Approaches to improving the health of populations in developing countries continue to rely heavily on top-down, issue-specific strategies such as immunizations, child survival, reproductive health, HIV/AIDS, tuberculosis and malaria. While “top-down,” issue-specific approaches are necessary in order to obtain the support of policymakers and donors, these approaches too often fail to give adequate attention to strengthening the health service delivery system at the community level, nor do they necessarily take the needs and interests of the local community into account.  These “top-down,” issue-specific approaches too often fail as well to give adequate attention to involving communities in making the health service delivery system more effective and to building the community's capacity to identify and address its own health problems.

Growing evidence from many countries supports the concept that community-based approaches can be highly effective in improving the health of populations, especially when these approaches are connected to other community-based activities for social and economic improvement. Local communities, even when they are composed of mostly illiterate people, have the capacity to work as partners with governments, with health and development agencies, and with non-governmental organizations in identifying local priorities and in implementing appropriate strategies. Such approaches also promote empowerment of individuals and communities, social justice, equity, community participation, and inter-sectoral approaches to health improvement – principles endorsed in the 1978 Alma Ata Declaration of Health for All.

The Working Group affirms that community-based approaches represent one of the most effective public health tools available for improving the health of poor populations. In spite of substantial progress in improving the health of poor populations in recent decades, more than 10 million children are dying each year from readily preventable or treatable conditions, 585,000 pregnant women are dying each year from readily preventable or treatable conditions, 40.3 million people are infected (as of December 2004) with HIV, and 3.1 million people died in 2004 from this preventable condition. Furthermore, very few people living in developing countries have access to health care services that incorporate current standards of care -- not only for HIV/AIDS but for other serious, common readily treatable conditions.

The Working Group considers how the health problems of local communities (as the local people themselves define them and as local epidemiological data define them) and how the underlying determinants of these health problems can be addressed by giving community members a leadership role in working with government agencies, non-governmental organizations, and technical advisors in the design, implementation, and evaluation of health improvement activities.

The “Global Strategy Framework on HIV/AIDS,” prepared by UNAIDS, states:  “It is at the community level that the outcome of the battle against AIDS will be decided…. Local capacity for prevention, care and support efforts need to be recognized, affirmed and strengthened.” As it is with AIDS, so it is also with the other major causes of readily prevent-able or treatable causes of serious morbidity and mortality throughout the developing world. 

The Working Group seeks to encourage interest in and knowledge about this approach, to promote awareness of successful examples of using this approach, and to encourage the scaling up of this approach to regional and national populations. The Working Group also seeks to encourage the recognition of the value of this approach in health policies and in the funding of health programs. Finally, the Working Group promotes networking and information sharing among its members, who share a common interest in community-based approaches to health improvement. In summary, the Working Group aims to help strengthen the role of the community in health improvement in resource-poor populations.

History

Beginning in the early 1990s, interest emerged among members of the International Health Section of the American Public Health Association to bring a stronger focus to community-based primary health care in developing countries. This interest arose from the fact that top-down, issue-specific approaches tended to dominate the agenda of the Section and the presentations given at the annual meetings of APHA.

For several years, a session on community-based primary health care was held as part of the regular program of the annual meeting of APHA. These were well-attended and well-received. The late Dr. John Wyon, retired Senior Lecturer at the Harvard University School of Public Health and advocate for the community-based approach to public health more generally, began to work with colleagues and interested newcomers in pursuit of the idea of strengthening APHA’s support of the community-based approach to public health and primary health care in developing countries. For several years, meetings were held to discuss how best to move toward this goal. Joining Dr. Wyon in these discussions were:

Other individuals participated but were less regular in their attendance. This success led to the formal establishment of the Working Group on Community-Based Primary Health Care in 1997 as a formal part of the International Health Section of APHA. 

