Lessons Learned From Primary Health Care Programs Funded by the Aga Khan Foundation Gregory P Loos, EdD, MPH, MS Assistant Professor of international Health, School of Public Health, University of Hawaii 1960 East-West Road, Honolulu, Hawaii 96822, USA
Gresory Laos, Professor of International Health, School of Public Hmlth, univusity of Hawaii 1960 wWest Road, Honolulu, Hawaii 96822, USA
The Aga Khan Foundation (AKF), in collaboration with Aga Khan University and Aga Khan Health Services, has been a major donor agency supporting health care initiatives in South-east Asia and other later developing areas. A central focus of AKFfunded programs during the last ten years has been on primary health care (PHC). Eight such programs are the subject of a special report, commissioned by AKF and prepared by University Research Corporation Center for Human Services. Published in 1992, the report covers programs funded during the prior decade and located in four developing countries: Bangladesh (1 program), India (2), Kenya (2) and Pakistan (3). Threefourths of the programs are located in rural areas. Combined, these eight programs serve nearly half a million persons. Their emphasis, however, centers on 150,000 women of childbearing age and children under five years of age. Though different in approach, the connecting thread underlying all eight P H C projects reviewed was their mobilization of community involvement, and how this participation contributed to increased program effectiveness and sustainability. Community-based commitment to the targeted projects took several forms: program organization in Vur, Pakistan, and Junagadh, India; Program ownership in Bajju, India; or, citizen empowerment in Kisumu and
Mombasa, Kenya. Though community niobilization took many forms, one consensus finding of the Report was that it was critical for project success. Other conclusions of the Report cited three additional factors essential to the success of PHC. These are: 1) the crucial importance of a good management information system (MIS), preferablyone that iscomputerized; 2) that locally-enrolled community health workers(eitherpaid or voluntary) are essential, primarilyas links to other health personnel than as independent providers; and, 3) that increased program effectiveness and impact is founded on the delivery of basic health services, such as increased immunizations, maternalcareand family planning, growth monitoring and nutrition, and the treatment of common diseases, e.g., diarrheal disease, malaria and anemia.
As a result of the AKF-funded programs, all residents in the target communities now live within five kilometers of health services. All programs emphasized outreach services using mobile teams and community settings such as schools and meeting halls. Unfortunately, the Report noted that the “delivery of women’s health services was sometimes disjointed,” often resulting in missed o p p o r t u n i t i e s for services a n d
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inconsistent care. To circumvent this shortcoming, the Report emphasized theuse ofMISand householdregistration, thus permitting greater follow-up services and client tracking. The principal interventions of all programs were community education and consumer motivation. The most effective health care interventions were immunizations for young children and tetanus toxoid for pregnant women. Increased ORT treatment for diarrhea was moderately successful. On theother hand, growth monitoring and nutrition education proved problematic and child spacing received little attention. Presently, there is no indication that a n y program has had any notable impact on fertility. Though no one program implemented the full range of PHC services advocated at Alma Ata, none was singularly focused. By beingcommunitybased, each program integrated a degree of intersectoral activity, and several also implemented incorne-
generating schemes t o increase the likelihood ofsustaining the project as donor support dissipates. In fact, the report stressed that “programs shouldgive the highest priority to actions that will enhance sustainability,” acknowledging that “diversity of financial and managerial sources.. .appears to be the key to success.” However, only the program in Bajju, India, looked at PHC as a means to socio-economic development. To date, there has been minimal cost recovery for services and no measurable effect on socio-economic status in any of the project communities. A noted shortcoming of most programs was the lack of cost data, not only for planning purposes, but also for evaluating the effects of projects. While many of the healthrelated indicators studied in the Report were notable, these benefits must eventually be cost analyzed to determine overall effectiveness, the potential for future project sustainability, and the possibility of replication elsewhere,
To date, lessons learned from one project have not been incorporated into the development and operation of the others; an undertaking A K F acknowledges “sh o u 1d be done.” As the only common linkage among projects, cross-fertilization of information ought to be an undertaking of AKF and its collaborators; hopefully, this Report is the first step towards fulfilling this obligation. While the logic of P H C is evidenced by each of these projects, and use of community-based approaches laudable, succeeding efforts must focus on longer-term planning, including finance and management structures, and the establishment of cost effectiveness criteria as a foundation for operations research in order to tailor services offered and service delivery mechanisms. Sustained programming following the loss of donor support will require clarification of plans and revenue sources to afford the necessary resources.
