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It’s evidence time for primary health care

14 May 2008, 14:19

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by Robert Walgate

Carissa Etienne, WHO Assistant Director General for health systems, stresses the need for evidence, information and research to make cost-effective health policies in developing countries. Specifically, and with passion, she calls for a systematic review of all research on primary health care since Alma Ata to provide real evidence on what works and fails. Community health workers should also be studied, she says – all against a measure of health outcomes.

>RHN: In your career as Chief Medical Officer of Dominica in the Caribbean, then as Assistant Director of PAHO, and now as Assistant Director-General for Health Systems and Services of WHO in Geneva, you’ve shown yourself very concerned with evidence. Can you tell us why?

Carissa Etienne: In the Caribbean and in our interaction with other countries I have seen us make the same mistakes over and over again. And I have seen us make us make interventions that have not been evidenced-based, and we haven’t had the outcome we had hoped for. And for me outcomes are very important, because they mean how do we affect the quality of life of those who are poor, marginalised and vulnerable.

Most of us have started with very good intentions, but without evidence we can become very ineffective and inefficient.

>RHN: Could you give us a couple of examples? What mistakes have been made again and again, without evidence?

READ ON: Biography of Carissa Etienne

CE: Well, for example – the distribution and allocation of budgets to health districts and local levels without proper epidemiological and demographic evidence. It’s very difficult to know with good confidence what are all the health needs of a certain population.

Without the information gathering that’s so essential – and also so much of a constraint in many developing countries – it’s really a lot of guesstimates.

>RHN: That’s in part to do with not having a proper data gathering within the health service, isn’t it?

READ ON: Interview with Carissa Etienne in PAHO Today

CE: Yes, and as you know in some countries not even the vital registration system [counting the births, deaths and causes of death] is working or properly organised. For some the basic health information system is non-existent, broken; in others where this is a health information system there is very little analysis.

A lot of health research is done about developing countries, and particularly research that takes place in developing countries, but a lot of that is really made by researchers in the North; and sometimes they don’t have adequate focus on the local problems – or an understanding of the local situation.

Hence the analysis of that research and the conclusions sometimes do not speak to the realities of the local level.

READ ON: WHO health systems cluster

So how can we help developing countries to create an information system that yields the data that is needed for planning and decision making? And at the same time how do we help them build capacity to define their research needs – and conduct it themselves?

>RHN: Did you come to these views early, in Dominica, or from your international experience?

CE: This is an emerging view, based on my experiences in the Caribbean but also significantly in PAHO as well. In PAHO at our governing body meetings, ministers are often saying ‘we need a health information system, so we have the appropriate information at the appropriate time, when we need it to make a decision! When are you going to help us do that?’ That is what they say.

>RHN: So what kind of evidence have you been able to find and use, in your experience, that actually has been useful to you? Have you found anything that’s been appropriate?

CE: Well certainly: you know when I worked in PAHO we insisted on having all of the information before making decisions or taking action, and our technical divisions were the ones responsible for getting that evidence.

Take blood donations, for example – the evidence that blood from paid donors has a higher risk of being infective, than if you take it from voluntary unpaid donors. That was very important for the management of blood banks.

Even in health systems, the gathering of data that shows that families can be totally impoverished by trying to gain access to health services [catastrophic health expenditures] – that was also an important piece of information.

And in the Americas, studies showing how the fragmentation of health services was having an effect on the health and welfare of different segments of the population – they were significant.

“The WHO Director General, Margaret Chan, has enunciated her own vision – utilizing the primary health care approach for health system strengthening, and I think that’s my remit.”


>RHN: What’s your vision for the Health Systems and Services cluster in WHO? What role do you think research and evidence will play in it?

CE: I often say that because I’m a team leader, par excellence, I don’t like to speak about my own vision! I like to speak of the process to develop a collective vision. That’s very important.

But the Director-General, Margaret Chan, has enunciated her own vision – utilizing the primary health care approach for health system strengthening, and I think that my remit, and within the cluster, is how do we build within the health systems framework an emphasis on the key building blocks of the primary health care approach?

And for primary health care we are not merely referring to the first level of care, but to a strategy that embodies equity and rights and solidarity – that speaks to all of the elements of the primary health care strategy.

>RHN: It means looking at the health system from the point of view of the poorest and most remote user.

CE: Yes, but also the city dweller and whatever makes somebody marginalised. It is not merely for poor countries – it’s also relevant for developed countries…

>RHN: Where there are immense health inequities, even in a rich economy like the United States, for example…

CE: Exactly. So how do they look through the lens of equity, and organize a health system that recognizes there is a private sector as an important player, that we are building a health system within a health sector, but also recognizes that that health sector interacts with so many other sectors”

>RHN: I was struck that the DG enunciates a ‘2X2X2’ approach in which one of the twos combines both health systems and research. She said that these two were strategic: “Capacity building – particularly strengthening health systems – and information and knowledge. Here I mean getting the evidence right and setting the agenda for research and development.” So she combines health systems and research in one strategic bundle.

“Is there any evidence that there were benefits [from primary health care] and that it can be sustained? Do we have evidence of what worked and what did not work?”


