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Implementing what works: a case study of integrated primary health care revitalisation in Timor-Leste

Implementing what works: a case study of integrated primary health care revitalisation in... Background: Revitalising primary health care (PHC) and the need to reach MDG targets requires developing countries to adapt current evidence about effective health systems to their local context. Timor-Leste in one of the world’s newest developing nations, with high maternal and child mortality rates, malaria, TB and malnutrition. Mountainous terrain and lack of transport pose serious challenges for accessing health services and implementing preventive health strategies. Methods: We conducted a non-systematic review of the literature and identified six components of an effective PHC system. These were mapped onto three countries’ PHC systems and present a case study from Timor-Leste’s Servisu Integrado du Saude Comunidade (SISCa) focussing on MDGs. Some of the challenges of implementing these into practice are shown through locally collected health system data. Results: An effective PHC system comprises 1) Strong leadership and government in human rights for health; 2) Prioritisation of cost-effective interventions; 3) Establishing an interactive and integrated culture of community engagement; 4) Providing an integrated continuum of care at the community level; 5) Supporting skilled and equipped health workers at all levels of the health system; 6) Creating a systems cycle of feedback using data to inform health care. The implementation case study from Timor-Leste (population 1 million) shows that in its third year, limited country-wide data had been collected and the SISCa program provided over half a million health interactions at the village level. However, only half of SISCa clinics were functional across the country. Attendances included not only pregnant women and children, but also adults and older community members. Development partners have played a key role in supporting this implementation process. Conclusion: The SISCa program is a PHC model implementing current best practice to reach remote communities in a new developing country. Despite limited resources, village level healthcare and engagement can be achieved but takes a long-term commitment and partnership. Background care’ and ‘primary health care’ which more broadly mobilises The thirty-year anniversary of the 1978 Alma-Ata declar- societies to transform health systems driven by values such as ation called for the revitalisation of Primary Health Care as equity, solidarity and participation [2]. “a set of guiding values for health development, a set of Whilst the Alma-Ata Declaration did not see the principles for the organisation of health services, and a achievement of health for all by 2000, the rebirth of many range of approaches for addressing priority health needs of these ideals within the broader cross-sectoral develop- and the fundamental determinants of health” [1]. The ment agenda in the Millennium Development Goals World Health Report in that same year was careful to make (MDGs) has continued a level of commitment, arguably at the distinction between the service-delivery-focused ‘primary a greater level. However, as the world sits a few years away from the MDG target date of 2015, there has been patchy * Correspondence: lyndal.trevena@sydney.edu.au achievement, particularly in the health-related goals MDG Sydney School of Public Health, University of Sydney, Room 321b, Edward 4,5 and 6 worldwide [3] and the focus in many countries Ford Building (A27), Sydney, NSW 2006, Australia Full list of author information is available at the end of the article © 2014 Martins and Trevena; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 2 of 11 http://www.apfmj.com/content/13/1/5 continues to be on vertically-driven, selective programs A case study of the implementation of PHC revitalisation and donor-driven agendas. was documented by the first author of this paper (NM), the Current thinking advocates for integration, a con- former health minister and developer of the Servisu Inte- tinuum of care approach and closer linkage of health to grado du Saude Comunidade (SISCa) program. The second development [1]. This has been accompanied by a grow- author was an independent observer of the program over a ing body of knowledge about what has worked and what four month period. Since the SISCa concept had been has not. Encouragingly, the evidence supports a number adapted partly from the Cuban and Indonesian systems we of the principles and components which were part of the also mapped the PHC revitalisation strategies onto these original Alma-Ata Declaration but the challenges of im- three country systems. Finally, we were able to obtain locally plementation remain. In this paper we summarise the collected data about the extent of SISCa implementation evidence-base for six core principles and components of after three the first three years (Figure 1). effective primary health care and provide a case example from Timor-Leste of how they have been implemented. Results Six components of an effective primary health care system Method 1. Strong leadership, partnership and government in We conducted a non-systematic review of the literature human rights for health using key words primary healthcare, health outcome and The World Health Organisation’s constitution states that systematic review in Medline, the Cochrane Database of “the enjoyment of the highest attainable standard of health Systematic Reviews, DARE and Health Technology Assess- is one of the fundamental rights of every human being”. ment. To try and capture reports in the grey literature we The protection of human rights for health can only be also search Google and key international development achieved through inter-sectoral action requiring a ‘whole of agency websites. We used a series of articles published in government’ commitment [4]. Social development and the Lancet for the 30-year anniversary of the Alma Ata good governance are linked to strong comprehensive Declaration as a core set of papers and hand-searched the primary health care systems [5]. These require leadership bibliographies of these and related articles. Articles were in- and commitment to appropriate strategies and funding by cluded if they provided some level of systematic review of national governments. A review showed that of the four- evidence relating to PHC in low or middle-income coun- teen countries furthest along the path of progress towards a tries. This case study does not include any experimental re- comprehensive and equitable primary health care system, search, nor any research carried out on humans or animals almost all have benefited from strong government commit- and as such did not require ethics committee approval. ment to an agreed national essential health package with Strong leadership and government in human rights for health Creating asystems Prioritisation of cycle of feedback cost-effective using data to interventions inform health care Primary Health Care Establishing an Supporting skilled interactive and and equipped integrated culture health workers at of community all levels of the engagement health system Providing an integrated continuum of care at the community level Figure 1 Core principles & components for effective implementation of primary health care. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 3 of 11 http://www.apfmj.com/content/13/1/5 Table 1 MDG-related cost-effective interventions for defined priorities and links to the not-for-profit sector, non- primary health care in developing countries government organisations and other service providers in Cost-effective interventions: MDG the system [5]. Goals -Promotion of reproductive health and family planning 4,5 2. Prioritisation of cost-effective interventions There is a growing body of evidence for cost-effective in- -Promotion of appropriate care-seeking and antenatal care in 4,5 pregnancy terventions which can be implemented at the primary -Promotion of skilled care for childbirth 4,5 care level in developing countries. A pragmatic coverage of these interventions in the maternal, neonatal and -Exclusive breastfeeding advice and support 4 child health area, would prevent 20-30% of maternal Preventive interventions: deaths, 20-21% neonatal deaths and 29-40% of post- -Provision/availability of contraceptives for birth spacing 1,4,5 neonatal deaths [6]. If 99% coverage of this package is -Cord care and clean delivery kits 4,5 achieved, their model predicts that this would increase -Iron, folate or multiple micronutrient supplementation in 4,5 to 67.3% of maternal deaths, 45% neonatal and 79% of pregnancy post-neonatal deaths averted. -Balanced protein-energy supplements during pregnancy in 1,4,5 The list of twenty seven proven interventions in Table 1 food-insecure populations provides a road-map for countries who, under the MDG -Calcium supplementation for PIH 4,5 targets aim to reduce child mortality by two-thirds, reduce -Low dose aspirin in high risk pregnancies 4,5 the maternal mortality ratio by three-quarters and to have -Anti-retrovirals in HIV-infected individuals and PMTCT 4,5,6 halted and begun to reverse the incidence of HIV/AIDS, malaria and others diseases (including TB). Prioritising these -Antibiotics for premature rupture of membranes 4,5 interventions clearly within a nation’s health strategy and -Antenatal steroids for those at risk of pre-term birth 4,5 planning is clearly important to achieving these outcomes. -EPI (including new vaccines for HIB, pneumococcal and 4 rotavirus) 3. Establishing an interactive and integrated culture of -Vitamin A supplementation in children 4 community engagement -Zinc supplementation in children for prevention of diarrhoea 4 Community engagement goes to the heart of the principles and pneumonia of Alma Ata and yet, has often been the component of pri- -Insecticide treated bed-nets for family 4,5,6 mary health care that has been most neglected. Within this -Intermittent preventive treatment for malaria in pregnant 4,5,6 construct of ‘community engagement’ it’simportant to dis- women and children (IPT) tinguish between ‘participation', ‘mobilisation’ and ‘em- -*Household-level water storage and disinfection* 4,5,6,7 powerment’. Participation can either be active or passive Treatment interventions: involvement whereas ‘mobilisation’ usually refers to com- -Promotion and use of skilled birth attendants at health facilities 4,5 munities responding to directives from health professionals to improve their health. More recently, there has been an -Interventions for prevention of post-partum haemorrhage and 4,5 use of oxytocics. important return to ‘empowerment’ strategies that have -Basic newborn resuscitation with bag and mask 4 health workers acting as facilitators with communities to identify strategies and make decisions that impact on the -Improved diarrhoea management (zinc and ORT) 4 ‘process’ of health improvement [7,8]. -Community detection and treatment of pneumonia with short 4 Community-mediated interventions can improve health course amoxicillin outcomes although many of these have been top-down -Improved case management of malaria (including ACTs) 6 strategies through training community health workers and -Recognition, triage and treatment of severe malnutrition in 1,4 less often through bottom-up or interactive models of com- affected children in the community setting munity engagement. A Cochrane review of eighteen trials -*Active case identification of TB in households and treatment 6 showed that community-based interventions did not show with DOTs any reduction in maternal mortality (RR 0.77; 95% CI 0.59 Adapted from Bhutta et al. [6]. *denotes additional new items of relevance to Timor-Leste context. to 1.02) but did significantly reduce maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92), neonatal mortality (RR 0.76; 95% CI 0.68 to 0.84), stillbirths (RR 0.84; 95% CI 0.74 to review by Bhutta et al. found the pooled effect of 0.97), and perinatal mortality (RR 0.80; 95% CI 0.71 to community-based interventions resulted in a 31% reduction 0.91). It also increased the referrals to health facilities for in neonatal mortality (RR = 0.69, 95%CI 0.61-0.77), a 29% pregnancy-related complications by 40% (RR 1.40; 95% CI reduction in peri-natal mortality (RR = 0.71, 95% CI 0.61- 1.19 to 1.65), and improved the rates of early breastfeeding 0.84) and 29% reduction in maternal morbidity (RR = 0.71, by 94% (RR 1.94; 95% CI 1.56 to 2.42) [9]. A separate 95% CI 0.53-0.94) [6]. