and its remarkable influences on programs and policies in India and beyond.

Can the primary health care model affect the determinants of neonatal, post-neonatal and maternal mortality? A study from Brazil

BACKGROUND

The state of São Paulo recorded a significant reduction in infant mortality from 1990 to 2013, but the desired reduction in maternal mortality was not achieved. Knowledge of the factors with impact on these indicators would be of help in formulating public policies. The aims of this study were to evaluate the relations between socioeconomic and demographic factors, health care model and both infant mortality (considering the neonatal and post-neonatal dimensions) and maternal mortality in the state of São Paulo, Brazil.

METHODS

In this ecological study, data from national official open sources were used to conduct a population-based study. The units analyzed were 645 municipalities in the state of São Paulo, Brazil. For each municipality, the infant mortality (in both neonatal and post-neonatal dimensions) and maternal mortality rates were calculated for every 1000 live births, referring to 2013. Subsequently, the association between these rates, socioeconomic variables, demographic models and the primary care organization model in the municipality were verified. For statistical analysis, we used the zero-inflated negative binomial model. Gross analysis was performed and then multiple regression models were estimated. For associations, we adopted "p" at 5%.

RESULTS

The increase in the HDI of the city and proportion of Family Health Care Strategy implemented were significantly associated with the reduction in both infant mortality (neonatal + post-neonatal) and maternal mortality rates. In turn, the increase in birth and caesarean delivery rates were associated with the increase in infant and maternal mortality rates.

CONCLUSIONS

It was concluded that the Family Health Care Strategy was a Primary Care organization model that contributed to the reduction in infant (neonatal + post-neonatal) and maternal mortality rates, and so did actors such as HDI and cesarean section. Thus, public health managers should prefer this model when planning the organization of Primary Care services for the population.

Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health. We then argue that an even bolder approach, which fully embraces the Alma-Ata vision of primary health care, could deliver substantially greater SDG progress, by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and being a catalyst for advancing and amplifying universal health coverage and synergies among SDGs.

Maternal mortality due to hemorrhage: population-based study in Turkey

Objective: The aim of this study was to determine the epidemiological characteristics of maternal mortality due to postpartum hemorrhage, and to investigate whether national preventative measures of the Maternal Mortality Program have been successful in Turkey. Design: A population-based cohort study. Setting: Turkish National Maternal Mortality Data collected by the Turkish Ministry of Health. Participants: Women who died due to hemorrhage during pregnancy or after delivery within the initial 42 days, from 2012 to 2015, throughout Turkey (N = 812/146). Main outcome measures: The preventability and problems in each maternal death due to hemorrhage. Results: A total of 779 maternal deaths were identified during the study period. Our estimate of the Maternal Mortality Ratio (MMR) in the 3-year period was 19.7 per 100,000 live births. Of the 779 deaths, the report listed 411 as direct and 285 as indirect deaths. Direct obstetric complications were the leading causes of maternal deaths, the most common of which was maternal cardiovascular diseases (21%) and obstetric hemorrhage (20.6%). Conclusion: Improving data surveillance and implementing national guidelines for the prevention and management of major complications of pregnancy, childbirth, and puerperium is necessary to reduce MMR. The healthcare authorities of Turkey should continue to set a sustainable development goal of ≤70 maternal deaths per 100,000 live births by 2030. We believe our results may provide useful information for other developing countries that are aiming to reduce maternal mortality, as well as mobilize global efforts to improve women's health.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 4. child health findings

Background

This paper assesses the effectiveness of community–based primary health care (CBPHC) in improving child health beyond the neonatal period. Although there has been an accelerated decline in global under–5 mortality since 2000, mortality rates remain high in much of sub–Saharan Africa and in some south Asian countries where under–5 mortality is also decreasing more slowly. Essential interventions for child health at the community level have been identified. Our review aims to contribute further to this knowledge by examining how strong the evidence is and exploring in greater detail what specific interventions and implementation strategies appear to be effective.

Methods

We reviewed relevant documents from 1950 onwards using a detailed protocol. Peer reviewed documents, reports and books assessing the impact of one or more CBPHC interventions on child health (defined as changes in population coverage of one or more key child survival interventions, nutritional status, serious morbidity or mortality) among children in a geographically defined population was examined for inclusion. Two separate reviews took place of each document followed by an independent consolidated summative review. Data from the latter review were transferred to electronic database for analysis.

Results

The findings provide strong evidence that the major causes of child mortality in resource–constrained settings can be addressed at the community level largely by engaging communities and supporting community–level workers. For all major categories of interventions (nutritional interventions; control of pneumonia, diarrheal disease and malaria; HIV prevention and treatment; immunizations; integrated management of childhood diseases; and comprehensive primary health care) we have presented randomized controlled trials that have consistently produced statistically significant and operationally important effects.

Conclusions

This review shows that there is strong evidence of effectiveness for CBPHC implementation of an extensive range of interventions to improve child health and that four major strategies for delivering these interventions are effective.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 6. strategies used by effective projects

BACKGROUND

As part of our review of the evidence of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH), we summarize here the common delivery strategies of projects, programs and field research studies (collectively referred to as projects) that have demonstrated effectiveness in improving child mortality. Other articles in this series address specifically the effects of CBPHC on improving MNCH, while this paper explores the specific strategies used.

