Assessment of human and material resources available for primary eye-care delivery in rural communities of southwestern Nigeria

Integration of primary eye-care (PEC) into the existing primary healthcare (PHC) system is efficient in reaching rural communities. Baseline assessment of human and material resources for primary eye-care delivery in a rural local government area of southwestern Nigeria with projected population of 126,625 was conducted. Data on number and cadre of all PHC facilities and health-workers were collected. All facilities were visited and materials required for basic PEC inspected. Forty-one (42.3%) community health extension workers, 42 (43.3%) health assistants, 3 (3.1%) community officers of health and 11 (11.2%) registered nurses administered PHC in 27 health facilities. No worker had training in PEC and none of the centres had all the materials for basic PEC delivery. Although procurement of materials and training of health-workers in basic PEC delivery is required, the healthcare facilities and workers currently available are adequate to commence integration of PEC into the PHC system.

Achieving child survival goals: potential contribution of community health workers

There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.

Maternity Services and the Role of the Traditional Birth Attendant, Bidan Kampung, in Rural Malaysia

This study was undertaken to explore the roles played by bidan kampungs and understand their contribution to rural Malay women during pregnancy and childbirth hundred sixteen pregnant women, 13 Western midwives, and 12 bidan kampungs were recruited using convenience and snowball sampling. Data were collected from focus groups, in-depth interviews, field notes, and observations. The findings indicated that although the women were happy to have Western maternity care, they valued the social and spiritual support received from bidan kampungs during pregnancy and postnatal care. Western care was considered useful for "modern" illnesses. The traditional maternity care that women received included pantang or ritual prohibitions that helped them through pregnancy and helped them achieve better postnatal recovery. The study indicates that there is a need to combine Western and traditional care for the benefit of the pregnant women and their infants' health.

Scaling up Integrated Management of Childhood Illness to the national level: achievements and challenges in Peru

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.

How to bridge the gap in human resources for health

Human resources are the crucial core of a health system, but they have been a neglected component of health-system development. The demands on health systems have escalated in low income countries, in the form of the Millennium Development Goals and new targets for more access to HIV/AIDS treatment. Human resources are in very short supply in health systems in low and middle income countries compared with high income countries or with the skill requirements of a minimum package of health interventions. Equally serious concerns exist about the quality and productivity of the health workforce in low income countries. Among available strategies to address the problems, expansion of the numbers of doctors and nurses through training is highly constrained. This is a difficult issue involving the interplay of multiple factors and forces.

Factors influencing the retention and attrition of community health aides/practitioners in Alaska

CONTEXT

The Community Health Aide Program (CHAP) is a unique program employing local, indigenous peoples as primary care nonphysician providers in extremely remote frontier, tribal Alaskan communities. With attrition rates up to 20%, recommendations for improving retention are necessary to maintain access to health services for Alaska Natives in these communities.

PURPOSE

The purpose of this study was to identify factors contributing to retention in Alaska's CHAP program.

METHODS

Key informant interviews were conducted with 41 community health aides/practitioners (CHA/Ps) in 15 villages statewide. Efforts were made to ensure the sample included a mix of villages with high retention of health aides and villages with lower retention. Geographic and ethnic diversity were also considered. Transcripts were coded using NUD*IST software, and data were analyzed for differences between high retention and low retention villages and between more experienced and less experienced CHA/Ps.

FINDINGS

Five fundamental needs of health aides were identified as crucial for retention of personnel. These needs include strong co-worker support, access to basic training, a fully staffed clinic, good community support, and supportive families.

CONCLUSIONS

For 35 years, the CHAP program has worked to diminish health disparities for Alaska Natives. Though unique challenges associated with the job have factored into low retention of CHA/Ps, improved retention is possible with easier access to basic training, increased support from colleagues and community, enhanced team-building skills, and better on-call schedules.

The community-directed, ivermectin-treatment programme for onchocerciasis control in Uganda--an evaluative study (1993-1997)

The first 5 years of a community-directed, ivermectin-treatment programme, to control onchocerciasis in 1805 endemic communities in 10 districts in Uganda, are evaluated. Each year, the desired treatment coverage of the population eligible to take invermectin (90%) was achieved in 42.6%-51% of the 1713 communities for which complete data were available; 67%-74.8% achieved 80% coverage. The annual cost per person treated with ivermectin (ACPTI) was much higher in the districts with small populations to be treated (< 15,000) than in those with large populations (> 40,000) (U.S.$0.40 v. U.S.$0.10 or less). The community members' acceptance of the programme was related to their attendance at health-education sessions (P = 0.009), and their participation in the mobilisation of other community members increased greatly when they were allowed to take part in the selection of the community-based distributors (CBD) and the choice of treatment sites. The overall target ratio of one CBD/71 families was attained by 1997. However, the failure of some trained CBD to participate in the treatment exercise prevented some communities achieving 90% treatment coverage. Providing CBD with cash incentives or externally derived incentives 'in kind' proved counter-productive whereas locally generated incentives 'in kind' were simply regarded as the normal obligations of the community. District health staff successfully integrated the programme with their other health commitments, but the involvement of CBD in other programmes proved detrimental to their performance. Other constraints identified were rebel insurgency in some areas, and abnormally heavy rains in hilly areas with poor roads.

