Expanding Primary Health Care

Sam AdjeiNHIA 10th Anniversary Conference

Outline

• Introduction• Definitions of PHC• Global evolution of PHC• Goal, objectives and strategies• Ghana’s organization of PHC• Package of services• Financing of services• Assessing performance• Moving forwards

Introduction

Evolution of health delivery systems 20yr cycle• 1957- Basic health care– Emphasis on infrastructure

• 1977/78- Health for All based on PHC – Emphasis on rapid expansion of services

• 1997- Health sector Reforms and SWAP– Health systems strengthnening and MDGs

• 2015- Post MDG

Definition and global commitment

Many definitions of PHC – here is the JLN’s

Primary care is the level of a health services system that provides entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and coordinates or integrates care, regardless of where the care is delivered and who provides it.

Essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination

First-contact access for each new need; long-term person-based care (not disease-oriented), comprehensive care for most health needs, and coordinated care when it is sought elsewhere.

“The provision of outpatient non-secondary and non-tertiary preventive and curative care, with a particular focus on ensuring the quality delivery of health interventions prioritized by both countries and the global health community against the highest disease burdens”

Global commitments to PHC repeated over time, but not realized in practice

Alma Ata(WHO members)

Recognized PHC as an essential right, and committed

governments to launching and sustaining PHC as part of a

national health system

Haikko Declaration(40 member countries)

Reaffirmed Alma Ata

19861978 2008

Ouagadougou Declaration(All African region members)

Reaffirmed Alma Ata

Birchwood Declaration(South Africa members)

Reaffirmed Alma Ata

Americas Region Declaration(All Latin American members)

Reaffirmed Alma Ata

Countries still continue to struggle with issues of organizational structures, demand, and financing of primary health care

Ghana experience

• Goals, organization

Goal, objectives and strategies of Ghana PHC

• Goal: – Maximise total life of Ghanaians

• Objectives: 1) Achieve basic and primary health care for 80 of people2) Effectively attack the diseases problems that contribute 80 of

morbidity and mortality

• Strategies: 1. Improve accessibility-coverage of services2. Improve quality of PHC3. Improve and strengthen management capacity to support to

the primary level

Organization of care

NATIONAL Policy -MOHGHS

POLICY - MOH AND

GHS

TERTIARY CARE

REGIONAL LEVEL STRATEGY TRANSLATION

-RHMT

SECONDARY CARE

-REGIONAL HOSPITALS

DISTRICT LEVEL PRIMARY HEALTH CARE

1ST REFERAL HOSPITAL

District level organizationLevel Name Population Human ResourcesA Community 200-5000 TBA, CFHW, CEDWB Sub district 5-10,000 CHN, MIDWIFE, PA C District 175-24,000 DHMT-DDHS, DMOH,

DPHN, DNTO, DHI

The community level was problematic: there was little evidence that their training and deployment effectively

affected morbidity and mortality. The MOH therefore took a decision to replace them with trained staff. Hence the Community-based Health Planning and Services-CHPS

Initiative which uses CHO.

What is CHPS

• Stands for Community-based Health Planning Services

• Involves relocating a CHN (CHO) into community with defined population (zone)

• Works with volunteers• Supported by community through CHC• Has a set of functions to perform• Supervised by sub district team

Community Health Care

District Health

Management Team

Clinical Determinants Track

CHOCM TBA CP

Social Determinants Track

CHWSPrayer Camps

Trad. Healers

Env. & Sanit.

Officers

Com. Dev.

Officers

C H Vs

CHPS Compound

Health Centres

District Hospitals

Ref

Ref

Ref

Ref

M&L

Planning, M&E

Service & Surveilla

nce

Sub-district health management team

Services/priority interventions

Health services-for PHC in 1978

• education concerning prevailing health problems and the methods of preventing and controlling

• promotion of food supply and proper nutrition; • adequate supply of safe water and basic sanitation;• maternal and child health care, including family planning; • immunization against the major infectious diseases; • prevention and control of locally endemic diseases; • appropriate treatment of common diseases and injuries; • and provision of essential drugs;

