Accelerating progress in achieving the millennium development goal for children through community-based approaches

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

Bugs in the Bed: Addressing the Contradictions of Embedded Science with Agile Implementation Research

Implementation research often fails to have its intended impact on what programs actually do. Embedding research within target organizational systems represents an effective response to this problem. However, contradictions associated with the approach often prevent its application. We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. Structural contradictions impede host institution ownership of research processes and utilization of results. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. Known as "agile science," this paradigm combines scientific rigor with management decision making. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making.

The role of rehabilitation care workers in South African healthcare: A Q-methodological study

BACKGROUND

The South African Department of Health identified the need to train a new cadre of community health worker (CHW) in the field of rehabilitation as part of their 2030 Health Plan that aims to improve primary healthcare (PHC) and community-based rehabilitation (CBR). Community health workers can be effectively utilised in CBR if their role is understood and their potential is not limited by professional protectionism and scepticism. A clear understanding of the scope of practice of a new cadre will minimise resistance by health professionals.

OBJECTIVES

The aim of this study was to explore rehabilitation health professionals' perception of the role of the new cadre, called rehabilitation care workers (RCWs), in South African healthcare.

METHODS

Q-methodology was used to gather and interpret the data. A convenient sample of 16 health professionals participated in the study. Participants ranked statements about the role of the RCWs from strongly agree to strongly disagree. Data were entered into PQMethod software program for statistical and factor analysis.

RESULTS

Two factors emerged. Participants loading onto Factors 1 and 2 were of the opinion that RCWs' role would be to strengthen PHC and CBR and to promote participation of people with disabilities (PWD) in intermediate care and community.

CONCLUSION

Rehabilitation health professionals' positive perception of the new cadre is encouraging so that it could ensure their effective utilisation in CBR. Rehabilitation care workers were perceived as capable of enhancing the lives of PWD by ensuring inclusive development.

Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017

INTRODUCTION

The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed.

METHODS

Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised.

RESULTS

We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period.

CONCLUSION

Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania

Background

This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts.

Methods

From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy.

Results

The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2–85.6 in the intervention group and 82.7/1000 (95% CI 78.5–87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88–1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3–77.3) in the intervention group and 77.4/1000 (95% CI 73.8–81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86–1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89–1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74–1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1–59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76–0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85–1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07–1·88], p = 0·015).

Conclusions

Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months.

Trial registration

Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana

Background

The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival.

Methods

Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care.

Results

The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age.

Conclusion

GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up.

Does the provision of community health services offset the effects of poverty and low maternal educational attainment on childhood mortality? An analysis of the equity effect of the Navrongo experiment in Northern Ghana

The Government of Ghana has instituted a National Poverty Reduction Program with an initiative known as the Community-based Health Planning and Services (CHPS) as its core health development strategy. CHPS was derived from a plausibility trial of the Navrongo Health Research Centre testing four contrasting primary health care strategies: i) Training unpaid volunteers to promote health in communities, ii) placing nurses in communities with training and supplies for treating childhood illnesses, iii) combining the nurse and volunteer approaches, and iv) sustaining a comparison condition whereby clinic services were provided without community resident workers. This paper presents an age-conditional proportional hazard analysis of the long term impact of community health worker exposure among 94,599 children who were ever under age five over the January 1, 1995 to December 2010 period, adjusting for age conditional effects of shifts in exposure type as CHPS was scaled up in Navrongo project area over the 1995-2000 period. Results show that children whose parents are uneducated and relatively poor experience significantly higher mortality risks than children of the educated and less poor. Conditional hazard regression models assess the impact of CHPS on health equity by estimating the interaction of equity indicators with household exposure to CHPS service operations, adjusting for age conditional exposure to original Community Health and Family Planning Project (CHFP) service strategies as scale-up progressed. The association of mortality risk among children with uneducated and relatively impoverished mothers is offset by exposure to community health nursing services. If exposure is limited to volunteer-provided services alone, survival benefits arise only among children of relatively advantaged households. Findings lend support to policies that promote the CHPS nurse approach to community-based services as a core health component of poverty reduction programs.

Approaches and strategies used in the training and supervision of Health Extension Workers (HEWs) delivering integrated community case management (iCCM) of childhood illness in Ethiopia: a qualitative rapid appraisal

Background

Globally, preventable and treatable childhood conditions such as pneumonia, diarrhoea, malaria, malnutrition and newborn conditions still account for 75% of under-five mortality. To reduce the mortality rate from these conditions, Ethiopia launched an ambitious Health Extension Programme (HEP) in 2003. Trained Community Health Workers (CHWs), named Health Extension Workers (HEWs) were deployed to deliver a package of care which includes integrated Community Case-Management (iCCM) of common childhood diseases.

