Community health and primary health care: the value of home visitation

4 September, 2021

Dear Friends and Colleagues:

I would like to share with you an article by Atul Gwande, published on August 23 in The New Yorker entitled “Costa Ricans live longer than us. What’s the secret?” [ https://www.newyorker.com/magazine/2021/08/30/costa-ricans-live-longer-t... ]. This article is significant because it describes Costa Rica’s primary health care system, which consists of teams of one doctor, one nurse, and a salaried community health worker to serve four or five thousand people. There are one thousand of these teams in Costa Rica, a country with five million people. The community health worker visits every home at least once a year, with those at higher risk (such as an elderly person living alone or a person with a disability) receiving three preventive visits a year and those with at moderate risk receiving two visits a year. This merger of home visits for preventive care and home visits when needed for more acute needs with primary health care provided by higher-level providers at a PHC clinic has enable Costa Rica to have a higher life expectancy than the United States while spending a lower percentage of its income on health. Gawande’s article emphasizes the value of the Costa Rican primary health care system for the United States, but the value of the approach extends to countries throughout the world.

As many of you know, Atul Gawande is a much-heralded surgeon, writer, and public health leader. He is an endocrine surgeon at the Harvard/Brigham and Women’s Hospital and a professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health. In addition, he has been a staff writer for The New Yorker magazine since 1998 and has written four New York Times best-selling books (most famously Being Mortal). Of current importance, he was nominated in July by President Biden to become the Director of the Bureau of Global Health of the United States Agency for International Development (still awaiting congressional confirmation) [ https://www.reuters.com/world/us/biden-nominate-surgeon-author-atul-gawa... ].

The approach which Gawande has so beautifully illustrated was independently developed by a team I led in Bolivia in the early 1980s. We had demonstrated a decline [ https://www.jstor.org/stable/23499347 ] by half in the mortality rate of children younger than 5 years of age (from 20% to 10%). When we convened an Expert Panel in 1993 to assess the effectiveness of our model (which we called the census-based, impact-oriented, or CBIO, approach [ https://www.sciencedirect.com/science/article/abs/pii/S0277953698004067 ]), the Panel decided that it was too expensive (though it cost only $9 per capita per year to provide comprehensive primary health care services!) and that it was disempowering since it provided basic health services at the doorstep. Consequently, USAID decided the approach wasn’t worth pursuing, unfortunately. Nonetheless, the value of the principles of CBIO approach has gradually become increasingly apparent, though it is far from mainstream. Furthermore, community health worker programs around the world are, in my view, at the dawn of a new era when CHWs will play an increasingly important role in healthcare delivery everywhere.

Two recent articles describing how this approach implemented over a 30-year period in a peri-urban area of Montero, Bolivia, has produced an under-5 mortality equivalent to that in the United States (0.7%): article 1 [ https://www.oatext.com/implementing-the-census-based-impact-oriented-app... ] and article 2 [ https://www.oatext.com/implementing-the-census-based-impact-oriented-app... ]. In 2018, Ari Johnson and his colleagues reported that their program of frequent home visits in periurban Bamako, Mali, had been able to achieve a similar under-5 mortality rate [ https://gh.bmj.com/content/bmjgh/3/2/e000634.full.pdf ].

Let us all hope that Atul Gawande will be installed soon in his new position at USAID and that his awareness of the power of community-based primary health care can influence policy and practice for the better!

Feel free to share this with anyone or any listserv that you think would be appropriate.

Warm regards,

Henry

Henry B. Perry, MD, PhD, MPH

Senior Associate, Health Systems Program

Department of International Health

Johns Hopkins Bloomberg School of Public Health

Baltimore, MD, USA 21205

Hperry2@jhu.edu; 443-797-5202

HIFA profile: Henry Perry is a Senior Scientist at the Johns Hopkins Bloomberg School of Public Health, USA. Professional interests: Community health and primary health care. hperry2 AT jhu.edu