METHODS

We screened 12 166 published reports in PubMed of community-based approaches to improving maternal, neonatal and child health in high-mortality, resource-constrained settings from 1950-2015. A total of 700 assessments, including 148 reports from other publicly available sources (mostly unpublished evaluation reports and books) met the criteria for inclusion and were reviewed using a data extraction form. Here we identify and categorize key strategies used in project implementation.

RESULTS

Six categories of strategies for program implementation were identified, all of which required working in partnership with communities and health systems: (a) program design and evaluation, (b) community collaboration, (c) education for community-level staff, volunteers, beneficiaries and community members, (d) health systems strengthening, (e) use of community-level workers, and (f) intervention delivery. Four specific strategies for intervention delivery were identified: (a) recognition, referral, and (when possible) treatment of serious childhood illness by mothers and/or trained community agents, (b) routine systematic visitation of all homes, (c) facilitator-led participatory women's groups, and (d) health service provision at outreach sites by mobile health teams.

CONCLUSIONS

The strategies identified here provide useful starting points for program design in strengthening the effectiveness of CBPHC for improving MNCH.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long-term mortality impact

Background

There is limited evidence about the long–term effectiveness of integrated community–based primary health care (CBPHC) in improving maternal, neonatal and child health. However, the interventions implemented and the approaches used by projects with such evidence can provide guidance for ending preventable child and maternal deaths by the year 2030.

Methods

A database of 700 assessments of the effectiveness of CBPHC in improving maternal, neonatal and child health has been assembled, as described elsewhere in this series. A search was undertaken of these assessments of research studies, field project and programs (hereafter referred to as projects) with more than a single intervention that had evidence of mortality impact for a period of at least 10 years. Four projects qualified for this analysis: the Matlab Maternal Child Health and Family Planning (MCH–FP) P in Bangladesh; the Hôpital Albert Schweitzer in Deschapelles, Haiti; the Comprehensive Rural Health Project (CRHP) in Jamkhed, India; and the Society for Education, Action and Research in Community Health (SEARCH) in Gadchiroli, India.

Results

These four projects have all been operating for more than 30 years, and they all have demonstrated reductions in infant mortality, 1– to 4–year mortality, or under–5 mortality for at least 10 years. They share a number of characteristics. Among the most notable of these are: they provide comprehensive maternal, child health and family planning services, they have strong community–based programs that utilize community health workers who maintain regular contact with all households, they have develop strong collaborations with the communities they serve, and they all have strong referral capabilities and provide first–level hospital care.

Conclusions

The shared features of these projects provide guidance for how health systems around the world might improve their effectiveness in improving maternal, neonatal and child health. Strengthening these features will contribute to achieving the goal of ending preventable child and maternal deaths by the year 2030.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel

BACKGROUND

The contributions that community-based primary health care (CBPHC) and engaging with communities as valued partners can make to the improvement of maternal, neonatal and child health (MNCH) is not widely appreciated. This unfortunate reality is one of the reasons why so few priority countries failed to achieve the health-related Millennium Development Goals by 2015. This article provides a summary of a series of articles about the effectiveness of CBPHC in improving MNCH and offers recommendations from an Expert Panel for strengthening CBPHC that were formulated in 2008 and have been updated on the basis of more recent evidence.

METHODS

An Expert Panel convened to guide the review of the effectiveness of community-based primary health care (CBPHC). The Expert Panel met in 2008 in New York City with senior UNICEF staff. In 2016, following the completion of the review, the Panel considered the review's findings and made recommendations. The review consisted of an analysis of 661 unique reports, including 583 peer-reviewed journal articles, 12 books/monographs, 4 book chapters, and 72 reports from the gray literature. The analysis consisted of 700 assessments since 39 were analyzed twice (once for an assessment of improvements in neonatal and/or child health and once for an assessment in maternal health).

RESULTS

The Expert Panel recommends that CBPHC should be a priority for strengthening health systems, accelerating progress in achieving universal health coverage, and ending preventable child and maternal deaths. The Panel also recommends that expenditures for CBPHC be monitored against expenditures for primary health care facilities and hospitals and reflect the importance of CBPHC for averting mortality. Governments, government health programs, and NGOs should develop health systems that respect and value communities as full partners and work collaboratively with them in building and strengthening CBPHC programs - through engagement with planning, implementation (including the full use of community-level workers), and evaluation. CBPHC programs need to reach every community and household in order to achieve universal coverage of key evidence-based interventions that can be implemented in the community outside of health facilities and assure that those most in need are reached.

