POPULATION
HEALTH AND
PRIMARY
HEALTH CARE
ACTION
Vivian Lin
Director, Health Sector Development
World Health Organization (Western Pacific
Regional Office)
Providing an international
perspective
• From PHC to UHC
• Post 2-15 Development Agenda and Universal health
coverage (UHC)
• Reviewing Community-oriented Primary Care
• Population health planning for primary health care
• Moving to integrated, partnership-based approach
• Conclusion
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Universal Health Coverage
PHC–based health system
• an overarching approach to the organization
and operation of the health system
• makes the right to the highest attainable level
of health its main goal
• maximizes equity and solidarity
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Universal Health Coverage
PHC–based health system
• Composed of a core set elements that guarantee
universal access to services that are:
– acceptable to the population
– equity-enhancing
• Provides comprehensive, integrated, and
appropriate care over time
• Emphasizes prevention and promotion, and assures
first contact care
• Families and communities are its basis for planning
and action
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Universal Health Coverage
Experience says PHC works
International evidence suggests that health
systems based on strong PHC orientation
– have better and more equitable health outcomes
– are more efficient
– have lower costs
– achieve higher user satisfaction
than health systems with only weak PHC
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Universal Health Coverage
PHC transformed into UHC?
• 2008 World Health Report – renewal of
primary health care – need for health systems
to respond better and faster to changing
health challenges
• 2010 World Health Report – health financing –
to achieve universal health coverage and
improve population health outcomes
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Universal Health Coverage
THE POST-2015 DEVELOPMENT
AGENDA
• High-level Eminent Persons Panel pillars for
development – leave no one behind, inclusive
growth, sustainable development, good
governance, quality of life
• Health related aspects:
– Complete MDGs
– NCDs
– UHC
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Universal Health Coverage
What is Universal Health
Coverage (UHC)?
• Access to good quality of needed services
– Prevention, promotion, treatment, rehabilitation and
palliative care
• Financial protection
– No one faces financial hardship or impoverishment by
paying for the needed services.
• Equity
– Everyone, universality
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Universal Health Coverage
Three Dimensions of UHC
UHC contributes to good health
and beyond…
• UHC improves or maintains health through
coverage for needed services.
• UHC contributes to poverty reduction.
– Good health enables adults to earn income and children
to learn, giving them more opportunities to escape from
poverty.
• UHC is a vehicle to build social solidarity, national
pride and trust in the government.
• UHC offers a way of sustaining gains and
protecting investments in the current set of healthrelated MDGs.
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Universal Health Coverage
UHC – core to WHO work
• UHC in WHO’s history
 WHO's constitution (1948)
 Alma-Ata Declaration (1978)
 WHR on Primary Health
Care (2008)
 WHR on Health Systems
Financing-The Path to
Universal Coverage (2010)
 Rio Declaration on SDH
(2011)
 UN High-level Meeting on
NCDs (2011)
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•
Post-2015 Agenda
– All countries (rich or poor) can
make progress
– Offers a way of sustaining gains
and protecting investments of
health-related MDGs
– Accommodates the changing
agenda for global health and other
internationally agreed health goals,
such as NCDs
– Concerns health equity and the
right to health
• Independent of post 2015 agenda,
UHC remains core to WHO work
Universal Health Coverage (UHC)
Affordability
Financial
protection
Quality
Accessibility
Equity
High quality
people-centered
and integrated
interventions
Acceptability
Services
Availability
COMMUNITY-ORIENTED
PRIMARY CARE AT THE CORE
KEY PRINCIPLES
• Use epidemiological
and clinical skills
• Address determinants
and consequences of
health and illness
• Concern with
environment/ family/
individual; with health
services and behaviors
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IDEAL FEATURES
• Population - identified community
• Governance - allow community
involvement
• Information - facilitate planning and
evaluation
• Funding - incentives for costeffective services
• Workforce - team-based, combine
public health and clinical medicine
skills
• Service - comprehensive,
coordinated, consumer focused
COPC= Partnership between Population
Health and Clinical Services
Target
Type of Function (1)
Primary
Generalised - population Pop Health
Secondary
Tertiary
Pop Health
Pop Health
Generalised - individuals PH/ClinicalMed PH/CM
PH/CM
Selective
?
