Community action for health in Kyrgyzstan: an integrated approach of health promotion and primary health care provision in rural areas to scale up hypertension detection: good practice brief

COMMUNITY ACTION FOR HEALTH IN KYRGYZSTAN: an integrated approach of health promotion and primary health care provision in rural areas to scale up hypertension detection GOOD PRACTICE BRIEF Summary Motivation Bringing health closer to the people: community action for health Community Action for Health (CAH) in Kyrgyzstan is a health promotion programme built on direct citizen participation. Village health committees (VHCs), made up of volunteers, work with primary health care services to identify health-related priorities and implement health actions. One of the most ambitious health actions has focused on hypertension, contributing to improvements in early detection and subsequent monitoring of people with high blood pressure. Kyrgyzstan’s rate of avoidable mortality from cardiovascular disease is one of the highest in the WHO European Region. Hypertension is one of the risk factors, but late detection and poor compliance with medication are persistent problems. According to WHO calculations based on the 2007 Kyrgyz Integrated Household Survey, only 27% of people with high blood pressure were aware of their condition, and only 14% of those who were aware had taken their medication in the past 24 hours. Awareness and compliance with treatment among men were even lower, at around 20% and 8%, respectively. Although primary health care workers have been measuring blood pressure routinely for years (72% of people over 30 years of age who reported visiting a primary health care centre in 2007 had their blood pressure checked), many people still do not seek care at this level. Men aged 40–60 years are a particular concern because of their low rate of use of primary health care. A cornerstone of Kyrgyzstan’s pioneering health system reforms in the past 20 years has been a new model of health promotion based on community empowerment in conjunction with strengthening of primary health care. The CAH programme started as a pilot project in one rayon (district) in 2002, with the support of the Swiss Agency for Development and Cooperation and the Swiss Red Cross and in partnership with the Kyrgyz Ministry of Health and the Mandatory Health Insurance Fund. Once the programme had proved its potential, the Ministry included it as a component of the This brief is part of our work programme on strengthening the health system response to noncommunicable diseases. For the full report on Kyrgyzstan and other information, check out our website at http://www.euro.who.int/en/health-systems- response-to-NCDs. Key Messages • Engaging individuals and empowering communities can contribute to improved outcomes for complex health problems, such as hypertension. • An attitude of partnership is essential for the success of a community health programme. • In countries with severely under-diagnosed hypertension, community outreach and mobilization are essential to persuade people to go to health facilities for diagnosis and follow-up. • Community action for health works well if it is not a stand- alone eff ort but an integral part of the health system. • Countrywide expansion of community action for health is a result of step-by- step scaling up of a well- designed, evaluated pilot project. • The signifi cance of the community action for health programme goes beyond the health actions of VHCs. CAH website: www.cah.kg Schüth T, Djamangulova T, Aidaraliev R, et al. (2014). The Community Action for Health programme in the Kyrgyz Republic. Overview and results. Bishkek, Swiss Red Cross (Issue Paper on Health Series, No. 3a; https:// www.redcross.ch/de/shop/studien-und-factsheets/community- action-for-health-in-the-kyrgyz-republic). Jakab M, Smith B, Sautenkova N, et al. (2014). Kyrgyzstan country assessment. Better noncommunicable disease outcomes: challenges and opportunities for health systems. Copenhagen, WHO Regional Office for Europe. • Engaging individuals and empowering communities can contribute to improved outcomes for complex health problems, such as hypertension. When communities become partners in the health care system, creative approaches to a number of health issues such as hypertension become possible. Countrywide implementation of the CAH programme resulted in coverage of virtually all villages and towns, which increased awareness of hypertension to a remarkable degree in a relatively short time. • An attitude of partnership is essential for the success of a CAH programme. The commitment of volunteers depends on continuous experience that their issues and interests are being taken seriously. This begins with the use of participatory tools to identify the priorities in communities and then to act on them. Further, health care personnel are trained to interact with VHCs in an appreciative way in order to foster independent, critical thinking. Above all, success requires sustained support for VHCs in their organizational development. The resulting empowerment and the concomitant sense of growth and potential are the main rewards and motivation for voluntary work. VHCs thus perform health actions such as that for hypertension with a sense of ownership and commitment. • In countries with severely under-diagnosed hypertension, community outreach and mobilization are essential to persuade people to go to health facilities for diagnosis and follow-up. Primary health care workers are often overstretched and cannot incorporate outreach into their regular workload, even if in principle it is their task. Meaningful outreach covering a suffi cient number of people can be achieved with the help of community volunteers. In order for this to be sustainable, however, they must be supported by community capacity-building. • Community action for health works well if it is not a stand-alone eff ort but an integral part of the health system. This guarantees its sustainability and attracts potential donor organizations to cooperate and invest in the programme. It also ensures coordination of health actions. In parallel to the hypertension health action, primary health care staff were trained in improved diagnosis, documentation and management of hypertensive patients. Therefore, people found to have elevated blood pressure received optimal care from primary