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 4 of 11 http://www.apfmj.com/content/13/1/5 Unfortunately, early evidence for the effectiveness of 5. Supporting skilled and equipped health workers at all community empowerment strategies was largely replaced levels of the health system by an exclusive focus on evidence-based cost-effective in- There are many challenges in retaining and supporting terventions whose effects could be more easily quantified health workers which can threaten emerging primary in the 1990s and early 2000’s [8]. The research and global health care systems. Efficient systems and good govern- health community needs to embrace new research ance must ensure appropriate financing and distribution methodologies which measure the processes of decision- of essential medications and equipment in a sustainable making and empowerment in communities. Such strategies system. Effective and clear referral pathways must be have the potential to not only improve health literacy, but available for serious clinical cases. also to address local cultural issues and health beliefs as well However, developed world experience shows that sim- as geographic and health challenges specific to that commu- ply having staff and systems in place does not necessarily nity [10]. Studies which develop and evaluate complex inter- translate evidence into practice. Cost-effective interven- ventions to facilitate informed decision-making for tions exist and a number of international protocols have communities in developing country settings may help to im- been translated and adapted for country-specific con- proveunderstanding of this in thefuture[11]. texts. However, the real challenge lies with the effective implementation of such interventions, guidelines and protocols. A review of four randomised and six non- 4. Providing an integrated continuum of care at the randomised controlled studies in developing countries community level looking at the effect of education and training on health Several important analyses have recently looked at what professional behaviour. These showed an improvement has worked and what has not. Rohde et al. took life ex- in compliance with guidelines but the effect was not sus- pectancy against gross national income (GNI) and identi- tained. A range of educational formats, including locally fied that the top thirty low and middle income countries adapted and facilitated sessions were used but none were could be categorised as having one of three types of pri- compared head-to-head. There is insufficient evidence mary health care systems - selective primary health care, to assess the effectiveness of educational outreach, local primary health care in transition, or comprehensive pri- opinion leaders, use of mass media, and reminders. Edu- mary health care [5]. Selective primary health care systems cational materials alone are unlikely to influence change focussed on specific interventions delivered vertically but [15]. Creating effective ways of keeping health profes- at the community level. Comprehensive primary health sionals up-to-date in developing countries is an impor- care systems on the other hand, have a strong focus on tant item for the future research agenda. community health workers, good referral systems to the district level, equitable access to services for all, including the poorest communities and those geographically isolated 6. Creating a systems cycle of feedback using data to and the use of data for decision-making. These countries inform health care were more likely to have more skilled birth attendances, Feedback with data to communities and to health pro- lower maternal and child mortality, higher contraceptive fessionals is likely to improve the implementation of ef- prevalence, better immunisation coverage and inter- fective strategies into practice [15]. In fact, this is the sectoral outcomes such as access to safe drinking water, only strategy that has been shown to have such an effect school attendance by girls and adult literacy levels [5]. in developing countries through one randomised and They are also associated with improved effectiveness, three non-randomised controlled studies (all hospital- equity and efficiency [12]. based). Several of the studies highlighted that sustain- Comprehensive primary health care systems should be ability can be limited by organisational barriers. One best placed to implement a ‘continuum of care’ across the suggested framework for the implementation of an inte- lifecycle. Maternal and child health advocates have re- grated primary health care strategy puts data collection cently described how this might look in practice by aiming and feedback as a vital part of an effective health system. for universal coverage with integrated essential care pack- This requires governments to support their district man- ages across the maternal and child health lifecycle and agers to implement, monitor and evaluate their health alongside other strategies such as malaria, TB, water and services and to disseminate the results. At the central sanitation programs [13]. Whilst the association between and district health sector level, the use of data in the better health and comprehensive primary health care is process of planning and monitoring policy and service encouraging, a separate review comparing the effect of in- delivery is challenging but has the potential to focus lim- tegrated services against fragmented services was incon- ited resources on identified gaps and to highlight areas clusive and unable to find enough experimental evidence of success. At the service provision and community level to infer causality [14]. it can also be used for audit and feedback for quality Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 5 of 11 http://www.apfmj.com/content/13/1/5 improvement for health providers and for empowerment [17]. The medical workforce was instantly supplied in of communities [16]. 2004 by the Cuban government through a bilateral agree- ment supplying several hundred Cuban doctors to Timor- Implementing the core components of PHC revitalisation Leste and the training of one thousand Timorese doctors, in practice: A case study from Timor-Leste initially in Cuba and now at the National University of Timor-Leste (formerly known as East Timor) lies on the Timor-Leste (UNTL). These Timorese graduates are now eastern side of the island of Timor, with the western half starting to work within the Timorese health system. Inter- being part of Indonesia. It is located to the north of national technical advisors in the Ministry of Health are Australia and west of Papua. The total population is ap- gradually being phased out and local policy development proximately one million, with the majority of people liv- is exemplified by the recent development of the new Na- ing in remote villages (sucos and aldeias) in rugged tional Health Strategy of Timorese Policymakers. mountain terrain, often cut-off by landslides and flooded The 2003 Timor-Leste Demographic Health Survey re- rivers during the wet season. From the 16th century on- ported that one-quarter of the population reported that wards, Timor-Leste was a Portuguese colony, occupied it took more than two hours to reach their usual health briefly by Japan in World War II and defended by Aus- provider and 86% walked to their nearest health facility. tralian and Dutch forces. There was a brief period of By 2008 a national study of health-seeking behaviour re- semi-independence in mid-November 1975 but Timor- iterated that participants still described long and difficult Leste was invaded by Indonesia on 7 December 1975 journeys to seek assistance for illness, using locally avail- and occupied until the UN took over in 1999 and subse- able traditional remedies as an alternative with limited quently became a formally independent nation on May capacity to engage in preventive health behaviours [18]. 20, 2002 after UN-supervised elections in 2001. The sta- Although the Ministry of Health established one com- bility of Timor-Leste in the first few years of democracy munity health centre (CHC) with moderate in-patient was fragile with a serious conflict breaking out in 2006 facilities in each of the thirteen districts, and one CHC and many people being internally displaced. Only since with no in-patient capacity in each sub-district, there 2007 has there been a period of stability and economic was not the capacity to reach one health post in every progress. Timor-Leste has oil and gas reserves managed village cluster (suco) with only 198 of the planned 442 in trust by the World Bank which provide a regulated established. One of the key reasons for developing the income source for the nation. SISCa program was to address this shortfall at the com- munity level, improving uptake of preventive healthcare Structure of the overall health system and health-seeking and access to basic medical services. behaviour During the past ten years the Government of Timor- Development of the SISCa (Servico Integrado da Saude Leste has established a tiered health system with the fol- Comunitaria) and coverage lowing basic structure (Figure 2). In 2008, the SISCa program commenced with each sub- Most effort has been on the establishment of core infra- district CHC required to deliver the SISCa program structure, human resource planning and placement across monthly in every suco (village), usually in an outdoor the health system. There are currently 2.2 nurses per meeting area, or a local resident’s home. The team in- 1,000 population and 0.1 doctors per 1,000 population cludes a doctor, midwife, health promotion officer, nurse 1 tertiary referral hospital 5 District Referral Hospitals 65 Community Health Centres – district one per sub- 198 Health Posts – several in each sub-district (plan upscale to 442) 503 Integrated Primary Health Care outreach to villages SiSCa Community Health Workers at Village level Figure 2 Overall structure of the Timor-Leste Health System. