Evolution of, and new challenges for Primary Health Care in the context of

1
Evolution of, and new challenges for Primary
Health Care in the context of Health for All
A personal experience and view
2
Public Health Research Information Systems in
the Dev. World

• Prior to WW-2
• Colonial medicine (French, British, Dutch,
  German) limited to curative measures,
  en/epidemics, bacteriology/parasitology
• Epid. Information on total population groups
  spotty, biased, largely inaccurate.
• Post WW-2
• Military Medicine (e.g. Namru, etc.) Interest in
  disease patterns of total population groups
• Epidemiological surveys, disease causation,
  nutritional determinants of disease
• Search for control of major (infectious) disease
  processes
• Search for means of fertility control

3
Public Health Research Information Systems in
the Dev. World

• Two important milestones in Health System
  Research framing the period
• Population-wide survey of Haiti (Sebrell, 1959)
• Mortality patterns in the Americas (Puffer
  Serrano, 1973)

4
The Decline in Child Mortality in the mid-19th to
late 20th centuries (England Wales)
3
6
4 5
1
2
1, 2 causative orgs of diphtheria pertussis
identified 3, 6, start of natl immunizations
for diphtheria and measles 4 penicillin
available 5 start of immun. for pertussis
5
Guidelines for the Development of Health
Intervention Programs (1950 1970)

• focus on Health Problem priorities,
• pay special attention to the most vulnerable
  groups,
• offer solutions that are both effective and
  affordable,
• identify and appoint the lowest member on the
  health service team, that is sufficiently
  trained, capable to diagnose the condition and
  administer first treatment, as agent for service
  delivery,
• the intervention must be acceptable to, and
  involve the local community

6
Priority Problems of the Preschool Child
7
Potential for Child Survival, using available
interventions, 1975
Cause of Death Percent of all deaths ADSMR Achieved Reduction in Mort. () Potential ADSMR
Nonspecific DD 19.5 9.2 50 4.6
Low BWT incl. Prematurity 17.0 8.3 30 5.8
Intraut. Asphxia, incl B.trauma 14.3 6.8 25 5.1
ARI 14.2 6.6 40 4.0
Other treatable conds 16.3 7.8 35 5.1
Other non-tr. or unknown 18.7 9.2 Assumed 0 9.2
All 100 48 30 34
Age disease specific mortality rate where
obtained ADSMR/PotADSMR measure of performance
8
Major Achievements

• Eradication of Small Pox
• Control of Cholera DD through Oral Rehydration
• Control of ARI through antibiotics given by
  paramedicals
• World-wide immunization of children against
  Diphtheria, Pertussis Tetanus, Measles, Mumps,
  Rubella and (miliary and cerebral) Tuberculosis
• Making readily available modern methods of
  contraception to all parts of the developing
  world
• Improving pregnancy-, delivery- and post-partum
  care through training and support of TBAs
• Awareness about the importance of nutritional
  disorders, their surveillance and treatment
• Use of medical auxiliaries to carry out tasks
  previously reserved for doctors.
• Mobilizing village communities to identify and
  assist with the search for, and implementation of
  solutions

9
Reasons for program failures

• Disparity between the Research and Service
  settings.
• Health Worker charged with implementing PHC ill
  prepared for his/her role
• Health System Inertia - new programs compete with
  ongoing and regular government services for
  resources.
• Disregard of factors of ecological setting in
  the development of programs
• Ongoing civil strive, and natural disasters.

10
Social, cultural, environmental, political,
economic ecosystem
Management and Organization
Service Distribution
Support Systems
Service Outputs
Service Inputs
Community Participation
Service Outcomes
Health Problems/Needs
11
Principal Inputs at Micro Level
SERVICE INPUTS
12
INPUTS The Sailboat-structure of the Health
Care Delivery System
III
II
Levels of Care
Curative Dx Services
I
Prom./Prev. Services
COMMUNITY lt gt CHW
13
PHC Facility AssessmentList of countries
Location Year Subject Carrier Org.
Egypt 1978 Hlth Centers/Units Reg. Gov.
Cameroon 1982 PHC services Ds Project
S. Sudan 1982 PHC services Ds Project
Uganda 1989 Basic Health S. Reg. Gov.
Tanzania 1990 Family Hlth Serv. Ds Project
Mali 1991 PHC services Ds PGov S
Yemen 1991 PHC services Ds Gov S
Malawi 1992 PHC services Reg. Gov.
14

• Manual
• used for
• Assessmt

15
PHC facility assessment1. Health Problem
Identificationa. Vital statistics registration
Outpatient
16
PHC facility assessment2a. Adequacy of phys.
infrastructure
In non-project, government services
including government services
17
PHC facility assessment2b. Program Relevance
18
PHC facility assessment3. Input Distribution
(Access)
In of days the facility was open in the 3
months preceding the survey in/including
government services
n.e. not examined
19
PHC facility Assessment4. Hlth services output

• Average outpatients/hlth worker/day
  average homevisits per hh/year
• of pregnant women who had 2 tet.tox.
  Injections during pregnancy

20
PHC facility assessment5) Health Services
Utilization

• consultations/person/year
  consultations/preschooler/year
• average of antenatal
  visits/pregnancy

21
HS Model-II WHO Health System Conceptual
Framework Tasks Objectives(Macro, central
level)
Tasks Functions
Health System Objectives
Stewardship (Oversight)
Responsiveness (to peoples expectations)
Resource Generation (Investment and training)
Delivering Services (Provision)
Health
Fair (financial) Contribution
Financing (collecting, pooling, purchasing)
22
Health and Defense Expenditures(in US per year)
Country GNP/cap (US PPP) GNP for Health Gov.Hlth. Exp./cap Gov.Def. Exp./cap Def. Exp of Hlth Exp
Canada 35078 6.0 2090 531 25
France 29 644 7.5 2213 1189 53
Sri Lanka 3481 1.6 55 31 56
Pakistan 2396 0.5 13 51 392
Cuba 996 22.0 218 61 14
Rwanda 813 1.7 14 6 43
23
PHC according to Alma Ata

