Attaining health for all through community partnerships: principles of the census-based, impact-oriented (CBIO) approach to primary health care developed in Bolivia, South America (original) (raw)
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2020
Background: Strengthening primary health care (PHC) is now widely accepted as essential for achieving global health goals, including Universal Health Coverage. However, there are few examples of innovative approaches to the provision of comprehensive PHC services that have been implemented over more than a few years and that have evidence of long-term effectiveness. In contrast, the evidence for effectiveness of selected PHC interventions assessed over shorter periods of time is abundant. Objectives: This study describes the implementation of the census-based, impact-oriented (CBIO) approach for a program in Montero, Bolivia, managed by the Consejo de Salud Rural Andino (CSRA) that has been in operation for three decades, since 1988. A second paper in the series describes the effectiveness of the program, including population coverage of key interventions and changes in child and maternal mortality in the program area, over this period. Methods: We reviewed available documents, prio...
2020
Background: Even though strengthening primary health care (PHC) is now widely accepted as essential for achieving global health goals, evidence regarding the long-term effectiveness of comprehensive PHC programs remains limited. In contrast, the evidence for effectiveness of selected interventions assessed over shorter periods of time is abundant. Objectives: This report is the second in a series of two papers. The first paper describes the history and implementation features of the census-based, impact-oriented (CBIO) approach by the Consejo de Salud Rural Andino (CSRA)/Montero Comprehensive Primary Health Care Program that has been in operation for three decades, since 1988. This second paper in the series presents evidence of program effectiveness, including long-term trends in child and maternal mortality. Methods: We reviewed available documents, prior evaluations, and health information system data. We carried out interviews with 19 key informants. Finally, we reviewed data fr...
2003
Community-based comprehensive primary healthcare programmes are a widely-promoted strategy for improving child survival in less-developed countries, but limited documentation exists concerning their effectiveness in actually reducing child mortality. This study examined the impact of a communitybased comprehensive primary healthcare programme on child survival in Bolivia. Mortality rates from two intervention areas where Andean Rural Health Care (ARHC) had been conducting child-survival activities for 5-9 years were compared with those from two geographically-adjacent comparison areas that lacked such activities and that were virtually identical to the intervention areas in socioeconomic characteristics. Vital events were registered at the time of regular visit to all homes. In the comparison areas, limited services were available which reached only a small percentage of the population, while in the intervention areas, prenatal care, immunizations, growth monitoring, nutrition rehabilitation, and acute curative services were readily available to the entire population. In 1992-1993, the annual rates of mortality of children, aged less than five years, were 205.5 per 1,000 and 98.5 per 1,000 in the comparison and intervention areas respectively. The absolute difference in mortality of 107.0 deaths per 1,000 (95% confidence interval [CI], 72.7-141.3 per 1,000) represented 52.1% (95% CI, 35.2-68.8%) lower mortality of children aged less than five years in the intervention areas compared to the control communities. These results suggest that the provision of community-based, integrated health services can significantly improve child survival in poor countries. Better-designed and larger field trials of community-based comprehensive primary healthcare programmes in multiple regions of the world are needed to provide a stronger scientific basis for developing this approach further in developing countries.
International Journal for Equity in Health
Background Social and community participation is a fundamental component of the development of renewed primary healthcare (PHC). With the recognition of health as a right, such participation is a significant part of the design of public policies aimed at this sector. These policies contribute not only to overcoming inequity in the provision of this type of services but also to a reduction in social inequalities as a whole. Through a comparative analysis, this study aimed to explain the conditions through which ethnic-rural territories of the Colombian Pacific coast participate in health to contribute to the generation of policies and programs in territories with similar conditions. Methods The work was developed through the use of multiple techniques and strategies for information collection and analysis. These include several semi-structured interviews, multiple observation exercises and analysis based on a set theory, i.e., qualitative comparative analysis (QCA). The latter aims t...
The Journal of Rural Health, 1988
It has been almost twenty years since the author's initial experiences of working as a medical student in rural primary care in Bolivia. Throughout this time, the opportunity has arisen to participate in the provision of rural health services and to work closely with the Ministry of Health and private organizations involved in rural health care. Many Bolivian health professionals and rural inhabitants have provided valuable insights into the problems of rural health care and their possible solutions. As a consequence, it is they who are the real authors of this manuscript. Appreciation is expressed to the Bolivian staff of Andean Rural Health Care and other professional colleagues in Bolivia with whom the author has worked.
