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Friday, November 19, 2010

Accountability Starts Here

I’ve realized along with Adam that I need to provide some background before going on to more specific issues. Recently I’ve developed a focus on neonatal health, which—as someone most interested in macroscopic, interdisciplinary, systems-level approaches—has been a bit of a departure from my modus operandi. And, in line with the need to take a more nuanced perspective—as Ben alluded to with his own evolving conception of microfinance—I want to use this opportunity to critically assess and justify my focus on neonatal health. I think this can be a useful exercise for all of us (e.g. to ensure we don’t fall into the “sexy disease” trap). Furthermore, I think it can have the most utility when routinized as an ongoing process, with a community of peers to keep us accountable (Richard Levins’ take on how we navigate the often contradictory implications of our triple identities as workers, activists and intellectuals is particularly interesting with regards to this). And, needless to say, it’s also one of the functions I envisioned for this blog.

And so without further ado, why I’ve become interested in neonatal health:

1. Key neglected cause of mortality: Worldwide, 4 million newborn deaths (deaths within the first 28 days of life) occur every year. These deaths have been largely neglected by programs and policymakers until the last decade. The inadequacy of past child survival interventions in reducing the global neonatal mortality rate (NMR) is evident in comparison with the gains made for postneonatal, under-five mortality, which fell by 45% from 1983-1999, whereas global NMR declined by only 11%. Addressing neonatal deaths is now essential to achieving Milenium Development Goal (MDG) 4 on child survival as they constitute nearly 40% of all under-5 child mortality.

2. Equity: Low- and middle-income countries are grossly overrepresented in the burden of neonatal mortality; contributing 99% of total deaths. Disparities exist within these countries as well, as the NMR among the poorest families is 19-44% higher than among the richest.

3. Something can be done! The vast majority of neonatal deaths are preventable, particularly if early detection and proper treatment are administered by caregivers and first-line health workers (1,2,3,4,5,6!).

4. Integration: Neonatal health serves as a natural window into reducing maternal mortality (MDG 5; an important contributor to global deaths, and reflective of greater women’s empowerment and equity issues), as pregnancy-related care serves as many women’s first introduction to the health system. And, this window can be extended for ongoing child health interventions.

5. DALYs + Cost effectiveness: Interventions for the continuum of care between maternal, neonatal and child health are especially pertinent when assessing the 10 leading risk factor causes of DALYs for low-income countries (Table 1). Particularly, interventions for childhood malnutrition, safe water/sanitation/hygiene, safe sex (family planning, condom promotion, etc.), breastfeeding and indoor air pollution from solid fuels are correlated with nearly 35% of total DALYs. These risk factors galvanize low-cost, technologically simple health education and behavior change interventions—which provide some the best cost effectiveness ratios ($ per DALY averted) of any in our arsenal (Table 2).

6. Finally, it helps me wrap my head around the ever-complex and often nebulous issues of health systems strengthening, delivery and scale-up. For example, we cannot reduce NMR or maternal mortality without addressing health workforce issues for skilled attendance at delivery or functional referral systems for emergency obstetric care.

Most critically, all the above reasons support my conviction in the principles of community-based primary health care (CBPHC). The principles of CBPHC also provide an incredibly useful guiding framework for the items in #6.In addition to employing a rights-based and equity-orientation to health, they also warn against reductionistic applications of DALYs and cost-effectiveness (see: dangers of Selective Primary Health Care).

The Declaration of Alma Ata affirmed the international community's commitment to primary care, however, follow-through has been lacking.

Instructive operational aims of CBPHC include: 

1.     Integrating ‘preventive, curative and promotive services’ via ‘functional and mutually supportive referral systems’ and multi-cadre ‘health teams’

2.     Targeting all interventions ‘at the most peripheral practicable level of the health services by the worker most simply trained for this activity'; i.e. reach people ‘where they are’ and use community-level health workers

3.     Maximizing acceptability, appropriateness and sustainability of interventions via ‘maximum reliance on the available community resources'

4.     Employing comprehensive approaches which are ‘fully integrated with the services of the other sectors involved in community development'

5.     Empowering via community participation in ‘the planning and implementation of their healthcare'

6.     Embedding feedback loops for improvement and accountability; PHC is the ‘first step in the continuing health care process'
It seems I’ve come full circle on the accountability theme; an unintentional feedback loop! And, as always, I’m excited to be engaged in the process of developing our own community as well.

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