By: Henry Perry
Originally posted here on April 11, 2016.
YouTube Link: Census-Based, Impact-Oriented (CBIO) Approach: A Discussion between Henry Perry and Daniel Palazuelos
The census-based, impact-oriented (CBIO) approach to improving the health of communities emerged in Bolivia in the 1980s when I was working there with the Andean Rural Health Project, a collaboration between Duke University, the Bolivian Methodist Church, and the Bolivian Ministry of Health. We were guided by a very wise and highly experienced professor at Harvard named John Wyon. John had spent 10 years in north India leading a community-based study that was the first field trial of a family planning program in a developing country. Field workers visited every home every two weeks not only to promote family planning but also to collect information on pregnancies, births, deaths, illnesses and migrations. Thus, it also became the first rigorous community-based longitudinal epidemographic study in a developing country, and the book describing this work (John Wyon and John Gordon, The Khanna Study, Harvard University Press, 1971) became a public health classic. Among other things, their research identified for the first time the importance of neonatal tetanus as a cause of neonatal mortality, the contraceptive effect of breastfeeding during the first 6 months after childbirth, and the increased mortality among children 18-23 months of age during the weaning period. Through that experience, John came to see the value of routine visitation of all homes as a powerful strategy for delivery of health interventions and for surveillance.
John mentored me during the early years of our work in Bolivia, and our Bolivian team slowly but surely became passionate advocates for the approach that we developed with John’s guidance. The following publications contain documents describing the CBIO approach as developed in Bolivia:
- Perry H, Robison N, Chavez D, Taja O, Hilari C, Shanklin D, and Wyon J. 1998. The census-based, impact-oriented approach: Its effectiveness in promoting child health in Bolivia, South America. Health Policy and Planning 13: 140-151.
- Perry H, Robison N, Chavez D, Taja O, Hilari C, Shanklin D, and Wyon J. 1999. Attaining Health for All through community partnerships: Principles of the census-based, impact-oriented approach developed in Bolivia, South America. Social Science and Medicine 48:1053-1067.
- Perry H, Shanklin D, and Schroeder D. 2003. Impact on infant and child mortality of a community-based, comprehensive primary health care program in Bolivia. Journal of Health, Population and Nutrition 21:383-95.
These articles were based on a comprehensive evaluation of the CBIO approach prepared for the US Agency for International Development in 1993: Perry H. The Census-Based, Impact-Oriented Approach and Its Application by Andean Rural Health Care in Bolivia, South America, 1993 (three volumes, available at https://www.curamericas.org/cbio/). An Expert Panel of distinguished global health experts met to discuss the approach and its relevance for broader application. Their report (also available at https://www.curamericas.org/cbio/) called for further development of the approach and its application in other settings. Two limitations of the approach identified by the panel were (1) its “high”cost ($9.83 per capita to provide comprehensive primary health care services) and (2) the fostering of dependence on program beneficiaries (because it provided services at the doorstep). Both of these limitations are, at least in my view, quite minor.
Unfortunately, CBIO never caught on with other NGOs or donor organizations such as USAID; it did become the heart of the work of Curamericas Global, the NGO that emerged out of the Andean Rural Health Project. Today CBIO principles are used in a number of important programs around the world although they do not specifically refer to CBIO as the name of its methodology. Perhaps the most important of these is SEARCH, a pioneering NGO based in central India. Another is the BRAC Manoshi Project, providing maternal, neonatal and child health services to almost seven million people living in the slums of Bangladesh.(1)
A manual describing some of the practical approaches to implementing CBIO is available at: http://pdf.usaid.gov/pdf_docs/PBAAC582.pdf (The Census-Based, Impact-Oriented Methodology: A Resource Guide for Equitable and Effective Primary Health Care, 2005, by David Shanklin and Donna Sillan).
As we move toward a more comprehensive and integrated approach to working with communities to help them improve their health, I am convinced the CBIO approach will have an increasingly important role to play in guiding program implementation toward ending preventable child and maternal health by 2035 and eventually achieving Health for All. The discussion between Daniel Palazuelos and me is an opportunity to obtain an introduction to CBIO, its history, its effectiveness, and its potential for improving the health of communities.
(1) See: The BRAC Manoshi Approach to Initiating a Maternal, Neonatal and Child Health Project in Urban Slums with Social Mapping, Census Taking, and Community Engagement. 2014. Dhaka, Bangladesh: BRAC, available at: http://www.brac.net/sites/default/files/portals/Manoshi-book-v3-1.pdf and Marcil L, Afsana K, Perry HB. First steps in initiating an effective maternal, neonatal and child health program in urban slums: The BRAC Manoshi Project’s experience with community engagement, social mapping and census taking in Bangladesh. Journal of Urban Health 2016;93(1):6-18.)
Henry B. Perry, MD, PhD, MPH
Senior Scientist, Health Systems Program
Department of International Health
Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland, USA