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 6 of 11 http://www.apfmj.com/content/13/1/5 and/or lab technician depending on available health 1,000 live births in 2004–2009 [21]. The MDG4 target workforce. During this early implementation period, for under-five mortality by 2015 is 53 per 1,000 live support is also provided by non-government organisa- births and the 2010 Demographic Health Survey (DHS) tions who act as development partners in strengthening reported it is currently 64 per 1,000 live births. There the health system. The model has similarities to the has also been an almost threefold increase in the num- Indonesian Posyandu program [19] but provides a more ber of children 12–23 months considered by the WHO comprehensive primary health care model as show in to be “fully immunized”, from 18 percent in 2003 to 53 Table 2. It has also borrowed elements from the Cuban percent in 2009 [21] and a recent report by the UNDP system which includes active case finding, home visit- goes so far as to suggest that these improvements could ation and community health registers. Table 2 shows be attributable, at least in part, to the SISCa program how these three country examples map across the six [22]. Ministry of Health routinely collected data in 2010 components of effective primary health care outlined in suggests this immunisation coverage may have risen fur- the first part of this paper. ther to around 66 per cent [23]. Routinely collected data There are six components (tables) within the SISCa also shows that the proportion of children under five be- structure. ing weighed has increased from 14.1 per cent in 2008 to 21.2 per cent in 2010 [23]. The SISCa program is provid- Table one: Registration ing a platform for a more assertive effort to address this Family registration (Registo Saude Familiar): Each suco problem. should have a register of all households to be used to monitor key health indicators nationally and locally. The Table three: Maternal health and family spacing data include names and ages of all household members, The MDG5 target for reduced maternal mortality may number of pregnant women, chronic diseases, children not be achieved by 2015 with a maternal mortality ratio with malnutrition, immunisations, TB cases, recent of 557 per 100,000 [24] and the Ministry of Health births and any deaths in the household. It forms the de- reporting 450 per 100,000 live births [23]. Midwives are nominator for the ‘library of registers’ which are an im- in attendance if possible, and a register is maintained of portant functional component of the SISCa program all pregnancies. The first half of the patient held record (described later in this article). Once the family register book (LISIO) is completed for pregnant mothers and the is completed it can be updated every month by the local second half is for the infant and child. A proactive ap- health team who should be aware of new pregnancies, proach is taken to identifying pregnant women within births, illnesses and deaths. the community and encouraging them to attend the SISCa for antenatal care. The health team also actively Table two: Nutrition assistance and child health seeks out women who may have delivered recently and promotion require a postnatal check which may involve home visits. Malnutrition is a significant problem in Timor-Leste A range of family spacing options are available alongside with almost half of children under five years stunted, health promotion videos and other resources which seek underweight or malnourished. Mothers are encouraged to facilitate informed choice in family spacing. to bring all children under-five to be weighed and have The proportion of women having at least one ante- their mid-upper-arm circumference measured. Counsel- natal care increased from 61 percent in 2003 to 86 per- ling and referral for under-nutrition is integrated with cent in 2009 and there has been an increase in skilled this service. Exclusive breastfeeding and good maternal birth attendance from 18.4 per cent in 2003 to 29.9 per nutrition is encouraged. Children are offered Vitamin A cent [20,24]. The proportion of women receiving postna- and de-worming treatment every six months and child- tal care has also increased from 14.6 per cent to 32 per hood immunisations are administered. Potential agricul- cent in the same period, fertility rates have fallen from tural solutions to food insecurity should be explored and 7.8 to 5.5 and contraceptive coverage has increased from mothers taught how to cook healthy meals for young 10 per cent to 22.3 percent. children using local foods through meetings with the local leaders, cooking demonstrations and posters or Table four: Hygiene, sanitation and malaria prevention flyers with pictures of healthy food options. Food sup- Health promotion staff, community health workers plements and supplies can be distributed to families at (PSFs), NGOs and others work with communities on risk. Inter-sectoral collaboration with agriculture can be personal hygiene, bed-net promotion, vector control and facilitated through the SISCa program’s community en- water and sanitation strategies. Hand-washing demon- gagement and surveillance. strations and bed-net distribution to all households of Timor-Leste has seen infant mortality fall from 68 per pregnant women and children under five are important 1,000 live births in the period 1999–2003 [20] to 44 per responsibilities of this table. Community health workers Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 7 of 11 http://www.apfmj.com/content/13/1/5 Table 2 Implementation of effective PHC components in remote communities - SISCa, Posyandu and Cuban systems Principles and components of SISCa program in Timor-Leste Posyandu program in Indonesia Cuban primary health care system effective primary health care Values Component 1 Strong leadership and Health as a human right in Government support for health Post-revolutionary socialist government in human Timor-Leste’s constitution since as a basic human need to live government responsible rights for health 2002. Free basic healthcare for a productive life. Primary care for healthcare as a human all citizens free via social insurance right and free for all citizens scheme (if eligible) Component 2 Establishing an interactive Community empowerment Use of community Active community and integrated culture of through community health workers volunteers (cadres) to participation encouraged community engagement (PSF), women’s self-help groups provide support to communities in health system and village councils through family doctor outreach as a joint social responsibility Structural Component 3 Prioritisation of cost Six tables targeting MDGs 1,4,5,6,7 Five tables targeting maternal Comprehensive primary effective interventions but also providing some and child health (MDGs 1,4 & 5) healthcare (family & preventive comprehensive ambulatory via monthly clinics at community medicine, inter-sectoral action) care via monthly outreach healthcare post mainly via family doctors clinics in villages (sucos) based at community clinics but who also live in the communities. Component 4 Provide an integrated Comprehensive coverage of maternal Outreach clinic focus Doctor-led health team in continuum of care & child health, active case finding and on maternal local polyclinic. Active case- home visits including TB, leprosy, and child health finding and home visitation malaria control to whole community. from these facilities. High General ambulatory care for all ages coverage of health facilities including chronic disease in remote areas. management. Occasional outreach specialist care (eg dental, eyes) Functional Component 5 Supporting skilled and Healthcare delivery and referral at Village midwife and immunisation High ratio of doctors per equipped health workers at all outreach clinics by doctors, midwives, nurse deliver MCH program with community, with responsibility levels of system nurses and health promotion staff supervision of doctor from for local health outcomes with support of NGOs sub-district clinic Component 6 Create a systems cycle of A ‘library’ of register books Data collection and Local register books of community feedback using data to for each community feedback not systematic health data systematically collected inform healthcare and maintained by family doctors are also asked to complete a household survey (called Table five: Ambulatory primary care Kubasa) on water, sanitation and hygiene prior to the A doctor or nurse is available to assess sick children and SISCa. As with the other surveys and registers these adults and can prescribe basic treatments or refer to se- form a ‘library’ or virtual database for each community. condary care services as required. Treatment of child- Access to clean drinking water and adequate sanitation hood respiratory disease, gastroenteritis, implementation remains a major problem for Timor-Leste. The number of of IMCI, case detection of malaria and TB including households using an improved water source only in- spot sputum collection and rapid-tests for malaria and creased from 53 per cent to 63 per cent between 2003 and the commencement of treatment or referral can occur. 