health care providers. This further increased the number of patients who took their medication. • Countrywide expansion of CAH is a result of step-by-step scaling up of a well-designed, evaluated pilot project. This strategy allowed the programme to sow the seeds of trust while developing a new paradigm in the fi eld of health and ensuring learning by doing. The results prompted the Kyrgyz Ministry of Health to adopt community action as a cornerstone of health promotion and primary health care. • The signifi cance of the CAH programme goes beyond the health actions of VHCs. As described above, empowerment is an essential part of the programme, and there have been numerous VHC initiatives to address local determinants of health. The programme fosters the sense that civic participation is possible and useful and hence strengthens civil society. New leaders are created, who stand out through their commitment to social well-being, some of them being elected to local self-government bodies. And, as most VHC members are women, the CAH programme is helping to change traditional gender roles, as seen in several studies. Lessons learned Further sources Contact us Manas Taalimi National Health Sector Reform Programme 2006–2010 and provided funding to hire the necessary personnel. This commitment attracted other international donors for countrywide expansion of the CAH programme. Currently, it covers about 90% of the villages in Kyrgyzstan – over 3 million people; and, since 2014, an adapted version covers all urban areas as well. The CAH programme is best described as a partnership between VHCs and the health system. The main partners of the VHCs in the health system are the “health promotion units”, which provide VHCs with regular training on health actions and assist in their organization. As they are located in family medicine centres, the health promotion units link population-based health promotion and individual health services. Primary care providers also interact closely with the VHCs and thus increase their engagement within their communities, beyond receiving patients. VHC delegates form rayon health committees to coordinate activities among themselves and with rayon health services. At national level policy discussions, an association of VHCs represents them and coordinates with the Republican Health Promotion Centre in the planning, design and implementation of health actions for conditions including hypertension, anaemia, goitre, brucellosis and alcohol abuse, among others. The decision-making power of VHCs has gradually been enhanced. They have gained the right to establish their own agendas to address broader determinants of health in their communities and have also begun to be involved in policy development and participatory budgeting with their local governments. From the early days, high blood pressure topped the list of health problems identified by the communities during participatory assessments in all oblasts (regions). It was the third most frequent and burdensome disease for women, the second for men and the most burdensome for poor people. Health action on hypertension was developed in close collaboration with VHCs. The initial aim was to address awareness, detection, regular check-ups and compliance with medication. This approach proved to be too demanding for the VHCs and ineffective for a high- prevalence disease like hypertension. The health action was therefore simplified, resulting in its current form. Its focus is now on screening to improve people’s awareness of hypertension. Since 2011, an annual “hypertension week” has been held, during which VHCs screen as many adults as they can with semi-automatic blood pressure cuffs. The organization of screening is left to the VHCs. Most use a combination of house visits and fixed locations for blood pressure measurement. People with elevated blood pressure are given special attention, whether or not they have a previous diagnosis of hypertension. VHC members explain the danger of cardiovascular diseases and the importance of daily, lifelong medication. A booklet explaining cardiovascular disease and its risk factors in detail is given to each person, and they are sent to their primary care provider for verification, further diagnosis and management. VHCs record people’s name, address and blood pressure and give the lists to primary care providers so that they can follow up people who do not consult them. In urban areas, screening was initially done by primary care providers who positioned themselves at highly frequented places. Since 2015, public health committees – the new counterparts to VHCs in urban areas – have joined this health action in urban communities. In the lead-up to hypertension week, countrywide TV spots inform people about screening and encourage them to seek out the volunteers. Figure 1. Hypertension screening week results Figure 2. Hypertension awareness in rural and urban areas Source: CAH overview and results Source: Kyrgyz Integrated Household Survey, 2007, 2011, 2015 Impact Health action on hypertension The CAH programme has contributed to a signifi cant improvement in early detection and management of hypertension, and the number of people screened during the annual hypertension weeks has increased each year. Since 2011, a total of 1.75 million people have been screened for elevated blood pressure, comprising about half the adult population of Kyrgyzstan. Screening identifi es both people with elevated blood pressure who were not aware of their condition and also people who are aware of their hypertension but do not know that it is uncontrolled, i.e. their blood pressure reading was elevated at the time of screening (Figure 1). The approach of the CAH programme has had a signifi cant impact on hypertension awareness and control nationwide. According to WHO calculations from the nationally representative Integrated Household Survey, awareness of having hypertension increased from 27% in 2007 to 45% in 2015. The increase was greater in rural areas, where VHCs work. As a result, a large urban–rural gap in awareness of hypertension status noted in 2007 had disappeared by 2015 (Figure 2). Compliance with anti-hypertensive medicines also improved during this period. The proportion of people with elevated blood pressure who reported having taken their medication in the past 24 hours was 33% in 2015, in contrast to 14% in 2007.