International Working Group for Health Systems Strengthening

Organization and management of Service Delivery in Urban Primary Health Care Settings are a critical component of improving health coverage and outcome. Thailand, Bangladesh, and Ethiopia have made significant strides in enhancing primary health care by improving the urban health system.

Dr Ambulai Johnson and Dr Sudipta Ghoshal, IWG Blog 2022

In 2018, the Astana Declaration renewed the global commitment to the PHC made 40 years earlier at Alma-Ata. The Astana declaration serves as a guide to enrich health service delivery in improving primary health care through the commitment of profound support from governments, non-governmental organizations, professional organizations, academia, and global health and development organizations. While the World Urbanization Prospects show that 68% of the world population projects to live in urban areas by 2050, cities or urban settings are known to play an active role in all societies. At the same time, they serve as a breeding ground for poverty, inequality, environmental hazards, and communicable diseases while straining public health systems and resources.

Through this blog, we provide a unique lens towards community health workers in Urban Primary Health service delivery in Thailand, Bangladesh, and Ethiopia due to their country’s experiences, challenges, and lessons on service delivery, governance, human resource, and public participation in delivering primary health care services in an urban setting for improved healthcare.

Thailand: Service Delivery in Urban Primary Health Care Settings

Bangkok currently has a 70 million urban population, which is expected to rise to 72% by 2050. Bangkok is rapidly urbanizing, with an increased burden of communicable and non-communicable diseases (NCDs). Thailand has played a critical role in supporting PHC infrastructure development since the 1970s to obtain universal health coverage. Today, Thailand has recognized the need to reduce high levels of inequalities between rural and urban populations. They intend to prioritize a comprehensive range of services delivery and health promotion to achieve two foremost goals: to expand effective primary health care and improve the financial accessibility of primary health care. Thailand produced more than 800,000 trained health volunteers that served 12 million households in 2010; today, the number projects to be 1 million for community-based health promotion and disease prevention programs through the Bangkok Health Security Fund. At the community level, a health worker at PHC centers works closely with all sub-districts and district hospitals nationwide to improve PHC.

Thailand’s long-term success has still been challenging because of the shortage of doctors with the most significant gaps in rural areas. Also, financial burdens are preventing rural and urban dwellers from accessing primary care services. So, the need for sufficient human resource capacities and a substantial increase of adequate health service by providing an effective referral system would address inequities in rural and urban health settings. These are enabling factors and challenges highlighted to improve the organization and management of Service Delivery in Urban Primary Health Care Settings in Thailand, Bangkok.

Bangladesh: Service Delivery in Urban Primary Health Care Settings

Bangladesh Rural Advancement Committee (BRAC) is one of the driving forces behind developing strategies to promote primary healthcare.  BRAC has the largest NGO-led CHW (Shasthya Shebika, supported by the Shasthya Karmi) network in Bangladesh to address the gaps in urban primary health care and urban slum programs. BRAC engages over 100,000 CHWs in building a resilient community-based healthcare system (Doucet, 2018).  BRAC’s Manoshi project, launched in 2007, has been scaled up to 10 cities covering 7 million urban slum dwellers. More than 4,500 trained CHWs are deployed in 2000 slums and 41 Maternity Centers to aid in knowledge dissemination on family planning, immunization, maternal and child health services, HIV/AIDS, and a Water Sanitation and Hygiene (WASH) program. The program contributed to building pit latrines and improving waste management and water supply.  The integration of CHW programs enabled the country to reach national and international commitments towards strengthening primary health care. Notwithstanding such successes, the lack of community engagement income generation to ensure continuity of care for vulnerable groups, lack of integration of CHWs with the formal health system, poor adherence to referral compliance, intense competition with the unregulated pluralistic private sector, and the lack of sustained financing remains a challenge of various ongoing BRAC projects.

In a recent webinar organized by the International Institute of Primary Health Care- Ethiopia. Dr. Morseda intimated the need for equity and intervention are important goals.  According to the speaker, Urban Primary Health Care could be achieved by ensuring quality health care is delivered in communities and by building community health workers’ capacity to increase the trust mothers and families have in their provision of health care services. Unarguably, long-term engagement with CHWs will ensure continuity of care and improve the commitment of CHWs in the emerging field of technology to address complex contexts like urban slums as lessons learned from Bangladesh.

Ethiopia: Service Delivery in Urban Primary Health Care Settings

CHWs have a long history of strengthening the health system in Ethiopia, dating as far back as the formation of the Alma Ata Conference on Primary Health Care. CHW program has been strongly supported by the Ethiopian government by establishing the Health Extension Workers (HEWs). In 2004, Ethiopia considered Health Extension Workers (HEWs), and Community Health Workers (CHWs), as an essential component to improving PHC to achieve universal health coverage. They are known as the Health Development Army (HDA) volunteers. Those programs have led to the rapid expansion of CHW programs in Ethiopia over the past decade. In terms of implementation work in the community, the HEWs support both the health posts and the community, while the HAD volunteers’ solely help increase primary health care operation on a part-time basis (less than 2 hours per week) within their communities. In context, both the HEWS and the HDA volunteers contribute to health promotion, disease prevention, and treatment of uncomplicated and non-severe illnesses, such as malaria, pneumonia, diarrhea, and malnutrition in the community.

Despite the successes of Ethiopia PHC through its HEP, there remain persistent challenges to address urban primary health care in Ethiopia (UHEP). Some of those challenges are lack of government operational budget for UHEP, wide disparities in the levels of health knowledge, attitudes, and behaviors among urban populations on community outreach, poor multi-sectoral coordination, and political instability.  To help address these challenges, Ethiopia needs to implement strategies that include and empower communities to address urban primary health. Dr. Mirgissa stated in a recent webinar series that “urban primary health care is the most neglected area of public health.” As such, he considers urban health as a significant obstacle to Ethiopia’s healthcare system and an exciting focus for government intervention as risk factors loom.

Conclusion

Organization and management of Service Delivery in Urban Primary Health Care Settings are a critical component of improving health coverage and outcome. Thailand, Bangladesh, and Ethiopia have made significant strides in enhancing primary health care by improving the urban health system. The need for urban communities’ organization, the improvement of primary healthcare infrastructures, financial barriers to strengthen immediate health care access, and an effective referral system are necessary for improving overall community health. CHWs play a critical role in these health systems, as stewards of health. There is a need to invest in strengthening their role across health systems, as a means to strengthen community health across levels.