2009 and household with inadequate sanitation reduced Active case detection of TB and malaria has seen the na- from 70 per cent to 57.1 per cent [20,24]. The number of tional case detection rates increase from 76 per cent in children under five sleeping under a bed-net has increased 2005 to 84 per cent and cohort cure rates rise from 61 from 21.2 per cent in 2007 to 45.5% in 2009 [22]. per cent in 2005 to 73 per cent in 2008 [25]. Ministry of Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 8 of 11 http://www.apfmj.com/content/13/1/5 Figure 3 Proportion of monthly SISCa clinics functioning by district 2010. Health data also suggests that malaria incidence has re- opportunity to change and improve service quality and duced with 132.9 cases per 1,000 in 2008 and 104.2 per respond to community needs. For example, local teams 1,000 in 2010 [23]. may identify poor child nutrition rates as a significant local issue allowing discussion about local solutions and ongoing monitoring of the impact. These functional ele- Table six: Health promotion activities ments have been amongst the most challenging to im- Activities may include showing films, using flipcharts, plement in a low tech environment with limited staff group discussions or one-to-one counselling on issues and community workers with lower levels if numeracy that are relevant to the community (eg good child nutri- and literacy. It will take time to instil a culture of audit tion, malaria prevention, management of gastroenteritis and feedback and to empower communities and local in children, birth spacing methods, promoting birth at health teams in this way. health facilities etc.). SISCA Functional elements (A ‘library’ of registers for each SISCa coverage and impact on health-seeking behaviour community, Health care and delivery Audit and feedback The SISCa program was specifically designed to revital- for quality improvement) ise primary healthcare in an equitable fashion following The collection of registers for each community provides ongoing surveys showing difficulties accessing health a rich dataset to inform health planning and services. facility-based services and poor implementation of pre- Timor-Leste has poor or non-existent internet coverage ventive healthcare strategies. Challenges remain with in most districts, necessitating manual book registers for health workforce shortages persisting in some areas and the moment. It is hoped that eventually this ‘library of many communities being isolated by flooded rivers in registers’ will become electronic linking peripheral cen- the wet season. In 2010, Ministry of Health data shows tres with each other the central facilities. SISCa coverage varied between 30 and 89% per cent SISCa participation rates and evaluations can be fed across the country (see Figure 3) but over half a million back to health workers and communities affording an visits were made to SISCa clinics across the year. The Figure 4 Distribution of SISCa attendees by age 2010 (Total attendances 555,608). Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 9 of 11 http://www.apfmj.com/content/13/1/5 Figure 5 (See legend on next page.) Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 10 of 11 http://www.apfmj.com/content/13/1/5 (See figure on previous page.) Figure 5 SISCa activities operating in the community. Photos A&B: Typical SISCa locations. Photos C& D: Community worker weighs an infant and a nurse immunises a young baby. Photos E&F Pregant women wait for ANC and a family spacing consultation with nurse. Photos G &H: Hand-washing and bed-net distribution. Photos I&J: Basic medical services and a simple dispensary. Photos K&L: Health promotion activities using flipcharts, posters and films. SISCa attendances reflect access to a comprehensive has extended their primary health care system to integrate range of healthcare services with a substantial number basic health service package delivery with active health pro- of older children and adults attending in addition to motion in community outreach. Although it is not possible mothers and babies. (See Figure 4) Although pregnant to infer causality, the current improvements in health ser- women were a small proportion of those seen at SISCa vice utilisation, immunisation coverage and reduction in clinics in 2010, the 2009–2010 Demographic Health Sur- TB and malaria are encouraging and serve to illustrate how vey reports that 55.10% pregnant women received at the SISCa concept aims to reach remote mountainous least four antenatal visits. Further evaluation needs to communities with targeted and effective interventions. The explore whether women prefer and choose to go to recently published UN Human Development Report for health facilities for their antenatal care than at the SISCa Timor shows the country is on track for many of the health clinic and to what extent the SISCa program has allowed MDGs with the need for a more concerted effort in measles a relationship to develop between midwives and women vaccine coverage, maternal mortality, HIV/AIDS education within these remote communities. As the coverage of and malaria control. Strengthening the current system SISCa clinics improves it will be important to build on will hopefully help to achieve these targets which will be this framework of improved access to healthcare through a major achievement for one of the world’s youngest better quality care and using the data to inform at all independent nations. levels of the system (Figure 5). Competing interests Both authors declare: no support from any organisation for the submitted work; Implementing the six components of effective primary no financial relationships with any organisations that might have an interest in health care the submitted work in the previous three years, no other relationships or During the first few years of implementation of the SISCa activities that could appear to have influenced the submitted work. Dr Nelson Martins is the former Health Minister for Timor-Leste but has no program, some of the components of effective primary commercial or other conflicts of interest with the development of the SISCa health care have been easier to achieve than others. Strong program. A/Professor Trevena is a primary care and public health academic leadership and the inclusion of health as a human right in who has collaborated with the Ministry of Health, Timor-Leste on health systems strengthening and capacity building activities over the past four the country’s constitution have been fundamental in getting years. She has no commercial or other conflicts of interest with the SISCa the program started and sustained. The SISCa program has program or with any other aspect of this manuscript. remained as a core component in the new 20 year National Strategic Development Plan. The framework of SISCa al- Authors’ contributions lows for the prioritisation of many of the cost-effective in- NM is the key developer of the Serviso Integrado de Saude Comunitaria terventions listed in Table 1, although not everything on (SISCa) concept and has led its implementation over the past four years. He has met with A/Prof LT regularly and discussed and jointly decided on this list is part of national protocols and, like most coun- the scope and outline of the paper. He provided detailed content for the tries, there are substantial variations in the implementation SISCa component of the paper and has contributed to multiple revisions of these. Engagement with communities has been reflected of the manuscript. A/Prof LT has completed and synthesised the major evidence review on effective primary health care for this paper and has in theattendancerates showninFigure4butthe role and worked jointly with NM on writing and revising the manuscript from its sustainability of community volunteers continues to need inception. She has coordinated and sourced much of the data which supports strengthening. Integrated healthcare is at the core of the the case study. She will be the corresponding author on the paper. Both authors read and approved the final manuscript. SISCa program and has been more widely achieved than other components through the structural components of SISCa. The health workforce in Timor-Leste continues to Acknowledgements Thanks to staff at the Ministry of Health, Timor-Leste and to Health Alliance expand and up-skill with strengthened referral pathways International (HAI) and TAIS for helping to source data and resources for the and supply chains being identified as a priority in the new preparation of this manuscript. HAI also provided office space, and access to strategic plan. Data systems and feedback cycles will likely several SISCa support visits for A/Prof Trevena in Timor-Leste. be the most challenging component of the system to imple- ment (Figure 3 and 4). Funding source A/Prof Trevena’s work in Timor-Leste was supported by an Australian Government Endeavour Executive Award which provided travel and living Conclusion expenses for her study leave period. The Australian Government is a major This paper has identified six core components of an effect- donor of aid to Timor-Leste but had no direct input or influence over this ive PHC revitalisation. It has described how Timor-Leste manuscript. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 11 of 11 http://www.apfmj.com/content/13/1/5 Author details 21. NSD, Macro I: Timor-Leste Demographic and Health Survey 2009–10. Faculty of Medicine and Health Sciences, University Nacionale Timor-Leste, In Book Timor-Leste Demographic and Health Survey 2009–10. Calverton, Dili, Timor-Leste. Sydney School of Public Health, University of Sydney, Maryland USA: National Statistic Directorate Timor Leste, Ministry of Finance Room 321b, Edward Ford Building (A27), Sydney, NSW 2006, Australia. and ICF Macro; 2010. 22. UNDP: Timor Leste Human Development Report: Managing natural Received: 5 April 2013 Accepted: 9 February 2014 resources for human development. Developing the non-oil economy to Published: 24 February 2014 achieve the MDGs. In Book Timor Leste Human Development Report: Managing Natural Resources for Human Development. Developing the Non-Oil Economy to Achieve the MDGs. New York: United Nations Development References Program; 2011. 1. Lawn J, Rohde J, Rifkin S, Were M, Paul V, Chopra M: Alma-Ata 30 years on: 23. Timor-Leste MH, Ministry of Health: Data provided by the Ministry of revolutionary, relevant, and time to revitalise. Lancet 2008, 372:917–927. Health, Timor-Leste. In Book Data Provided by the Ministry of Health. 2. WHO: World Health Report: Primary Health Care - Now more than ever. Timor-Leste; 2010. In Book World Health Report: Primary Health Care - Now more than ever. 24. ICF: Timor-Leste Demographic and Health Survey 2009–2010: Preliminary Geneva: World Health Organisation; 2008. http://www.who.int/whr/2008/en/ Report. In Book Timor-Leste Demographic and Health Survey 2009–2010: (Accessed 11/02/2014). Preliminary Report. Calverton, Maryland, USA: National Statistics Directorate, 3. UN: Millenniun Development Goals Report.In Book Millenniun Ministry of Finance, Democratic Republic of Timor-Leste; 2010. Development Goals Report. New York: United Nations; 2010. http://www.un. 25. WHO: Tuberculosis country profiles: Timor-Leste. World Health org/millenniumgoals/reports/shtml. (Accessed 11/02/2014). organization, geneva. 2010. http://www.who.int/tb/country/data/profiles/ 4. Braveman P, Gruskin S: Poverty, equity, human rights and health. en/index.html. (Accessed 11/02/2014). Bull World Health Organ 2003, 81:539–545. 5. Rohde J, Cousens M, Chopra M, Tangcharoensathien V, Black R, Bhutta Z, doi:10.1186/1447-056X-13-5 Lawn J: 30 years after Alma-Ata: has primary health care worked in Cite this article as: Martins and Trevena: Implementing what works: a countries? Lancet 2008, 372(9642):950–961. case study of integrated primary health care revitalisation in Timor- Leste. Asia Pacific Family Medicine 2014 13:5. 6. Bhutta Z, Ali S, Cousens S, Ali T, Haider B, Rizvi A, Okong P, Bhutta A, Black R: Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make? Lancet 2008, 372:972–989. 