Advances in Medical Education and Practice, 2020
Purpose: Community health workers (CHWs) play integral roles in primary health care provision in low-and middle-income countries (LMICs). This is particularly true in underdeveloped areas where there are acute shortages of health workers. In this study, we evaluated the development and community utilization of a CHW training program in the Loreto province of Peru. Additionally, a community-oriented training model was designed to augment access to basic health information in underserved and isolated areas of the Amazon. Methods: Health resource utilization was compared in each community by surveying community members before and after implementation of the CHW training program, which utilized a community participatory program development (CPPD) model. Results: All communities demonstrated significantly increased CHW utilization (p = 0.026) as their initial point of contact for immediate health concerns following CHW training implementation. This increase in CHW utilization was accompanied by trends toward decreased preferences for local shamans or traveling to the closest health post as the initial health resource. Conclusion: The community-focused, technology-oriented model utilized in this study proved an effective way to promote the use of CHWs in the Amazon region of Loreto, and could prove valuable to CHW capacitation efforts within other Peruvian provinces and in other LMICs around the world.
International Journal for Equity in Health, 2023
Background Community-based health interventions have been an integral part of recent health gains globally. An innovative approach to delivering community health care combines the Census-Based, Impact-Oriented (CBIO) Approach with Care Groups and Community Birthing Centers called Casas Maternas Rurales. CBIO+ was adopted by Curamericas/Guatemala in its Maternal and Child Health Project, 2011-2015. Here, we describe the opinions of Project staff and local government health care workers about the strengths and challenges of CBIO+. Methods Self-administered questionnaires, key informant interviews, and focus group discussions were used to obtain the views of 21 staff members from Curamericas/Guatemala as well as 15 local government health workers. The evaluation focused on four primary areas: (1) advisability of integrating the CBIO+ Approach into the government's rural health system, (2) staff knowledge of the CBIO+ Approach, (3) advantages, disadvantages and challenges of the CBIO+ Approach, and (4) proposed improvements to the CBIO+ Approach. The data were coded into categories and from these categories themes were derived. Results The most commonly mentioned advantage of CBIO+ was the inclusion of the community in program planning, which improved participation. Many respondents noted that the CBIO+ Approach was challenging to implement in communities with internal conflicts. Among other challenges mentioned were coordinating (both among the Project staff and with others in the communities), maintenance of a high level of community participation, and overcoming opposition of men to women's participation in Care Groups. The staff mentioned a number of possible changes, including increasing male involvement, raising salaries for community-level paid staff, providing volunteers with incentives, and improving coordination both internally and externally. There was a strong demand among the local Ministry of Public Health and Social Welfare staff for the Project to continue. Conclusion The CBIO+ Approach and its implementation by Curamericas/Guatemala was overall embraced by local staff. By eliciting feedback while the project was ongoing, actionable areas for improvement were identified.
International Journal for Equity in Health, 2023
Background The Curamericas/Guatemala Maternal and Child Health Project, 2011-2015, was implemented in the Western Highlands of the Department of Huehuetenango, Guatemala. The Project utilized three participatory approaches in tandem: the Census-Based, Impact-Oriented (CBIO) Approach, the Care Group Approach, and the Community Birthing Center Approach. Together, these are referred to as the Expanded CBIO Approach (or CBIO+). Objective This is the first article of a supplement that assesses the effectiveness of the Project's community-based service delivery platform that was integrated into the Guatemalan government's rural health care system and its special program for mothers and children called PEC (Programa de Extensión de Cobertura, or Extension of Coverage Program). Methods We review and summarize the CBIO+ Approach and its development. We also describe the Project Area, the structure and implementation of the Project, and its context. Results The CBIO+ Approach is the product of four decades of field work. The Project reached a population of 98,000 people, covering the entire municipalities of San Sebastián Coatán, Santa Eulalia, and San Miguel Acatán. After mapping all households in each community and registering all household members, the Project established 184 Care Groups, which were composed of 5-12 Care Group Volunteers who were each responsible for 10-15 households. Paid Care Group Promoters provided training in behavior change communication every two weeks to the Care Groups. Care Group Volunteers in turn passed this communication to the mothers in their assigned households and also reported back to the Care Group Promoters information about any births or deaths that they learned of during the previous two weeks as a result of their regular contact with their neighbors. At the outset of the Project, there was one Birthing Center in the Project Area, serving a small group of communities nearby. Two additional Birthing Centers began functioning as the Project was operating. The Birthing Centers encouraged the participation of traditional midwives (called comadronas) in the Project Area. Conclusion This article serves as an introduction to an assessment of the CBIO+ community-based, participatory approach as it was implemented by Curamericas/Guatemala in the Western Highlands of the Department of
Background. Community-managed health programs (CMHPs) were designed to promote community selfdetermination in addressing health needs, but there is a need to evaluate how CMHPs can lead to better outcomes while accommodating changes in the national health system, which requires analysis of current CMHP interventions, institutional and community readiness, and points of interface with other health facilities. Objective and Methods. This preliminary study aimed to guide an eventual effort to develop a framework to ensure CMHPs sustainably improve health outcomes. A preliminary analysis of results from a community participatory research was done in which baseline health characteristics, related social determinants, level of involvement of CMHPs with the local government health system, and quality of life were documented through surveys, focus group discussions and key informant interviews, both in a community with an established CMHP (Murcia, Negros Occidental, Philippines), and a cont...