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Prescribed Minimum Benefits and Primary Care
the Circle

• Session address the necessity to review the
  PMBs to include primary care
• Address specifically the norms and standards
  within the district health system
• Examine basic packages which prevail in other
  countries
• By Professor Shan Naidoo
• Adjunct Professor and Chief Specialist
• School of Public Health
• University of the Witwatersrand

The BHF Southern African Conference 22-25 July07
Sun City
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This Analysis from a Public Health vantagepoint.
the Circle

• The value of a public health approach
• Addresses all levels of prevention, treatment and
  rehabilitation
• It promotes the individuals welfare by fostering
  healthy, strong and safe families, communities
  and workplaces
• It views the individual within a social milieu
  and explores the influence of cultural, family,
  and community values on behaviour.
• It also looks at organizational and political
  behaviour
• It examines public policy (e.g. On income,
  education, health care and employment)
• It views behaviour along a health related
  continuum (health enhancing to illness producing)
  
• It also emphasises an integrated approach and a
  systems view
• It addresses opportunities as well as constraints
• The public health perspective allows for a
  comprehensive analysis of the biological,
  behavioural, social and economic determinants of
  health and ill health
• It also leads to multiple strategies and points
  of intervention!

The BHF Southern African Conference 22-25 July07
Sun City
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What is Public Health

• Public Health is the process of mobilizing local,
  state, national and international resources to
  ensure the conditions in which people can be
  healthy.(Oxford Textbook of Public Health)
• The Four major public health strategies
• Preventing disease and promoting health
• Improving medical care
• Promoting health enhancing behaviour, and
• Controlling the environment.

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What is Health

• Health is not merely the absence of disease or
  infirmity but the presence of physical, mental
  and social well being (WHO, 1974).

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What is Health..

• Health is your adaptive capacity for becoming
  whole.
• Healing is regaining that adaptive capacity.
• Concept of WHOLON.
• Health and Development often used interchangeably.

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What is development

• Improving the quality of life of people,
• To uproot poverty,
• To promote well-being..

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Strategies for Development

• Education
• Job Creation
• Housing
• Primary Health Care
• Social Welfare

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Introduction to Primary Health Care

• The Declaration of Alma Ata
• Primary Health Care is essential health care
  based on practical, scientifically sound and
  socially acceptable methods and technology made
  universally accessible to individuals and
  families in the community through their full
  participation and at a cost that the community
  and country can afford to maintain at every stage
  of their development in a spirit of self-reliance
  and self determination.

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Primary Health care cont

• It forms an integral part both of the countrys
  health system, of which it is the central
  function and main focus, and of the overall
  social and economic development of the community.
  It is the first level of contact of individuals,
  the family and community with the national health
  system bringing health care as close as possible
  to where people live and work, and constitutes
  the first element of a continuing health care
  process.

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Principles of PHC

• Equity
• Community Involvement
• Focus on Prevention
• Multisectoral Approach
• Appropriate Technology.

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The Elements of Primary Health Care Includes at
least

• Education concerning prevailing health problems
  and the methods preventing and controlling them,
• Promotion of food supply and proper nutrition,
• An adequate supply of safe water and basic
  sanitation,
• Maternal and child health care, including family
  planning,
• Immunisation against major infectious diseases,
• Prevention and control of locally endemic
  diseases,
• Appropriate treatment of common diseases and
  injuries, and
• Provision of essential drugs.

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How to define a basic package of health services?
the Circle

• How to define a basic package of health services
  for a tax funded or social insurance based health
  care system?
• Editorial F.Rutten J. van Bussbach
• Criteria used by countries include the
  effectiveness and cost-effectiveness of
  treatments, the necessity of treatment for the
  individual, the severity of the disease, the
  collective versus the individual responsibility,
  and the efficiency of insuring the service.
• They argue that what is needed is an ethical
  framework suggesting criteria and values to be
  used systematically in priority setting.
• They also suggest that more transparency in
  priority setting in health care will contribute
  to a wider support in society for the difficult
  choices in health care which are inevitable!

The BHF Southern African Conference 22-25 July07
Sun City
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Defining the Health Benefit Basket in nine
European Countries
the Circle

• Evidence from the European Union Health BASKET
  Project
• Original Papers J.Schreyogg, T.Stargard,
  M.Velasco-Garrido R.Busse (Eur J Health Econom
  Suppl 1, 2005)
• This article identifies and analyses the
  framework for health baskets, the taxonomy of
  benefit catalogues for curative services, and the
  criteria for in- or exclusion of benefits in nine
  EU member states ( Denmark, England, France,
  Germany, Hungary, Italy, The Netherlands, Poland
  and Spain).
• Note the distinction between benefit basket and
  benefit catalogue!
• Main Findings are that the criteria are often not
  transparent and are varied.
• There may be scope for a European core basket?