7. Freire P: Pedagogy of the Oppressed; 1970. 8. Rosata M, Laverack G, Grabman L, Tripathy P, Nair N, Mwansambo C, Azad K, Morrison J, Bhutta Z, Perry H, et al: Community participation: lessons for maternal, newborn, and child health. Lancet 2008, 372:962–971. 9. Lassi ZS, Haider BA, Bhutta ZA: Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev 2010, 10(11):CD007754. doi:10.1002/14651858. CD007754.pub2. 10. Trevena L, Barratt A: Integrated decision making: definitions for a new discipline. Patient Educ Couns 2003, 50:265–268. 11. Craig P, Dieppe P, Macintyre S, Mitchie S, Nazareth I, Petticrew M: Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008, 337. 12. Kruk M, Porignon D, Rockers P, Van Lerberghe W: The contribution of primary care to health and health systems in low - and middle-income countries: a critical review of major primary care initiatives. Soc Sci Med 2010, 70:904–911. 13. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE: Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 2007, 370:1358–1369. 14. Briggs C, Garner P: Strategies for integrating primary health services in middle- and low-income countries at the point of delivery. Cochrane Database Syst Rev 2006:CD003318. doi:003310.001002/14651858. CD14003318.pub14651852. 15. Siddiqi K, Newell J, Robinson M: Getting evidence into practice: what works in developing countries? Int J Qual Health Care 2005, 17:447–453. 16. Ekman B, Pathmanathan I, Lijestrund J: Integrating health interventions for women, newborn babies, and children: a framework for action. Lancet 2008, 372:990–1000. Submit your next manuscript to BioMed Central 17. Langenbrunner J, Somanathan A: Financing Health Care in East Asia and and take full advantage of: the Pacific. In Book Financing Health Care in East Asia and the Pacific. City: The World Bank; 2011. • Convenient online submission 18. Zwi A, Blignault I, Glazebrook D, Correia V, Bateman Steel C, Ferreira E, Pinto B: • Thorough peer review Timor-Leste Health Care Seeking Behaviour Study. In Book Timor-Leste Health Care Seeking Behaviour Study. City: The University of New South Wales, Sydney; 2009. • No space constraints or color figure charges 19. Leimena SL: Posyandu: a community based vehicle to improve child • Immediate publication on acceptance survival and development. Asia Pac J Public Health 1989, 3:264–267. 20. Ministry of Health & National Statistics Office, University of Newcastle, • Inclusion in PubMed, CAS, Scopus and Google Scholar Australian National University: Timor-Leste 2003 Demographic and Health • Research which is freely available for redistribution Survey. In Book Timor-Leste 2003 Demographic and Health Survey. Newcastle, Australia; 2003. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Implementing what works: a case study of integrated primary health care revitalisation in Timor-Leste

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Springer Journals
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Copyright © 2014 by Martins and Trevena; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/1447-056X-13-5
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Abstract

Background: Revitalising primary health care (PHC) and the need to reach MDG targets requires developing countries to adapt current evidence about effective health systems to their local context. Timor-Leste in one of the world’s newest developing nations, with high maternal and child mortality rates, malaria, TB and malnutrition. Mountainous terrain and lack of transport pose serious challenges for accessing health services and implementing preventive health strategies. Methods: We conducted a non-systematic review of the literature and identified six components of an effective PHC system. These were mapped onto three countries’ PHC systems and present a case study from Timor-Leste’s Servisu Integrado du Saude Comunidade (SISCa) focussing on MDGs. Some of the challenges of implementing these into practice are shown through locally collected health system data. Results: An effective PHC system comprises 1) Strong leadership and government in human rights for health; 2) Prioritisation of cost-effective interventions; 3) Establishing an interactive and integrated culture of community engagement; 4) Providing an integrated continuum of care at the community level; 5) Supporting skilled and equipped health workers at all levels of the health system; 6) Creating a systems cycle of feedback using data to inform health care. The implementation case study from Timor-Leste (population 1 million) shows that in its third year, limited country-wide data had been collected and the SISCa program provided over half a million health interactions at the village level. However, only half of SISCa clinics were functional across the country. Attendances included not only pregnant women and children, but also adults and older community members. Development partners have played a key role in supporting this implementation process. Conclusion: The SISCa program is a PHC model implementing current best practice to reach remote communities in a new developing country. Despite limited resources, village level healthcare and engagement can be achieved but takes a long-term commitment and partnership. Background care’ and ‘primary health care’ which more broadly mobilises The thirty-year anniversary of the 1978 Alma-Ata declar- societies to transform health systems driven by values such as ation called for the revitalisation of Primary Health Care as equity, solidarity and participation [2]. “a set of guiding values for health development, a set of Whilst the Alma-Ata Declaration did not see the principles for the organisation of health services, and a achievement of health for all by 2000, the rebirth of many range of approaches for addressing priority health needs of these ideals within the broader cross-sectoral develop- and the fundamental determinants of health” [1]. The ment agenda in the Millennium Development Goals World Health Report in that same year was careful to make (MDGs) has continued a level of commitment, arguably at the distinction between the service-delivery-focused ‘primary a greater level. However, as the world sits a few years away from the MDG target date of 2015, there has been patchy * Correspondence: lyndal.trevena@sydney.edu.au achievement, particularly in the health-related goals MDG Sydney School of Public Health, University of Sydney, Room 321b, Edward 4,5 and 6 worldwide [3] and the focus in many countries Ford Building (A27), Sydney, NSW 2006, Australia Full list of author information is available at the end of the article © 2014 Martins and Trevena; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 2 of 11 http://www.apfmj.com/content/13/1/5 continues to be on vertically-driven, selective programs A case study of the implementation of PHC revitalisation and donor-driven agendas. was documented by the first author of this paper (NM), the Current thinking advocates for integration, a con- former health minister and developer of the Servisu Inte- tinuum of care approach and closer linkage of health to grado du Saude Comunidade (SISCa) program. The second development [1]. This has been accompanied by a grow- author was an independent observer of the program over a ing body of knowledge about what has worked and what four month period. Since the SISCa concept had been has not. Encouragingly, the evidence supports a number adapted partly from the Cuban and Indonesian systems we of the principles and components which were part of the also mapped the PHC revitalisation strategies onto these original Alma-Ata Declaration but the challenges of im- three country systems. Finally, we were able to obtain locally plementation remain. In this paper we summarise the collected data about the extent of SISCa implementation evidence-base for six core principles and components of after three the first three years (Figure 1). effective primary health care and provide a case example from Timor-Leste of how they have been implemented. Results Six components of an effective primary health care system Method 1. Strong leadership, partnership and government in We conducted a non-systematic review of the literature human rights for health using key words primary healthcare, health outcome and The World Health Organisation’s constitution states that systematic review in Medline, the Cochrane Database of “the enjoyment of the highest attainable standard of health Systematic Reviews, DARE and Health Technology Assess- is one of the fundamental rights of every human being”. ment. To try and capture reports in the grey literature we The protection of human rights for health can only be also search Google and key international development achieved through inter-sectoral action requiring a ‘whole of agency websites. We used a series of articles published in government’ commitment [4]. Social development and the Lancet for the 30-year anniversary of the Alma Ata good governance are linked to strong comprehensive Declaration as a core set of papers and hand-searched the primary health care systems [5]. These require leadership bibliographies of these and related articles. Articles were in- and commitment to appropriate strategies and funding by cluded if they provided some level of systematic review of national governments. A review showed that of the four- evidence relating to PHC in low or middle-income coun- teen countries furthest along the path of progress towards a tries. This case study does not include any experimental re- comprehensive and equitable primary health care system, search, nor any research carried out on humans or animals almost all have benefited from strong government commit- and as such did not require ethics committee approval. ment to an agreed national essential health package with Strong leadership and government in human rights for health Creating asystems Prioritisation of cycle of feedback cost-effective using data to interventions inform health care Primary Health Care Establishing an Supporting skilled interactive and and equipped integrated culture health workers at of community all levels of the engagement health system Providing an integrated continuum of care at the community level Figure 1 Core principles & components for effective implementation of primary health care. