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Equity &Health Systems Bill Brieger | 02 Sep 2011 09:06 am

Five Models of Equitable Access to MCH Services

Five models of equitable access to maternal and child health (MCH) services are the focus on a new article by Talukder and Rob.  We wonder what lessons these models hold for improving access to malaria treatment and preventive services, which should be integrated into MCH.

The five model programs from Asia and Africa listed below do cover malaria-endemic communities –

  • Community Health Volunteers Program in Bangladesh (BRAC)
  • Lady Health Workers Program in Pakistan (LHW)
  • Reproductive and Child Health Alliance Program in Cambodia (RACHA)
  • Community-based Health Planning and Services in Ghana (CHPS)
  • Tanzania Essential Health Interventions Project (TEHIP)

Each model addresses innovative ways of strengthening and managing health systems so that communities are reached and linked with the wider health system. At least four of the models involve community health workers who may be volunteers or receive a stipend.

BRAC is well known for involving community members in health provision and links their sustainability to microfinance opportunities and sales of basic health commodities.  This model has been used in malaria endemic areas of Bangladesh, the Chittagong Hill Tract. An evaluation of the effort reported that …

BRAC and the Ministry of Health implemented the national malaria control programme under GFATM and BRAC would be responsible for supplying LLIN to 80% household, as well as deploying health workers in every union to provide RDT (rapid diagnostic tests) and AL (artemether-lumefantrine) at the grass root level.

Community volunteers were effective in ensuring that the target goal for the supply of LLIN and retreatment of ITN were surpassed, but there was still competition with drug vendors in the provision of malaria treatment.

BRAC is now implementing its model with community health promoters supported by microfinance to implement malaria control as part of its overall health interventions in Liberia.

RACHA takes a different approach to promoting equity, especially gender equity in health service access. “RACHA works almost exclusively in support of the Ministry of Health’s priorities and programs. It does not provide health services or operate health facilities but works through the MOH service network and its community links to translate MOH technical policy and program priorities into quality effective intervention programs in the field.”

RACHA enhances health worker skills, guarantee quality assurance, improve supply mechanisms and create demand in the community.  RACHA also provides midwife training and delivery kits and microfinance to support the midwives. Although malaria is not specifically mentioned, quality assurance is certainly essential to addressing the problem of artemisinin resistance in the region.

Lady Health Workers are an core component of Pakistan’s primary health care efforts. According to WHO LHWs …

…act as a liaison between the formal health system and the community and disseminate health education messages on hygiene and sanitation. The programme is strongly rooted in the primary health care concept and it aims to achieve universal health coverage. Each Lady Health Worker serves around 1000 individuals.

LHWS receive a small salary of about US$ 343 per year. “Lady Health Workers provide essential drugs for treatment of minor ailments such as diarrhoea, malaria, acute respiratory tract infection, intestinal worms, etc., as well as contraceptive materials to eligible couples.”

dscn0272-chps-in-a-market-stma-district-2.jpgGhana’s CHPS program ensures that communities and specially trained community nurses work together to provide primary health care to under-served rural areas, including of course, malaria treatment.  While community volunteers are part of the effort, the overall community takes responsibility for providing a simple structure for a clinic and nurse housing.

Talukder and Rob note that the CHPS effort has resulted in decreased child mortality and and fertility rates in communities with what are known as the CHPS compounds. Up-to date information on the number of CHPS compounds is not available at the Ghana Health Service website, but estimates from 2008 are that “National coverage is now approximately 9% percent of the population.”

Finally, the TEHIP focuses of strengthening planning and management capacity of district health services.  According to ODI, the two pilot districts showed that …

TEHIP has brought about a change in the way that local health policy and practice is planned and resources are allocated across geographical and technical areas. At the district level health care workers and managers are more in control of resources and processes. This has also contributed towards a more robust decentralisation of the health care provision.

Because of TEHIP, “Child mortality in the two districts fell by over 40% in the 5 years following the introduction of evidence-based planning; and death rates for men and women between 15 and 60 years old declined by 18%.”

These results were achieved because the evidence-based planning model yielded an increase in average clinic visits per child from 2.8 to 5.8 a year. “More children were treated for malaria, more early cases of worms were spotted, more eye infections were caught, more AIDS messages were shared, and more mothers had exposure to family planning information.”
While these equity-fostering interventions have resulted in improvements in malaria indicators as well as broader child and maternal health statistics, they appear to have varying levels of scale-up and sustainability.  They all demonstrate the need for new ways of planning and managing district health services, and in at least three cases show the importance of community involvement.  A couple demonstrate innovative ways of using microfinance to sustain community health worker commitment.

Overall the lesson is one that has been voiced since the dawn of the Roll Back Malaria Partnership – we cannot roll back malaria without health system reform.

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