The BHF Southern African Conference 22-25 July07
Sun City
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A Basic Package of Health Services for Afghanistan
the Circle

• March 2003/1382
• Main purposes are
• 1. To provide a standardised package of basic
  services which forms the core of service delivery
  in all primary health care facilities and
• 2. To promote a redistribution of health services
  by providing equitable access, especially in
  undeserved areas.

The BHF Southern African Conference 22-25 July07
Sun City
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Contents of the Basic Package of Health Services
for Afghanistan
the Circle

• Maternal and Newborn Health
• Antenatal Care, Delivery Care, Postpartum Care,
  Family Planning, Care of the Newborn
• Child Health and Immunizations
• EPI services (routine and outreach), IMCI
• Public Nutrition
• Micronutrient supplementation, treatment of
  malnutrition
• Communicable Diseases
• Control of Tuberculosis and Malaria
• Mental Health
• Community management of mental problems, health
  facility based treatment of out- and inpatients
• Disability
• Physiotherapy integrated into PHC services,
  Orthopaedic services expanded to hospital level
• Supply of Essential Drugs

The BHF Southern African Conference 22-25 July07
Sun City
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Primary health care in Africa
the Circle

• No real information on Africa re basket of
  services.
• A comparative analysis of city-wide public
  sector projects in Lusaka and Dar es Salaam
• Roger Few, Trudy Harpham Sarah Atkinson
• Health Place, 2003
• This article compares attempts in two projects
  in Zambia and Tanzania to strengthen urban
  primary health care in the public sector and make
  it more inclusive.
• Conclusions similarity in findings. Most
  positive aspect was gains in capacity building(
  management training of staff). Also, given
  improvements in facilities, urban populations
  were readily prepared to utilise the primary
  health tier. Community participation in terms of
  community ownership was less clear.

The BHF Southern African Conference 22-25 July07
Sun City
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World Health Organisation
the Circle

• Paucity of work
• Emergency and Essential Surgical Care
• Surgical Care at the District Hospital
• The Integrated Management for Emergency and
  Essential Surgical Care toolkit
• Primary Care in the Drivers Seat
• Essential Health Technologies
• Management for Health Services Delivery

The BHF Southern African Conference 22-25 July07
Sun City
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The Primary Health Care Package for South Africa
the Circle

• Norms and standards for health clinics
• Norms and Standards for Community Based Clinic
  Initiated Services
• Department of Health
• Pretoria
• March 2000
• All the necessary components of a comprehensive
  primary care package are described and norms and
  standards for each component are described

The BHF Southern African Conference 22-25 July07
Sun City
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The PHC package for South Africa a set of
norms and standards
the Circle

• A norm is defined as a statistical normative rate
  of provision or measurable target outcome over a
  specified period of time e.g. For PHC clinics
  the clinic renders comprehensive integrated PHC
  services using a one stop approach for at least 8
  hours a day, five days a week.
• A standard is defined as a statement about a
  desired and acceptable level of health care e.g.
  Medicines for PHC services medicines and
  supplies as per the EDL for PHC.

The BHF Southern African Conference 22-25 July07
Sun City
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Core norms and standards for PHC Services
the Circle

• Womens Reproductive Health
• Integrated Management of Childhood Illnesses
• Diseases prevented by immunisation
• Adolescent and Youth Health
• Management of Communicable Diseases
• Cholera and Diarrhoeal Disease Control
• Dysentery, Helminths
• Sexually Transmitted Diseases (STD)
• HIV/AIDS
• Malaria, Rabies
• Tuberculosis, Leprosy
• Prevention of Hearing Impairment due to Otitis
  Media
• Rheumatic Fever and Haemolytic streptococcal
  infection

The BHF Southern African Conference 22-25 July07
Sun City
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Core norms and standards for PHC services cont..
the Circle

• Trauma and Emergency
• Oral Health
• Mental Health
• Victims of Sexual Abuse, Domestic Violence and
  Gender Violence
• Substance abuse
• Chronic Diseases and Geriatrics
• Diabetes and Hypertension
• Rehabilitative Services
• Community Level Water and Sanitation
• Community Level Home-Based care
• DOTS Strategy
• Integrated Nutrition Programme
• School Health Services
• Community Based Rehabilitation

The BHF Southern African Conference 22-25 July07
Sun City
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Critique

• Confusion between basic benefit package and
  disease defined package.
• The latter requires a diagnosis!
• Argue that we define the basic benefit package as
  a basket of services that should be provided at
  PHC level followed by the detail as benefit
  catalogues perhaps
• Current language used needs to be consistent with
  Primary Health Care philosophy.

