PHC & UC What do we mean by “primary health care” in the 21st century?Wim Van Lerberghe

SDC HEALTH NETWORKFACE 2 FACE MEETING7. - 11. APRIL 2014

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n2Language matters

“à toutes fins utiles, cet hôpital universitaire portera le nom de centre de soins de santé primaires” (1980)

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The origins of universal coverage

The roots of PHC

Between faith, confusion and disillusion

Crowding and fragmentation

The renewal of health for all: changing expectations

PHC in the XXst century

Definitions

Is this too much to aim for?

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1. The origins of universal coverage

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15XIXth century doctors in Europe

Face-to-face remains the norm until mid- 19th century, but

In emerging cities independent doctors are not the only model

With the public health reforms come public health officers who also care for the poor

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16The birth of the modern hospital

Number increases after 1830

Become effective (science, labs, techniques, Florence Nightingale [1820-1910])

Come under control of doctors

Repositories of science

New prestige (WW1)

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17Workers movement:

demand and expectations ↑

Hospitals loose stigma of charity

Effectiveness attracts paying patients

A favour to the poor becomes a right for the workers

Doctors want clients who can pay

Worker pressure for access

Hospital pressure clients with abilty

to pay

Politicians à la Bismark

From solidarity to social security

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18Bismarck’s response

1883: Compulsory sickness insurance Management by local organisations

Employers (2/3) and employees (1/3) contribute, state not

Free choice, fee for service plus capitation

1911: covers 77% of employees plus dependants

1919: France imitates Germany;

1920s: UK reluctantly follows but moves to tax funding in 1930s;

the American 1910-20 campaign is defeated

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19The modern hospital:

scientific, symbolic and expensive

“Modern” and distinct from other care since 1920:

Central & symbolic in perception of users in career of doctors in income of doctors compared to individual

practitioners in expenditure on

health

More expensive: reliance on fees and donations is not enough

WWII: Europe: hospitals forced to co-operate with governments

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110

Coverage expands and the state’s role becomes central

Bargains on everything

Involvement becomes natural

Instrument for redistribution

“ How to provide care to the destitute?” becomes “ Who has right to care, in what quality and quantity?”

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1900 1910 1920 1930 1940 1950 1960 1970

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2. The origins of PHC

The colonial legacy

Health care as integral part of colonization

« Lutte contre les grandes endémies » (F)

Urban Hygiene

Campaigns and national programmes

A network of services (E, B)

Success of ‘ European curative care ’: injections, surgery

Hospitals plus improvised network of dispensaries

At independence health care is

free,

public or quasi-public (little or no "private")

institutional (no family doctor)

Managed by public sector administrators

At independence the role of state is not challenged, but new actors shape reality

The urban elites medicalise … "Africanisation" = access to technology:

medicalisation (specialists)

curative bias (preventive neglected)

hospitalcentrism (investments, budgets, personnel…)

… with support of the medical civil service Budgets go to large hospitals, cities, elite

Rural areas are neglected

… the politicians get worried…

Contradictions between the discourse of independence & rural reality

Contrasts between regions and rural - uran

Persistence of mass disease delegitimises political powers

… and the technocrats panic

As development technicians Shift efforts to disease control

programmes : smallpox, trypanosomiasis, malaria...

"Scientific" and controllable

Mix of success and disappointments

As managers: « this is getting out of hand »

“we cannot afford those vertical programmes”

there is not enough money

1970 ’s: economic growth of < 1%/year

Oil crisis 72-74

Drought Sahel 68-74 0

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G, O G, P S, O S, P

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PHC as “the” solution

1970s: Persistence of mass disease, rural

deprivation, hospital model unsustainable

Alternative approaches to meeting basic health needs in developing countries

From technology to health for the people, from health for the people to health by the people

Cold war

1978: Alma Ata: PHC as a movement to move towards health for all, underpinned by values of:

solidarity,

social justice,

the right to better health for all,

Access, resources, participation

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3. Between faith, confusion and disillusionMODEL FAILURE OR IMPLEMENTATION FAILURE?

