Academic journal article Bulletin of the World Health Organization

Retrospective Comparative Evaluation of the Lasting Impact of a Community-Based Primary Health Care Programme on Under-5 Mortality in Villages around Jamkhed, India/Une Evaluation Comparative Retrospective De I'impact Durable D'un Programme De Soins Medicaux Communautaires Primaires Sur la Mortalite Des Enfants De Moins De 5 Ans Dans Les Villages Proches De Jamkhed En Inde/Evaluacion

Academic journal article Bulletin of the World Health Organization

Retrospective Comparative Evaluation of the Lasting Impact of a Community-Based Primary Health Care Programme on Under-5 Mortality in Villages around Jamkhed, India/Une Evaluation Comparative Retrospective De I'impact Durable D'un Programme De Soins Medicaux Communautaires Primaires Sur la Mortalite Des Enfants De Moins De 5 Ans Dans Les Villages Proches De Jamkhed En Inde/Evaluacion

Article excerpt

Introduction

The Bellagio Child Survival Study Group brought the issue of child survival to the forefront of the global health care agenda in 2003 when it reported that 10 million children were dying every year. (1) Reducing child mortality by two-thirds before 2015 is one of the United Nations Millennium Development Goals. (2) As the Bellagio series and the Lancet neonatal survival series (3) and Alma-Ata series (4) all point out, most of these deaths are preventable. In India, as in many developing countries, providing even basic health care in rural areas is a major challenge for the government. Analyses of India's health system have suggested that rural health care has been neglected by the government and that increasing privatization may further reduce health care in remote areas. (5,6)

Community-based primary health care provided by trained community residents has been shown to improve child survival in areas with high child mortality. The Warmi project in Bolivia and the Society for Education, Action and Research in Community Health (SEARCH) in Maharashtra, India, have demonstrated significant reductions in perinatal and neonatal mortality. (7,8) Recent trials in Nepal and in Uttar Pradesh, India, have reported reductions in neonatal mortality of 30% and 52%, respectively. (9,10)

Many aid agencies strive to address the lack of health care and improve child survival in developing countries, but they rarely conduct rigorous independent evaluations of their work. Such evaluations are expensive, carry the risk of showing negative results and are under-appreciated by donors. Consequently, there are few credible data on the impact of ongoing aid work. (11-15) Though randomized controlled interventions can generate such data, (15) a study with prospectively assigned controls is seldom an option and retrospective approaches must therefore be used to assess the impact of aid efforts.

The Comprehensive Rural Health Project

The Comprehensive Rural Health Project (CRHP), one of the inspirations for the 1978 International Conference on Primary Health Care at Alma-Ata, has been working for the past 40 years to address the issues highlighted in the aforementioned Lancet series. (1,3,4) It has had a major influence in health policy circles, including the World Health Organization (WHO) and schools of public health, (16) and is a rare example of a long-term community-based primary health care project. The project was highlighted in the Alma-Ata Rebirth and Revival series as a model for delivering primary health care to poor rural regions, (4) and--if found to be effective upon rigorous evaluation--could prove important for achieving the Millennium Development Goals on child mortality reduction elsewhere in India and in other vulnerable areas.

CRHP was founded in 1970 by physicians Mabelle and Rajnikant Arole, who envisioned a system that delivered both curative and preventative care to India's most vulnerable people. Based in the town of Jamkhed, CRHP also serves surrounding areas in the central part of Maharashtra state. The area is predominantly rural, poor and drought-prone. Public health care and education are notoriously poor. CRHP has gradually expanded from a single hospital in Jamkhed and currently covers approximately 300 communities with a total population of over 500 000 people. (17)

Activities in project villages

The CRHP model, which focuses on community-centred primary health care, is described in detail elsewhere. (17,18) Activities in the project villages are carried out at three levels: village health workers, mobile health teams and the secondary-care hospital in Jamkhed.

Village health workers, who are the cornerstone of the model, are local women selected by their communities, often from the lowest caste. They receive intensive training from CRHP trainers in primary health care and health promotion, including family planning, women's and children's health and home birth delivery. …

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