CE: And I think it’s important, now we are on this new course of primary health care, that we are at the point where the sceptics are asking ‘did it work?’

>RHN: You mean going back to Alma Ata and what happened after that?

CE: Exactly. Is there any evidence that there were benefits and that it can be sustained? Do we have evidence of what worked and what did not work?

Evidence exists, but we really have to apply some rigour in really looking to find all the research that has been done [on this] and to pull it together, to categorise it. I think we are past the time when we can just say ‘Of course it works! There are countries with good experiences!’

We ourselves, at WHO, need to be able to tell our member states ‘this is the evidence’.

>RHN: That’s very interesting – so you think it’s going to be valuable, you think, to do a systematic review of all the evidence on primary health care?

CE: Yes. I think so. So our members can make informed decisions towards primary health care, where they want to go.

“I’m a team leader, par excellence, I don’t like to speak about my own vision! I like to speak of the process to develop a collective vision. That’s very important.”


I think it’s true that the Secretariat is in very much of a listening mode as far as that is concerned, listening to what member states are saying and what they are calling for.

>RHN: In relation to primary health care?

CE: Yes. And to health systems strengthening and their concepts of the primary health care approach. We think it’s going to be country-specific.

>RHN: Well of course the WHO does have to listen to its member states; it’s essentially a tool of the member states…

CE: Yes, yes…

>RHN: …but it also has a great deal of expertise at the centre, and in the regions, and in the country offices, and among its many many expert groups; so it always seems a bit disingenuous to me when people say they have to defer entirely to the countries!

CE: No, no, and I think we’d be reneging on our responsibilities to defer entirely to countries; I think we will need to continue to work in terms of providing options, recognizing that the realities in our countries are different.

So we will have to prepare a menu of options, so when we sit with country X, we can say, look, for your particular situation and needs, we think these are the options, and these the advantages and disadvantages.

>RHN: Furthermore I guess the bottom line regarding evidence, for primary health care, is that WHO has got to be prepared to hear what it might consider the ‘wrong message’: so if you learn from your systematic reviews that primary health care did not work, or was not cost-effective or whatever, would you listen to that lesson?

CE: Yes. And the follow-up question would be why, why didn’t it work? When I hear ‘it didn’t work’ the next thing I say is what is ‘it’? Because frankly the world did not implement the Alma Ata concept. It relegated it to care for the very poor and very rural.

But inherent in the primary health care declaration of Alma Ata was also this higher concept of ‘health development’, and development in general, which says that equity is important, that it must be a multisectoral approach, that your policies that you pass on health even at the highest national level have an impact on health and well-being. That part of it was definitely ignored.

>RHN: How strong do you think health system evidence has to be? It’s not like physics, is it, or even a clinical trial; what constitutes for you good evidence in relation to health system strengthening, or indeed primary health care?

CE: I certainly would like to see what service delivery models have been beneficial in terms of integrating care in terms of the impact on mortality, morbidity and quality of life.

>RHN: You want to measure health outcomes in relation to different kinds of health system structure.

CE: Yes. Then putting this evidence, and letting countries decide. It’s always their decisions. I would like to see it terms of skills mix, what has been the impact of using different categories of health care workers. What have community health workers contributed to health and wellbeing?

SEE OPINION: Used and abused – community health workers need a policy

>RHN: Indeed. And they are being very widely used – we have a report in this issue of RealHealthNews in which it’s said that in Nigeria alone 68 different federal health programmes are using these workers, and programmes outside the health sector too. I would agree with you that we urgently need to study how that works!

CE: And in terms of your scarce funding and workforce – how best to organize that workforce? If you spend the money on specialists, what impact does that have on general health and well-being? If you spend it on a greater skills mix, what is the outcome?

I think in my heart I know the answer, but I should not depend on my gut feeling!

>RHN: Yes we’ve all got anecdotal experiences that we can bring to bear on these things but you need research to determine what is generalisable and what really works.

CE: Exactly. Many countries are at the point where they feel that they are spending a lot on health – although the evidence does not show that – and that they are not getting the outcomes that they are expecting.

So we have to be able to help them make those decisions.

>RHN: A lot of these questions need local answers – these studies need to be done everywhere, don’t they?

READ ON: Alliance for Health Policy and Systems Research

CE: Yes I think so. Our Alliance for Health Policy and Systems Research working with clusters in WHO did some policy-maker interviews in some 24 countries, asking for their needs for evidence, and their knowledge gaps. We did this for health financing, the role of the non-state sector, and human resources, and we are already beginning to have a feel for what some of those knowledge gaps are.

>RHN: So there are some general questions that everyone is asking.

SEE INTERVIEW: Palestine unites for research plans

CE: Yes. Governments want to know the implications of universal coverage in different settings. And what is the acceptability of different methods to households. How best should they design universal coverage schemes?

>RHN: We report in this issue on studies in Palestine and other low and middle income countries in the Middle East and North Africa, asking governments and politicians and health professionals and civil society the question, what research do they need to improve health delivery, and the result is a long series of extremely practical questions.

CE: Exactly. They are struggling and we have to help them find answers!

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