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The District Services Package according to the
norms and standards document
the Circle

• Three important aspects characterise the DHS
• District hospitals are integrated with the PHC
  clinics and Community Health Centres and they
  provide a comprehensive package of health care
  delivery for the full range of medical disorders.
• The DHS is embedded in the community it serves
  and should be integrated with home-based care and
  the Community Health Worker programme.
• The DHS is integrated with community governance
  structures. It is through this that the tenet of
  community participation of the PHC approach is
  realised.
• Critique is that it is maybe its again too
  medical and perhaps too vague. No norms and
  standards have been defined.

The BHF Southern African Conference 22-25 July07
Sun City
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International Review of Basic Benefit Packages
and a proposal for a South African Benefit
the Circle

• Discovery Health 2005
• Definition of a Basic Benefit Package is a
  health insurance plan determined and mandated by
  the government to provide the population with
  access to equal, basic health care at an
  affordable cost.
• Used 5 categories and 150 variables
• Looked at Argentina, Brazil, Chile, Mexico,
  Netherlands, Australia, Switzerland, USA and
  Taiwan

The BHF Southern African Conference 22-25 July07
Sun City
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Consultative Investigation into Low Income
Medical Schemes
the Circle

• Final report
• 7 April 2007

The BHF Southern African Conference 22-25 July07
Sun City
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Establishment of a new prescribed minimum benefit
for LIMS Schemes
the Circle

• A. GP Consultations.
• B. Pathology and radiology investigations
  ordered by GP -
• subject to a defined formulary.
• C. Dental Consultations
• D. Optometry
• E. Medicines - based on DOH EDL for primary care
  suitably supplemented
• F. Emergency Transport
• What about Maternity Care and inpatient care for
  LIMS members???

The BHF Southern African Conference 22-25 July07
Sun City
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Development of an Essential Health Care Package
proposal for Medical AID Schemes in South
Africas transition towards SHI
the Circle

• Prepared for Board of Healthcare Funders of
  Southern Africa
• February 2007
• Informed by the policies of the NDOH, existing
  legislation, the Health Charter, scientific
  literature and work done by the private sector to
  date.
• Draws an important distinction between an
  essential care package and an insured package
• Essential care packages are public health need
  and benefit driven whereas insurance is
  individual patient and disease driven.

The BHF Southern African Conference 22-25 July07
Sun City
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Development of an Essential Health Care Package
proposal for Medical AID Schemes cont.
the Circle

• An essential healthcare package can be defined as
  a plan that provides a minimum compulsory set of
  benefits that all health insurers should cover.
• It is a set of basic entitlements to services
  that must be funded and provided for the benefit
  of all.
• The EHP generally includes a primary care
  component (focussing on preventative programmes,
  mother and child care, oral health, etc.) and a
  hospital component sometimes differentiated by
  hospital level.
• The inclusion and exclusion criteria for
  developing countries is guided by need firstly
  and then by cost-effectiveness. (NB principle)

The BHF Southern African Conference 22-25 July07
Sun City
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The process of setting an Essential Health Care
Package

• Could follow two tracks
• 1. Defining broad categories of services such as
  consultation, medicine (EDL), pathology, etc. NB
  in equity. And/or,
• 2. Specifying all the diseases, with inclusion
  and exclusion criteria that must be included on
  the list of benefits such as the DPT/CDL.
  Potentially inequitable.
• I suggest that we start with 1. but may need to
  consider 2. if we looking at supplementary
  insurance?
• Compare with EU benefit package and catalogues!

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What are the recommended benefits?
the Circle

• Primary Care Benefit
• GP consultations exclusions questioned (mental
  health)
• Maternity Care Services
• Pathology and Radiology Medicross formulary
• Dental Consultations dental procedure
  formulary
• Optometry makes reference to LIMS
• Medicines hospital level of EDL
• Emergency Transport extremely important!
• Hospital Inpatient care Benefit based on BOD?
• Public Sector unrestricted. 100 UPS fees.
• Private Sector inpatients. Listed conditions.
  DOH reg. fees!

The BHF Southern African Conference 22-25 July07
Sun City
31
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The way forward!
the Circle

• A substantial amount of good work has already
  been done need to use this!
• Can use NDOH norms and standards as a basis.
• BHF together with the NDOH, Treasury and Civil
  Society need to finalise this asap.
• Challenge is to incorporate more of the PHC
  principles (equity, multisectoral approach,
  appropriate technology, focus on prevention) and
  the Health Charter requirements into the scheme.
• Dont forget the management challenges!

The BHF Southern African Conference 22-25 July07
Sun City
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Thank You!
the Circle
The BHF Southern African Conference 22-25 July07
Sun City