Objectives

This qualitative study aimed to explore approaches and strategies used in the HEW training and supervision as part of an evaluation of the Catalytic Initiative to Save a Million Lives.

Method

A qualitative rapid appraisal study using focus group discussions and in-depth interviews was conducted.

Results

Training of HEWs followed a cascaded training of trainer approach supported by implementing partners under guidance of the Ministry of Health. A comprehensive planning phase enabled good coverage of districts and consistency in training approaches. Training was complemented by on-going supportive supervision. HEW motivation was enhanced through regular review meetings and opportunities for career progression.

Conclusion

These findings describe a thorough approach to training and supervision of HEWs delivering iCCM in rural Ethiopia. Ongoing investments by partners will be critical for long-term sustainability.

Community Involvement in Health Systems Strengthening to Improve Global Health Outcomes: A Review of Guidelines and Potential Roles

Definitions of health systems strengthening (HSS) have been limited in their inclusion of communities, despite evidence that community involvement improves program effectiveness for many health interventions. We review 15 frameworks for HSS, highlighting how communities are represented and find few delineated roles for community members or organizations. This review raises the need for a cohesive definition of community involvement in HSS and well-described activities that communities can play in the process. We discuss how communities can engage with HSS in four different areas-planning and priority-setting; program implementation; monitoring, evaluation, and quality improvement; and advocacy-and how these activities could be better incorporated into key HSS frameworks. We argue for more carefully designed interactions between health systems policies and structures, planned health systems improvements, and local communities. These interactions should consider local community inputs, strengths, cultural and social assets, as well as limitations in and opportunities for increasing capacity for better health outcomes.

Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era

Background

Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies.

Discussion

In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, “learning for leverage,” NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, “thought leadership,” NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, “joint venturing,” NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts.

Conclusion

With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel

BACKGROUND

The contributions that community-based primary health care (CBPHC) and engaging with communities as valued partners can make to the improvement of maternal, neonatal and child health (MNCH) is not widely appreciated. This unfortunate reality is one of the reasons why so few priority countries failed to achieve the health-related Millennium Development Goals by 2015. This article provides a summary of a series of articles about the effectiveness of CBPHC in improving MNCH and offers recommendations from an Expert Panel for strengthening CBPHC that were formulated in 2008 and have been updated on the basis of more recent evidence.

METHODS

An Expert Panel convened to guide the review of the effectiveness of community-based primary health care (CBPHC). The Expert Panel met in 2008 in New York City with senior UNICEF staff. In 2016, following the completion of the review, the Panel considered the review's findings and made recommendations. The review consisted of an analysis of 661 unique reports, including 583 peer-reviewed journal articles, 12 books/monographs, 4 book chapters, and 72 reports from the gray literature. The analysis consisted of 700 assessments since 39 were analyzed twice (once for an assessment of improvements in neonatal and/or child health and once for an assessment in maternal health).

RESULTS

The Expert Panel recommends that CBPHC should be a priority for strengthening health systems, accelerating progress in achieving universal health coverage, and ending preventable child and maternal deaths. The Panel also recommends that expenditures for CBPHC be monitored against expenditures for primary health care facilities and hospitals and reflect the importance of CBPHC for averting mortality. Governments, government health programs, and NGOs should develop health systems that respect and value communities as full partners and work collaboratively with them in building and strengthening CBPHC programs - through engagement with planning, implementation (including the full use of community-level workers), and evaluation. CBPHC programs need to reach every community and household in order to achieve universal coverage of key evidence-based interventions that can be implemented in the community outside of health facilities and assure that those most in need are reached.

CONCLUSIONS

Stronger CBPHC programs that foster community engagement/empowerment with the implementation of evidence-based interventions will be essential for achieving universal coverage of health services by 2030 (as called for by the Sustainable Development Goals recently adopted by the United Nations), ending preventable child and maternal deaths by 2030 (as called for by the World Health Organization, UNICEF, and many countries around the world), and eventually achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978. Stronger CBPHC programs can also create entry points and synergies for expanding the coverage of family planning services as well as for accelerating progress in the detection and treatment of HIV/AIDS, tuberculosis, malaria, hypertension, and other chronic diseases. Continued strengthening of CBPHC programs based on rigorous ongoing operations research and evaluation will be required, and this evidence will be needed to guide national and international policies and programs.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 1. rationale, methods and database description

BACKGROUND

Community-based primary health care (CBPHC) is an approach used by health programs to extend preventive and curative health services beyond health facilities into communities and even down to households. Evidence of the effectiveness of CBPHC in improving maternal, neonatal and child health (MNCH) has been summarized by others, but our review gives particular attention to not only the effectiveness of specific interventions but also their delivery strategies at the community level along with their equity effects. This is the first article in a series that summarizes and analyzes the assessments of programs, projects, and research studies (referred to collectively as projects) that used CBPHC to improve MNCH in low- and middle-income countries. The review addresses the following questions: (1) What kinds of projects were implemented? (2) What were the outcomes of these projects? (3) What kinds of implementation strategies were used? (4) What are the implications of these findings?

