Primary Health Care: How different Primary Health Care: How different will it be in the 21st Century? will it be in the 21st Century?

UNWRA Health Services: Past, Present and FutureCommodore Hotel, Thursday 23rd June 2011

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Primary Health CarePrimary Health Care

Idea of comprehensive primary health care Idea of comprehensive primary health care operates at two levels: operates at two levels:

as as overall approach of health workoverall approach of health work, which , which is part of the overall social and economic is part of the overall social and economic development of the community; and development of the community; and

as a as a level of contact and care level of contact and care within the within the health system reconfigured to emphasize health system reconfigured to emphasize the essential health needs of the the essential health needs of the population population

Primary health care: the vision of Primary health care: the vision of AlmaAlma--AtaAta

Alma Ata Declaration of 1978 is a landmark in Alma Ata Declaration of 1978 is a landmark in the history of public health and for WHOthe history of public health and for WHO

Universal values and principles of Universal values and principles of comprehensivecomprehensive PHCPHC

Health equity, social justice, universal accessHealth equity, social justice, universal access

Community participation, health a human rightCommunity participation, health a human right

regardless of residence, gender, social status and regardless of residence, gender, social status and cultural identity cultural identity

Year 2008, the 30th Anniversary of Alma Ata, Year 2008, the 30th Anniversary of Alma Ata, provided opportunity to reaffirm commitment to provided opportunity to reaffirm commitment to PHC PHC

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Evolution of Primary Health Care: A birdEvolution of Primary Health Care: A bird’’s s eye view eye view

19791979-- Selective PHCSelective PHC: considered pragmatic, : considered pragmatic, financially sustainable, politically palatablefinancially sustainable, politically palatable

1980s 1980s -- Structural Adjustment ProgramsStructural Adjustment Programs: : required reduced spending on social sectors required reduced spending on social sectors and levy charges for primary care and levy charges for primary care

19881988-- WHO advised member states to allocate WHO advised member states to allocate at least 5% of GDP to achieve HFA at least 5% of GDP to achieve HFA

19931993-- World Bank WDRWorld Bank WDR: Investing in Health : Investing in Health defined a defined a basic benefit package basic benefit package of essential of essential health interventions health interventions

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Evolution of Primary Health Care: A Evolution of Primary Health Care: A birdbird’’s eye views eye view

1998- WHO reinvigorated Health For All in the 21st Century

2000-WHO’s millennium World Health Report on health systems

2000- Millennium Development Goals Declaration

2005- WHO Commission on Social Determinants of Health [SDH]

2008- 30th Anniversary and revival of PHC, World Health Report on PHC,

2008 - Report of Global the Commission on SDH

2010 – World Health Report – Path to Universal Coverage

Primary Health Care Primary Health Care -- 19781978

International Conference on Primary Health International Conference on Primary Health Care, AlmaCare, Alma--Ata, USSR, 6Ata, USSR, 6--12 September, 197812 September, 1978

Eight components:•Public Education•Proper Nutrition•Clean Water & Sanitation•Maternal & Child Health Care•Immunization•Local Disease Control•Accessible Treatment•Drug Provision

Values and Principles:•Equity•Social justice•Participation•Appropriate technology•Patient centeredness

1980 – Comprehensive vs. Selective Primary Health Care

Renewal of Primary Health Care calls for universal coverage reform - 2008

Universal coverageequity and social justice

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Four areas of PHC ReformsFour areas of PHC Reforms

Universal coverage reforms that ensureUniversal coverage reforms that ensure health health systems contribute to health equity, social justice systems contribute to health equity, social justice and the end of exclusion, primarily by moving and the end of exclusion, primarily by moving towards universal access and social health towards universal access and social health protection;protection;

Service delivery reforms that reService delivery reforms that re--organize organize health health services around peopleservices around people’’s needs and s needs and expectations, to make them socially relevant and expectations, to make them socially relevant and more responsive to the changing world, while more responsive to the changing world, while producing better outcomes;producing better outcomes;

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Four areas of PHC ReformsFour areas of PHC Reforms

Public policy reforms that secure healthier Public policy reforms that secure healthier communities, by integrating public health actions communities, by integrating public health actions with primary care, by pursuing healthy public with primary care, by pursuing healthy public policies across sectors policies across sectors ………………; and; and

Leadership reforms that replace disproportionate Leadership reforms that replace disproportionate reliance on command and control on one hand, reliance on command and control on one hand, and laissezand laissez--faire disengagement of the state on faire disengagement of the state on the other, by the inclusive, participatory, the other, by the inclusive, participatory, negotiationnegotiation--based leadership based leadership …………....

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DISEASEORIENTED

RISK FACTORORIENTED

Primary Health Care: the Driving Force for developing National Health Systems

WELLNESSWELLNESS

ILLNESSILLNESS

HEALTH PROMOTION HEALTH PROMOTION ORIENTEDORIENTED

Innovations in primary health care in countries of the Eastern Mediterranean Region

District health system

Sultanate of Oman - Welayat Health System

Islamic Republic of Iran - Shabakeh Behdashti

Community Health workers

Pakistan – 100,000 females CHWs recruited by government

IRI – Recruitment of 25 000 male and female Behvarz

Integration of medical education with health services

Islamic Republic of Iran, Tunisia

Experience with public private partnership for PHC services

Lebanon, Afghanistan

Family health practice model

Jordan, Egypt, Bahrain, Oman, Saudi Arabia, Tunisia, UNWRA

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Characteristics of a Family Practice Characteristics of a Family Practice Model Model

