Targeting Improved Access -- SEAM Conference 2001 -- Round Table Discussions

2001 SEAM Conference - Targeting Improved Access

Roundtable #4: Community-Based Care Initiatives

Moderator Chitr Sitthi-amorn, Professor, School of Public Health, Chulalongkorn University, Thailand

Resource persons Malcolm Bryant, John Chalker, Douglas Keene

Note takers Rena Eichler, Helena Walkowiak (lead)

View the PowerPoint presentation online.
View the transcript of the presentation online.
Download the transcript of the presentation (PDF - 114KB).

Background and Issues

The community-based care (CBC) component of SEAM is based on the premise that community participation is an essential element of successful and sustainable health programs, especially those that involve chronic and disabling conditions. Community participation can confer the advantages of extended coverage and quality, greater coordination of resources, improved equity, and self-reliance. In order to better design and implement system interventions to increase access, it will also be important to adapt systems to enable communities and individuals to utilize these interventions appropriately. This will require empowerment of individuals to change behaviors and seek care when necessary, encouragement of community actions, development of norms, identification of resources to enable individual action, and effective interactions with high-quality service systems including facilities. With community involvement, improved utilization of services will be more likely to result in the intended health outcomes because-

Community action and support is needed to enable individual and family behavior change. Effectively managing chronic conditions requires changes in behavior that are more likely when social norms support and reinforce them.
Active community engagement can contribute to better adherence to treatment. The active role that patients and their families play in community-based care helps to ensure that culturally appropriate decisions are made on how prevention and care should be made available.
The management of illness must take place close to where people live. Most of the care and management of illness in the developing world is provided by families. This is especially true for chronic conditions, which only account for a small proportion of effort by primary health care facilities. Home care, sometimes supported by outreach workers, is the norm.
Community engagement improves prospects for sustainability. Communities and community-based organizations both raise and coordinate resources that are used to support patients.

It is generally assumed that by bringing services closer to the people themselves there will bež

A greater understanding for the need for services
Community ownership of the services
Empowerment of individuals to act on health-related issues
Improved access to services
Improved quality of services

These factors will in turn lead to increased use of services.

This perspective was brought to the forefront with the declaration of Alma Ata, and is a key principle underpinning the primary health care movement. However, while there are many examples of community-based care being successfully implemented on a small scale around the world, there are too few examples of community-based care being brought to sufficient scale to effect real changes in the public health. It seems that the ability to conceptualize community-based health services is generally much more highly developed than the ability to deliver effective community-based health services.

The HIV/AIDS pandemic offers a new challenge and a new opportunity for community-based services. Community-based approaches have been used in the prevention of HIV infection by promoting changed sexual behavior through mass media and education in the workplace, school, and high transmission areas, and by focusing on risk groups in their environment. However, at the present time, community-based care and treatment are rare.

Access to care and treatment is difficult because drugs, laboratory tests, and skilled, knowledgeable personnel are typically based in larger hospitals and facilities. This leaves many hundreds of thousands of sick people unable to access quality care, and enables unscrupulous individuals to prey on sick people's desperation for help by charging large amounts of money for ineffectual remedies or drugs within the community. At the same time, improperly trained and educated healers give wrong (and frequently dangerous) advice.

Facility-based services rapidly become overwhelmed by patients suffering with complications of HIV/AIDS, which further decreases access and availability of both HIV/AIDS services and general maternal and child health services.

Community-based approaches that offer appropriate quality care and treatment can both alleviate the burden on existing facilities and increase accessibility of services. The challenge is that in order to do so, new paradigms in treatment and care need to be developed and accepted. New delivery and support mechanisms need to be developed and, most importantly, a lessened degree of control over care and delivery by health care professionals needs to be accepted.

SEAM recognizes that CBC models need the participation of local people in all stages-identifying needs, planning activities, implementing activities, reviewing the results, and making any necessary changes in a continuous cycle. This requires an ongoing, equal dialogue between health services and communities and means that there is not a "one-size-fits-all" model of community-based services-different models will develop depending on the local needs and conditions, the nature of the organizations, and the institutional environment.

This roundtable looks at the specific challenges that must be faced, barriers that must be overcome, and possible models for effective community-based care on a public health scale.

Discussion Points

What are the key enabling factors that are necessary in the environment to make community-based care possible?
What are the major drivers for community action that results in community-based care?
What actions and activities can outside agencies take to stimulate change at the community level?
What are the incentives that stimulate individuals in a community to initiate change?
What is the most appropriate specific framework that can lead to improved access to services through community-based care?

Background Materials

Beith, Alexandra, Rena Eichler, Jeffrey Sanderson, and Diana Weil. October 2001 (draft). Analytical Framework to Consider the Impact of Incentives and Enablers to Improve the Performance of Tuberculosis Control Programs. Arlington, VA: Center for Pharmaceutical Management, Management Sciences for Health.

Bryant, Malcolm. November 2001 (draft). Approach to Increase Access to Health Care Through the Provision of Community-Based Health Services. Arlington, VA: Center for Pharmaceutical Management, Management Sciences for Health.

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