CONCLUSIONS

Stronger CBPHC programs that foster community engagement/empowerment with the implementation of evidence-based interventions will be essential for achieving universal coverage of health services by 2030 (as called for by the Sustainable Development Goals recently adopted by the United Nations), ending preventable child and maternal deaths by 2030 (as called for by the World Health Organization, UNICEF, and many countries around the world), and eventually achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978. Stronger CBPHC programs can also create entry points and synergies for expanding the coverage of family planning services as well as for accelerating progress in the detection and treatment of HIV/AIDS, tuberculosis, malaria, hypertension, and other chronic diseases. Continued strengthening of CBPHC programs based on rigorous ongoing operations research and evaluation will be required, and this evidence will be needed to guide national and international policies and programs.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 1. rationale, methods and database description

BACKGROUND

Community-based primary health care (CBPHC) is an approach used by health programs to extend preventive and curative health services beyond health facilities into communities and even down to households. Evidence of the effectiveness of CBPHC in improving maternal, neonatal and child health (MNCH) has been summarized by others, but our review gives particular attention to not only the effectiveness of specific interventions but also their delivery strategies at the community level along with their equity effects. This is the first article in a series that summarizes and analyzes the assessments of programs, projects, and research studies (referred to collectively as projects) that used CBPHC to improve MNCH in low- and middle-income countries. The review addresses the following questions: (1) What kinds of projects were implemented? (2) What were the outcomes of these projects? (3) What kinds of implementation strategies were used? (4) What are the implications of these findings?

METHODS

12 166 reports were identified through a search of articles in the National Library of Medicine database (PubMed). In addition, reports in the gray literature (available online but not published in a peer-reviewed journal) were also reviewed. Reports that describe the implementation of one or more community-based interventions or an integrated project in which an assessment of the effectiveness of the project was carried out qualified for inclusion in the review. Outcome measures that qualified for inclusion in the review were population-based indicators that defined some aspect of health status: changes in population coverage of evidence-based interventions or changes in serious morbidity, in nutritional status, or in mortality.

RESULTS

700 assessments qualified for inclusion in the review. Two independent reviewers completed a data extraction form for each assessment. A third reviewer compared the two data extraction forms and resolved any differences. The maternal interventions assessed concerned education about warning signs of pregnancy and safe delivery; promotion and/or provision of antenatal care; promotion and/or provision of safe delivery by a trained birth attendant, screening and treatment for HIV infection and other maternal infections; family planning, and; HIV prevention and treatment. The neonatal and child health interventions that were assessed concerned promotion or provision of good nutrition and immunizations; promotion of healthy household behaviors and appropriate utilization of health services, diagnosis and treatment of acute neonatal and child illness; and provision and/or promotion of safe water, sanitation and hygiene. Two-thirds of assessments (63.0%) were for projects implementing three or fewer interventions in relatively small populations for relatively brief periods; half of the assessments involved fewer than 5000 women or children, and 62.9% of the assessments were for projects lasting less than 3 years. One-quarter (26.6%) of the projects were from three countries in South Asia: India, Bangladesh and Nepal. The number of reports has grown markedly during the past decade. A small number of funders supported most of the assessments, led by the United States Agency for International Development. The reviewers judged the methodology for 90% of the assessments to be adequate.

CONCLUSIONS

The evidence regarding the effectiveness of community-based interventions to improve the health of mothers, neonates, and children younger than 5 years of age is growing rapidly. The database created for this review serves as the basis for a series of articles that follow this one on the effectiveness of CBPHC in improving MNCH published in the Journal of Global Health. These findings, together with recommendations provided by an Expert Panel which has guided this review, that are included as the last paper in this series, will help to provide the rationale for building stronger community-based platforms for delivering evidence-based interventions in high-mortality, resource-constrained settings.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 2. maternal health findings

BACKGROUND

We summarize the findings of assessments of projects, programs, and research studies (collectively referred to as projects) included in a larger review of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH). Findings on neonatal and child health are reported elsewhere in this series.

METHODS

We searched PUBMED and other databases through December 2015, and included assessments that underwent data extraction. Data were analyzed to identify themes in interventions implemented, health outcomes, and strategies used in implementation.

RESULTS

152 assessments met inclusion criteria. The majority of assessments were set in rural communities. 72% of assessments included 1-10 specific interventions aimed at improving maternal health. A total of 1298 discrete interventions were assessed. Outcome measures were grouped into five main categories: maternal mortality (19% of assessments); maternal morbidity (21%); antenatal care attendance (50%); attended delivery (66%) and facility delivery (69%), with many assessments reporting results on multiple indicators. 15 assessments reported maternal mortality as a primary outcome, and of the seven that performed statistical testing, six reported significant decreases. Seven assessments measured changes in maternal morbidity: postpartum hemorrhage, malaria or eclampsia. Of those, six reported significant decreases and one did not find a significant effect. Assessments of community-based interventions on antenatal care attendance, attended delivery and facility-based deliveries all showed a positive impact. The community-based strategies used to achieve these results often involved community collaboration, home visits, formation of participatory women's groups, and provision of services by outreach teams from peripheral health facilities.

CONCLUSIONS

This comprehensive and systematic review provides evidence of the effectiveness of CBPHC in improving key indicators of maternal morbidity and mortality. Most projects combined community- and facility-based approaches, emphasizing potential added benefits from such holistic approaches. Community-based interventions will be an important component of a comprehensive approach to accelerate improvements in maternal health and to end preventable maternal deaths by 2030.