METHODS

12 166 reports were identified through a search of articles in the National Library of Medicine database (PubMed). In addition, reports in the gray literature (available online but not published in a peer-reviewed journal) were also reviewed. Reports that describe the implementation of one or more community-based interventions or an integrated project in which an assessment of the effectiveness of the project was carried out qualified for inclusion in the review. Outcome measures that qualified for inclusion in the review were population-based indicators that defined some aspect of health status: changes in population coverage of evidence-based interventions or changes in serious morbidity, in nutritional status, or in mortality.

RESULTS

700 assessments qualified for inclusion in the review. Two independent reviewers completed a data extraction form for each assessment. A third reviewer compared the two data extraction forms and resolved any differences. The maternal interventions assessed concerned education about warning signs of pregnancy and safe delivery; promotion and/or provision of antenatal care; promotion and/or provision of safe delivery by a trained birth attendant, screening and treatment for HIV infection and other maternal infections; family planning, and; HIV prevention and treatment. The neonatal and child health interventions that were assessed concerned promotion or provision of good nutrition and immunizations; promotion of healthy household behaviors and appropriate utilization of health services, diagnosis and treatment of acute neonatal and child illness; and provision and/or promotion of safe water, sanitation and hygiene. Two-thirds of assessments (63.0%) were for projects implementing three or fewer interventions in relatively small populations for relatively brief periods; half of the assessments involved fewer than 5000 women or children, and 62.9% of the assessments were for projects lasting less than 3 years. One-quarter (26.6%) of the projects were from three countries in South Asia: India, Bangladesh and Nepal. The number of reports has grown markedly during the past decade. A small number of funders supported most of the assessments, led by the United States Agency for International Development. The reviewers judged the methodology for 90% of the assessments to be adequate.

CONCLUSIONS

The evidence regarding the effectiveness of community-based interventions to improve the health of mothers, neonates, and children younger than 5 years of age is growing rapidly. The database created for this review serves as the basis for a series of articles that follow this one on the effectiveness of CBPHC in improving MNCH published in the Journal of Global Health. These findings, together with recommendations provided by an Expert Panel which has guided this review, that are included as the last paper in this series, will help to provide the rationale for building stronger community-based platforms for delivering evidence-based interventions in high-mortality, resource-constrained settings.

Predictive Accuracy of Chest Radiographs in Diagnosing Tachypneic Children

OBJECTIVE

To test the predictive accuracy and reporting reproducibility of digital chest radiographs under low-resource conditions.

METHODS

One hundred thirty four tachypneic children who presented to two Indian hospitals were enrolled. Based on review of 16 variables recorded in the Emergency Room (ER) by a senior pediatrician, children were given one of the four clinical diagnoses: pneumonia, wheezy disease, mixed and non-respiratory. Every child also had a digital CXR. It was interpreted by ER physician, pediatrician and two independent radiologists. All used the same standardized interpretation system (one or more of: normal, minor patches, major patches, hyperinflation, lobar change, pleural effusion).

RESULTS

The 10 % of CXRs showing pleural effusions reliably predicted pneumonia and disease severity. For all other CXR findings, the correlation between CXR interpretation and clinical diagnosis was moderate to poor. Apart from pleural effusions, inter-observer agreements between interpretations made by ER physician, pediatrician and radiologist were also poor (kappa <0.4).

CONCLUSIONS

With the exception of pleural effusions, CXR findings, interpreted by a radiologist, had moderate to poor power to predict respiratory diagnosis or disease severity defined by a pediatrician. Value of CXRs was further reduced by poor inter-observer agreement. When investigating tachypneic children under low-resource conditions, CXRs should be used with a clear understanding of their limitations.

Acceptability of malaria rapid diagnostic tests administered by village health workers in Pangani District, North eastern Tanzania

Background

Malaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania.

Methods

A cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs.

Results

Among 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs.

Conclusion

RDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals.

