Health systems and the community
Authors: Vinod Paul
Journal: BMJ (2004)

The need to strengthen health systems in developing countries in the drive to reach the United Nations' millennium development goals is under the spotlight.1 But one key component of health systems, the activities that take place in the community that have an impact on health, gets insufficient attention.

The World Health Organization's definition of health systems includes “all the activities whose primary purpose is to promote, restore, or maintain health.”2 Community participation in activities that improve the health of individuals, families, and communities should be an integral part of the health system. Such activities should be at the centre of any concerted action to improve health. Yet the community's role and participation are sidelined in most top-down health programmes—a reason why many international and national programmes fail to deliver.

Engaging local communities to participate in identifying their own health priorities spurs the development of innovatory culturally acceptable solutions with locally available resources. In Bolivia, a study using such participation in planning services for mother and infant care reduced perinatal mortality from 117 to 44 per 1000 births.3,4 Manandhar et al in Nepal report a reduction in maternal and neonatal mortality associated with a positive change in behaviour among women, which included seeking appropriate medical help, institutional delivery, and use of clean delivery kit.5 In an uncontrolled project in rural Kanpur in India, a participatory learning approach led to improved birth preparedness, better birth spacing, early initiation of breast feeding, and improved care seeking for maternal emergencies.5

Weak demand for services seems to be a major obstacle in attaining the health related millennium development goals.6 Interventions which promote the demand for appropriate services linked to improvement in their provision could be the key to decisive gains in the quest for millennium development goals.

In this issue, Costello argues that community based strategies must be harnessed to save maternal and newborn lives (p 1166). Research supports that this is an effective way to improve neonatal survival in resource poor settings.4,7-9 Evidence is also trickling in to support the notion that important gains in maternal health could accrue through community based interventions. In addition to the Nepal experience,4 the Gadchiroli home based newborn care initiative documented an unexpected 50% reduction in maternal morbidity associated with the introduction of a community based programme involving traditional birth attendants and village health workers (A Bang, personal communication, 2004).

Health services can be classified into three categories.10 Services focused on individuals—for example, skilled obstetric care—which require well resourced health systems. Outreach services providing, for example, immunisation and vector control, require periodic input from healthcare providers. Family and community services—many such services depend on implementing strategies that are known to promote behaviour that improves health, for example, breast feeding or safe sex. Unlike the first two categories, these services can be provided by community based organisations and commercial networks.

Even in the absence of any new resources a plethora of evidence based interventions can be implemented on a large scale fairly rapidly in resource poor countries through family and community oriented services, facilitated by using community participation. In maternal, newborn, and child health these include birth and emergency preparedness; maternal calorie and micronutrient supplementation; insecticide treated bed nets to prevent malaria; clean delivery and simple resuscitation (for home deliveries by trained traditional birth attendants), hygienic care of cord and skin; prevention and management of hypothermia; immediate and exclusive breast feeding; appropriate complementary feeding; extra care of low birth weight infants; healthy home practices and early care seeking in sickness; and management of diarrhoea and pneumonia.

As has been seen in the Nepal and Gadchiroli studies, rural women can be transformed into effective and acceptable agents of change in maternal and child health with training and orientation.4,8 Processes to facilitate community participation can be built on and integrated with other non-health development activities. Community action led by women has the potential to change societies.

One of the biggest challenges in health, namely neonatal and maternal mortality, is the bane of the less developed countries. Of the 3.9 million neonatal deaths, 98% occur in low income countries.11 Likewise, almost all (99.5%) of the 529 000 maternal deaths occur in the developing regions of the world.12 Although the medical cause of an illness is the same everywhere, contribution of indirect causes and risk factors is different in poor societies compared with affluent ones. Access to effective health care determines the survival of a sick child or mother once a serious illness sets in; but the health systems in the resource restricted countries, or regions within countries, have little resemblance to those in resource-rich settings. Inevitably, even though interventions (such as drugs, vaccines, or healthy behaviours) are universal, effective delivery strategies to take them to the needy in the prevailing socioeconomic and cultural and health system scenarios are likely to be quite different in the developing countries. We need more investment in relevant research in developing countries to find local solutions to health problems, and we need to create new opportunities for sharing of experiences between developing countries in the delivery of health care.