• Major points
• Universal accessibility for individuals
  families
• At an affordable cost
• As integral part of the countrys health system
  of the social/economic development of the
  community
• Services must be equitably distributed
• Involve community participation
• Be accompanied by intersectoral coordination

24
Major Challenges for the provision of PHC

• CLIMATE CHANGE ITS CONSEQUENCES ON HEALTH
• WORLD WIDE FOOD CRISIS - AVAILABILITY, COST
• CONTIN. GOVERNMENTAL IRRESPONSIBILITY
• WEAKNESSES OF HLTH SOCIAL SYSTEMS
• INCREASING ECONOMIC DIVIDE
• NEW ENDEMICS/PANDEMICS
• CONTINUED CIVIL STRIVE
• POPULATION INCREASE

25
Potential Solutions 1national

• Redesign/strengthen a basic Health Care Delivery
  System under Responsibility of Government using
  WHOs 1978 template as model
• If needed Tailor-make Structural Adjustments for
  Care Levels II and III but assuring continued
  Access to System for poor to all levels (modified
  Reform process)
• Funding to come from
• Taxation
• Budget Adjustment (e.g. from Defense to SS)
• External Aid (multilateral, bilateral)
• In decreasing order of priority

26
Approaches to health system development
Potential Solutions 2national
Health Sector Reform Primary Health Care as in Alma Ata Attributes
Utilitarian Social egalitarian Ideology promoted
Selective essential package of services Comprehensive Overall approach
Restricted role of the government Greater public sector involvement Role of governments
Efficiency and competition Equity and Social justice Focus on
Economists Socially driven scientists Champions
Structural Programmatic Type of reforms
Basic Rights Approach
Reform Approach
27
(No Transcript)
28
Potential Solutions - 3national

• Adjust Budget in Favor of Social Services
  including Health
• Improve Health Planning M/E in public sector
  through use of modern techniques
• Monitor Adjust Macro and Micro Health Service
  Delivery Systems on need basis and following HS
  Analysis
• Increase Community Awareness about existing
  Problems and explain necessary Actions and
  Consequences
• Introduce Reduce Wastage program

29
Potential Solutions 4international

• Strengthen Global-Watch Organizations
• Table explore Idea of Rich Poor Parrainnage
  Associations (Example DDR-W.Germany)
• Initiate Neighbourhood Assistance Preparedness
  for Nat. Disaster Programs
• Launch Education Programs on Global
  Responsibilities re Human Rights, Equity,

30
Infant Mortality and Under 5 Mortality Oman
1970-2006
200
181
150
100
118
50
11.0
10.25
//
//
//
//
0
1970
1975
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
2000
2006
Infant Mortality Rate
Under 5 Mortality Rate
DGHA - MOH
31
THANK YOU FOR YOUR ATTENTION
32
(No Transcript)
33
(No Transcript)
34
PHC facility assessmentList of Countries and
respective Reports
35
An early definition of PHC

• PHC is the application of health care
  services of promotive, preventive, or curative
  nature that have been shown to be effective and
  affordable, to prevailing priority health
  problems and needs.
• PHC is provided by a health care professional
  doctor, nurse or other paramedical on first,
  and if subsequently required, continued contact
  to an individual or family in response to a
  health problem or health need identified by
  patient, patient relative or the health care
  professional .

36
Social, cultural, environmental, political,
economic ecosystem
Management and Organization
Service Distribution
Support Systems
Service Output
Service Inputs
Community Participation
Service Outcome
Health Problems
A.A.Kielmann
37
Principal Inputs at Micro Level
SERVICE INPUTS
38
Health and Defense Expenditures 1) High Income
Countries(approx.)
Country GNP/cap (US ) GNP for Health Gov.Hlth. Exp./cap Gov.Def. Exp./cap Def. Exp of Hlth Exp
Luxemb. 70014 4.8 3341 462 14
USA 41674 6.1 2548 1964 78
Canada 35078 6.0 2090 531 25
France 29 644 7.5 2213 1189 53
Malaysia 11466 1.9 218 65 30
Turkey 7784 4.9 378 215 56
39
Health and Defense Expenditures 2) Mid-income
countries(approx.)
Country GNP/cap (US ) GNP for Health Gov.Hlth. Exp./cap Gov.Def. Exp./cap Def. Exp of Hlth Exp
Egypt 5049 1.7 85 47 55
Morocco 3547 2.0 72 76 106
Sri Lanka 3481 1.6 55 31 56
Pakistan 2396 0.5 13 51 392
Yemen 2276 1.6 37 49 132
India 2126 0.9 20 24 120
40
Health and Defense Expenditures 3) Low-income
Countries(approx.)
Country GNP/cap (US ) GNP for Health Gov.Hlth. Exp./cap Gov.Def. Exp./cap Def. Exp of Hlth Exp
Kenya 1359 1.8 25 8 32
Bangladesh 1268 1.7 21 6 29
Cuba 996 22.0 218 61 14
Rwanda 813 1.7 14 6 43
Malawi 691 2.3 16 1 6
Niger 613 1.1 20 8 40
41
OLD AND EMERGING THREATS, LIKELY CONSEQUENCES AND
POTENTAL SOLUTIONS
Continuing new threats
Likely consequences
Necessary response