Unit cost analysis of training and deploying paid community health workers in three rural districts of Tanzania

Background

Tanzania, like other African countries, faces significant health workforce shortages. With advisory and partnership from Columbia University, the Ifakara Health Institute and the Tanzanian Training Centre for International Health (TTCIH) developed and implemented the Connect Project as a randomized cluster experimental trial of the childhood survival impact of recruiting, training, and deploying of a new cadre of paid community health workers (CHW), named “Wawazesha wa afya ya Jamii” (WAJA). This paper presents an estimation of the cost of training and deploying WAJA in three rural districts of Tanzania.

Methods

Costing data were collected by tracking project activity expenditure records and conducting in-depth interviews of TTCIH staff who have led the training and deployment of WAJA, as well as their counterparts at Public Clinical Training Centres who have responsibility for scaling up the WAJA training program. The trial is registered with the International Standard Randomized Controlled Trial Register number (ISRCTN96819844).

Results

The Connect training cost was US$ 2,489.3 per WAJA, of which 40.1 % was for meals, 20.2 % for accommodation 10.2 % for tuition fees and the remaining 29.5 % for other costs including instruction and training facilities and field allowance. A comparable training program estimated unit cost for scaling-up this training via regional/district clinical training centres would be US$ 833.5 per WAJA. Of this unit cost, 50.3 % would involve the cost of meals, 27.4 % training fees, 13.7 % for field allowances, 9 % for accommodation and medical insurance. The annual running cost of WAJA in a village will cost US$ 1.16 per capita.

Conclusion

Costs estimated by this study are likely to be sustainable on a large scale, particularly if existing regional/district institutions are utilized for this program.

Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone

BACKGROUND

Global acute malnutrition (GAM) is the sum of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). The use of different foods and protocols for MAM and SAM treatment can be cumbersome in emergency settings.

OBJECTIVE

Our objective was to determine the recovery and coverage rates for GAM of an integrated protocol with a single food product, ready-to-use therapeutic food (RUTF), compared with standard management.

METHODS

This was a cluster-randomized controlled trial in Sierra Leone conducted in 10 centers treating GAM in children aged 6-59 mo. The integrated protocol used midupper arm circumference (MUAC) as the criterion for admission and discharge, with a MUAC <12.5 cm defining malnutrition. The protocol included a decreasing ration of RUTF and health maintenance messages delivered by peers. Standard therapy treated MAM with a fortified blended flour and SAM with RUTF and used weight-for-height to determine admission to the treatment program. Coverage rates were the number of children who received treatment/number of children in the community eligible for treatment.

RESULTS

Most of the children receiving integrated management had MAM (774 of 1100; 70%), whereas among those receiving standard management, SAM predominated (537 of 857; 63%; P = 0.0001). Coverage was 71% in the communities served by integrated management and 55% in the communities served by standard care (P = 0.0005). GAM recovery in the integrated management protocol was 910 of 1100 (83%) children and was 682 of 857 (79%) children in the standard therapy protocol.

CONCLUSION

Integrated management of GAM in children is an acceptable alternative to standard management and provides greater community coverage. This trial was registered at clinicaltrials.gov as NCT01785680.

Care Groups II: A Summary of the Child Survival Outcomes Achieved Using Volunteer Community Health Workers in Resource-Constrained Settings

Care Group projects resulted in high levels of healthy behavior, including use of oral rehydration therapy, bed nets, and health care services. Accordingly, under-5 mortality in Care Group areas declined by an estimated 32% compared with 11% in areas with child survival projects not using Care Groups.

The Care Group approach, described in detail in a companion paper in this journal, uses volunteers to convey health promotion messages to their neighbors. This article summarizes the available evidence on the effectiveness of the Care Group approach, drawing on articles published in the peer-reviewed literature as well as data from unpublished but publicly available project evaluations and summary analyses of these evaluations. When implemented by strong international NGOs with adequate funding, Care Groups have been remarkably effective in increasing population coverage of key child survival interventions. There is strong evidence that Care Groups can reduce childhood undernutrition and reduce the prevalence of diarrhea. Finally, evidence from multiple sources, comprising independent assessments of mortality impact, vital events collected by Care Group Volunteers themselves, and analyses using the Lives Saved Tool (LiST), that Care Groups are effective in reducing under-5 mortality. For example, the average decline in under-5 mortality, estimated using LiST, among 8 Care Group projects was 32%. In comparison, among 12 non-Care Group child survival projects, the under-5 mortality declined, on average, by an estimated 11%. Care Group projects cost in the range of US$3–$8 per beneficiary per year. The cost per life saved is in the range of $441–$3,773, and the cost per disability-adjusted life year (DALY) averted is in the range of $15–$126. The Care Group approach, when implemented as described, appears to be highly cost-effective based on internationally accepted criteria. Care Groups represent an important and promising innovative, low-cost approach to increasing the coverage of key child survival interventions in high-mortality, resource-constrained settings. Next steps include further specifying the adjustments needed in government health systems to successfully incorporate the Care Group approach, testing the feasibility of these adjustments and of the effectiveness of Care Groups in pilot programs in government health systems, and finally assessing effectiveness at scale under routine field conditions in government health programs.

