Expanding Primary Health Care Sam Adjei NHIA 10th Anniversary Conference Outline • • • • • • • • • Introduction Definitions of PHC Global evolution of PHC Goal, objectives and strategies Ghana’s organization of PHC Package of services Financing of services Assessing performance Moving forwards Introduction Evolution of health delivery systems 20yr cycle • 1957- Basic health care – Emphasis on infrastructure • 1977/78- Health for All based on PHC – Emphasis on rapid expansion of services • 1997- Health sector Reforms and SWAP – Health systems strengthnening and MDGs • 2015- Post MDG Definition and global commitment Many definitions of PHC – here is the JLN’s Essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination Primary care is the level of a health services system that provides entry into the system for all new needs and problems, provides personfocused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and coordinates or integrates care, regardless of where the care is delivered and who provides it. First-contact access for each new need; long-term person-based care (not disease-oriented), comprehensive care for most health needs, and coordinated care when it is sought elsewhere. “The provision of outpatient non-secondary and nontertiary preventive and curative care, with a particular focus on ensuring the quality delivery of health interventions prioritized by both countries and the global health community against the highest disease burdens” Global commitments to PHC repeated over time, but not realized in practice Haikko Declaration (40 member countries) Reaffirmed Alma Ata 1978 Alma Ata (WHO members) Recognized PHC as an essential right, and committed governments to launching and sustaining PHC as part of a national health system 1986 Ouagadougou Declaration (All African region members) Reaffirmed Alma Ata 2008 Birchwood Declaration (South Africa members) Reaffirmed Alma Ata Americas Region Declaration (All Latin American members) Reaffirmed Alma Ata Countries still continue to struggle with issues of organizational structures, demand, and financing of primary health care Ghana experience • Goals, organization Goal, objectives and strategies of Ghana PHC • Goal: – Maximise total life of Ghanaians • Objectives: 1) Achieve basic and primary health care for 80 of people 2) Effectively attack the diseases problems that contribute 80 of morbidity and mortality • Strategies: 1. Improve accessibility-coverage of services 2. Improve quality of PHC 3. Improve and strengthen management capacity to support to the primary level Organization of care NATIONAL REGIONAL LEVEL DISTRICT LEVEL POLICY Policy - MOH AND -MOHGHS GHS TERTIARY CARE STRATEGY TRANSLATION -RHMT SECONDARY CARE -REGIONAL HOSPITALS PRIMARY HEALTH CARE 1ST REFERAL HOSPITAL District level organization Level Name Population Human Resources A Community 200-5000 TBA, CFHW, CEDW B Sub district 5-10,000 CHN, MIDWIFE, PA C District 175-24,000 DHMT-DDHS, DMOH, DPHN, DNTO, DHI The community level was problematic: there was little evidence that their training and deployment effectively affected morbidity and mortality. The MOH therefore took a decision to replace them with trained staff. Hence the Community-based Health Planning and Services-CHPS Initiative which uses CHO. What is CHPS • Stands for Community-based Health Planning Services • Involves relocating a CHN (CHO) into community with defined population (zone) • Works with volunteers • Supported by community through CHC • Has a set of functions to perform • Supervised by sub district team Ref Community Health Care District Hospitals District Health Management Team M&L Ref Sub-district health management team Health Centres Clinical Determinants Track Ref CHPS Compound Ref CM CHO CHWS TBA CP Planning, M&E Social Determinants Track Trad. Healers Prayer Camps Env. & Sanit. Officers Com. Dev. Officers C H Vs Service & Surveilla nce Services/priority interventions Health services-for PHC in 1978 • education concerning prevailing health problems and the methods of preventing and controlling • promotion of food supply and proper nutrition; • adequate supply of safe water and basic sanitation; • maternal and child health care, including family planning; • immunization against the major infectious diseases; • prevention and control of locally endemic diseases; • appropriate