Time for an additional paradigm? The community-based catalyst approach to public health.

Abstract

Introduction Governments, major foundations, and international organizations sometimes shift the focus on development initiatives in a fad-like manner, even changing in mid-course. They may also rely on single approaches for tackling complex problems rather than employing multiple strategies. An additional paradigm for public health could bridge the divide between building systems and focusing on a specific disease. A community-based catalyst approach appears to be useful in some situations; the approach presented here is based on ten essential elements and five criteria for using local volunteers in community-based initiatives. Fads and single-mindedness Governments, major foundations and other organizations tend to change focus roughly in unison, suggesting that they are vulnerable to fads, perhaps more so because of the often destructive tension that has existed since the 1800s between "horizontal" and "vertical" approaches (1). Also, they frequently select one principal approach to complex problems, although complexity generally demands multiple strategies. In the middle of the twentieth century, large projects were in Favour among those seeking to facilitate development, but in the 1970s, bad press about "white elephant" projects (e.g. big hospitals in poor countries) helped to drive a dramatic switch to low-technology infrastructure in peripheral localities. In 1970 "traditional birth attendants" (who assist with normal births after limited training) became a focus of the United Nations Population Fund (UNFPA) and of the United Nations Children's Fund (UNICEF), with little back-up for obstetric complications. The Declaration of Alma-Ata in 1978 reinforced the heavy focus on local (under-supported) health workers. Subsequently, education and the goal of developing "civil society" (enhancing social structures outside government) gained favour, as bilateral donors, and especially the major foundations, largely abandoned support for health. Now, with the exception of Japan and the USA, the favoured avenue for bilateral assistance is budget support via ministries of finance for health and other "soft" development areas, though not for airports, harbours and similar "hard" development areas. Massive shifts from one primary strategy, to another have numerous disadvantages. For instance, successful activities being carried out under an approach no longer favoured may be terminated. At The World Bank, most loans for distinct health projects have been cancelled following a shift to budgetary support through "poverty reduction support credits" (PRSCs), a "sector-wide approach". AbouZahr showed how "cautious champions", including well-intentioned international agencies, had even changed their approach several times during a single initiative as they tried to reduce the persistent and scandalously high rates of maternal mortality (2)--equivalent to the number of people who would be killed if one jumbo jet crashed every 4 hours. Contrasting realities Considerable funding for health infrastructures since the Declaration of Alma-Ata has arguably brought relatively little improvement in the provision of adequate health care to poor populations in some contexts. "For a decade, the figure of 500 000 maternal deaths a year has been part of the statistical liturgy" (3). Meanwhile, several disease eradication efforts have been singularly successful in the face of severe corruption, poverty, weak health infrastructures, political chaos and war, using limited resources. The eradication of dracunculiasis (guinea-worm disease) has received less funding since its inception than the poliomyelitis campaign uses each year. Yet the incidence of dracunculiasis has been reduced by more than 99.5%, from an estimated 3.5 million cases in 1989 to 15 522 cases, of which only 1479 were outside Ghana and Sudan, provisionally reported in 2004. The Onchocerciasis Control Programme (which was not an eradication programme) enjoyed similar success for 28 years (1974-2002). …