Community- and Facility-based Programs
Protecting and improving health, especially in poor communities, requires a combination of community- and facility-based activities, with support from central levels of organization, as well as some centrally run programs (for example, food fortification). The place of these activities in a strategy is likely to vary, depending on level of development (of infrastructure, health services, and socioeconomic status) and on many local factors. For the poorest societies, the first priorities are basic preventive services, notably immunization, access to basic drugs, and management of the most serious threats to health, such as some access to emergency care. Moving up the development scale, starting community-based activities may soon become cost effective for prevention, referral, and management of some diseases (notably diarrhea) when coverage of health services is poor. Community-based programs continue to play a key role until health services, education, income, and communications have improved to the point that maternal and child mortality has fallen substantially and malnutrition is much reduced; at this intermediate development level, the needs are less felt, and health services again take on a more prominent role. In this scheme, the widely felt need for better access to emergency obstetric services is problematic, requiring a well-developed human and physical infrastructure, yet arguably being one of the highest priorities.
Facility-based programs can be seen either as linking with the community program (referrals, home visits from clinics, and so forth) or as actually being part of the same enterprise. A distinction is that community-based activities take place outside the health facility, in the home or at a community central point, even if they may be supported by health personnel based in health facilities. The local workers in community-based programs may be drawn from the community itself, may be home visitors from a health center or clinic, or may sometimes be volunteers supervised by these home visitors. Many community-based programs come under the health sector, whatever the exact arrangements with local health services. Regarding specific program components, we return to the relative role of community programs and facilities later.
The integrated management of infant and childhood illness (IMCI) program provides guidance mainly on the curative health aspects and contains a number of nutrition activities (for example, administration of vitamin A capsules). Links to local health facilities are essential for the maintenance of the community activities and for referral in cases of illness (see chapter 63). As the IMCI training and implementation progresses, it should integrate directly with CHNPs (in fact, become part of the same exercise), which will add treatment of additional diseases. IMCI addresses diarrhea, acute respiratory infection (ARI), malaria, nutrition, immunization, safe motherhood, and essential drugs (WHO 1997). The 16 key practices for child survival defined in the context of IMCI (Kelley and Black 2001, S115) are exactly those to be promoted within CHNPs, and most are already included (four are nutritional).
Decentralization should be considered in this context. Although decentralized systems might be thought to be more effective in supporting CHNPs, the evidence for this assumption is scarce. Decentralization can reduce resources available at the local level if it involves devolving responsibility without the concomitant budgetary resources (Mills 1994). For example, in Kenya, decentralization did not accompany devolving authority for raising revenue locally. In other cases (for example, the Philippines), decentralization has involved a shifting of resources, but with priorities set in the local government units by locally elected officials (municipal and city mayors), these resources may be used for shorter-term priorities than under previous, centrally decided, policies.