treatment of common diseases and injuries; • and provision of essential drugs; Priority interventions-1996 • • • • • • Immunization Reproductive health programs Prevention and control of epidemics Health promotion Micronutrient deficiency control and prevention Management of locally endemic diseases – Malaria, TB, HIV, Oncho , filariasis etc • Emergency care for accidents and trauma Expressed Needs for Services at the Community level Most Popular Family Planning Counseling Defaulter tracing and continuing drug replacement ARI in Children Immunization and Vaccination Services School Health Services Malaria case management Nutrition Advisory Services and Product Distribution Growth Monitoring Care of Children (1-59 months) Care of Infants (7-28 days) Diarrheal Disease Management Distribution of contraceptive pills and condoms Post-delivery care of Mothers Popular Care for neonates (0-7 days) Antenatal Care Services on expectant mothers Antenatal Education in Groups Dispensing of Antibiotics Least Popular Road Traffic Accidents (care of victims/casualties) Hypertension Management Insertion and Removal of Family Planning Implants TB Treatment HIV/AIDS Treatment Minor Surgery (eg., Incision and Drainage) Diabetes Management Dispensing of approved traditional Medicines Delivery Yaws, Elephantiasis, Schistosomiasis Injuries and Poisoning Obesity Management Ulcer Management Dispensing Class C Drugs Comparison of disease problems Top 10 conditions- 1977 Top 10 conditions-2003 • • • • • • • • • • • • • • • • • • • • Malaria Prematurity Measles Birth Injury Sickle Cell Disease Child pneumonia Malnutrition Dysentry Neonatal tetanus Accidents Malaria Anemia Pneumonia Stroke Typhoid Fever Diarrhea HPTN Hepatitis Meningitis Sepsis Financing Trends in resource allocation Year Per Capit Govt Expend Headquarters Tertiary Secondary Primary or district 1976 $3-5 - 40 45 15 1996 $6-7 28 31 17 23 2001 $10-12 16 19 23 42 2012 $30-50 42-50 Where is the money coming from NHIS a major player • • • • • • Contributes to 70-80 per cent of facility IGF Contributing now 30-40 per cent of income DWHIS focuses on the district Capitation is for primary health care Selection of PPP can be skewed to lower level Potential of capitation for preventive care not yet explore • Can be considered in national roll out Performance measurements Measuring performance • Data sources include – – – – – – Routine administrative data Program statistics Surveys by GSS- MICS,GDHS, GLSS Demographic surveillance centre Other research studies Composite assessment- Holistic Assessment • Joint MOH-Partners Summit for policy/ strategy • New Performance League table can be examined Organization of assessment • • • • • BMC Review and performance hearing Interagency performance review In-depth review of key areas of concern Independent Sector Review Report to Parliamentary Select Committee on health • Annual Joint MOH-partner Summit Areas of assessment • • • • • • • Goal 1: Mortality changes Goal 2: Reduce excess morbidity Goal 3: reduce inequality in service SOB 1: Human Resources XXX SOB2: Health, reproduction and nutrition SOB3: Capacity Development SOB4: Governance and Financing 1/04/2010 DEBRIEFING INDEPENDENT REVIEW TEAM 25 Challenges and way forward Some challenges • The capacity of DHMTs, sub district and community teams • Public private partnership • Package of interventions • Decentralization • Financial strategies • Evidence base for decision including Mand E Moving forwards -1 Influencing factors • Demographic transition – Aging population, urbanization • Economic transition – Low to middle income • Changing disease burden – Double burden of diseases • Financing changes – The rise of NHIS, fragmented donor sources Moving forwards-2 ICT potential • Mobile Technology for Community Health (MoTeCH) • E-Blood Bank an electronic (web-based) blood tracking system • Community-based electronic registration System for EPI • DHIMS2 • E-Claim Conclusion • A lot has changed since 35 years • Post MDG discussions affords opportunity for a major thrust to rekindle PHC globally • Because more than ever PHC is needed to address equity issues and link services to financial risk protection • Opportunity to enhance quality in PHC • Advances in technology mist be maximised • Performance system that compares where countries are will be an advantage.