In this section of our lecture, we're going to build on what we've talked about previously in terms of diagnostic methods. But we're going to be looking at them as applied to a specific package of services that a volunteer might deliver. Some of the issues we've talked about previously are a bit open ended, where the community has more say in the types of things that they want to learn, and want to control. programs are more, can be more variable across different districts. But here, we're coming into the situation that we commonly see in many countries, where there is a specific package of primary health care services that need to be delivered. So we'll talk about how we can do our training needs diagnosis based on a package that a country may develop. We might want to consider ultimately that the whole idea of community health workers is based on the concept of primary health care that was articulated in the Alma Ata Declaration back in 1978. Alma Ata was then the capital of Kazakhstan. It's called Almaty now, but, this was a major international gathering that set the pace for global health. primary healthcare there was defined as something that was universally accessible to individuals, families at the community level, right where they needed, but also the key point is, through their full participation. And, again, the declaration said that primary healthcare would rely on or be delivered through formal health workers, such as physicians, nurses, midwives, community workers of the type that we've been talking about here, volunteer village or community health workers, traditional practitioners and of course others. One thing that we would hope primary health care does is respond to the express needs of the community because these vary from place to place. again, getting back to the point we said earlier about the training needs diagnosis being a bit more open ended as we talked about it before. And, this activity, this whole process of primary healthcare would be carried out in the spirit of partnership and service. And we will stress again the importance of partnership between health service and the community in making sure that village health workers are delivering services that are needed. So ideally, as we said, primary health care should be based on what the community wants. It may be first aid for farm accidents. It may be treatment of children with fever. But again, what we're seeing in many efforts to increase coverage of basic child, maternal health services is a package of services that would be nationally sanctioned. These may include something like treating malaria, something like handing out bed nets, something like promoting hand washing and distribution of soap, and this would be something that would be seen as a key package of interventions that would address the major causes of child or maternal mortality. This issue of, of specific elements in a package is not new. Not long after 1978, the international community was worried that the Alma Ata Declaration was too broad, and they came up with what they called at that time selective primary healthcare. And a number of agencies, whether it was USA, UNICEF, other NGOs, researchers in universities said we really can't respond to everything the community wants. Let's develop selective primary health care that focuses on some of the major causes of morbidity and some of the major issues of health promotion. So, in that package, in those days, it was called GOBI, Growth-monitoring, Oral re-hydration, Breastfeeding and Immunization. And to that was added family planning and girl's education. But the, the idea was that, of course, diarrhea is a major cause of death. malnutrition is a major underlining factor in other causes of death. So growth monitoring to make sure the child is growing, would be part of these primary health care packages. Breastfeeding promotion. Immunization. And again these are not necessarily things that village health workers would deliver, but they may be things that they could do health education on. They could definitely promote oral rehydration therapy even if it's mixing salt, sugar solution at home in the village or distributing packets, or referring people to get immunization, or mobilizing the village if immunization was done on a mobile basis. We have village health workers, of course. Community-based distributors doing family planning in markets and in villages around, around the world. This idea of if a specific package, selected package could be, it would be easier to implement, it would have a greater impact on mortality. At least this was the idea. So it was getting away from responding to the community's felt needs. Interestingly enough, along the way around the mid 1990's we were looking at the problem of river blindness, or onchoceriasis, and realized that in many places, of course, there had been aerial spraying to kill black flies along rivers. But this would not work throughout Africa. It was great in the Sahel region where if there was a very marked dry season, and you could actually fly over and see the rivers. in the forest areas in Africa you could not necessarily see streams and rivers through the forest canopy, it would be harder to reach them, there were many more sources of flowing water in the rainy season. and so what was discovered is this drug Ivermectin, and if any of you have dogs or cattle, you may realize that this drug and its derivatives used for heartworms and other kinds of veterinary use, that Merck Sharp & Dohme, the company that developed it, realized that it might be also valuable for humans, and it went through tests. And it was determined that what it did was it provided clearance of all the microfilaria of onchocerciasis worms, in the body, and if this was done prior to the transmission season, when the black flies are going around biting people, they would have no larvae to carry to the next person. so this, if done over a period of 15, 20 years, could potentially eliminate transmission. So it was an exciting finding at the time that there was a simple drug that could help reduce transmission throughout Africa. And the company actually donated free, until further notice, it's still being donated free to control this problem. What was unique about it was that it wasn't done strictly as a health service program, driving out and giving people medicine. The concept was developed using village health workers. The community would select its own village health workers, as we talked about, and the health system would train them, provide them with the supplies of Ivermectin. And the community would organize how it wanted to carry out the distribution, whether they wanted to have it at a central place, whether they wanted to go door to door, for how many, y'know, weeks they wanted to do this. And they would then submit summaries back to the health center, and this would be repeated every year, but the community would take charge. So here we had something that was a selective package of interventions, this drug ivermectin, but the approach was different in the sense that it wasn't based in the health system. It was based in the community and letting the community take charge. So this was an interesting thing that people thought about. And slowly, over time, other interventions were added. Sometimes, this was done on a district-by-district or country-by-country basis. Said, okay, if these people can distribute ivermectin successfully, the communities can organize that. Can they also do the same thing for filters to prevent guinea worm? Can they do the same thing for oral rehydration? so this was something that was done informally. Eventually WHO and partners, through their tropical disease research program, tested the idea of adding on to the ivermectin distribution things like bed net distribution, things like malaria management, the malaria drugs, vitamin A distribution. And this was a successful program, and