HOW PHC LOST CREDIBILITY

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Multiple interpretations…

PHC = no more doctors, no more hospitals

PHC = programmes

PHC = the state no longer has to pay

PHC = participation = user fees

Harare: back to: PHC = district health care

… and a harsh reality

The State disappears…

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Millions of $US

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(MU

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… and the system starves

81 82 83 84 85 860

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Gvt funding of district health care: constant $/inh/yr

Amidst pauperisation and war, some districts thrive

But most dont

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4. Crowding and fragmentationOF THE DANGER OF GOOD INTENTIONS

BONO

MSF

250 PPPH WEFPHA

World Bank

More and new players

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ECC

MOH(15 Staff)

Damian Foundation

Memisa

Cordaid

Oxfam GB

Cemubac

Int and Nat NGO's (Development and church related)

NGO's (Emergency)

Multilateral agencies

MSF Belgium

BASICS

Caritas

CRS

Louvain development

Bilateral Funding / Technical agencies

FometroWorldVision

BDOM

Salvation army

Asrames

World bank

More than 200 health partners

State and Parastatal organisations

Fonds Social de la République

BCECO

13 MoHDepartments

52 specialised programs

11 provincial management

team

11 Provincial Ministries of Health

Ministry of Finance

Ministry of Education

Faculties of Medicine

Schools of Public Health

Novib

Merlin

Sanru

Gavi

ECHO

UNFPA

UNAIDS

UNICEFEU

UNHCR

WHO

IMF

Global Fund

WFP

13 Donor Government program coordination committees

Apefe

PSF-CI

GTZ

SIDA

ACDIBTC CTB

USAID

DFID

BAD

VVOB

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And management becomes more difficult (logistics in Burundi)

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The focus on priorities starts ignoring legitimate demand

Is it OK for someone to get a fatal preventable stroke as long as they don’t die of HIV?

Is it OK to get a C-section, but no care after a car accident?

A growing disconnect between global discourse and the field reality of providing care

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Results are uneven

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5. So why renew PHC (or, rather, health for all)? FRUSTRATION AND CHANGING EXPECTATIONS

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Modernization & changing Values

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Africa

before 1921

1921-30

1931-40

1941-50

1951-60

1961-70

1971-80

after 1980

before 1921

1931-40

1941-50

1951-60

1961-70

1971-80

after 1980

Self-Expression Values +_

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before 1921

after 1980

after 1980

after 1980

after 1980

before 1921

before 1921

Modernization: long-term increase of secular-rational and self-expression values

Confirmed by cohort differences in all cultural zones except Africa.

Mass attitudinal changes conducive to democracy

See http://www.worldvaluessurvey.org,; a/o Inglehart, R. & Welzel, C. Changing Mass Priorities: The Link between Modernization and Democracy. 2010

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Pressure for more democratic relations

Economic Developmen

t

Emphasis on self-

expression values

Emphasis on desire to

have a say in what affects

your life

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Frustration about inappropriate care

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Frustration about impoverishing care

In ½ countries, user charges account for over half of all health expenditures

• 100 M pushed in poverty

• 150 M catastrophic expenditure

• 1300 M no access

The huge blind-spot of unregulated commercial care in L & MIC

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People care about health but there are things they don’t like

• Inverse care

• Fragmented care

• Impoverishing care

• Unsafe care

• Wasted money

2012-01-24

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Frustration about slow response to new challenges

Climate change, urbanization, aging, globalization, chronic diseases, multi-morbidity, inequalities…

Mismatch between expectations and performance in dealing with the 3 transitions:

demographic

epidemiologic

demand

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6. “PHC” in the XXIst century

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Everybody is unhappy (except the development set)

Politicians: the disconnect between discourse and performance is dangerous

Policy makers: this gets out of hand, we need more value for money

Professionals: this is not what we studied for

Citizens: we’re not getting proper care and we’re being ripped off

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It is not about poor care for poor people in poor countries

PHC is not cheap: it requires considerable investment, but it provides better value for money than its alternatives

PHC is cheap and requires only a modest investment

Primary care as coordinator of a comprehensive response at all levels Primary care as the antithesis of the hospital

Global solidarity and joint learning Bilateral aid and technical assistance

Guiding the growth of resources for health towards universal coverage Management of growing scarcity and downsizing

Pluralistic health systems operating in a globalized context Government-funded and delivered services with a centralized top-down management

Institutionalized participation of civil society in policy dialogue and accountability mechanisms

Participation as the mobilization of local resources and health-centre management through local health committees

Teams of health workers facilitating access to and appropriate use of technology and medicines

Simple technology for volunteer, non-professional community health workers

Promotion of healthier lifestyles and mitigation of the health effects of social and environmental hazards

Improvement of hygiene, water, sanitation and health education at village level

A comprehensive response to people’s expectations and needs, spanning the range of risks and illnesses

Focus on a small number of selected diseases, primarily infectious and acute

Dealing with the health of everyone in the community Concentration on mother and child health

Transformation and regulation of existing health systems, aiming for universal access and social health protection

Extended access to a basic package of health interventions and essential drugs for the rural poor