The Astronomy of Africa's Health Systems Literature During the MDG Era: Where Are the Systems Clusters?

Growing international concern about the need for improved health systems in Africa has catalyzed an expansion of the health systems literature. This review applies a bibliometric procedure to analyze the acceleration of scientific writing on this theme. We focus on research published during the Millennium Development Goal (MDG) era between 1990 and 2014, reporting findings from a systematic review of a database comprised of 17,655 articles about health systems themes from sub-Saharan African countries or subregions. Using bibliometric tools for co-word textual analysis, we analyzed the incidence and associations of keywords and phrases to generate and visualize topical foci on health systems as clusters of themes, much in the manner that astronomers represent groupings of stars as galaxies of celestial entities. The association of keywords defines their relative position, with the size of images weighted by the relative frequency of terms. Sets of associated keywords are arrayed as stars that cluster as "galaxies" of concepts in the knowledge universe represented by health systems research from sub-Saharan Africa. Results show that health systems research is dominated by literature on diseases and categorical systems research topics, rather than on systems science that cuts across diseases or specific systemic themes. Systems research is highly developed in South Africa but relatively uncommon elsewhere in the region. "Black holes" are identified by searching for terms in our keyword library related to terms in widely cited reviews of health systems. Results identify several themes that are unexpectedly uncommon in the country-specific health systems literature. This includes research on the processes of achieving systems change, the health impact of systems strengthening, processes that explain the systems determinants of health outcomes, or systematic study of organizational dysfunction and ways to improve system performance. Research quantifying the relationship of governance indicators to health systems strengthening is nearly absent from the literature. Long-term experimental studies and statistically rigorous research on cross-cutting themes of health systems strengthening are rare. Studies of organizational malaise or corruption are virtually absent. Trend analysis shows the emergence of organizational research on specific priority diseases, such as on HIV/AIDS, malaria, and tuberculosis, but portrays a lack of focus on integrated systems research on the general burden of disease. If health systems in Africa are to be strengthened, then organizational change research must be a more concerted focus in the future than has been the case in the past.

Catalyzing the scale-up of community-based primary healthcare in a rural impoverished region of northern Ghana

Ghana's Community-based Health Planning and Services (CHPS) initiative develops accessible healthcare with participatory community support, using strategies developed and tested by a project of the Navrongo Health Research Centre. In 1996, the project was expanded to a district-wide four-celled trial. In response to evidence that strategies could reduce fertility and childhood mortality, a replication project was launched to develop methods for scale-up. Based on experience gained, CHPS scale-up was launched in 2000. Although CHPS now reaches all of Ghana's districts, the pace of scale-up within districts has been slow. In response, the Ministry of Health conducted a review of factors that constrain CHPS scale-up and problems that detract from its original evidence-based design. To resolve problems that were identified, a project was launched in 2010 to test means of accelerating CHPS scale-up and expand its range of care. Known as the Ghana Essential Health Interventions Program (GEHIP), the project provided catalytic revenue to four treatment district managers for 3 years, in conjunction with implementation of strategies for comprehensive leadership development and community partnership. Monitoring systems were developed to gauge CHPS coverage time trends in all nine study districts. GEHIP successfully accelerated CHPS implementation, producing 100% of its targeted community coverage within 5 years of implementation. Coverage in comparison districts also improved. However, the rate of coverage and per cent of the population reached by CHPS in comparison districts was only half that of GEHIP districts. GEHIP success in completing CHPS coverage represents the initial stage of a national program for strengthening community health systems in Ghana. Copyright © 2015 John Wiley & Sons, Ltd.

Impact of health education intervention on malaria prevention practices among nursing mothers in rural communities in Nigeria

Introduction:

Malaria is the most prevalent parasitic endemic disease in Africa, which is preventable, treatable and curable. This study aims to assess the effect of health education intervention on the knowledge, attitude, and prevention practices amongst mothers of under-five children in a rural area of Ogun State, Nigeria.

Materials and Methods:

The study design was a quasi-experimental study carried out in Ijebu North Local Government Area of Ogun State. A multistage random sampling technique was used in choosing the required samples and a semi-structured questionnaire was used to collect relevant information. A total of 400 respondents were recruited into the study with 200 each in both the experimental and control groups and were followed up for a period of 3 months.