since then other groups have used that model. Sometimes they've added on where there are community volunteers doing ivermectin distribution. Sometimes they've taken the model of this community taking charge of distribution to other areas where they're was no onchocerciasis. So again, testing systematically if the volunteers, which we call the community-directed distributors, can handle more tasks, and it was quite successful. So this package, as we said, included ivermectin, which was already there, malaria medicine, insecticide-treated gnats, vitamin A, and they did try directly observed treatment for tuberculosis. that was the only one that was difficult because of the social stigma attached with TB and people in the community didn't want others to know if they had it. And also, the health workers were a bit concerned that volunteers would be, giving out TB drugs in the community. So, that was the only one for system reasons, and for social stigma reasons that didn't work. But again, these packages did work, and I think it set the stage for something that's come up, y'know, in the past five, ten years called integrated community case management. This is a key package of treatment activities that prevents some of the major causes of death in children below five years of age. So, treating malaria, treating diarrhea. Actually we wouldn't call it treatment because it's not a curative drug, but it's providing the oral rehydration because death comes from, from dehydration with diarrhea. And then acute respiratory illness like pneumonia. So having the, somebody in the village, a volunteer having medicine for malaria, the ORS, the oral rehydration solution packets and hopefully zinc tablets to go with that, and then an approved antibiotic that could be used at the community level, cotrymoxazole or amoxicillin. sometimes this package has been supplemented with deworming medicine. Promotive and preventive activities, also, making sure that the volunteers distribute insecticide treated nets. There's even a module that is being tried out in some countries of doing interventions for, neonatal, health promotion, such as promoting breast feeding and also keeping babies warm after they're born. So, one thing, that this program has been carried out in a variety of ways. Just because the services are provided in the community, doesn't mean it's carried out like community directed intervention where the community actually participates and runs the program. Sometimes they may select the volunteer, but the agency is the one who actually manages the volunteers after the community has selected them. So there are varying degrees of community participation involved. And so what we would like to see, ideally, is that these new interventions, this package, be delivered through a community directed intervention approach where the community is a partner with the health system. And, and again we discussed that in the previous lectures about the importance of the community and the health system working together as partners and the health system encouraging the community to take as much responsibility as possible. One interesting package is the Malaria Plus Package in Nigeria. This evolved from some of the world bank malaria booster program grants in some of the states where the major source of money was to be focused on malaria prevention and treatment. but at the same time, recognizing that people in the community, children in particularly, are threatened by other diseases. And so this, package was developed and included up to 19 specific activities that could happen. So this is something, a ch, a challenge we did test, as I mentioned before in this tropical disease research project, adding on 3 or 4 things to existing ivermectin distribution. And of course, what happened then is that the community may have decided, we need more than 1 volunteer. Okay. Someone be responsible for nets. Someone continue doing Ivermectin distribution. Somebody take care of case management, diarrhea, malaria, that type of thing. But when you start getting 19 things, it may get a bit difficult. Now, of course, what can happen is that you can start off with some of the essential things, and later on, through continuing education of your village health workers, add new skills and ideas and and services that they can provide. But this Malaria Plus Package included a variety of maternal health, child health interventions to reduce morbidity. Some were health education activities, which would not be too difficult to manage, but it's just a lot of things to remember in terms of promoting immunization for example. but what we're getting at is even with all these 19 different services, you can't start up via a village health worker, volunteer village health worker training program with 19 things. it's the time they have to be away for training would not be enough. But if again you have the community volunteers coming together once a month to submit their returns and get more supplies at the health center, that type of thing, while they're there together, the nurse could teach them one new thing every now and then, and build up from a basic package of a few things. So this is, this is the kind of thing we have to think about with our packages, is the ability to add on new things. How much can be added? How does the community take responsibility? Do they respond by selecting more volunteers? this is the kind of thing that we, that we're concerned about. because we certainly don't want to overburden volunteers, such that they don't have time to do their regular work. Again, looking at the Malaria Plus package, we really are seeing this as an extension of local government, of services, an extension of community mobilization and communication, so there're quite a number of things involved. it requires much more supervision on the part of the health team to make sure these things happen. So, the, the stress if you're going to develop a package is to take it slowly and carefully. One of the issues, therefore, when you have a package, and you've decided on the three, four, maybe five at most, start-up activities, you'll still need to do the same kind of training needs diagnosis with your interviews, with your observations, with your review of records, to see how well positioned the health system, the communities, and the volunteers are to take up these new skills. So, some of the things you would want to do is interviews in the community. What do they think about the medicines? What do they think about the diseases? What's their experience been? with these, you'll want to talk to the people about community leaders about the volunteer capacity, can they handle these things. Get the volunteers own views about what more they think they can handle, what they want to do. reviewing of documents, you'd look at the national technical guidelines for all of these things, whether it's guidelines for oral rehydration or guidelines for hygiene, whatever it is. So you would want to do this diagnostic work of interviewing, observing, and reviewing of documents and records around the components of that package. So in summary, throughout this lecture, we've looked at how we can best determine the needs of people who are going to be trained, and relating that of course to the people who are going to serve, and again relating that to the people who are going to supervise them, basing it hopefully as much as possible on community expressed needs. But at the same time, we recognize the reality that governments and health departments do want to have a impact on the major causes of morbidity and mortality in their community, so they may, be basing their training on a minimum care package. In either case, we would want to learn about what the trainees need. What they, what skills, what knowledge, what attitudes they need, through interviews, through review of documents and observation of their performance. Thank you.