CURRENT CONCERNS OF PHC REFORMS EARLY ATTEMPTS AT IMPLEMENTING PHC

PHC is not cheap: it requires considerable investment, but it provides better value for money than its alternatives

PHC is cheap and requires only a modest investment

Primary care as coordinator of a comprehensive response at all levels Primary care as the antithesis of the hospital

Global solidarity and joint learning Bilateral aid and technical assistance

Guiding the growth of resources for health towards universal coverage Management of growing scarcity and downsizing

Pluralistic health systems operating in a globalized context Government-funded and delivered services with a centralized top-down management

Institutionalized participation of civil society in policy dialogue and accountability mechanisms

Participation as the mobilization of local resources and health-centre management through local health committees

Teams of health workers facilitating access to and appropriate use of technology and medicines

Simple technology for volunteer, non-professional community health workers

Promotion of healthier lifestyles and mitigation of the health effects of social and environmental hazards

Improvement of hygiene, water, sanitation and health education at village level

A comprehensive response to people’s expectations and needs, spanning the range of risks and illnesses

Focus on a small number of selected diseases, primarily infectious and acute

Dealing with the health of everyone in the community Concentration on mother and child health

Transformation and regulation of existing health systems, aiming for universal access and social health protection

Extended access to a basic package of health interventions and essential drugs for the rural poor

CURRENT CONCERNS OF PHC REFORMS EARLY ATTEMPTS AT IMPLEMENTING PHC

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Start from what people value and expect you to provide

Having a say in what affectstheir lives and that of their families Health equity, solidarity, social inclusion: hence UC

Universal access + financial protection;

Redistribution through pooling; social legitimacy

Living in communities where health is protected and promoted: hence Social Determinants

Sources of ill-health (E)

Sources of inequalities (LA)

Good care: hence PC-PC

Health authorities that can be trusted

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PHC as a set of interlocked reforms

Shifting to primary care has to go along with:

• Ensure UC: access plus social health protection

• Integrate public health actions with primary care and pursue healthy public policies

• Replace command & control and laissez-faire disengagement with inclusive, negotiation-based leadership.

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It doesn’t come automatically

Shifting to primary care requires major changes to HRH, payment, incentives, financing, division of tasks between hospital and community ...

This is bound to create resistance

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The sustainability argument: PC as a managerial response to the challenges of ageing, technology and demandEC: “Contain spending pressures through efficiency gains, to ensure fiscally sustainable access”:

reduce unnecessary use of specialist and hospital care while improving primary care services

EC (DG ECFIN) report, 2010

MoU Greece & Portugal:

gate-keeping, referral, primary care;

monitoring and feedback to providers;

rationalization of hospital networks

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People-centered Primary Care

Entitlements:• Access• Quality• User voice

Five desirable features of care:• Effective• Safe• Comprehensive

and integrated• Continuous• Person-

centered

An organization where form follows function: • Close-to-client,

personal relation• Explicit

responsibility for a defined population

• Networked: point of entry, gatekeeper, back-up

• Coordination of care

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People-centered?

To contain costs

To improve standards

To empower patients

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ImportantCritical

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7. Definitions

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Check the date!!!http://www.who.int/healthsystems/hss_glossary/en

1978: PHC =A movement to get to Health for All by focusing on “Essential” health care

1980s: divergent interpretations in LIC: PHC = A package of 8 components;

interpretations;

in Europe: primary care and determinants

1990s: PHC = Primary Care: The point of entry level of care (HC, GP, FD, VHW),

>> District Health Care

LIC: replaced by disease control

M/HIC: accelerated focus on primary care

Mid 2000: convergence: PHC = a set of reforms to steer health systems towards health for all

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Primary care

the part of a health services system that assures

Person focused care over time to a defined population,

Comprehensiveness: only rare or unusual manifestations of ill health are referred elsewhere,

Coordination of care such that all facets of care (wherever received) are integrated,

Continuity of care

Quality: effective, safe, parcimonious, people-centred.  

the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community

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8. Is this too much to aim for?

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2000 2002 2004

20102006 2008

0% 0 a 25% 25 a 50% 50 a 75% 75 a 100%

Programa Saúde da FamíliaBrazil:

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Thailand:

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China:

Disease prevention services

Access to drugs in despensary

Coverage of severe diseases by insurance

Convienience in seeing doctors

Timely reimbursement

Quality of mdeical staff

Reduction of financial burden to patients

Affordability of care

0% 20% 40% 60% 80% 100%

National Citizen Satisfaction Survey, 2009-11

Improved Same Worse

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Portugal: Effective and efficient

Improved user satisfaction

Improved professional satisfaction

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A personal relation

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Thank you for your patience