PERSPECTIVES
Time for an additional paradigm? The community-based catalyst approach to public health
Anders R. Seim
Health & Development International (HDI), Svestad Marine Park, N-1458 Fjellstrand, Norway (email: anders@hdi.no)
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 (19742002). For less than US$ 1 per person protected per year, 25 million hectares of land, abandoned due to river blindness, was re-cultivated and able to feed 17 million people. And more than 9 million children were born to a future free of this scourge. Similarly, efforts to eliminate lymphatic filariasis are making real progress using annual mass administration of donated drugs to interrupt transmission among the billion people at risk, in combination with treatment (mostly self-treatment) of lymphoedema and elephantiasis, and surgery for men with urogenital manifestations.
A way forward: the community-based catalyst approach to public health
Rather than abandoning the lessons that led to "basket funding", "poverty reduction" and "budget support" for public health, and suggesting a new fad, this and other evidence (4, 5) argues for using perhaps 510% of funds on an additional approach, termed the community-based catalyst approach to public health. This option focuses on observable results and applies the tools of disease eradication to selected non-eradicable diseases, with the aims of dramatically improving health outcomes and strengthening health systems.
Observations over 15 years have helped the author to identify 10 elements of recently successful disease-eradication programmes (Box 1). These elements must arguably all be in place for the community-based catalyst approach to function, as an engine, brakes and a steering mechanism must be present for a car to function successfully. When specific criteria are met (Box 2), a community-based catalyst approach is ideal.
Community-based catalyst elements can cost approximately US$ 2 million per annum for a 12-country effort in Africa, a paltry amount when compared to the economic and other benefits obtainable, including averted suffering and enhanced dignity. For consortia of donor countries and foundations, such amounts are well within reach.
Several conditions appear ready for a conscientious effort. Obstetric fistula, as a signal indicator for the obstructed labour, maternal and infant deaths and suffering that lie behind it, seems particularly well suited. Although this condition was eliminated in many places years ago, it still afflicts millions elsewhere (6). Also, routine health services seem unlikely to adequately address African trypanosomiasis (sleeping sickness) in the immediate future. Yet, a community-based catalyst approach might bring that deadly impediment to the public's health under even better control than was achieved in the 1960s.
At the health systems level, using the human resources organized for eradicating dracunculiasis, Burkina Faso and Togo are considering addressing issues as diverse as cleft lip and palate, club foot, noma, Buruli ulcer and malaria. For noma (a childhood infection with 90% mortality causing major facial damage in survivors), and artemisinin combination therapy for uncomplicated malaria, correct treatment within 24 hours is key, as it is for detecting and containing dracunculiasis.
Recent disease eradication efforts under the most difficult of circumstances have demonstrated how successful a catalytic approach to public health can be. It seems to be time to use tools from disease eradication programmes in some focused community-based efforts, to address carefully selected non-eradicable diseases.
Acknowledgements
I am grateful to the national dracunculiasis eradication programme managers in currently and formerly endemic countries; to Dr Donald R. Hopkins, Dr Ernesto Ruiz-Tiben and others at the Carter Center; to a number of lymphatic filariasis researchers especially Dr Gerusa Dreyer and Dr Joaquim Noroes in Recife, Brazil; to Dr David Addiss, Dr Patrick Lammie, Dr Frank Richards and others at the US Centers for Disease Control and Prevention (CDC), to Professor Eric Ottesen of Emory University who previously coordinated the lymphatic filariasis elimination programme at WHO; to lymphatic filariasis programme managers and other ministry of health professionals in Burkina Faso, Ghana, Togo and the United Republic of Tanzania, and to Professor David Molyneux at the Liverpool School of Tropical Medicine; Dr Yankum Dadzie, former Director of the Onchocerciasis Control Programme at WHO and currently chairman of the Global Alliance for Lymphatic Filariasis Elimination yet a strong advocate for system-wide, "basket funded", infrastructure-building approaches; to Dr Bernhard Liese of The World Bank; to Dr Linda Bartlett of CDC and Dr Berit Austveg of Norway's national Board of Health as well as other dedicated professionals in the field of women's health; to Health & Development International's board of directors and colleagues in several nongovernmental organizations, and to others, for insights and stimulating discussions, both recently and in the past. The anonymous reviewers are thanked for their helpful comments, and Peter Taylor of Palladian Partners (USA) for his excellent editorial suggestions. 
Competing interests: none declared.
References
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