The fifth, sixth and seventh papers in the eight-part Series in The Alma-Ata Special Issue of The Lancet focus on community participation and interventions for maternal, newborn and child (MNCH) primary health care (PHC).
Paper five, authored by Professor Anthony Costello, Institute of Child Health, University College London, UK, looks at the fourth and seventh articles of The Alma Ata Declaration, which focus on community involvement. The authors say: "Community mobilization can bring about cost-effective and substantial reductions in mortality and improvements in the health of newborn infants. Nonetheless community mobilization is not a feature of most large-scale primary health care programmes, because it is characterised by several controversies. What form should it take to most effective? Does it effectively address the socioenvironmental risk factors that underpin health problems and mortality? How does it work? What role does it have to play in interventions for maternal survival? How can it be scaled up effectively?"
They conclude: "Might [community participation] be essential only as a transitional strategy: crucial for the poorest and most deprived populations but largely irrelevant once health care systems are established? Or is the failure to incorporate community participation into large-scale primary health care programmes a major reason why we are failing to achieve Millennium Development Goals (MDGs) 4 and 5 for reduction of maternal of maternal and child mortality?"
Paper six is authored by Professor Zulfiqar A. Bhutta, The Aga Khan University, Karachi, Pakistan, and colleagues. They say systematic review has identified 37 key promotional, preventive, and treatment interventions for MNCH in PHC. The authors say: "Some are especially suitable for delivery through community support groups and health workers, whereas others can only be delivered by linking community-based strategies with functional first-level referral facilities. Examples of these interventions include enhanced packages for antenatal care in mothers, community based care and management of newborns and improved case management of childhood diarrhoea and pneumonia. Case studies of MNCH indicators in Pakistan and Uganda show how PHC interventions can be used effectively.
The authors conclude: "Inclusion of evidence-based interventions in MNCH programmes in primary health care at pragmatic levels of coverage in these two countries could be prevent 20-30% of all maternal deaths (up to 32% with capability for caesarean section at first level facilities), 20-21% of newborn deaths, and 29-40% of all post-neonatal deaths in children aged less than five years. Focusing on addressing MNCH and survival in primary health care is both feasible and a priority for countries to reach their MDG goal targets for reducing maternal and child mortality."
The seventh paper, by Dr Jerker Liljestrand, Lund University and Malmö University Hospital, Sweden, and colleagues say that experiences from several Asian and African countries show that MCNH can be improved by integrated packages of cost-effective health care, implemented incrementally according to health system capacity. Such interventions would include community-based action, combined with social measures to target education, infrastructure, and poverty and mobilise public and private sector resources.
The authors conclude: "Interventions need to be planned and implemented at the district level, which requires strengthening of district planning and management skills. Furthermore, districts need to be supported by national strategies and policies, and, in the case of the least developed countries, also by international donors and other partners. If packages for maternal, newborn, and child health care can be integrated within a gradually strengthened primary health-care system, continuity of care will be improved, including access to basic referral care before and during pregnancy, birth, the postpartum period, and throughout childhood."
Professor Anthony Costello, Institute of Child Health, University College London, UK T) +44 (0) 7515 396475 E) a.costello@ich.ucl.ac.uk
Professor Zulfiqar Bhutta, The Aga Khan University, Karachi, Pakistan T) +92 +92-300-8236813 E) zulfiqar.bhutta@aku.edu
Dr Jerker Liljestrand, Lund University and Malmö University Hospital, Sweden T) +46 767653095E) jerker@ystad.nu
Full papers: http://press.thelancet.com/AA567.pdf
Journal
The Lancet