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Gresory Laos, Professor of International Health, School of Public Hmlth, univusity of Hawaii 1960 wWest Road, Honolulu, Hawaii 96822, USA
The Aga Khan Foundation (AKF), in collaboration with Aga Khan University and Aga Khan Health Services, has been a major donor agency supporting health care initiatives in South-east Asia and other later developing areas. A central focus of AKFfunded programs during the last ten years has been on primary health care (PHC). Eight such programs are the subject of a special report, commissioned by AKF and prepared by University Research Corporation Center for Human Services. Published in 1992, the report covers programs funded during the prior decade and located in four developing countries: Bangladesh (1 program), India (2), Kenya (2) and Pakistan (3). Threefourths of the programs are located in rural areas. Combined, these eight programs serve nearly half a million persons. Their emphasis, however, centers on 150,000 women of childbearing age and children under five years of age. Though different in approach, the connecting thread underlying all eight P H C projects reviewed was their mobilization of community involvement, and how this participation contributed to increased program effectiveness and sustainability. Community-based commitment to the targeted projects took several forms: program organization in Vur, Pakistan, and Junagadh, India; Program ownership in Bajju, India; or, citizen empowerment in Kisumu and
Mombasa, Kenya. Though community niobilization took many forms, one consensus finding of the Report was that it was critical for project success. Other conclusions of the Report cited three additional factors essential to the success of PHC. These are: 1) the crucial importance of a good management information system (MIS), preferablyone that iscomputerized; 2) that locally-enrolled community health workers(eitherpaid or voluntary) are essential, primarilyas links to other health personnel than as independent providers; and, 3) that increased program effectiveness and impact is founded on the delivery of basic health services, such as increased immunizations, maternalcareand family planning, growth monitoring and nutrition, and the treatment of common diseases, e.g., diarrheal disease, malaria and anemia.
As a result of the AKF-funded programs, all residents in the target communities now live within five kilometers of health services. All programs emphasized outreach services using mobile teams and community settings such as schools and meeting halls. Unfortunately, the Report noted that the “delivery of women’s health services was sometimes disjointed,” often resulting in missed o p p o r t u n i t i e s for services a n d
233
Downloaded from aph.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
inconsistent care. To circumvent this shortcoming, the Report emphasized theuse ofMISand householdregistration, thus permitting greater follow-up services and client tracking. The principal interventions of all programs were community education and consumer motivation. The most effective health care interventions were immunizations for young children and tetanus toxoid for pregnant women. Increased ORT treatment for diarrhea was moderately successful. On theother hand, growth monitoring and nutrition education proved problematic and child spacing received little attention. Presently, there is no indication that a n y program has had any notable impact on fertility. Though no one program implemented the full range of PHC services advocated at Alma Ata, none was singularly focused. By beingcommunitybased, each program integrated a degree of intersectoral activity, and several also implemented incorne-
generating schemes t o increase the likelihood ofsustaining the project as donor support dissipates. In fact, the report stressed that “programs shouldgive the highest priority to actions that will enhance sustainability,” acknowledging that “diversity of financial and managerial sources.. .appears to be the key to success.” However, only the program in Bajju, India, looked at PHC as a means to socio-economic development. To date, there has been minimal cost recovery for services and no measurable effect on socio-economic status in any of the project communities. A noted shortcoming of most programs was the lack of cost data, not only for planning purposes, but also for evaluating the effects of projects. While many of the healthrelated indicators studied in the Report were notable, these benefits must eventually be cost analyzed to determine overall effectiveness, the potential for future project sustainability, and the possibility of replication elsewhere,
To date, lessons learned from one project have not been incorporated into the development and operation of the others; an undertaking A K F acknowledges “sh o u 1d be done.” As the only common linkage among projects, cross-fertilization of information ought to be an undertaking of AKF and its collaborators; hopefully, this Report is the first step towards fulfilling this obligation. While the logic of P H C is evidenced by each of these projects, and use of community-based approaches laudable, succeeding efforts must focus on longer-term planning, including finance and management structures, and the establishment of cost effectiveness criteria as a foundation for operations research in order to tailor services offered and service delivery mechanisms. Sustained programming following the loss of donor support will require clarification of plans and revenue sources to afford the necessary resources.
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