The Urban Health Project, Karachi
Professor and Chair, Community Health Sciences, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
Sir The article by Tollman & Zwi on health system reform and the role of field sites is a call to re-examine this role in relation to evidence-based policy and programme development (1). The authors note their intention to document all existing demographic and health surveillance field sites in Africa, Asia and Latin America. This is timely in terms of the Urban Health Project (UHP) of the Aga Khan University, which has just completed a grant funding cycle.
Primary health care interventions over a 10-year period have achieved major reductions in infant and maternal mortality at project sites in squatter settlements of Karachi, Pakistan, with significant lessons for urban health systems development. In view of the recognition by the World Bank that Karachi is representative of many large cities in developing countries, where the public sector has had difficulty coping with rapid urban growth (2), there is merit in sharing this experience with other countries.
The Aga Khan University has pursued the systems development aspect of its work through prototype projects in urban and rural health settings (3). The UHP falls into a category of projects that has contributed to the development of national programmes of primary health care and family planning and provincial health systems development at the district level, including the implementation of health information systems. In Karachi itself, such projects have helped to complement an overwhelmed public sector and constitute models of good practice (4). While UHP was the first project of its type in Pakistan, other health science institutions have since launched similar initiatives, transforming the earlier model of institution-based education into one that is now more integrated with primary health care.
As communities reach new levels of capacity, the initiatives, emphases and even actual project sites necessarily change. For example, the management information system approach reported in 1993 was quite elaborate, and efforts were required to simplify it (3). Greater use is now made of surveys to assess health status and the impact of interventions (5). Tollman & Zwi comment that field sites can support investigations for efficacy and effectiveness, as well as action research. Recent examples of such investigations from UHP include iron supplementation strategies in pregnancy, access to emergency obstetric care, water quality technology, and contraceptive choices.
When viewed as a platform for the assessment of more discrete interventions, however, the distinction blurs between demographic and health surveillance field sites and other field sites with more specific purposes. After all, most interventions must eventually be tested in operational settings that reflect reality. To justify the distinction, one must return to the primary health care agenda, including the elements of community participation, sustainable local organizations with representative structures, income generation, and gender equity.
There clearly is a need for open, objective and ongoing scientific debate on how to obtain full benefit from the extraordinary efforts that have brought such valuable field sites into existence, and their potential to contribute to new knowledge and policy applications. It is equally clear that producing and disseminating transferable results from these field sites, to demonstrate their value, will play a key role in their future viability.
1. Tollman SM, Zwi AB. Health system reform and the role of field sites based upon demographic and health surveillance. Bulletin of the World Health Organization, 2000, 78: 125134.
2. World development report 1999/2000. Entering the 21st century. New York, Oxford University Press for The World Bank, 1999.
3. Husein K et al. Developing a primary health care management information system that supports the pursuit of equity, effectiveness and affordability. Social Science and Medicine, 1993, 36: 585596.
4. Urban Health Project a health programme in squatter settlements in Karachi. In: Models of good practice relevant to women and health. London, Commonwealth Secretariat, 1998.
5. Rabbani F. A view of the citys health from the Aga Khan University, Karachi, Pakistan. Urban Health and Development Bulletin, 1999, 2: 99111.