Guidelines

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Primary health care
Now, more than ever
Presentation to World Congress on Public Health
Istanbul Turkey, April 28, 20008 Tim Evans,
Assistant Director General, Information, Evidence
and Research
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Outline of Presentation

• What we mean by PHC
• Five reasons for PHC renewal
• Four PHC reforms
• Moving forward now

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How experience has shifted the focus of PHC
Early attempts at PHC Current
concerns of PHC Reforms

• Universal access, comprehensive services
• All disadvantaged groups
• Health risks, illness across life course
• Healthy global and local environments
• Managing growth to universal coverage
• Public/private mixed health systems
• Global solidarity, joint learning
• Coordinated referral to appropriate care
• PHC is not cheap, but good value for money

• A basic package for the rural poor
• Mother and child focus
• Acute, infectious, diseases
• Healthy local environment
• Scarcity and downsizing
• Government, top-down services
• Bilateral aid, technical assistance
• First level care, not hospitals
• PHC is cheap

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A. What we mean by PHC?

• Mobilization of society,
• lay people, communities, health professionals,
  government, private sector and civil society
• Driven by the shared values,
• equity, solidarity, social justice and
  participation
• To deal with current and future challenges to
  health,
• Through four strategic reforms of health systems
• universal coverage
• people-centered care
• healthy public policies
• stronger leadership

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B. Five reasons for a renewal of PHC

• Realignment of values and rising expectations
• People across the world increasingly expect
• a say in what affects their lives
• access to quality, people-centred care
• protection of the health of their families and
  communities
• health equity, social inclusion, solidarity
• health authorities that can be trusted and relied
  upon
• Disconnect between expectations and experience of
  health systems

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2. Significant progress in health, but not a
given child deaths in 1975 and 2006 by country
and total health expenditure (THE)
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Significant progress in health, but not a
given child deaths in 2006
Feasible lt 3 million
At 1978 rates
At 1978 rates gt 16 million
Actual lt 10 million
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3. Pervasive inequalities
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4. The difficult adaptation to new challenges
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5. The need for leadership and steering
Health systems do not naturally gravitate
towards meeting social expectations nor towards
giving value for money
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5. The need for leadership and steering

• "People in poor countries are sick not primarily
  because they are poor but because of other social
  organizational failures including health
  delivery, which are not automatically ameliorated
  by higher income"
• Angus Deaton, WIDER
  Annual Lecture, September 29, 2006.

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C. Four PHC Reforms

• Renewing PHC through 4 areas for reform

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Every year, globally, 150 million people suffer
financial catastrophe and 100 million people are
pushed into poverty due to health spending
First do no harm!
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1. Universal Coverage reforms

• "Progressive" financing for health for all
• based on pre-payment and pooling mechanisms to
• Ensure availability of services, and
• Eliminate financial barriers to access
• But that is not enough
• mobilize beyond the health sector to social
  protection schemes
• give visibility and voice to the invisible and
  voiceless
• reach the unreached

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2. Service delivery reforms shifting
to primary care

• Putting people first four features of good care
• Person-centeredness
• Comprehensiveness and integration
• Continuity of care
• A personal relationship with regular and trusted
  providers
• Organizing primary care networks accordingly
• Shifting the entry point bringing care closer to
  the people
• Shifting accountability responsibility for a
  well-identified population
• Shifting power the primary care team as the hub
  of coordination

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(No Transcript)
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3. Public policy reforms health in
all policies

• Health systems
• Health workforce education, skill mix, work
  conditions, retention
• Essential medicines RD, manufacture,
  procurement, supply chains
• Classical Public health
• Water and sanitation
• Outbreak preparedness and response
• Tobacco taxation, bans on advertising
• Cross-government and society
• Food and nutrition
• Employment
• Trade
• Urban development

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Public policies for health systems
World Health Report 2006 Health workers save
lives! Critical shortage of health workers in 57
countries 4.3 million more health workers
needed to provide essential interventions New
public policies necessary for training,
recruitment, retention and migration.
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Where there is no pill
Steps to reduce road user vulnerability

• Low cost speed control
• Rumble strips and speed humps
• Identification of crash hot spots
• Pedestrian safety targets in towns

Peden M et al. eds. Results from Accra, Ghana, as
found in the World Report on Road Traffic Injury
Prevention. World Health Organization 2004.
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Commission on Social Determinants of Health

• Overarching Recommendations
• Improve Daily Living Conditions
• e.g. early childhood development
• 2. Tackle the Inequitable Distribution of Power,
  Money, and Resources
• e.g. gender equity
• 3. Measure and Understand the Problem and
  Assess the Impact of Action.
• e.g. equity gauges

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4. Leadership reforms
participation and effective government

• Identify key roles responsibilities of
  government
• And those of other actors civil society,
  professions, private sector.
• Inclusive leadership and policy dialogue
• Less "command-and-control", more
  "steer-and-negotiate"
• Interdependence in health globally
• Mechanisms for effective global governance in
  health
• Invest in capacity for leading and governing the
  health sector
• Larger, more complex health systems require
  "evolution" and "growth" in public sector
  functions

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4. Leadership reforms
participation and effective government

• Findings related to government
• Stable and functional investment environment
• Long-term view a multi-decade process
• Strategies, priorities and role of government
  evolves
• Willingness to experiment and learn
• Manage uncertainty
• Act in the interests of all citizens
• Not simply itself or subgroups

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Competencies for Cross-Government Policy
Health Impact Assessments Cross-sectoral
budgeting Joined up policies Course corrections
Credible champions
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D. Seizing the opportunities for moving forward
now
Rapid-growth economies

• Learn to do more with more
• leverage sector's expansion for PHC reforms
• Negotiate a virtuous cycle
• Balance needs, supply and demand
• Capitalize on pressure from civil society

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D. Seizing the opportunities for moving forward
now

• Low-growth economies

• Learn to do more with more
• leverage sector's expansion for PHC reforms
• Financing for universal coverage
• Innovative integration of services
• Electronic medical records to enhance continuity
  of care
• Systems synergies with Global Health Initiatives
• Align donor assistance with PHC reforms

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D. Seizing the opportunities for moving forward
now

• Mobilize Drivers of Reform
• Knowledge and Learning Systems
• Competent and Committed Workforce
• Empowered and Engaged Citizens

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D. Seizing the opportunities for moving forward
now

• Can we afford renewal of PHC?
• Its not cheapbut represents a better use of
  existing resources for health
• No evidence that it is less affordable
• Growing evidence on high returns on investment in
  PHC reforms
• Less impoverishment, better health and health
  services, lower costs
• In the context of an economic downturn....
• Learning from history both the mistakes and the
  successes
• PHC reforms more likely to
• buffer the downside more than alternatives
• respond to citizen expectations for a social
  safety net in health
• The real questions, therefore are
• Can we afford not to pursue the renewal of PHC
  now?
• Can we afford to wait?