Partnership for Primary Health Care Services (PPHCS) Project

Please note that this is a closed, archived program.

September 2003 - August 2006

Pact began working in Myanmar in 1996 with implementation of microfinance services for the poor in Myanmar's central dry zone. In 2001 Pact's microfinance clients approached Pact with concerns about the lack of financial support to meet health-related needs. In response Pact developed the Partnership for Primary Health Care (PPHC) project. The rationale for PPHC was that while improvements in income are generally linked to economic conditions for improved health, the converse is equally true. Without a foundation of health, income-generating activities become less viable. PPHC was initiated as a service to Pact's microfinance clients in March of 2001 and addressed barriers to improved health through a mix of financial support services and health education.

In 2003, building on the positive experiences of PPHC, Pact expanded the concept to 364 villages in four townships through the Partnership for Primary Health Care Services (PPHCS) project. PPHCS emphasizes community empowerment as a means of promoting more committed and, therefore, more sustainable community responses to health promotion and disease prevention. Through its activities with rural villages, Pact seeks to establish environments in which:

• Communities are aware of the causes of prevalent diseases, methods of prevention, and appropriate modes of and access to care and treatment.
• Communities develop and implement action plans to address self-defined local health priorities.
• Communities develop new or strengthen existing community-based organizations that coordinate and oversee:
  • development and implementation of individual and community plans to improve health environments and promote behaviors that support disease prevention and care, with an emphasis on TB and HIV/AIDS,
  • access to treatment and care of emergent and recurring health problems,
  • locally managed funds applied to the community-defined health needs of individuals and the community as a whole, and
  • where appropriate, local supplies of non-prescriptive drugs and medical supplies.
• Communities have access to TB and HIV/AIDS prevention and care services appropriate to their needs.
• Communities explore and pursue development of microfinance systems based upon community-based savings or microfinance institutions as a means to sustain community health financing and to alleviate poverty.

Pact's approach

A Community Health and Development (CHD) approach provides the cornerstone of our interventions. This approach involves a three-day community workshop that attempts to address the behavioral determinants (attitudes, commitments and perceptions) that impact sustainable change in health at the community level. The agenda is nonprescriptive and enables the community to explore the health situation in their village, analyzing the nature of diseases they are burdened with and developing action plans to address priority concerns. Plans can vary widely from describing steps that will result in improved latrine construction, to community-led HIV/AIDS education for self-identified vulnerable groups, or development of procedures to ensure that people on directly observed treatment short courses (DOTs) get their treatments. The approach acknowledges that emphases on health education alone are typically insufficient to motivate changes in behavior in support of improved health. Commitment to act is more likely to result from community self-analysis of their health concerns and self-development of appropriate responses to them.

Information, education and communication (IEC) activities employ simple participatory story telling tools that require little input from workshop facilitators. Self-discovery of environmental and health linkages are emphasized over the technical soundness of participant knowledge. However, the knowledge must be sufficient to initiate appropriate action. By putting health cause and effect relationships into concrete terms and making public statements about these relationships, the program builds individual and group commitment to acting on the knowledge. In effect the communities themselves become their own health educators and change advocates.

Prevention will not eliminate disease. Pact's approach empowers communities to have knowledge of and access to basic treatments within their own communities. Village Pharmacy Depots, managed by Village Health Volunteers and supervised by local self-defined community organizations, are an essential service that allows local access to preventative and curative nonprescriptive drugs and supplies.

Where this is insufficient individuals are encouraged to access government health system services. Loans from community-generated Village Health Funds, with matching grants from Pact, help those who are too ill to overcome the obstacles of poverty and distance to seek appropriate treatments. The Village Health Fund has a social function, not designed to specifically benefit individuals, but rather the health of the community at large. One person benefiting from the fund is a benefit to the community as a whole, particularly when treatments made available through the fund help prevent disease transmission. Community management of such a fund is important, as these experiences inspire communities to conceive other community-driven development initiatives. One such example was to use the VHF mechanism to generate funding for replacement of a community water supply engine.

The sustainable community management of these institutions and change initiatives are primarily founded on community commitment to maintain them. The approach's community-driven nature helps to build this. Communities design their own specific management systems, sometimes relying on existing organizations within the community, other time creating new ones. Pact helps these community organizations develop their technical, financial and organizational capacity through targeted support meeting the needs of each individual community. Pact and employed Village Health Promoters, visit project communities regularly to help assess and deliver capacity building services while more formal finance and management training activities supplement this.

Interim results

• An extensive baseline survey of health needs was undertaken among 4799 of the 68,918 households within the project villages. The main observations from the survey were that people are somewhat aware of the causes of disease, disease symptoms, and appropriate modes of prevention, but are less certain of effective treatment methods. Perceptions of disease prevalence are shown here. These perceptions match well with data from the township health institutions, where diarrhea/dysentery, acute respiratory infection, malaria, TB and snake bite dominate the morbidity and mortality statistics.
• Community prioritized and designed intervention strategies tend to match perceptions of disease burdens. The chart to the left shows the themes under which community action plans were developed. Bias toward TB and Village Health Fund strengthening are assumed to arise from a bias in our focus.
• The concept of the village health fund was introduced in 65 new project villages with 10,073 households, who contributed a total of Ks 2,438,900. Cumulative contributing membership of the funds stands at 41,999 households, representing 62% of all households in the project villages. Eight-six percent of the members are women. Monthly health loan disbursements have increased by more than a factor of four over rates experienced under the original PPHC project. This is far in excess of the 32% growth in membership over the period. The total value of the VHF has grown from Ks 13,237,699 at the beginning of the project to Ks 20,999,087 as of July 2004.
• As each infectious TB case typically infects 10 others, at least one of which usually develops active TB themselves, TB is treated as a challenge for the community, not a misfortune of individuals, and certainly not as a problem for which outside direction should be awaited.184 people who received grants for TB sputum testing tested positive and subsequently began receiving treatment. (Those who did not avail themselves of a grant but nonetheless went for testing were not included.) Those who tested positive account for 29% of all the 2003 sputum positive cases found in the four townships. When one considers that the project villages cover only 42% of the four townships' population, the case detection and treatment support mechanism of PPHCS provides a significant impetus to the National TB Control Program. Although not included in these figures, the advent of a TB case mapping approach in the CHD, the monthly rate of identified suspect cases increased dramatically.
• Currently TB treatment default rates exceeding 9% are threatening a rapid spread of multidrug resistant TB strains that result in an epidemic that no longer responds to treatment. A TB case register to track TB cases and support DOTS adherence has been developed. Community derived plans to address TB typically tap into intrinsic community organizations that monitor DOTS compliance throughout the community and create social norms for suspect cases to undergo testing for their own sake and for the sake of the community. The organizational mechanism through which this is done varies from community to community, building on existing strengths.