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 3 of 11 http://www.apfmj.com/content/13/1/5 Table 1 MDG-related cost-effective interventions for defined priorities and links to the not-for-profit sector, non- primary health care in developing countries government organisations and other service providers in Cost-effective interventions: MDG the system [5]. Goals -Promotion of reproductive health and family planning 4,5 2. Prioritisation of cost-effective interventions There is a growing body of evidence for cost-effective in- -Promotion of appropriate care-seeking and antenatal care in 4,5 pregnancy terventions which can be implemented at the primary -Promotion of skilled care for childbirth 4,5 care level in developing countries. A pragmatic coverage of these interventions in the maternal, neonatal and -Exclusive breastfeeding advice and support 4 child health area, would prevent 20-30% of maternal Preventive interventions: deaths, 20-21% neonatal deaths and 29-40% of post- -Provision/availability of contraceptives for birth spacing 1,4,5 neonatal deaths [6]. If 99% coverage of this package is -Cord care and clean delivery kits 4,5 achieved, their model predicts that this would increase -Iron, folate or multiple micronutrient supplementation in 4,5 to 67.3% of maternal deaths, 45% neonatal and 79% of pregnancy post-neonatal deaths averted. -Balanced protein-energy supplements during pregnancy in 1,4,5 The list of twenty seven proven interventions in Table 1 food-insecure populations provides a road-map for countries who, under the MDG -Calcium supplementation for PIH 4,5 targets aim to reduce child mortality by two-thirds, reduce -Low dose aspirin in high risk pregnancies 4,5 the maternal mortality ratio by three-quarters and to have -Anti-retrovirals in HIV-infected individuals and PMTCT 4,5,6 halted and begun to reverse the incidence of HIV/AIDS, malaria and others diseases (including TB). Prioritising these -Antibiotics for premature rupture of membranes 4,5 interventions clearly within a nation’s health strategy and -Antenatal steroids for those at risk of pre-term birth 4,5 planning is clearly important to achieving these outcomes. -EPI (including new vaccines for HIB, pneumococcal and 4 rotavirus) 3. Establishing an interactive and integrated culture of -Vitamin A supplementation in children 4 community engagement -Zinc supplementation in children for prevention of diarrhoea 4 Community engagement goes to the heart of the principles and pneumonia of Alma Ata and yet, has often been the component of pri- -Insecticide treated bed-nets for family 4,5,6 mary health care that has been most neglected. Within this -Intermittent preventive treatment for malaria in pregnant 4,5,6 construct of ‘community engagement’ it’simportant to dis- women and children (IPT) tinguish between ‘participation', ‘mobilisation’ and ‘em- -*Household-level water storage and disinfection* 4,5,6,7 powerment’. Participation can either be active or passive Treatment interventions: involvement whereas ‘mobilisation’ usually refers to com- -Promotion and use of skilled birth attendants at health facilities 4,5 munities responding to directives from health professionals to improve their health. More recently, there has been an -Interventions for prevention of post-partum haemorrhage and 4,5 use of oxytocics. important return to ‘empowerment’ strategies that have -Basic newborn resuscitation with bag and mask 4 health workers acting as facilitators with communities to identify strategies and make decisions that impact on the -Improved diarrhoea management (zinc and ORT) 4 ‘process’ of health improvement [7,8]. -Community detection and treatment of pneumonia with short 4 Community-mediated interventions can improve health course amoxicillin outcomes although many of these have been top-down -Improved case management of malaria (including ACTs) 6 strategies through training community health workers and -Recognition, triage and treatment of severe malnutrition in 1,4 less often through bottom-up or interactive models of com- affected children in the community setting munity engagement. A Cochrane review of eighteen trials -*Active case identification of TB in households and treatment 6 showed that community-based interventions did not show with DOTs any reduction in maternal mortality (RR 0.77; 95% CI 0.59 Adapted from Bhutta et al. [6]. *denotes additional new items of relevance to Timor-Leste context. to 1.02) but did significantly reduce maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92), neonatal mortality (RR 0.76; 95% CI 0.68 to 0.84), stillbirths (RR 0.84; 95% CI 0.74 to review by Bhutta et al. found the pooled effect of 0.97), and perinatal mortality (RR 0.80; 95% CI 0.71 to community-based interventions resulted in a 31% reduction 0.91). It also increased the referrals to health facilities for in neonatal mortality (RR = 0.69, 95%CI 0.61-0.77), a 29% pregnancy-related complications by 40% (RR 1.40; 95% CI reduction in peri-natal mortality (RR = 0.71, 95% CI 0.61- 1.19 to 1.65), and improved the rates of early breastfeeding 0.84) and 29% reduction in maternal morbidity (RR = 0.71, by 94% (RR 1.94; 95% CI 1.56 to 2.42) [9]. A separate 95% CI 0.53-0.94) [6]. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 4 of 11 http://www.apfmj.com/content/13/1/5 Unfortunately, early evidence for the effectiveness of 5. Supporting skilled and equipped health workers at all community empowerment strategies was largely replaced levels of the health system by an exclusive focus on evidence-based cost-effective in- There are many challenges in retaining and supporting terventions whose effects could be more easily quantified health workers which can threaten emerging primary in the 1990s and early 2000’s [8]. The research and global health care systems. Efficient systems and good govern- health community needs to embrace new research ance must ensure appropriate financing and distribution methodologies which measure the processes of decision- of essential medications and equipment in a sustainable making and empowerment in communities. Such strategies system. Effective and clear referral pathways must be have the potential to not only improve health literacy, but available for serious clinical cases. also to address local cultural issues and health beliefs as well However, developed world experience shows that sim- as geographic and health challenges specific to that commu- ply having staff and systems in place does not necessarily nity [10]. Studies which develop and evaluate complex inter- translate evidence into practice. Cost-effective interven- ventions to facilitate informed decision-making for tions exist and a number of international protocols have communities in developing country settings may help to im- been translated and adapted for country-specific con- proveunderstanding of this in thefuture[11]. texts. However, the real challenge lies with the effective implementation of such interventions, guidelines and protocols. A review of four randomised and six non- 4. Providing an integrated continuum of care at the randomised controlled studies in developing countries community level looking at the effect of education and training on health Several important analyses have recently looked at what professional behaviour. These showed an improvement has worked and what has not. Rohde et al. took life ex- in compliance with guidelines but the effect was not sus- pectancy against gross national income (GNI) and identi- tained. A range of educational formats, including locally fied that the top thirty low and middle income countries adapted and facilitated sessions were used but none were could be categorised as having one of three types of pri- compared head-to-head. There is insufficient evidence mary health care systems - selective primary health care, to assess the effectiveness of educational outreach, local primary health care in transition, or comprehensive pri- opinion leaders, use of mass media, and reminders. Edu- mary health care [5]. Selective primary health care systems cational materials alone are unlikely to influence change focussed on specific interventions delivered vertically but [15]. Creating effective ways of keeping health profes- at the community level. Comprehensive primary health sionals up-to-date in developing countries is an impor- care systems on the other hand, have a strong focus on tant item for the future research agenda. community health workers, good referral systems to the district level, equitable access to services for all, including the poorest communities and those geographically isolated 6. Creating a systems cycle of feedback using data to and the use of data for decision-making. These countries inform health care were more likely to have more skilled birth attendances, Feedback with data to communities and to health pro- lower maternal and child mortality, higher contraceptive fessionals is likely to improve the implementation of ef- prevalence, better immunisation coverage and inter- fective strategies into practice [15]. In fact, this is the sectoral outcomes such as access to safe drinking water, only strategy that has been shown to have such an effect school attendance by girls and adult literacy levels [5]. in developing countries through one randomised and They are also associated with improved effectiveness, three non-randomised controlled studies (all hospital- equity and efficiency [12]. based). Several of the studies highlighted that sustain- Comprehensive primary health care systems should be ability can be limited by organisational barriers. One best placed to implement a ‘continuum of care’ across the suggested framework for the implementation of an inte- lifecycle. Maternal and child health advocates have re- grated primary health care strategy puts data collection cently described how this might look in practice by aiming and feedback as a vital part of an effective health system. for universal coverage with integrated essential care pack- This requires governments to support their district man- ages across the maternal and child health lifecycle and agers to implement, monitor and evaluate their health alongside other strategies such as malaria, TB, water and services and to disseminate the results. At the central sanitation programs [13]. Whilst the association between and district health sector level, the use of data in the better health and comprehensive primary health care is process of planning and monitoring policy and service encouraging, a separate review comparing the effect of in- delivery is challenging but has the potential to focus lim- tegrated services against fragmented services was incon- ited resources on identified gaps and to highlight areas clusive and unable to find enough experimental evidence of success. At the service provision and community level to infer causality [14]. it can also be used for audit and feedback for quality Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 5 of 11 http://www.apfmj.com/content/13/1/5 improvement for health providers and for empowerment [17]. The medical workforce was instantly supplied in of communities [16]. 