The Community: strengthening the health system

from the bottom up

Dr Adrian Hopkins

Director of the Mectizan Donation Programme

The patients perspective on health systems

• How can I get help when I get sick?

• Will the staff at the health centre– Receive me– Treat me properly– Have the drugs I

need at a price I can afford

The crushing burden of chronic disease

• Multiple infections gradually squeeze out energy, and reduce immunity

• Reduced ability to work = loss of income

• More resources are needed for Health Care

• Morbidity is as important as mortality

STRENGTHENING HEALTH SYSTEMS TO IMPROVE HEALTH

OUTCOMES WHO’S FRAMEWORK FOR ACTION

EVERYBODY’S BUSINESS

The six building blocks of a Health System:

aims and desirable attributes

WHO: The first building block

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.  

Onchocerciasis : Life cycle

Adult filariaein nodules

Microfilariae in skin

Microfilariae in eyes and elsewhere in body

Microfilariae ingested By black fly during bite

Development of microfilariaein black fly

Infective larvae inhead of black fly

Infective larvae injected with black fly bite

Larvae develop into adults

Onchocerciasis and the eye

300,000 people are blind and 0.5 million visually impaired

40,000 estimated new cases of blindness per year

Onchocerciasis and the skin

• Parasites in the skin cause major irritation

• Chronic inflammation leads to permanent skin changes

Typical “Leopard skin” changes

Skin lesions due to severe itching

Onchocerciasis and the brain

• There is dwarfism in Uganda shown to be related to onchocerciasis

• There appears to be a relationship between certain types of epilepsy and severe onchocerciasis. ( some epilepsy is also improved after taking Mectizan®)

Mass Treatment with Ivermectin

• Mectizan® (ivermectin Merck) has been donated by Merck since 1987 “as much as is needed for as long as is needed.

• Mectizan® is safe for mass distribution• Is effective as a once yearly dose.• Can be given using a simple dose calculation

based on height.• Causes few side effects, except in highly infected

people, during the first treatment round.• BUT it has to be taken for 20 years.

Mass treatment Strategies

• 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

• Mobile teams are unsustainable over 15-25 years therefore a sustainable approach had to be developed

Community Directed Treatment with Ivermectin (CDTI)

• 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

• 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.

CDTI

After suitable Information, Education and Communication (IEC) the communities

1. Choose a distributor for training2. Do a census to calculate Mectizan requirements3. Organise the collection of Mectizan from a Health Centre

or other distribution point4. Organise a distribution method, house to house, fixed

point in village etc5. Help the distributor calculate the dose and distribute the

Mectizan6. Note the treatment statistics and report to the health

authorities7. Participate in community supervision

After 5 years communities should be ready to continue treatment alone with minimal help and supervision from the P.H.C. servicesEqually a mechanism is in place for mass distribution of other medicines

Treatment beyond the end of the road

And further

CDTI in Action in Burundi

CDTI Partnership in Southern Sudan• A CDTI workshop for

stakeholders was organised in Rumbek during the cease fire.

• WHO, NGDOs, and Health Secretariat staff worked out policy issues together.

• 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.

Onchocerciasis Treatments Approved

0

10

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60

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90

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90

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Treatment requirements to 2020

< APOC >

Study on Community-directed Interventions

• Main objective

– To determine the extent to which the CDI process can be used for the integrated delivery of health interventions with different degrees of complexity

• Specific objectives

– Determine effectiveness and efficiency of CDI as compared to current systems

– Identify critical factors that facilitate or hinder effective implementation and integration