Results:

There was no statistically significant differences observed between the experimental and control groups. Knowledge of indoor spraying increased from 14.7% to 58.2% (P < 0.001) and window and door nets increased from 48.3% to 74.8% (P < 0.001). The proportion of those with ITN use increased from 50.8% to 87.4% (P < 0.001) while those with practice of maintaining clean environment also increased from 40.4% to 54.5% (P < 0.001). There were no significant changes in all the practice of malaria prevention methods in the control group.

Conclusion:

This suggests that malaria control can be significantly improved in rural areas, if the caregivers are adequately empowered through appropriate health education intervention though change in attitude and belief may require a longer and persistent effort.

The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system

Background

Tanzania has been a pioneer in establishing community-level services, yet challenges remain in sustaining these systems and ensuring adequate human resource strategies. In particular, the added value of a cadre of professional community health workers is under debate. While Tanzania has the highest density of primary health care facilities in Africa, equitable access and quality of care remain a challenge. Utilization for many services proven to reduce child and maternal mortality is unacceptably low. Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers, but the Ministry of Health and Social Welfare (MoHSW ) lacks evidence that this merits national implementation. The Tanzania Connect Project is a randomized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga).

Description of intervention

Connect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilization, and alter reproductive, maternal, newborn and child health seeking behavior; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHA, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. In addition, Connect’s district-wide emergency referral strengthening intervention includes clinical and operational improvements.

Evaluation design

Designed as a community-based cluster-randomized trial, CHA were randomly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System (HDSS) in the three study districts. To garner detailed information on household characteristics, behaviors, and service exposure, a random sub-sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline. The referral system intervention will use baseline, midline, and endline facility-based data to assess systemic changes. Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system.

Discussion

Global commitment to launching community-based primary health care has accelerated in recent years, with much of the implementation focused on Africa. Despite extensive investment, no program has been guided by a truly experimental study. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities.

Trial registration: ISRCTN96819844

Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana

The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned.

Ghana's Community-Based Health Planning and Service (CHPS) initiative is envisioned to be a national program to relocate primary health care services from subdistrict health centers to convenient community locations. The initiative was launched in 4 phases. First, it was piloted in 3 villages to develop appropriate strategies. Second, the approach was tested in a factorial trial, which showed that community-based care could reduce childhood mortality by half in only 3 years. Then, a replication experiment was launched to clarify appropriate activities for implementing the fourth and final phase—national scale up. This paper discusses CHPS progress in the Upper East Region (UER) of Ghana, where the pace of scale up has been much more rapid than in the other 9 regions of the country despite exceedingly challenging economic, ecological, and social circumstances. The UER employed 5 strategies that facilitated scale up: (1) nurse recruitment from their home districts to improve worker morale and cultural grounding, balanced with some social distance from the village community to ensure client confidentiality, particularly regarding family planning use; (2) prioritization of CHPS planning and continuous review in management meetings to make necessary modifications to the initiative's approach; (3) community engagement and advocacy to local politicians to mobilize resources for financing start-up costs; (4) a shared and consistent vision about CHPS among health administration leaders to ensure appropriate resources and commitment to the initiative; and (5) knowledge exchange visits between new and advanced CHPS implementers to facilitate learning and scale up within and between districts.

Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact

INTRODUCTION

Evidence exists that community-based intervention packages can have substantial child and newborn mortality impact, and may help more countries meet Millennium Development Goal 4 (MDG 4) targets. A non-governmental organization (NGO) project using such programming in Mozambique documented an annual decline in under-five mortality rate (U5MR) of 9.3% in a province in which Demographic and Health Survey (DHS) data showed a 4.2% U5MR decline during the same period. To test the generalizability of this finding, the same analysis was applied to a group of projects funded by the US Agency for International Development. Projects supported implementation of community-based intervention packages aimed at increasing use of health services while improving preventive and home-care practices for children under five.

METHODS

All projects collect baseline and endline population coverage data for key child health interventions. Twelve projects fitted the inclusion criteria. U5MR decline was estimated by modelling these coverage changes in the Lives Saved Tool (LiST) and comparing with concurrent measured DHS mortality data.

RESULTS

Average coverage changes for all interventions exceeded average concurrent trends. When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases. The average improvement in modelled U5MR (5.8%) was more than twice the concurrent directly measured average decline (2.5%).

CONCLUSIONS

NGO projects implementing community-based intervention packages appear to be effective in reducing child mortality in diverse settings. There is plausible evidence that they raised coverage for a variety of high-impact interventions and improved U5MR by more than twice the concurrent secular trend. All projects used community-based strategies that achieved frequent interpersonal contact for health behaviour change. Further study of the effectiveness and scalability of similar packages should be part of the effort to accelerate progress towards MDG 4.