PH/CM
PH/CM
Indicated
PH/CM
PH/CM
Clinical Medicine
Source: Starfield (1996:1368)
PH = Public Health; CM = Clinical Medical Care
(1) Primary = intervention to prevent a problem from occurring; Secondary = intervention at a stage before a problem is manifested;
Tertiary = remediation to reverse manifestations of problem
INTERVENTIONS BY FUNCTION
AND TARGET GROUP
Target
Type of Function (1)
Primary
Secondary
Tertiary
Generalised population
Generalised individuals
Environmental
planning
Health education,
immunisation
Legal redress or
social welfare
Surveillance
systems
Selective
(population risk
factors)
Indicated (known
predisposition)
?genetic
engineering
Product safety
monitoring
Breast and
cervical cancer
screening
Blood lead
screening
Prophylactic
antibiotics
Follow-up after
disease
Quality
assessment of
clinical services
Home visiting
Source: Adapted from Starfield (1998:328)
(1) Primary = intervention to prevent a problem from occurring; Secondary = intervention at a stage before a
problem is manifested; Tertiary = remediation to reverse manifestations of problem
A partnership-based PHC system
Community
Nutrition
Environmental
Health
Dietary
Advice
Communicable
Disease
Counselling
Control Clinical
Mental
Health
Promotion
Care
Child Health
Early
Childhood
Development
Social Work
Community
Nursing
Home Support
Community
Development
HEALTH NEEDS – Central to population health
planning and prevention
• Groups! – health is not randomly distributed
• People live, work and play in context – demographic,
social, economic, cultural factors matter
• Objective measures + subjective status – perceptions
are realities
• Health hazards and risks – present and future
• Relativities - comparison with peer
communities/population groups
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Universal Health Coverage
PLANNING FOR POPULATION
HEALTH
• Starting points:
– Health: diseases and conditions (eg diabetes, cancer,
mental health), risk factors (eg alcohol, tobacco, physical
inactivity), protective factors (eg social support)
– People: children, older people, ATSI, CALD communities,
homeless
– Places and settings: localities, schools, workplaces
• Outcomes: health improvement; disease
prevention; health maintenance; quality of life
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Universal Health Coverage
CONTRASTING MODELS OF HEALTH
PLANNING
Population-based
Institution-based
1. Select health issue
1. Select health service
2. identify risks
2. determine current demand
3. evaluate population risk
level
3. forecast future demand
4. compared need with
current program
5. adjust resources
6. evaluate
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4. compare demand with
current capacity
5. adjust resources
6. evaluate
NEEDS ASSESSMENT
Analyse
information
and confirm
key issues
Collect
qualitative
data
Collect
quantitative
data
Stakeholder
consultation
Determine
strategic
issues and
missing
information
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Universal Health Coverage
Analyse
problem and
review
evidence
A PLANNING TAXONOMY
LIFE
COURSE
children
youth
Young
adult
Middle
aged
Older
adults
Health
promotion
Disease
prevention
Early
detection and
intervention
Episodic
and
acute
care
Sub-acute care
and rehabilitation
Long
term
care
Palliative
and
terminal
care
Population Health Model
Care
Coordinated
Self-managed
At Risk Population
Well Population
POPULATION HEALTH AND THE
CARE CONTINUUM
Well
Population
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At
Risk
• Community
-based
programs
• Screening
• Primary
prevention
• Secondary
prevention
• Early
intervention
Universal Health Coverage
Living with
controlled
chronic
disease
Uncontrolled
chronic
disease
• Selfmanagement
• Casecoordination
• Continuing
care
• Complications
management
Tertiary prevention &
Disease management
UTLISATION AND SERVICE SYSTEMS –
understanding from population perspective
• Diverse patient journeys
• Falling through the cracks
• Parallel primary care systems
• Financial, cultural, psychological barriers to
care seeking
• Level of health literacy
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Universal Health Coverage
Social Determinants of Health
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Universal Health Coverage
DEVELOPING STRATEGIES AND
SELECTING INTERVENTIONS
• Ottawa Charter a useful checklist:
– Healthy public policy
– Supportive environment
– Community action
– Personal skills
– Health services
• Review evidence and consider applicability, gaps in current system, and
scale needed to effect change (population strategy vs individual strategy)
• Weigh up options using multiple criteria, ensuring acceptability, feasibility,
and cost-effectiveness (or return on investment) are considered
• Use multi-voting amongst stakeholders
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Universal Health Coverage
Essential Packages of Services - MCH
Pre-pregnancy  Pregnancy  Birth  Postnatal  Neonatal  Infancy 
Childhood
Promoting breastfeeding
Promotion of healthy lifestyle (alcohol, diet, smoking, physical activity, etc.)
Antenatal
care
Safe
Postpartum
delivery
care
Management of childhood illness
Vitamin A,
micronutrients
Deworming
Immunization
Insecticide-treated nets and indoor residual spraying
Improved sanitation, Better nutrition and food access, and Health protection
Housing, Education, Employment, Early childhood 27
development,
Empowerment of women and gender equity
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Address service coverage gaps
Pre-pregnancy  Pregnancy  Birth  Postnatal  Neonatal  Infancy 
Childhood
100
G
A
P
80
G
60
A
50
40
P
20
0
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PARTNERSHIPS – Coordinated service
delivery and action on social determinants of
health
• Health services
• Social services
• Local government
• Community and consumer/patient
organisations
• Private sector
• Frontline staff
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Universal Health Coverage
Need for Integrated/Coordinated
Service Delivery
• People experience multiplicity of issues multiple determinants have multiple
outcomes, and clustered in localities and
populations
• Shared interests and objectives at service
delivery level (operational/informational
needs, common clients and partners)
• Co-benefits across service providers and
sectors
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Universal Health Coverage
Possible approaches for
coordination and integration
• Clustering of health issues
• Linking of service providers
• Settings as basis for intervention
• Population groups as frame of reference
• Clinical care and public health partnership
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Universal Health Coverage
Organisational Shifts (Marquardt)
Dimensions
Bureaucratic
Structure
Hierarchical
Boundaries
Fixed
Permeable
Focus
Institution
Client
Network
Teams and
alliances
Management Command and Participative
style
control
Culture
Compliance
Outcomes
GOVERNANCE – Managing the
networks and the course of events
• Participation ladder: information – consultation –
collaboration – ownership
• Who participates – advisory or decision-making?
Who decides in the first place? Accountability to
whom? And how?
• Successful partnerships – safe environment, clear
decision-making procedures, focus on joint priorities,
win-win, draw on complementarities, share the
credit
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Universal Health Coverage
CONCLUSION: THE UHC/PHC IDEAL