2004 by the Cuban government through a bilateral agree- ment supplying several hundred Cuban doctors to Timor- Implementing the core components of PHC revitalisation Leste and the training of one thousand Timorese doctors, in practice: A case study from Timor-Leste initially in Cuba and now at the National University of Timor-Leste (formerly known as East Timor) lies on the Timor-Leste (UNTL). These Timorese graduates are now eastern side of the island of Timor, with the western half starting to work within the Timorese health system. Inter- being part of Indonesia. It is located to the north of national technical advisors in the Ministry of Health are Australia and west of Papua. The total population is ap- gradually being phased out and local policy development proximately one million, with the majority of people liv- is exemplified by the recent development of the new Na- ing in remote villages (sucos and aldeias) in rugged tional Health Strategy of Timorese Policymakers. mountain terrain, often cut-off by landslides and flooded The 2003 Timor-Leste Demographic Health Survey re- rivers during the wet season. From the 16th century on- ported that one-quarter of the population reported that wards, Timor-Leste was a Portuguese colony, occupied it took more than two hours to reach their usual health briefly by Japan in World War II and defended by Aus- provider and 86% walked to their nearest health facility. tralian and Dutch forces. There was a brief period of By 2008 a national study of health-seeking behaviour re- semi-independence in mid-November 1975 but Timor- iterated that participants still described long and difficult Leste was invaded by Indonesia on 7 December 1975 journeys to seek assistance for illness, using locally avail- and occupied until the UN took over in 1999 and subse- able traditional remedies as an alternative with limited quently became a formally independent nation on May capacity to engage in preventive health behaviours [18]. 20, 2002 after UN-supervised elections in 2001. The sta- Although the Ministry of Health established one com- bility of Timor-Leste in the first few years of democracy munity health centre (CHC) with moderate in-patient was fragile with a serious conflict breaking out in 2006 facilities in each of the thirteen districts, and one CHC and many people being internally displaced. Only since with no in-patient capacity in each sub-district, there 2007 has there been a period of stability and economic was not the capacity to reach one health post in every progress. Timor-Leste has oil and gas reserves managed village cluster (suco) with only 198 of the planned 442 in trust by the World Bank which provide a regulated established. One of the key reasons for developing the income source for the nation. SISCa program was to address this shortfall at the com- munity level, improving uptake of preventive healthcare Structure of the overall health system and health-seeking and access to basic medical services. behaviour During the past ten years the Government of Timor- Development of the SISCa (Servico Integrado da Saude Leste has established a tiered health system with the fol- Comunitaria) and coverage lowing basic structure (Figure 2). In 2008, the SISCa program commenced with each sub- Most effort has been on the establishment of core infra- district CHC required to deliver the SISCa program structure, human resource planning and placement across monthly in every suco (village), usually in an outdoor the health system. There are currently 2.2 nurses per meeting area, or a local resident’s home. The team in- 1,000 population and 0.1 doctors per 1,000 population cludes a doctor, midwife, health promotion officer, nurse 1 tertiary referral hospital 5 District Referral Hospitals 65 Community Health Centres – district one per sub- 198 Health Posts – several in each sub-district (plan upscale to 442) 503 Integrated Primary Health Care outreach to villages SiSCa Community Health Workers at Village level Figure 2 Overall structure of the Timor-Leste Health System. Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 6 of 11 http://www.apfmj.com/content/13/1/5 and/or lab technician depending on available health 1,000 live births in 2004–2009 [21]. The MDG4 target workforce. During this early implementation period, for under-five mortality by 2015 is 53 per 1,000 live support is also provided by non-government organisa- births and the 2010 Demographic Health Survey (DHS) tions who act as development partners in strengthening reported it is currently 64 per 1,000 live births. There the health system. The model has similarities to the has also been an almost threefold increase in the num- Indonesian Posyandu program [19] but provides a more ber of children 12–23 months considered by the WHO comprehensive primary health care model as show in to be “fully immunized”, from 18 percent in 2003 to 53 Table 2. It has also borrowed elements from the Cuban percent in 2009 [21] and a recent report by the UNDP system which includes active case finding, home visit- goes so far as to suggest that these improvements could ation and community health registers. Table 2 shows be attributable, at least in part, to the SISCa program how these three country examples map across the six [22]. Ministry of Health routinely collected data in 2010 components of effective primary health care outlined in suggests this immunisation coverage may have risen fur- the first part of this paper. ther to around 66 per cent [23]. Routinely collected data There are six components (tables) within the SISCa also shows that the proportion of children under five be- structure. ing weighed has increased from 14.1 per cent in 2008 to 21.2 per cent in 2010 [23]. The SISCa program is provid- Table one: Registration ing a platform for a more assertive effort to address this Family registration (Registo Saude Familiar): Each suco problem. should have a register of all households to be used to monitor key health indicators nationally and locally. The Table three: Maternal health and family spacing data include names and ages of all household members, The MDG5 target for reduced maternal mortality may number of pregnant women, chronic diseases, children not be achieved by 2015 with a maternal mortality ratio with malnutrition, immunisations, TB cases, recent of 557 per 100,000 [24] and the Ministry of Health births and any deaths in the household. It forms the de- reporting 450 per 100,000 live births [23]. Midwives are nominator for the ‘library of registers’ which are an im- in attendance if possible, and a register is maintained of portant functional component of the SISCa program all pregnancies. The first half of the patient held record (described later in this article). Once the family register book (LISIO) is completed for pregnant mothers and the is completed it can be updated every month by the local second half is for the infant and child. A proactive ap- health team who should be aware of new pregnancies, proach is taken to identifying pregnant women within births, illnesses and deaths. the community and encouraging them to attend the SISCa for antenatal care. The health team also actively Table two: Nutrition assistance and child health seeks out women who may have delivered recently and promotion require a postnatal check which may involve home visits. Malnutrition is a significant problem in Timor-Leste A range of family spacing options are available alongside with almost half of children under five years stunted, health promotion videos and other resources which seek underweight or malnourished. Mothers are encouraged to facilitate informed choice in family spacing. to bring all children under-five to be weighed and have The proportion of women having at least one ante- their mid-upper-arm circumference measured. Counsel- natal care increased from 61 percent in 2003 to 86 per- ling and referral for under-nutrition is integrated with cent in 2009 and there has been an increase in skilled this service. Exclusive breastfeeding and good maternal birth attendance from 18.4 per cent in 2003 to 29.9 per nutrition is encouraged. Children are offered Vitamin A cent [20,24]. The proportion of women receiving postna- and de-worming treatment every six months and child- tal care has also increased from 14.6 per cent to 32 per hood immunisations are administered. Potential agricul- cent in the same period, fertility rates have fallen from tural solutions to food insecurity should be explored and 7.8 to 5.5 and contraceptive coverage has increased from mothers taught how to cook healthy meals for young 10 per cent to 22.3 percent. children using local foods through meetings with the local leaders, cooking demonstrations and posters or Table four: Hygiene, sanitation and malaria prevention flyers with pictures of healthy food options. Food sup- Health promotion staff, community health workers plements and supplies can be distributed to families at (PSFs), NGOs and others work with communities on risk. Inter-sectoral collaboration with agriculture can be personal hygiene, bed-net promotion, vector control and facilitated through the SISCa program’s community en- water and sanitation strategies. Hand-washing demon- gagement and surveillance. strations and bed-net distribution to all households of Timor-Leste has seen infant mortality fall from 68 per pregnant women and children under five are important 1,000 live births in the period 1999–2003 [20] to 44 per responsibilities of this table. Community health workers Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 7 of 11 http://www.apfmj.com/content/13/1/5 Table 2 Implementation of effective PHC components in remote communities - SISCa, Posyandu and Cuban systems Principles and components of SISCa program in Timor-Leste Posyandu program in Indonesia Cuban primary health care system effective primary health care Values Component 1 Strong leadership and Health as a human right in Government support for health Post-revolutionary socialist government in human Timor-Leste’s constitution since as a basic human need to live government responsible rights for health 2002. Free basic healthcare for a productive life. Primary care for healthcare as a human all citizens free via social insurance right and free for all citizens scheme (if eligible) Component 2 Establishing an interactive Community empowerment Use of community Active community and integrated culture of through community health workers volunteers (cadres) to participation encouraged community engagement (PSF), women’s self-help groups provide support to communities in health system and village councils through family doctor outreach as a joint social responsibility Structural Component 3 Prioritisation of cost Six tables targeting MDGs 1,4,5,6,7 Five tables targeting maternal Comprehensive primary effective interventions but also providing some and child health (MDGs 1,4 & 5) healthcare (family & preventive comprehensive ambulatory via monthly clinics at community medicine, inter-sectoral action) care via monthly outreach healthcare post mainly via family doctors clinics in villages (sucos) based at community clinics but who also live in the communities. Component 4 Provide an integrated Comprehensive coverage of maternal Outreach clinic focus Doctor-led health team in continuum of care & child health, active case finding and on maternal local polyclinic. Active case- home visits including TB, leprosy, and child health finding and home visitation