GIS/GPS to document increased access to community-based treatment for tuberculosis in Africa. Geographic information system/global positioning system

Application of geographic information system (GIS) and global positioning system (GPS) technology in the Hlabisa community-based tuberculosis treatment programme documents the increase in accessibility to treatment after the expansion of the service from health facilities to include community workers and volunteers.

Lay health advisors: a strategy for getting the word out about breast cancer

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSP's population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSP's evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.

Changes in empowerment: effects of participation in a lay health promotion program

The Camp Health Aide Program is a lay health promotion program for migrant and seasonal farmworkers. The program increases access to health care while facilitating leadership development and empowerment of individual farmworkers through training and experience as lay health promoters (camp health aides [CHAs]). This article describes a study which documents impacts on the CHAs of working as lay health promoters in terms of changes in personal empowerment. The authors developed a working definition of personal empowerment and interviewed 27 CHAs at three program sites (Arizona, New Jersey, and Florida) at three different times. CHAs are grouped in five descriptive categories reflecting varying degrees of change in empowerment over this period. Of the total group of 27 CHAs, 24 exhibited some increase in personal empowerment during the study period. These changes are described in detail, and implications are discussed.

Community health workers in Gazankulu

The aim of this paper is to give a brief description of the utilization of community health workers (CHWs) in Gazankulu. The general policy framework in which these health workers function is described briefly, and the way in which these workers function evaluated. This paper is intended as a modest contribution to evaluation research in the field of community health.

Community based health care in the Philippine highlands: the Hanunuo Mangyans of Mindoro

The feasibility and effectiveness of community participation in the planning and delivery of health care services among the Hanunuo Mangyans in the Philippine highlands is described. The Hanunuo are swidden cultivators and one of seven indigenous ethnic minorities in the forested interior of Mindoro island. Previous Mangyan studies have shown that they have poor health, are generally malnourished and continually susceptible to communicable diseases. The need to develop viable strategies to counter their health problems is pressing since Mindoro suffers from insufficient health care facilities and personnel, and health services are rarely available to Mangyans. Baseline surveys on the health and nutritional status of the Hanunuo population in the project site indicated that the following illnesses are most prevalent: upper respiratory tract infection, skin diseases, parasitism, anaemia and malaria. The more significant health problems of the Hanunuo include poor environmental sanitation, lack of medical personnel and drugs, inadequate knowledge of curative and preventive care, lack of adequate prenatal care, poor nutritional status and lack of health education. Also described are the participation of the community in project planning and decision making, the training workshops and resource manual for the community volunteers, the coverage areas and assigned tasks of the health workers, and the organisation of village health committees.

Health manpower allocation in developing countries

Most developing countries have shortages of health manpower in rural areas. To address this problem, national strategies have included the establishment of salaried posts for rural doctors, construction of rural hospitals and health centres, mandating periods of rural service for all new medical graduates, providing special financial incentives to attract practitioners to rural communities, furnishing transport of personnel, and restricting settlement in major cities. If universal entitlement to health care were legislated for, as in Western Europe and in socialist countries, rural as well as urban populations would be covered. China's development of the “barefoot doctor” dramatised the value of the briefly trained community health worker (CHW) after 1971. Unfortunately, CHWs in many countries proved disappointing, because of inadequate training, poor supervision, and other deficiencies. With political commitment, however, these problems can be overcome.

The effect of scale on cost projections for a primary health care program in a developing country

Accurate estimation of the recurrent costs of primary health care (PHC) activities is essential in light of the need for governments to assess whether and how these costs can be financed. This paper argues that expansion of the PHC activites will result in diseconomies of scale that are not captured by constant average cost projections of recurrent costs. An alternative estimation method which captures the effect of rising average unit costs is proposed with application of this method to data from the Republic of Niger. Results of the analysis show that the 'r-coefficient' (ratio of investment to recurrent costs) for PHC activities can double and costs can be 3 times larger after 12 years.