The Renewal of

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• The Renewal of
• Primary Health Care (PHC)
• in the Americas

Jonás Gonseth, MD, MPH, PhD. Associate Expert of
Quality of Healthcare Services Pan American
Health Organization/World Health Organization
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World Health Organization Regional Structure
EUROCopenhaguen,Denmark
HQGeneva,Switzerland
WPROManila,Philippines
PAHO/AMROWashington, DCUSA
EMROAlexandria,Egypt
SEARONew Delhi, India
AFROBrazzaville,Congo Dem. Rep.
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PAHO/WHO Member Countries

• Antigua and Barbuda Argentina Bahamas Barbados
  Belize Bolivia Brazil Canada Chile Colombia
  Costa Rica Cuba Dominica Ecuador El Salvador
• United States of America
• Grenada

• Participants
• France
• Netherlands
• United Kingdom
• Associate Member
• Puerto Rico
• Observing Countries
• Spain
• Portugal

Guatemala Guyana Haiti Honduras Jamaica Mexico
Nicaragua Panama Paraguay Peru Dominican
Republic Saint Kitts and Nevis Santa LuciaSaint
Vincent and the GrenadinesSurinameTrinidad and
Tobago Uruguay Venezuela
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PAHO/WHO IN THE REGION
CFNI
CAREC
INCAP
CEPIS
PANAFTOSA
Central Office
BIREME
CLAP
Country Offices
Panamerican Centers
http//www.ops-oms.org/Spanish/PAHO/ops_oms_sites.
htm
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The political scenario of population health in
the Americas
Bipolar world Cold War Capitalism vs
Socialism Anti-colonialist movement Third
World Multilateralism
Unipolar world War on terrorism Capitalism
hegemony Globalization Unilateralism Human
insecurity vulnerability
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Social Exclusion in Health

• 17 of births in LAC are not attended by skilled
  health personnel
• 82 million children without full immunization
• 152 million people without access to secure
  drinking water or basic sanitation
• 120 million without access to health services due
  to economic reasons
• 107 million without access to health services due
  to geographic reasons

• LAC population 500 million
• 27 without permanent access to basic health
  services 125 million
• 46 without public or private health insurance
  230 million
• USA 44 mill. people without social health
  protection

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Main Approaches to PHC
Emphasis

• Level of care

Primary Care

• Set of health services

Selective PHC

• Strategy for organizing health care systems

Alma Ata
Health and Human Rights Approach

• Philosophy permeating health and social actors

Adapted from Vuori, 1984
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Equity in the social development agenda

• Equity, a social, political, and developmental
  issue.
• Health, a pre-requisite for good governance,
  social stability, and sustainable development.
• A new health debate is also in place

• security issue
• foreign policy issue
• macro economic issue
• human rights issue and,
• global public good

Health as a
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Main challenges to health systems

• Guarantee social protection in health to all
  citizens
• Contribute to the elimination of inequities in
  access to health services
• Guarantee quality health services
• Assure excluded social groups equal opportunity
  to receive integral health care
• Satisfy the populations health needs and demands
• Eliminate the inability to pay as a barrier to
  access to health care

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PAHOs Framework For Technical Cooperation
Addressing the Unfinished Agenda
For the last time
National Health Development
Facing New Challenges
Protecting Achievements
For the first time
Forever
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Each Country Has a Different Focus In The
Framework
Priority Country
Highly Developed Country
Focus
Intermediate Country
Framework for Technical Co-operation
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Primary Health Care Renewal in The Americas

• Why renew?
• Context
• Initial stages
• Road ahead

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Why Renew?

• Inequity
• Persisting ill health
• Overburdened health systems
• Health and the development agenda

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Why Renew?

• PHC seen as essential condition for
• meeting agreed-upon developments goals MDG
• unfinished agenda/new challenges
• Addressing social determinants of health
• Greater coherence in widely divergent PHC
  approaches
• New tools and knowledge of best practices

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Context

• Progressyes however, persistent and growing
  inequalities
• Maternal mortality, malnutrition, HIV/AIDS, TB,
• Gaps in life expectancy between the richest and
  the poorest, rural and urban, indigenous,
  reaching nearly 30 years in some countries,

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First steps

• The 44th Meeting of the Directing Council of the
  Pan American Health Organization in 2003, the
  Member States - resolution calling for PHC
  renewal in the Americas.
• Working group, 2004
• Over 20 national consultations, 2005
• Regional Consultation in Montevideo, 2005
• Regional Declaration, CD 46/13

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Perceptions on PHC in The Americas

• Overwhelming support for PHC renewal
• Renewal represents more than adjustments to
  current trends
• Critical examination of meaning and purpose

