Wood already touched by fire is not hard to set alight.

Akan Proverb

The use of proverbs in Africa is a powerful communication tool. Proverbs alert the listener to the importance of a topic and convey ancestral wisdom often with richly evocative imagery. The beauty of proverbs is their universal and timeless truths, which incorporate multiple interpretations across domains, cultures, and countries. It is fitting to use the interpretations of this West African (Akan) proverb “Wood already touched by fire is not hard to set alight” as a framework to comment on the study in Pediatrics by Fiori et al,1  who report the impact of a pragmatic, effectiveness primary health care (PHC) suite of interventions across 10 022 households over a 5-year period in Kara, a low-resource region of northern Togo, West Africa. The authors report on mortality, health use, quality and coverage outcomes, and cost.

This year marks the 43rd anniversary of the landmark Alma-Ata Declaration, which codified PHC as the key pillar and strategy all countries should adopt to ensure improved health for all.2  Introducing a suite of interventions into global public health (GPH) to attain multiplicative benefit has long been an attractive yet elusive goal, and in numerous analyses, researchers report on this.3,4  The authors present the reality of implementing a community-based bundle of interventions in Kara, Togo. Using a before-and-after study design between 2015 and 2020, they report an impressive decrease in under-5 mortality rates (U5MRs) from 51 per 1000 to 35 per 1000 live births and note that this decline (30%) is approximately twice that of the national figures (14%). They also report many health use, coverage, and quality gains: a near doubling of home-based treatments by community health workers (46% from 24%), more women receiving any antenatal care (50% from 38%), higher facility-based childbirth rates (from 48% to 66% compared with 80% to 89%) in rural areas, and 50% more women who received postnatal care after leaving health facilities (60% from 38%).

This project required massive collaboration. The Demographic and Health Surveys and the Multiple Indicator Cluster Survey programs have collected, analyzed, and disseminated nationally represented data from >400 surveys across 90 low- and middle-income countries over the past 4 decades.5  These surveys are used to collect information on population, health, HIV, and nutrition. Often unknown to many clinicians, these data collection systems remain one of the most widely used and powerful GPH measurement, monitoring, and evaluation tools and require an army of staff to maintain. Additionally, executing this project included staff of the international nongovernmental organization Integrate Health, the Togolese Ministry of Health, a consortium of Togolese and North American partners, and a cumulative population of >10 000 households, reflective of the nature of PHC and the importance of purpose-driven, richly collaborative partnerships.

Numerous GPH projects wither and perish on the vine, once the watering streams of external funding cease. Using a top-down cost method, the authors report annual project costs to be $389 412.00, or $8.84 per person per year.

These estimates may mask significant inaccuracies. The top-down method, although pragmatic and widely used in GPH settings, is a blunter and less accurate approach that uses overall unit costs, fitted into formulae, to generate estimates. By contrast, the bottom-up method is more comprehensive and detailed and uses real service-level programmatic data to generate estimates.6  Although some authors caution against using the top-down approach to assess incremental costs, further inaccuracies may arise when project costs in one region of a country are used to generate national-level cost data.

With Togolese per capita health expenditure of $38.00, introduction of a new $8.82 per capita intervention bundle would require 25% increased funding. Over the past 2 decades, Togo has nearly doubled its health funding as a percent of gross domestic product, from 3.3% to 6.2%, yet this value falls woefully short of the 15% pledged in the Abuja Declaration by Heads of the African Union and calls into question the likelihood of the scale-up of such projects.7,8 

This article raises other questions. For example, neonatal mortality rates (NMRs) as a ratio of U5MR usually range between 0.4 and 0.7 in many resource-constrained settings.9  Yet in these analyses, the NMR/U5MR ratio in 2015 was 0.2 and rose to 0.3 by 2020. NMRs were vexingly stagnant, despite uptake of the interventions. The authors acknowledge the inherent limitations posed by the lack of reliable mortality data at the subnational level, household responder bias, and the small absolute number of reported child deaths. It is noteworthy that by 2020, the highest wealth quintiles (4 and 5) had doubled, and the poorest wealth quintile (1) had shrunk by two-thirds. Also, attainment of secondary education or higher increased by 50%, and those with no or only primary level education attainments halved. The implications of these broader changes likely also affect the results noted in this article.

PHC is critical to the advancement of health. Yet the coronavirus disease 2019 pandemic, among others, has highlighted how important yet vulnerable these PHC systems are.10  Governments need to be held accountable to prioritize health spending, promote innovation and the private sector, and simultaneously create an enabling environment for population-level demand activities.

Rigorous real-world analysis around the messy realities of GPH, although imperfect, will always be a powerful lever to better understand the impact of interventions, determine or reassess policy and priorities, plan program execution, and track progress toward national and GPH improvement. Most of all, it provides us inspiration to dare to strive for improved health care for all.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-035493.

     
  • GPH

    global public health

  •  
  • NMR

    neonatal mortality rate

  •  
  • PHC

    primary health care

  •  
  • U5MR

    under-5 mortality rate

1
Fiori
KP
,
Lauria
ME
,
Singer
AW
, et al
.
An integrated primary care initiative for child health in northern Togo
.
Pediatrics
.
2021
;
148
(
3
):
e2020035493
2
Rifkin
SB
.
Alma Ata after 40 years: primary health care and health for all-from consensus to complexity
.
BMJ Glob Health
.
2018
;
3
(
suppl 3
):
e001188
3
Lassi
ZS
,
Bhutta
ZA
.
Community-based intervention packages for reducing maternal and 379 neonatal morbidity and mortality and improving neonatal outcomes
.
Cochrane Database Syst Rev
.
2015
;(
3
):
CD007754
4
Pérez-Escamilla
R
,
Engmann
C
.
Integrating nutrition services into health care systems platforms: where are we and where do we go from here?
Matern Child Nutr
.
2019
;
15
(
suppl 1
):
e12743
5
The Demographic Health Survey Program
.
The DHS Program
.
Available at: https://dhsprogram.com. Accessed June 1, 2021
6
Cunnama
L
,
Sinanovic
E
,
Ramma
L
, et al
.
Using top-down and bottom-up costing approaches in LMICs: the case for using both to assess the incremental costs of new technologies at scale
.
Health Econ
.
2016
;
25
(
suppl 1
):
53
66
7
World Bank Group
.
Current health expenditure (% of GDP) - Togo
.
8
World Health Organization
.
The Abuja Declaration: 10 years on
.
9
Hedstrom
A
,
Perez
K
,
Umoren
R
,
Batra
M
,
Engmann
C
.
Recent progress in global newborn health: thinking beyond acute to strategic care?
J Perinatol
.
2019
;
39
(
8
):
1031
1041
10
Levine
O
,
Gawande
A
,
Lagomarsino
G
,
Kelley
E
,
Pearson
L
,
Pate
MA
.
A safer world starts with strong primary healthcare
.
The BMJ Opinion. October 26, 2020. Available at: https://blogs.bmj.com/bmj/2020/10/26/a-safer-world-starts-with-strong-primary-healthcare/. Accessed June 1, 2021

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.