European Forum for Primary Care: "Twinning Population
Health and Primary Care"
Barcelona, Spain, 1-2 September, 2014
WHO Strategy on People-Centered and
Integrated Health Services (PCIHS)
Hernan Montenegro
Coordinator
Services Organization and Clinical Interventions
Service Delivery and Safety (SDS)
Content
•
Rationale
•
Strategy analytical framework
•
Strategic directions on PCIHS
•
Strategy implementation
•
Next steps
Ongoing challenges for health
•
Access – 1/3 of people with mental health disorders
in HICs receive treatment, as low as 2% in LMICs
•
Availability – 58% of countries have any palliative
care program
•
Acceptability – delivering women experience
verbal abuse, condescension, intimidation and even
physical abuse
•
Quality of care – international survey of clinical
practice for heart failure found only 59% of quality of
care indicators achieve, under clinical trial
conditions
Emerging challenges for health services
•
Non-communicable diseases:
•
multiple-morbidities
•
long-term, continuous care
•
Service fragmentation
•
Existing and growing inequities
•
Recognition
challenges
of
to
the
significant
reforming
service delivery systems
health
Ongoing challenges for health
Lack of coordination
Coordination Of Care, Medical Errors, And Safety Among Sicker Adults In Eleven Countries,
2011
Percent of respondents who:
Experienced coordination gaps in past 2 years
Test results/
Specialist lacked
records not
Key
medical history or
available at
information
regular doctor not
appointment or
not shared
informed about
duplicate tests
among
specialist care
Country ordered
providers
AUS
19%
12%
19%
CAN
25
14
18
FRA
20
13
37
GER
16
23
35
NETH
18
15
17
NZ
15
12
12
NOR
22
19
25
SWE
16
18
20
SWI
11
10
9
UK
13
7
6
US
27
17
18
Any gap
36%
40
53
56
37
30
43
39
23
20
42
Experienced
gaps in
hospital/surgery
discharge
planning
55%
50
73
61
66
51
71
67
48
26
29
Reported
regular doctor
seemed
uninformed
about hospital/
surgery care
18%
19
15
17
9
19
18
35
15
11
12
Experienced
medical,
medication,
or lab error
19%
21
13
16
20
22
25
20
9
8
22
Reported
pharmacist
or doctor did
not review
prescription
s in past year
34%
28
58
29
41
31
62
55
25
16
28
Emerging challenges and opportunities
•
•
•
•
Demographic and Epidemiological Transition
Socio-political factors:
•
concerns about health care costs, and
cost-efficiency
•
Increasingly active and organized
consumers
Technological advances:
•
Patient self-monitoring and selfmanagement
•
Linkages between health care providers
(e.g. electronic medical records)
Globalization:
•
Export of unhealthy lifestyles
•
Medical tourism
Building on Global Commitments
•
Reinvigorating Primary Health Care (WHR 2008)
•
Health systems strengthening (Everybody’s Business 2007)
•
Universal Health Coverage (WHR 2010)
•
Rio Declaration on social determinants (2011)
•
Prevention and control of NCDs (UNGASS 2011)
•
Multiple regional reports
•
Growing global commitments– but can service delivery systems deliver?
Source: WHO, Primary Health Care- Now More than Ever, World Health Report, 2008
Understanding People Centered and Integrated
Health Services
Universal Health
Coverage
People Centered
Care
Integrated Health
Services
People centered and integrated care to support UHC
-The best case scenario-
Proposed analytical framework
Core principles guiding People-Centered and
Integrated Care
1.
Comprehensive
9.
Co-produced
2.
Equitable
10.
Respectful
3.
Sustainable
11.
Rights and responsibilities
approach
4.
Co-ordinated
12.
Collaborative care
13.
Shared accountability
14.
Evidence-informed
15.
Whole-systems thinking
5.
6.
7.
8.
Continuous
Holistic
Preventative
Empowering
Examples of interventions for each Strategic Action
Empowering
and engaging
people
Strengthening
governance &
accountability
Reorienting the
model of care
Coordinating
services
Creating an
enabling
environment
Health literacy
Decentralization &
devolution
Strengthening primary
care through
family/community
practice models
Integrating vertically
oriented services into
primary care services
Leadership and
development of
shared vision
Access to personal
health records
Performance basedcontracting &
financing
Expand ambulatory,
community & homebased care
Information systems
Inclusion into national
health policies,
strategies & plans
Self-management &
care
Provider report cards,
patient reported
outcomes & surveys
Comprehensive
benefits plans
Inter-professional
collaboration
Dedicated resources
Patient/family
involvement in clinical
decision making
Registration with
specific provider(s)
Health technology
assessments
Referral systems
Changing
organizational culture
Development of
community
organizations, etc.
Patient charters, etc.
Outreach services for
marginalized
communities, etc.
Inter-sectoral
partnerships, etc.
Reorienting the health
workforce, etc.
Strategy implementation
Country context
•
Low income countries
•
Middle income countries
•
High income countries
•
Some special cases:
•
Fragile/conflict affected states
•
Small island states
•
Large federal states
Strategy implementation
•
Country-led
•
Equity-focused
•
Ensuring that people’s voices are heard
•
Recognizing interdependence
•
Sharing knowledge
•
Learning/action cycles
Strategy implementation
Some key issues for health workforce (HWF)
•
HWF planning and skills mix
•
Capacity gaps and distribution
•
New roles and functions (e.g. network planning and management; clinical integration)
•
Regulation (e.g. certification, re-certification, flexibility to relocate)
•
Teamwork, multi-disciplinary teams and inter-professional collaboration
•
Organizational culture
•
Innovation and learning with bottom-up approaches
•
Performance assessment and mutual accountability
•
Co-production of health
•
Compensation, incentives and motivation
•
In service training and career development path
•
Competencies (e.g. systems thinking, teamwork, negotiation, conflict resolution)
•
Inter-professional training
•
Interim short training courses to compensate for lack of specialists
Next steps
•
Refine, publish and disseminate two versions of the
Strategy:
•
Shorter version for policy-makers
•
Larger version for broader technical audience
•
Mobilize resources in support of Strategy
•
Start rolling out implementation of Strategy jointly
with other partners during 2nd semester of 2014