Priority interventions-1996

• Immunization• Reproductive health programs• Prevention and control of epidemics• Health promotion• Micronutrient deficiency control and prevention• Management of locally endemic diseases– Malaria, TB, HIV, Oncho , filariasis etc

• Emergency care for accidents and trauma

Most Popular Popular Least PopularFamily Planning Counseling Care for neonates (0-7

days)Road Traffic Accidents (care of victims/casualties)

Defaulter tracing and continuing drug replacement

Antenatal Care Services on expectant mothers

Hypertension Management

ARI in Children Antenatal Education in Groups

Ulcer Management

Immunization and Vaccination Services

Dispensing of Antibiotics Dispensing Class C Drugs

School Health Services Insertion and Removal of Family Planning Implants

Minor Surgery (eg., Incision and Drainage)

Malaria case management TB Treatment Diabetes ManagementNutrition Advisory Services and Product Distribution

HIV/AIDS Treatment Dispensing of approved traditional Medicines

Growth Monitoring DeliveryCare of Children (1-59 months) Yaws, Elephantiasis,

SchistosomiasisCare of Infants (7-28 days) Injuries and PoisoningDiarrheal Disease Management Obesity ManagementDistribution of contraceptive pills and condomsPost-delivery care of Mothers

Expressed Needs for Services at the Community level

Comparison of disease problems

Top 10 conditions- 1977• Malaria• Prematurity• Measles• Birth Injury• Sickle Cell Disease• Child pneumonia• Malnutrition• Dysentry • Neonatal tetanus• Accidents

Top 10 conditions-2003• Malaria• Anemia• Pneumonia• Stroke• Typhoid Fever• Diarrhea• HPTN• Hepatitis• Meningitis• Sepsis

Financing

Trends in resource allocationYear Per Capit

Govt Expend

Headquarters Tertiary Secondary Primary or district

1976 $3-5 - 40 45 15

1996 $6-7 28 31 17 23

2001 $10-12 16 19 23 42

2012 $30-50 42-50

Where is the money coming from

NHIS a major player

• Contributes to 70-80 per cent of facility IGF• Contributing now 30-40 per cent of income• DWHIS focuses on the district• Capitation is for primary health care• Selection of PPP can be skewed to lower level• Potential of capitation for preventive care not

yet explore• Can be considered in national roll out

Performance measurements

Measuring performance

• Data sources include– Routine administrative data– Program statistics– Surveys by GSS- MICS,GDHS, GLSS– Demographic surveillance centre– Other research studies– Composite assessment- Holistic Assessment

• Joint MOH-Partners Summit for policy/ strategy• New Performance League table can be examined

Organization of assessment

• BMC Review and performance hearing• Interagency performance review• In-depth review of key areas of concern• Independent Sector Review• Report to Parliamentary Select Committee on

health• Annual Joint MOH-partner Summit

DEBRIEFING INDEPENDENT REVIEW TEAM

25

Areas of assessment

• Goal 1: Mortality changes• Goal 2: Reduce excess morbidity• Goal 3: reduce inequality in service• SOB 1: Human Resources XXX• SOB2: Health, reproduction and nutrition• SOB3: Capacity Development• SOB4: Governance and Financing

1/04/2010

Challenges and way forward

Some challenges

• The capacity of DHMTs, sub district and community teams

• Public private partnership• Package of interventions• Decentralization• Financial strategies• Evidence base for decision including Mand E

Moving forwards -1Influencing factors

• Demographic transition– Aging population, urbanization

• Economic transition– Low to middle income

• Changing disease burden– Double burden of diseases

• Financing changes– The rise of NHIS, fragmented donor sources

Moving forwards-2ICT potential

• Mobile Technology for Community Health (MoTeCH)

• E-Blood Bank an electronic (web-based) blood tracking system

• Community-based electronic registrationSystem for EPI• DHIMS2 • E-Claim

Conclusion

• A lot has changed since 35 years• Post MDG discussions affords opportunity for a major

thrust to rekindle PHC globally• Because more than ever PHC is needed to address

equity issues and link services to financial risk protection

• Opportunity to enhance quality in PHC• Advances in technology mist be maximised• Performance system that compares where countries

are will be an advantage.