Determinants of intermittent preventive treatment of malaria during pregnancy (IPTp) utilization in a rural town in Western Nigeria

BACKGROUND

Malaria infection in pregnancy is a major risk factor for maternal and child death, and substantially increases the risk of miscarriage, stillbirth and low birthweight. The aim of this study therefore is to assess the prevalence and determinants of Intermittent preventive treatment of Malaria [IPTp] utilization by pregnant women in a rural town in Western Nigeria.

METHODS

This study is an analytical cross-sectional study. All pregnant women that were due for delivery and were attending the three primary health care center in Sagamu town, Nigeria within a 2 months period were recruited into the study. A semi- structured questionnaire was used to collect relevant information.

RESULTS

A total of 255 pregnant women were recruited into the study. The mean age of respondents was 28.07 ± 5.12 years. The mean parity and booking age was 2.7 ± 1.67 and 4.42 ± 1.7 months respectively. The prevalence of Malaria attack in the last 3 months was 122(47.8%). Only 107/255 (40.4%) practice IPTp for malaria prevention during the current pregnancy, with only 14.6% of them taking the second dose during pregnancy as recommended. Chloroquine [27.1%] was the most frequently used medication for the treatment of Malaria in Pregnancy. Early booking age [OR = 1.11, C.I = 0.61-2.01], adverse last pregnancy outcome [OR = 1.23, C.I = 0.36-4.22], and parity [OR = 1.87, C.I = 0.25-16.09] were not statistically significantly associated with IPTp utilization. The only predictor of IPTp use was the knowledge of prophylaxis for malaria prevention [OR = 2.47, C.I = 1.06-3.52] using multivariate analysis.

CONCLUSION

The study concludes that most women who attend ANC in rural areas in Nigeria do not receive IPTp as expected. A major determinant of utilization of IPTp among the study population was the knowledge of prophylaxis for malaria prevention. This study highlights the importance of health education of the pregnant women in increasing IPTp uptake despite the regular drug stock out at the facility level in rural areas in low resource countries.

Community perspectives on roles and responsibilities for strengthening primary health care in rural Ethiopia

Government-community partnerships are central to developing effective, sustainable models of primary health care in low-income countries; however, evidence about the nature of partnerships lacks the perspective of community members. Our objective was to characterise community perspectives regarding the respective roles and responsibilities of government and the community in efforts to strengthen primary health care in low-income settings. We conducted a qualitative study using focus groups (n=14 groups in each of seven primary health care units in Amhara and Oromia, Ethiopia, with a total of 140 participants) in the context of the Ethiopian Millennium Rural Initiative. Results indicated that community members defined important roles and responsibilities for both communities and governments. Community roles included promoting recommended health behaviours; influencing social norms regarding health; and contributing resources as feasible. Government roles included implementing oversight of health centres; providing human resources, infrastructure, equipment, medication and supplies; and demonstrating support for community health workers, who are seen as central to the rural health system. Renewed efforts in health system strengthening highlight the importance of community participation in initiatives to improve primary health care in rural settings. Community perspectives provide critical insights to defining, implementing and sustaining partnerships in these settings.

Feasibility and acceptability of ACT for the community case management of malaria in urban settings in five African sites

Background

The community case management of malaria (CCMm) is now an established route for distribution of artemisinin-based combination therapy (ACT) in rural areas, but the feasibility and acceptability of the approach through community medicine distributors (CMD) in urban areas has not been explored. It is estimated that in 15 years time 50% of the African population will live in urban areas and transmission of the malaria parasite occurs in these densely populated areas.

Methods

Pre- and post-implementation studies were conducted in five African cities: Ghana, Burkina Faso, Ethiopia and Malawi. CMDs were trained to educate caregivers, diagnose and treat malaria cases in < 5-year olds with ACT. Household surveys, focus group discussions and in-depth interviews were used to evaluate impact.

Results

Qualitative findings: In all sites, interviews revealed that caregivers' knowledge of malaria signs and symptoms improved after the intervention. Preference for CMDs as preferred providers for malaria increased in all sites.

Quantitative findings: 9001 children with an episode of fever were treated by 199 CMDs in the five study sites. Results from the CHWs registers show that of these, 6974 were treated with an ACT and 6933 (99%) were prescribed the correct dose for their age. Fifty-four percent of the 3,025 children for which information about the promptness of treatment was available were treated within 24 hours from the onset of symptoms.

