Global Health Conference Focuses On Community Health
June 4th, 2008
 by
Maurice Middleberg
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The Global Health Council’s 35th Annual International Conference on Global Health, which ran from May 27 to May 31, 2008, featured the theme of Community Health: Delivering, Serving, Engaging, and Leading. The conference attracted more than 2,500 people representing NGOs, businesses, faith-based organizations, academic institutions, multilateral organizations, governments, and students from many different countries. Conference cochairs included Zafrullah Chodhury, founder of the People Health Center (Gonoshasthaya Kendra), Bangladesh; Jaime Sepulveda, director of Integrated Health Solutions at the Bill and Melinda Gates Foundation; and Miriam Were, chair, National AIDS Control Council, Kenya.
The community health theme provided focus on the 30th anniversary of Alma Ata and its call for giving priority to primary health care. The conference provided the forum for reflecting on both successes and failures in achieving health at the community level, while distilling lessons learned.
The opening plenary featured a trans-Atlantic dialogue between conference participants and the Geneva Health Forum on crafting a framework for effective community health. Speakers from BRAC, Tostan, the World Health Organization (WHO), Harvard University, and the governments of Norway and Ghana emphasized the importance of creating effective community-based health systems. Speakers pointed out that global disease-specific initiatives are often developed without first taking into consideration the “last mile” in service delivery. The links between conceptualization at the global level and delivery in villages and urban slums are often tenuous. Too frequently, the consequence has been to overwhelm local capacity or to build parallel systems that do not outlast an influx of donor resources. Speakers urged the leaders of global programs to begin with a clear understanding that working with and through communities to strengthen local capacity is essential to long-term sustainability.
In one well-attended session, participants discussed how the recently launched International Health Partnership (IHP+), which was announced by U.K. Prime Minister Gordon Brown last fall, might serve as a model for translating international initiatives to more effective and accountable health outcomes by using national government health plans as the central fulcrum for establishing predictable and consistent funding, engaging civil society, coordinating donors, and demonstrating measurable outcomes. Issues raised included the burden of multiple reporting instruments imposed by donors; the impact of national politics on determining health priorities; the health worker shortage; incorporation of corporate partners; and the different output and outcome measurements demanded by primary care systems versus disease-focused programs.
Multiple panels and workshops developed this community-focused theme around specific issues, including child health, reproductive health, cancer screening, nutrition, malaria, violence against women, HIV/AIDS, TB, mental health, orphans and vulnerable children, post-conflict health care, water and sanitation, and involvement of religious leaders. A thread through these workshops was showing that disease-specific programs can both meet their immediate ends and strengthen community health capacity through thoughtful program design.
The Health Worker Crisis
A major theme running through the Conference was the health worker crisis, especially at the community level. Speakers from Kenya, India, Nigeria, and Mozambique, among others, spoke of the multiple barriers to recruiting and retaining health workers at the community level, as well as innovative solutions in both the public and private sectors. The research symposium underlined the essential role of research at the community level to identify both barriers and supports for health workers.
Factors affecting health worker effectiveness include lack of supervision and support, failures in supply chains, incentives for community workers, difficult working conditions, burdens on the families of health workers, engagement of community leaders, and the processes for community involvement and ownership. However, there was wide agreement that there are no generic solutions that can be easily replicated. Community-based, participatory research is needed to design responses appropriate to context. Case studies from Liberia, the Democratic Republic of the Congo, Tanzania, Nigeria, China, Vietnam, India, Uganda, and Zambia illustrated private-sector approaches to remediating the health worker shortage. The private sector already provides the majority of health care in many countries. Speakers described how supportive public policies, as well as partnerships involving government, nonprofit, for-profit, and community-based entities can help train, recruit, and retain health workers in underserved areas.
“Thinking Along The Diagonal”
A third theme running through the conference was resolving the old debate between “vertical” and “horizontal” programs, by “thinking along the diagonal” and placing the community at the center. Exploring this theme in a lively and good humored final plenary were Henrietta Fore, U.S. Director of Foreign Assistance; Margaret Chan, WHO Director-General; Jaime Sepulveda, director of Integrated Health Solutions Development of the Bill and Melinda Gates Foundation; and Nils Daulaire, president of the Global Health Council; and moderated by Susan Dentzer, Editor-in-Chief of Health Affairs.
Margaret Chan reminded the participants the challenge facing the global health community was connecting the “first mile” of grand global health initiatives to the “last mile” of helping communities gain the tools by which they could take charge of their own health needs. The traditional image of service delivery at the community as the “last mile” is inadequate, failing to show adequate respect for the understanding that communities have of their own context. Mutual respect along the chain from first mile to last mile is the only way to achieve lasting progress in health; a circle involving communities, providers, and policymakers may be a better image than a chain.
Jaime Sepulveda, reflecting the Mexican experience, argued for an integrated approach to health delivery at the community, rejecting false dichotomies between horizontal and vertical approaches. In the Mexican context, interventions that responded to the actual burden of disease were systematically added until an integrated package was available to the poor. This data-driven package of essential health services yielded great gains in health status. At the same time, health systems were built by strengthening management and leadership, financing, service-delivery approaches, and resource generation. System development and disease fighting were treated as mutually supportive rather than antagonistic, with the result being long-term gains in the health of the Mexican people.
Nils Daulaire called for a new and different imagery — not vertical, horizontal, or diagonal, but “organic.” He stressed that health development is not a mechanical process, but a vital relationship between communities and service providers. In Nepal, progress in reducing child deaths from pneumonia came only after health providers actively engaged with mothers and developed mutual understanding about how to combat the disease within the context of poor rural households. This is the essential lesson: relationships and rules of engagement are needed between the health system and communities to achieve goals embraced by both. There is no substitute for the hard work of building relationships of trust and understanding — and no shortcut to achieving the bonds that will yield sustained gains in health and well-being.
Honoring Achievements In Global Health
The annual awards banquet was a highlight of the conference. This year, the Gates Award for Global Health was presented to the Aravind Eye Care System for its pioneering work in restoring sight to millions of poor people in India. The Jonathan Mann Award for Health and Human Rights went to Dr. Binayak Sen of India, for his dedication to improving health, living conditions, and respect for human rights among very poor, marginalized populations in central India. Dr. Sen is currently in prison and has been held without trial for more than a year. The Excellence in Media Awards were presented to the Wall Street Journal for its series on health in China; to Health-e, a South African news agency, for its coverage of health issues; and to Rockhopper TV for its documentary, “A Sporting Chance.” The Best Practices in Global Health Award was bestowed on Bette Gebrian and the Haitian Health Foundation for their innovative approaches to using information technology in rural Haiti to monitor and improve the health of more than 130,000 people in over 100 villages in rural Haiti.
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