WHAT CAN BE DONE: COMMUNITY PARTNERSHIPS FOR CHILD SURVIVAL
Families, especially parents and other primary caregivers, form the first line of care when an infant falls sick. They make the initial diagnosis of illness, assess its severity, select treatment and care options, procure and administer drugs and other remedies and decide whether or not to seek formal health care. Moreover, many of the preventive measures that can preserve the health and save the lives of young children and pregnant women require behaviour changes that begin in the household and are reinforced in the community. Empowering communities as well as households to participate in the health care and nutrition of mothers, newborns and children is, therefore, a logical way of enhancing the provision of care, especially in countries and communities where basic primary health care and environmental services are lacking.
Diversity of community partnerships for health
Community partnerships in maternal, newborn and child health recognize the need for community members to be actively engaged in their own health care and well-being. Rich in diversity, community partnerships are at times small-scale, involving only a few thousand or even a few hundred people; other initiatives, such as the Brazilian community health workers network, encompass thousands of workers covering millions of children and women. Some programmes emphasize supply-side elements, such as service provision through community health workers, while others focus more on demand-side initiatives to mobilize social demand for better health services. Some community health worker initiatives rely on voluntary participation, while others include payment in kind, in part or in cash. Some community-based programmes are nationally supported and integrated into the broader health system, while others have yet to be fully or partially incorporated.
Despite the varied ways in which community-based approaches to child health are organized, most of them serve a dual function, actively engaging community members as health workers and mobilizing the community in support of improved health practices. Such approaches are essential in reaching the most isolated or excluded, and they can also foster community ownership of health programmes, stimulate demand for quality health services from governments and add vitality to a bureaucracy-laden health system. Some key practices that promote child health and survival and in which the use of community health workers or community members themselves can be effective include healthier infant and child feeding practices, improved hygiene and sanitation, home-based care for simple illnesses, immunization, malaria prevention, referrals to the nearest health centre and antenatal care.
Tenets for a successful community-based approach to health
Evidence and experience has shown that successful community-based approaches embody some common features:
- Cohesive and inclusive community organization and participation: Programmes that build on established structures within a community, that are socially inclusive, and that include community members in planning, evaluation and implementation are among the most successful in developing countries.
- Support and incentives for community health workers: Community health workers, the main agents of community-based treatment, education and counseling, require incentives and support to prevent attrition, sustain motivation, and help workers meet their obligations.
- Adequate programme supervision and support: Supervision helps sustain community members’ interest and motivation and reduces the risk of attrition. Other important types of support include logistics, supplies and equipment.
- Effective referral systems to facility-based care: Hospitals and clinics are essential complements to successful community partnerships because they provide services that cannot be safely replicated elsewhere, such as emergency obstetric care. District health systems also serve as focal points for public health programme coordination.
- Cooperation and coordination with other programmes and sectors: An integrated approach to maternal, newborn and child health would benefit from collaboration between programmes and sectors addressing health, nutrition, hygiene, major diseases, food security, lack of transportation infrastructure and access to water and sanitation facilities.
- Secure financing: To be successful over the long term, community partnerships need stable financing to address issues of sustainability and equity, such as cost-sharing and financial incentives for community health workers.
- Integration with district and national programmes and policies: Active support from provincial and central governments, and integration into government policies, plans and budgets can sustain and support community-based initiatives. Consulting with representatives from the community, district and national levels and the donor community could develop target strategies and ensure that maternal and child survival feature prominently in national and decentralized plans and budgets, with clear goals and concrete benchmarks.
Some or all of these features can be seen in thriving community partnerships for maternal, newborn and child health around the world. The large-scale community health worker initiatives undertaken in Bangladesh (BRAC), India (Jamkhed and others) and Pakistan (Lady Health Workers,) for example, have all been led by local organizations – often women’s groups. These groups build on the established structures within communities that extend to other areas of development, including education and credit, as well as health. In the Philippines, the success of health workers at the barangay level, the smallest political unit in the country, was encouraged by the Barangay Health Workers’ Benefits and Incentives Act of 1995, which includes provisions for subsistence allowances, career enrichment, special training programmes and preferential access to loans. In Cambodia, for example, nongovernmental organizations cooperate and coordinate their programmes, by collaborating in a national Child Survival NGO Group that meets regularly in Phnom Penh. Members of this group and representatives from the Ministry of Health visit each other’s projects to examine and learn from advances and adaptations in approaches to maternal, newborn and child health care.
A rights-based approach to health
Finally, community partnerships in maternal, newborn and child health also form the heart of a rights-based approach to human progress. Participation is critical to enable people to achieve their full capabilities, exercise their rights to engage in public and community affairs, and foster equity, equality and empowerment – characteristics that are fundamental to sustainable human development and to the objectives of such compacts as the Universal Declaration of Human Rights, the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women and the Millennium Declaration, among many others.
Many countries, including some of the poorest in the world, have implemented successful community-based health programmes. The challenge now will be to learn from their experiences, scale up successful projects and pilot programmes and reach the millions of children whom the health system, so far, has passed by.