From the household survey 3700 children were identified who had an episode of fever during the preceding two weeks. 1480 (40%) of them sought treatment from a CMD and 1213 of them (82%) had received an ACT. Of these, 1123 (92.6%) were administered the ACT for the correct number of doses and days; 773 of the 1118 (69.1%) children for which information about the promptness of treatment was available were treated within 24 hours from onset of symptoms, and 768 (68.7%) were treated promptly and correctly.

Conclusions

The concept of CCMm in an urban environment was positive, and caregivers were generally satisfied with the services. Quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers. Innovation is required by everyone to make it viable.

Preventing malaria in pregnancy through community-directed interventions: evidence from Akwa Ibom State, Nigeria

BACKGROUND

Despite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The slow uptake of malaria prevention products appears to reflect lack of knowledge and resistance to behavioural change, as well as poor access to resources, and limited support of programmes by local communities and authorities.

METHODS

A recent community-based programme in Akwa Ibom State, Nigeria, is analysed to determine the degree to which community-directed interventions can improve access to malaria prevention in pregnancy. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and kindred in the treatment areas and trained to deliver ITNs and IPTp drugs as well as basic counseling services to pregnant women.

FINDINGS

Relative to women in the control area, an additional 7.4 percent of women slept under a net during pregnancy in the treatment areas (95% CI [0.035, 0.115], p-value < 0.01), and an additional 8.5 percent of women slept under an ITN after delivery and prior to the interview (95% CI [0.045, 0.122], p-value < 0.001). The effects of the CDI programme were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p-value < 0.001) relative to the control group. No effects on antenatal care attendance were found.

CONCLUSION

The presented results suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions. Given the relatively modest financial commitments they require, community-directed programmes appear to be a cost-effective way to improve malaria prevention; the participatory approach underlying CDI programmes also promises to strengthen ties between the formal health sector and local communities.

Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique

BACKGROUND

There is a growing body of evidence that integrated packages of community-based interventions, a form of programming often implemented by NGOs, can have substantial child mortality impact. More countries may be able to meet Millennium Development Goal (MDG) 4 targets by leveraging such programming. Analysis of the mortality effect of this type of programming is hampered by the cost and complexity of direct mortality measurement. The Lives Saved Tool (LiST) produces an estimate of mortality reduction by modelling the mortality effect of changes in population coverage of individual child health interventions. However, few studies to date have compared the LiST estimates of mortality reduction with those produced by direct measurement.

METHODS

Using results of a recent review of evidence for community-based child health programming, a search was conducted for NGO child health projects implementing community-based interventions that had independently verified child mortality reduction estimates, as well as population coverage data for modelling in LiST. One child survival project fit inclusion criteria. Subsequent searches of the USAID Development Experience Clearinghouse and Child Survival Grants databases and interviews of staff from NGOs identified no additional projects. Eight coverage indicators, covering all the project's technical interventions were modelled in LiST, along with indicator values for most other non-project interventions in LiST, mainly from DHS data from 1997 and 2003.

RESULTS

The project studied was implemented by World Relief from 1999 to 2003 in Gaza Province, Mozambique. An independent evaluation collecting pregnancy history data estimated that under-five mortality declined 37% and infant mortality 48%. Using project-collected coverage data, LiST produced estimates of 39% and 34% decline, respectively.

CONCLUSIONS

LiST gives reasonably accurate estimates of infant and child mortality decline in an area where a package of community-based interventions was implemented. This and other validation exercises support use of LiST as an aid for program planning to tailor packages of community-based interventions to the epidemiological context and for project evaluation. Such targeted planning and assessments will be useful to accelerate progress in reaching MDG4 targets.

A renewed focus on primary health care: revitalize or reframe?

The year 2008 celebrated 30 years of Primary Health Care (PHC) policy emerging from the Alma Ata Declaration with publication of two key reports, the World Health Report 2008 and the Report of the Commission on the Social Determinants of Health. Both reports reaffirmed the relevance of PHC in terms of its vision and values in today's world. However, important challenges in terms of defining PHC, equity and empowerment need to be addressed.This article takes the form of a commentary reviewing developments in the last 30 years and discusses the future of this policy. Three challenges are put forward for discussion (i) the challenge of moving away from a narrow technical bio-medical paradigm of health to a broader social determinants approach and the need to differentiate primary care from primary health care; (ii) The challenge of tackling the equity implications of the market oriented reforms and ensuring that the role of the State in the provision of welfare services is not further weakened; and (iii) the challenge of finding ways to develop local community commitments especially in terms of empowerment.These challenges need to be addressed if PHC is to remain relevant in today's context. The paper concludes that it is not sufficient to revitalize PHC of the Alma Ata Declaration but it must be reframed in light of the above discussion.