The one-day workshops sponsored on the Saturday prior to the APHA annual meeting have focused on the following topics:

1999 - Skills-Based Workshop on Community Health, Chicago

(practical aspects of the community-based approach to primary health care)

2000 - Community-Based Health Care: Lessons from Bangladesh to Boston , Boston

(a two-day symposium in collaboration with the Harvard School of Public Health Alumni Association, supported by the Rockefeller Foundation and Management Sciences for Health, published by MSH in 2002 as a book by the same title, edited by Jon Rohde and John Wyon)

2001 - Community-Based Health Care in Developing Countries: Status and Prospects, Atlanta

2002 - Community-Based Primary Health Care in Developing Countries: Applications, Concepts and Training, Philadelphia

2003 - Community-Based Primary Health Care: Tapping the Potential of Adult Learners and Monitoring and Evaluation, San Francisco

2004 - Community-Based Primary Health Care: Building Community Partnerships through Participatory Planning and Uncovering Evidence That the Model Works, Washington, DC

2005 - Community-Based Primary Health Care: Practical Steps to Achieve Successful Programs, Philadelphia

2006 - Using Community-Based Approaches to Meet the Challenges of the Millennium Development Goals in Health, Boston

2007- The Effectiveness of Community-Based Primary Health Care in Improving Child Health: A Review of the Evidence and Findings from the Field, Washington, D.C.

Current Activities

The current activities of the working group include promotion of Community-Based Primary Health Care (CBPHC) through regular meetings, a regular list server, its own website, and networking amongst members; a World Health Organization (WHO) funded project researching the evidence base supporting CBPHC; and administration of grants promoting CBPHC-related activities such as the current grant from the Colgate Palmolive company for supporting research related to behavioral hygiene practices.

The Working Group currently meets twice a year -- once at the time of the American Public Health Association (APHA) annual meeting and another at the Global Health Council annual meeting (end-May/early-June).

The Working Group sponsors a workshop on practical aspects of CBPHC (for novices and experienced), on the day prior to the opening of the APHA annual meeting (usually on a Saturday in November), and it provides time for discussion and networking among those who attend (including an informal dinner after the workshop).

Between these meetings members keep in contact by subscribing to a regular list serve (join on the website or email henry@future.org) and personal networking by email.

Our website can be reached through the International Health Section of the APHA website (www.apha.org). Click on "Sections" located under the "Member Groups and State Affiliates" tab.  Choose "International Health," click on "Committees" on the left menu, and choose "Community Based Primary Health Care Working Group."  On our website, you will find announcements about future workshops; statements about our purposes, activities and history; PowerPoint and text presentations illustrating contents of our most recent workshops; copies of our most recent list server messages and reports on recent group meetings; and a list of training materials and documents about community-based primary health care. The website, list server and the list of training materials are dynamic in nature. All those who are interested are encouraged to comment on contents of the website including the list of training materials and to keep in touch with the Working Group through subscription to the list server and by email. Please let us know what experience you have with the materials presented and make suggestions for improvement. We are particularly interested to hear about presentations we could put on the site or additional training materials in relationship to CBPHC that you think we may all benefit from.

The World Health Organization has awarded a small grant to our Working Group to investigate the evidence base supporting CBPHC. This grant was only recently awarded after a thorough application process. An expert committee of world leaders in our field is to be formed to guide this evidence-based research. Additional workers willing to help with this large task are encouraged to approach the co-chairs. As the literature in this area is diffuse, we are interested to receive or hear about any studies - whether descriptive only or more advanced and whether previously published or not that - we could include in this review.

The Colgate Palmolive grants, totaling $30,000, are awarded at the American Public Health Association (APHA) Annual Meeting. The grants are to be awarded on a competitive basis based on review of proposals by an expert committee. The applicants are young investigators doing original research in developing countries on improving personal hygiene.  
 

 For further information, contact:

Dr Henry Perry, Co-Chair  (henry@future.org)
     Future Generations, Franklin, West Virginia

Dr Paul Freeman, Co-Chair  (freeman.p.a@worldnet.att.net)
     Independent consultant, Seattle, Washington

Ms Connie Gates, Secretary  (connie@jamkhed.org)
     Jamkhed International Foundation, Carrboro, North Carolina