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PHC-based health systems

• PHC is more than just the delivery of health
  services or individuals that provide them
• New approach specifies organizational and
  functional elements that can be measured and
  evaluated
• Analysis of social values
• Reorientation to health promotion and prevention

PAHO/WHO
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Core Values, Principles and Elements in a
PHC-Based Health System
Universal coverage and access
First Contact
Comprehensive, integrated and continuing care
Intersectorial actions
Responsiveness to peoples health needs
Adequate and Sustainable resources
Quality-oriented
Family and community based
Intersectoriality
Right to the highest attainable level of health
Appropriate human resources
Equity
Government accountability
Emphasis on promotion and prevention
Participation
Solidarity
Optimal organization management
Appropriate care
Sustainability
Social justice
Pro-equity policies programs
Active participation mechanisms
Sound policy, legal institutional framework
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Regional Declaration on the New Orientations for
Primary Health Care (MONTEVIDEO-2005)

• Countries committed to
• Facilitate social inclusion and equity in health
• Foster intersectoral action
• Establishment of structural conditions that allow
  PHC renewal
• Ensuring financial sustainability
• Research and development and appropriate
  technology
• Network strengthening and partnerships of
  international cooperation in support of PHC

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Regional Declaration on the New Orientations for
Primary Health Care (MONTEVIDEO-2005)

• Countries committed to
• Promote PHC-based health systems
• Re-orient to health promotion and comprehensive
  and integrated care
• Orientation toward quality of care and patient
  safety
• Strengthening of human resources in health

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Mandates

• The 46th Directing Council (2005) prioritizes
  comprehensive and integrated care as a crucial
  factor for the efficiency of health system
  defining integration as the coordination among
  all parts of the health services to ensure that
  health needs are met.

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Mandates

• The Iquique Consensus (2007) the need for
  developing health services networks based on PHC,
  of public financing and universal coverage.
• The 27th Pan American Sanitary Conference (2007),
  Resolution PSC27.R10 Regional Policy and
  Strategy for Ensuring Quality of Health Care,
  Including Patient Safety

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Health Services the Predominant Model of Care

• Inefficient
• Not cost-effective
• Lack of management skills and competencies
• Ineffective
• Does not respond to peoples needs
• Lack of continuity of care
• Poor quality
• Not evidence-based
• Leads to exclusion

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Essential Public Health Function 9 significant
room for improvement
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Resolution PSC27.R10 Strategic Lines of Action

• Position quality and patient safety as a health
  sector priority
• Promote civil participation in quality
  initiatives
• Generate information and evidence on quality
• Develop, adapt, and support the implementation of
  quality solutions
• Develop a regional strategy to strengthen quality
  

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PHCs Impact on Population Health

• PHC was a significant contributor to improved
  population health in OECD countries

Macinko et al., 2003
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PHCs Impact on Population Health

• PHC reforms in Costa Rica significantly reduced
  mortality in adults and children

and adult mortality was reduced by 4
Rosero-Bixby, 2004
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PHCs Impact on Equity

• Expenditures on PHC are more pro-poor than any
  other type of spending on health care

Overall expenditures are pro-poor in 6 out 8 cases
PHC spending is more pro-poor
Equity
- Equity
Equity in Public Expenditures on Health in Latin
America, by Service Type
Data from Filmer, 2003
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Health Systems with Strong PHC Are More Efficient
Starfield Shi, 2002
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To facilitate these objectives, PAHO will

• Give priority to vulnerable populations,
  especially those contained in the MDGs
• Work across programs and collaborate with all
  levels of the Organization
• Build and expand on the developments already in
  place in the countries
• Create a Regional Observatory on Patient Safety
  and Quality of Health Care

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Effecting PHC Renewal PHC based health systems

• PHC competencies for personnel
• Methods for eliminating fragmentation of health
  services Integrated Healthcare Delivery Systems
• Accreditation and performance evaluation systems
  for primary care
• Mainstreaming PHC across programs
• Expanding Patient Safety Research in PHC

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Strengthening PHC team competencies

• Project developed in partnership with HR unit
• and designed as a technical cooperation
  strategy for the American countries
• Started being built in 2006
• Aimed to developing strategies to strengthen the
  renewal of PHC process
• Multidisciplinary approach
• Starting by the essential elements of PHC based
  systems, a set of competencies was identified

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Strengthening PHC team competencies

• Having identified the core competencies, a set of
  contents was developed
• The first output of this process is a virtual
  course aimed to leaders and decision makers
• Many international experts have participated
• The first edition of this course will start at
  the end of May and will last 6 months
• The participants will be selected from all
  countries across the Region