81

89 90

0

10

20

30

40

50

60

70

80

90

100

% o

f c

hil

dre

n t

ha

t re

ce

ive

d V

ita

min

A

Comparisondistricts

Vitamin A throughCDI for 1 year

Vitamin A throughCDI for 2 years

Vitamin A coverage

Target

P<0.001

31

5257

0

10

20

30

40

50

60

70

% o

f h

ou

se

ho

lds

ha

vin

g a

t le

as

t 1

IT

N

Comparisondistricts

ITN through CDI for 1 year

ITN through CDI for 2 years

Households with at least 1 ITN

RBM target

P<0.001

16

3633

0

10

20

30

40

50

60

70

% o

f h

ou

se

ho

lds

ha

vin

g a

t le

as

t 1

IT

N

Comparisondistricts

ITN through CDI for 1 year

ITN through CDI for 2 years

Children sleeping under ITN

RBM target

P<0.001

33

57

49

0

10

20

30

40

50

60

70

% o

f h

ou

se

ho

lds

ha

vin

g a

t le

as

t 1

IT

N

Comparisondistricts

ITN through CDI for 1 year

ITN through CDI for 2 years

Pregnant women sleeping under ITN

RBM target

P=0.014

28.6

54.9

69.4

0

10

20

30

40

50

60

70

80

% c

hil

dre

n w

ith

fe

ve

r w

ho

re

ce

ive

d

ap

pro

pri

ate

tre

atm

en

t

Comparisondistricts

HMM through CDI for 1 year

HMM through CDI for 2 years

Appropriate treatment of children with fever

RBM target

P<0.001

63.8

73.7

0

10

20

30

40

50

60

70

80

Tre

ate

d w

ith

iv

erm

ec

tin

(%

)

Comparison districts CDI districts

Ivermectin Treatment Coverage

APOC target

P<0.001

Costs to the Health System

District Level First Line Health Facility Level

Evolution of treatment with Mectizan® in the Americas 1989-2007 and Projection 2008-2015

1,50025,954

111,597

268,292

212,587

298,040

392,290

623,971

701,593

749,218

836,851

172,740

24,1720 0 0

29,75541,911

409,600

312,297

819,066

855,202852,721

729,690

568,780

518,566

847,888

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

20072008

20092010

20112012

20132014

2015

2012 Last year

of treatment

2015Last year

of post-MDA

surveillance

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

OEPAstarted

Lymphatic Filariasis(Elephantiasis)

• Found in many African countries and in Asia

Global elimination programmeUsing combination of two drugs

Morbidity Control is also needed

Surgery is also required for hydrocoele

Simple care of the skin done in a CBR programme reduces febrile episodes

Lymphatic Filariasis Treatments approved

Other NTDs and distribution systems• Shistosomiasis; normally orientated to

school children and school distribution systems

• Soil transmitted helminths; normally targeting mothers and children

• Trachoma; targeting mostly the whole community for MDA but adults for surgery

• All are more effective when reinforced by the community but they must be integrated with care.

What is Integration

• Your vision on integration depends on the lens you use.

• It is not just giving out 3 tablets instead of one

• It is not setting up a rapid delivery system which can exist as a parallel structure with government health services

• Integration is the inclusion of all important health interventions in the minimum package of activities within the PHC system

Partnerships for NTDs

• Ministry of Health ↔ Communities

• Geneva Global via GNNTDC, APOC, CBM for financial support

• Multiple partners for technical expertise and logistical support (SCI, WHO, APOC, CBM)

• Drug donation (Merck/ MDP)

AXIOMS ON MEDICAL CARE

• 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.

• Some form of medical care should be supplied to all the people all the time.

• 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.

• Medical care can be effective without being comprehensive.

• Medical services should be organized from the bottom up and not from the top down,

AXIOMS ON MEDICAL CARE

• The health needs of a community must be related to their wants.

• In developing countries medical care requires the adaptation and development of its own particular methodology.

• Medical care and the local culture are closely linked.

• Medical care must be carefully adapted to the opportunities and limitations of the local culture.

• 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.

(Maurice King 1966)

What is needed is a strong base

Communities

MoHProgramme

Specifics

ReportsData Management

DecentralisationFunds flowDrug distribution to Periphery

Health Districts

Policy AndTechnical Support

What is needed is a strong base or more input from communities

Communities

MoHProgramme

Specifics

Health Districts

Policy AndTechnical Support

Case Histories to conclude

Pimu Health Zone in DRC1. Vaccination programmes were organised by the

community

2. Health Centres were built and run by the community

3. MDA and hygiene were organised by the community

• What was achieved in a small level in the early 1980s has been reinforced by the latest work in NTDs:

• 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