Care provided within a community contextCare provided within a community context

PatientPatient--centered centered

WholeWhole--person orientation person orientation

Team approach Team approach

Elimination of barriers to accessElimination of barriers to access

Advanced information systemsAdvanced information systems

Emphasis on quality and safety Emphasis on quality and safety

Commitment to provide family medicineCommitment to provide family medicine’’s s basket of servicesbasket of services

Elements of family practice programElements of family practice program

Universal access to essential package Universal access to essential package of health services, of health services, based on BOD and of acceptable quality ;based on BOD and of acceptable quality ;

Fully registered population Fully registered population with PHC network through a with PHC network through a system of system of family foldersfamily folders, continuity of care;, continuity of care;

Well functioning Well functioning referral system referral system that ensures PHC that ensures PHC facilities serve as facilities serve as gatekeepergatekeeper, appropriate referral, timely , appropriate referral, timely feedbackfeedback

Workforce trained in family practice Workforce trained in family practice and led by a family and led by a family physician, that is motivated to establish a FP program physician, that is motivated to establish a FP program

Hospital is integral component of family practiceHospital is integral component of family practice program program and engaged in referral, training and monitoring support;and engaged in referral, training and monitoring support;

Elements of family practice program [2]Elements of family practice program [2]

Local health management is committed to Local health management is committed to well performing family practice program;well performing family practice program;

Automated health information system Automated health information system (including civil registration) for informed (including civil registration) for informed decisions at the local level;decisions at the local level;

Proactive community Proactive community that understands the that understands the benefits of a family practice program and is benefits of a family practice program and is involved in its establishment; involved in its establishment;

Financial protection Financial protection of households in the of households in the event of serious illnessevent of serious illness

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Benefit package of health services of Benefit package of health services of PHC ServicesPHC Services

Defining and developingDefining and developing

Basis Basis -- Burden of disease Burden of disease and risksand risks

Basic or essential vs. Basic or essential vs. ComprehensiveComprehensive

Public health interventionsPublic health interventions

Clinical interventions Clinical interventions

CostingCosting

Essential interventions Essential interventions includedincluded

Resources availableResources available

Marginal costs [cost of Marginal costs [cost of adding or enhancing an adding or enhancing an intervention] intervention]

FinancingFinancing

Tax basedTax based

Insurance basedInsurance based

Donor fundedDonor funded

Privately financedPrivately financed

ProvisionProvision

PublicPublic

Private for profit, not for Private for profit, not for profitprofit

Skills mix [Physician, nurse, Skills mix [Physician, nurse, medical technician, health medical technician, health worker etc.]worker etc.]

Monitoring Monitoring

IndicatorsIndicators

Means and mechanism Means and mechanism

Countries in Eastern Mediterranean Countries in Eastern Mediterranean –– Family Practice ProgramFamily Practice Program

Islamic Republic of Iran Islamic Republic of Iran

BahrainBahrain

Saudi ArabiaSaudi Arabia

JordanJordan

Iraq Iraq

EgyptEgypt

LibyaLibya

Syria Syria

UNWRAUNWRA

KuwaitKuwait

QatarQatar

United Arab EmiratesUnited Arab Emirates

OmanOman

LebanonLebanon

PalestinePalestine

Tunisia Tunisia

MoroccoMorocco

WHR 2010: Path to Universal CoverageWHR 2010: Path to Universal Coverage

Raising sufficient Raising sufficient resources for healthresources for health

Removing financial Removing financial risks and barriers to risks and barriers to accessaccess

Promoting efficiency Promoting efficiency and eliminating wasteand eliminating waste

Addressing inequalities Addressing inequalities in coveragein coverage

PHC and Social Determinants of Health PHC and Social Determinants of Health [SDH] [SDH] --20082008

Improve Daily Living Improve Daily Living ConditionsConditions

Tackle the Inequitable Tackle the Inequitable Distribution of Power, Distribution of Power, Money, and ResourcesMoney, and Resources

Measure and Understand Measure and Understand the Problem and Assess the Problem and Assess the Impact of Actionthe Impact of Action

Innovations in Primary Health Care: SDH and Community Development Approach

Tackle social determinants of health and health equity

women’s empowerment through education and employment

early child development

migrant workers – movements within and between countries

social dimensions of priority public health conditions

socially determined lifestyle and behaviors

conflicts and emergencies and the resulting health inequities

Community Based Initiatives (CBI)

Healthy Villages

Healthy Cities

Basic Development Needs and

Gender in Health and Development

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Tackling social determinants (SDH) of health through community based initiatives (CBI)

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Poor, rural, disempowered

community

Skills Development

Income Generation

Public Health Interventions

Organized & empowered community

Improved quality of

Life

COMMUNITY BASED INITIATIVES –Basic Development Needs Programme

Sustainability

Reduce Poverty

Address Social Determinants

Social Development

Community Organization

Women Development

Improved health

Health Systems based on Primary Health 

Care in the Eastern Mediterranean

Final thoughtsFinal thoughts

Values of PHC are Universal Values of PHC are Universal –– Equity, social Equity, social justice, participation, human rightsjustice, participation, human rights

Develop health systems based on the values of Develop health systems based on the values of PHC, but one size fits all approach will not workPHC, but one size fits all approach will not work

Family practice is the principle approach for Family practice is the principle approach for achieving PHC based health systems achieving PHC based health systems

Focus on financing, provision and governance Focus on financing, provision and governance while establishing health care serviceswhile establishing health care services

Tackling SDH and health equity should be Tackling SDH and health equity should be integral to any future PHC programsintegral to any future PHC programs

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Thank youThank you