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Accreditation system

• Focused on PHC networks
• Purpose
• To improve care quality in primary health care
  network
• Objectives
• To ensure that the network is able to provide
  good outputs and outcomes
• To promote a network of high quality facilities
  where new professionals can trained
• Started in March 2007

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Accreditation system

• A small group of experts was identified, and
  discussed a background draft
• Piloted in three countries, where many
  professionals working with the network
• were interviewed
• Its intended to fit any, either as an external
  or self evaluation tool
• It will be finished and ready to be launched at
  the end of May 2008

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Global Challenges
Research
Reporting and learning
Patients for patients safety
Solutions
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WHOs MULTIMODAL STRATEGY for HAND HYGIENE

• March 2007 Regional Workshop in San José, Costa
  Rica. Participation of delegates from over 20
  countries.
• Pilot Site in the Americas
• Hospital Los Niños, San José, Costa Rica.
• Complementary Sites
• Argentina
• Brazil
• Honduras

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(No Transcript)
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Patient Safety Research
Study of Adverse Events in hospitals, United
Kingdom 1999-2001
Harvard Medical malpractice Study 1984
Canadian Adverse Events Study 2004
Danish Adverse Event Study 2001
Utah and Colorado 1992
French Adverse Events Study, 2004
Spanish Adverse Events Study (ENEAS), 2006

First Edition ARG, COL, COR, MEX, PER 14,000 beds
60 hospitals
Study of Quality of Healthcare Services Australia
1992
IBEAS 2007
New Zealand Adverse Events Study, 2002
Cairo meeting on investigation methods 2006
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Ibero-American Study of Adverse Events IBEAS

• This project is coordinated by PAHO/WHO with
  WAPS/WHO and the Spanish Ministry of Health and
  Consumption.
• Objectives
• To estimate the prevalence of adverse effects on
  medium and large hospitals in Latin America.
• Knowledge transfer for replication by local
  authorities.
• Methodology analysis of clinical histories of
  the patients admitted during a week.
• Timetable April 2007 (Preparatory meeting in
  Buenos Aires, Argentina) July 2008 (first
  report).

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A potential next step in the Patient Safety
Research in the Americas? APEAS STUDY 2007 SPAIN
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Resultados
96.047 Consultas
21,4
2.059 Alertas
216 Falsos
716 Incidentes
7,5
18,63
1.074 EA
53 Complicaciones
11,18
114 Mínima relación
129 Ligera relación
217 Moderara relación
336 Muy probable relación
278 Total relación
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Prevalencia
Un 6,7 de los pacientes acumuló más de un EA.
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Tipo de efecto ( n 1108)
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Conclusiones APEAS

• La práctica clínica en AP es razonablemente
  segura.
• La seguridad del paciente es importante en AP.
• La prevención de los EA en AP debe ser una
  estrategia prioritaria.
• La etiología es multicausal factores
  relacionados con el uso de fármacos, con la
  comunicación, con la gestión y con los cuidados
• Los EA son consecuencia del uso de fármacos,
  evolución más tórpida de la enfermedad de base,
  consecuencia de procedimientos, infección
  nosocomial y consecuencia de los cuidados.
• Una cuarta parte de los EA no precisó cuidados
  añadidos, otra cuarta tuvo que ser derivada a
  especializada y la mitad fue resuelta en AP.

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DECLARACION BUENOS AIRES 30/15

• Hacia una estrategia de salud para la equidad,
  basada en la atencion primaria.
• Equity, universality and solidarity
• Health as a human right
• Human resources for health
• Health systems based on PHC

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WHO NEW DIRECTION
DR. MARGARET CHAN

• Decades of experience tell us that PHC is the
  best route to universal access, to ensure
  sustainable improvements in health outcomes, and
  the best guarantee that access be fair .
• I do not beleive that we will reach the MDGs
  unless we return to the values, principles,
  approaches of PHC .
• Margaret Chan, October 2007

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The Road Ahead

• Completing PHC where it has failed
• Strengthening PHC to address new challenges
• Locating PHC in the broader agenda of equity and
  human development

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• Are you ready to fight the political and
  technical battles required to overcome any social
  and economic obstacles and professional
  resistance to the universal introduction of
  Primary Health Care.
• Halfdan Mahler, 1978 Alma Ata Conference

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• I am morally and intellectually convinced that
  the vision of health for all and the primary
  health care strategy provide significant initial
  strength and have added impetus to the
  development of health throughout the world.
• Halfdan Mahler, 2007 Buenos Aires Conference

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Remember - The key actors