malaria control to whole community. from these facilities. High General ambulatory care for all ages coverage of health facilities including chronic disease in remote areas. management. Occasional outreach specialist care (eg dental, eyes) Functional Component 5 Supporting skilled and Healthcare delivery and referral at Village midwife and immunisation High ratio of doctors per equipped health workers at all outreach clinics by doctors, midwives, nurse deliver MCH program with community, with responsibility levels of system nurses and health promotion staff supervision of doctor from for local health outcomes with support of NGOs sub-district clinic Component 6 Create a systems cycle of A ‘library’ of register books Data collection and Local register books of community feedback using data to for each community feedback not systematic health data systematically collected inform healthcare and maintained by family doctors are also asked to complete a household survey (called Table five: Ambulatory primary care Kubasa) on water, sanitation and hygiene prior to the A doctor or nurse is available to assess sick children and SISCa. As with the other surveys and registers these adults and can prescribe basic treatments or refer to se- form a ‘library’ or virtual database for each community. condary care services as required. Treatment of child- Access to clean drinking water and adequate sanitation hood respiratory disease, gastroenteritis, implementation remains a major problem for Timor-Leste. The number of of IMCI, case detection of malaria and TB including households using an improved water source only in- spot sputum collection and rapid-tests for malaria and creased from 53 per cent to 63 per cent between 2003 and the commencement of treatment or referral can occur. 2009 and household with inadequate sanitation reduced Active case detection of TB and malaria has seen the na- from 70 per cent to 57.1 per cent [20,24]. The number of tional case detection rates increase from 76 per cent in children under five sleeping under a bed-net has increased 2005 to 84 per cent and cohort cure rates rise from 61 from 21.2 per cent in 2007 to 45.5% in 2009 [22]. per cent in 2005 to 73 per cent in 2008 [25]. Ministry of Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 8 of 11 http://www.apfmj.com/content/13/1/5 Figure 3 Proportion of monthly SISCa clinics functioning by district 2010. Health data also suggests that malaria incidence has re- opportunity to change and improve service quality and duced with 132.9 cases per 1,000 in 2008 and 104.2 per respond to community needs. For example, local teams 1,000 in 2010 [23]. may identify poor child nutrition rates as a significant local issue allowing discussion about local solutions and ongoing monitoring of the impact. These functional ele- Table six: Health promotion activities ments have been amongst the most challenging to im- Activities may include showing films, using flipcharts, plement in a low tech environment with limited staff group discussions or one-to-one counselling on issues and community workers with lower levels if numeracy that are relevant to the community (eg good child nutri- and literacy. It will take time to instil a culture of audit tion, malaria prevention, management of gastroenteritis and feedback and to empower communities and local in children, birth spacing methods, promoting birth at health teams in this way. health facilities etc.). SISCA Functional elements (A ‘library’ of registers for each SISCa coverage and impact on health-seeking behaviour community, Health care and delivery Audit and feedback The SISCa program was specifically designed to revital- for quality improvement) ise primary healthcare in an equitable fashion following The collection of registers for each community provides ongoing surveys showing difficulties accessing health a rich dataset to inform health planning and services. facility-based services and poor implementation of pre- Timor-Leste has poor or non-existent internet coverage ventive healthcare strategies. Challenges remain with in most districts, necessitating manual book registers for health workforce shortages persisting in some areas and the moment. It is hoped that eventually this ‘library of many communities being isolated by flooded rivers in registers’ will become electronic linking peripheral cen- the wet season. In 2010, Ministry of Health data shows tres with each other the central facilities. SISCa coverage varied between 30 and 89% per cent SISCa participation rates and evaluations can be fed across the country (see Figure 3) but over half a million back to health workers and communities affording an visits were made to SISCa clinics across the year. The Figure 4 Distribution of SISCa attendees by age 2010 (Total attendances 555,608). Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 9 of 11 http://www.apfmj.com/content/13/1/5 Figure 5 (See legend on next page.) Martins and Trevena Asia Pacific Family Medicine 2014, 13:5 Page 10 of 11 http://www.apfmj.com/content/13/1/5 (See figure on previous page.) Figure 5 SISCa activities operating in the community. Photos A&B: Typical SISCa locations. Photos C& D: Community worker weighs an infant and a nurse immunises a young baby. Photos E&F Pregant women wait for ANC and a family spacing consultation with nurse. Photos G &H: Hand-washing and bed-net distribution. Photos I&J: Basic medical services and a simple dispensary. Photos K&L: Health promotion activities using flipcharts, posters and films. SISCa attendances reflect access to a comprehensive has extended their primary health care system to integrate range of healthcare services with a substantial number basic health service package delivery with active health pro- of older children and adults attending in addition to motion in community outreach. Although it is not possible mothers and babies. (See Figure 4) Although pregnant to infer causality, the current improvements in health ser- women were a small proportion of those seen at SISCa vice utilisation, immunisation coverage and reduction in clinics in 2010, the 2009–2010 Demographic Health Sur- TB and malaria are encouraging and serve to illustrate how vey reports that 55.10% pregnant women received at the SISCa concept aims to reach remote mountainous least four antenatal visits. Further evaluation needs to communities with targeted and effective interventions. The explore whether women prefer and choose to go to recently published UN Human Development Report for health facilities for their antenatal care than at the SISCa Timor shows the country is on track for many of the health clinic and to what extent the SISCa program has allowed MDGs with the need for a more concerted effort in measles a relationship to develop between midwives and women vaccine coverage, maternal mortality, HIV/AIDS education within these remote communities. As the coverage of and malaria control. Strengthening the current system SISCa clinics improves it will be important to build on will hopefully help to achieve these targets which will be this framework of improved access to healthcare through a major achievement for one of the world’s youngest better quality care and using the data to inform at all independent nations. levels of the system (Figure 5). Competing interests Both authors declare: no support from any organisation for the submitted work; Implementing the six components of effective primary no financial relationships with any organisations that might have an interest in health care the submitted work in the previous three years, no other relationships or During the first few years of implementation of the SISCa activities that could appear to have influenced the submitted work. Dr Nelson Martins is the former Health Minister for Timor-Leste but has no program, some of the components of effective primary commercial or other conflicts of interest with the development of the SISCa health care have been easier to achieve than others. Strong program. A/Professor Trevena is a primary care and public health academic leadership and the inclusion of health as a human right in who has collaborated with the Ministry of Health, Timor-Leste on health systems strengthening and capacity building activities over the past four the country’s constitution have been fundamental in getting years. She has no commercial or other conflicts of interest with the SISCa the program started and sustained. The SISCa program has program or with any other aspect of this manuscript. remained as a core component in the new 20 year National Strategic Development Plan. The framework of SISCa al- Authors’ contributions lows for the prioritisation of many of the cost-effective in- NM is the key developer of the Serviso Integrado de Saude Comunitaria terventions listed in Table 1, although not everything on (SISCa) concept and has led its implementation over the past four years. He has met with A/Prof LT regularly and discussed and jointly decided on this list is part of national protocols and, like most coun- the scope and outline of the paper. He provided detailed content for the tries, there are substantial variations in the implementation SISCa component of the paper and has contributed to multiple revisions of these. Engagement with communities has been reflected of the manuscript. A/Prof LT has completed and synthesised the major evidence review on effective primary health care for this paper and has in theattendancerates showninFigure4butthe role and worked jointly with NM on writing and revising the manuscript from its sustainability of community volunteers continues to need inception. She has coordinated and sourced much of the data which supports strengthening. Integrated healthcare is at the core of the the case study. She will be the corresponding author on the paper. Both authors read and approved the final manuscript. SISCa program and has been more widely achieved than other components through the structural components of SISCa. The health workforce in Timor-Leste continues to Acknowledgements Thanks to staff at the Ministry of Health, Timor-Leste and to Health Alliance expand and up-skill with strengthened referral pathways International (HAI) and TAIS for helping to source data and resources for the and supply chains being identified as a priority in the new preparation of this manuscript. HAI also provided office space, and access to strategic plan. Data systems and feedback cycles will likely several SISCa support visits for A/Prof Trevena in Timor-Leste. be the most challenging component of the system to imple- ment (Figure 3 and 4). Funding source A/Prof Trevena’s work in Timor-Leste was supported by an Australian Government Endeavour Executive Award which provided travel and living Conclusion expenses for her study leave period. 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Asia Pacific Family MedicineSpringer Journals

Published: Feb 24, 2014

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