Transcript Changes and Challenges in Community Health & Development

Hospitals and
Community Health &
Development
Dr. Anil Cherian
Director, Community Health &
Development
Emmanuel Hospital Association
India
Outline of the Presentation
• Community health & development in EHA
• Role of the hospital
• Changes in the context. Redefining the
relationship between hospitals and
community based programmes.
• Principles of primary care that should be
incorporated in to hospital services and
care.
Emmanuel Hospital Association
• Federation of 20 Christian mission
hospitals.
– Started in 1971 – 37 years old
– 15 hospitals are rural
– 5 hospitals semi-urban
• 29 community health & development
projects.
– 20 locations – 18 are linked to hospitals and 2
are stand alone.
– The projects cover 3 million people
EHADevelopment
Units in
India
Status Map
Development of Community
Health in EHA
• 70’s – Hygiene education / Community Outreach.
• 80’s – Primary Health Care. 1984 EHA’s first PHC
project started (SHARE project started by Dr.Ted
Lankaster.
• 90’s – Expansion of the Community Health
involvement.
• 2000 – Repositioning of Community Health
Projects in the context of over all development.
EHA Vision for communities
Empowered communities that are healthy,
learning, prospering, caring, stewards of
their natural resources, living in
harmonious relationship, living in a clean
and safe environment, worshiping the true
and living God and reaching out to others
in need.
Kacchwa, 2001
Determinants of health
EHA Organizational Objectives
A. The major disease burden of the communities
served by our institutions and projects are
reduced equitably, through their participation
and at a cost that they can afford.
B. Communities prosper economically,
demonstrating good stewardship of their
available resources, living in a safe and clean
environment, constantly learning, demonstrating
mutual trust, cooperation and caring attitudes
towards other communities.
C. Individuals, families and communities become
disciples of Jesus Christ
EHA Strategic Review December
2007
Profile of our Current
Community Work
Disease
Specific
HIV
Tuberculosis
Malaria
Basic
Health
Care for
common
illness
Water,
Sanitation
& Hygiene
Nutrition /
Food
security
Literacy &
Education
– Formal,
Nonformal,
Vocational
Advocacy &
Community
Mobilization
Thrift/Savings
Micro-finance
Income
generation /
Livelihood
Village health
plan
Micro birth
plan
Community
Analysis
using
4 delays
Advocacy
Maternal
Child
Health
Community
Based
Monitoring
Service
delivery
Capacity
building
SHG role/support
activities
Community
level
sensitization
Reproductive & Child Health
Reproductive & Child Health
Immunisation
Women’s literacy
Women’s literacy
Participatory Learning Exercise
Women Action Group
Women’s groups
Walk for malaria
CBOs initiative for Health facilities
Monthly Volunteer’s Meeting
Challenges & choices
• Shift from a hospital / disease focus to
a community health focus.
Social
Determinants
of health
Health
Promotion
Preventive
Medicine
Primary
Care
Secondary
Level Care
Integrated Programmes
Continuum of care
Rehabilitation
Role of the hospital
• Initiate the Community Project. – Hospital
reputation is important for entry in to the
community.
• Administrative support
• Technical resource persons
– Health care
– Training
• Facilities shared reducing overhead
expenses.
Role of the hospital
• Important to support communities
initiatives with critical / emergency care.
• Financing
• Accountability
• Provide a faith community and family
support to community health programme
staff.
• Provide linkages with partners
Disadvantages
• Ownership
• Suspicion or mistrust
• Conflict of interests
– sharing of resources
•
•
•
•
Attitudes of hospital staff
Pre-conceived notions
Different time frameworks
Ghetto or “mission compound” mentality
A different drumbeat
Changes in the context
Non communicable Diseases
• The new killers – CVD, Diabetes,
Mental Illness including substance
abuse, Injuries which include
Accidents, RTA and Suicide, Asthma
and COPD
• Dual burden of disease.
• Risk-reduction / behaviour change
• Need for integrated “continuum of
care” programmes
Health Care Financing -India
• 82.4% of health care expenditure occurs in
the private sector of which 77.5% is from
out-of pocket payments.
• Of the 5% of GDP spent on health care
the government contribution is only 17.8%
which amounts to 0.9% of GDP.
• Health care in India is the most privatized
in the world
Medical expenses and
impoverishment
• Survey conducted in 3 districts in Gujarat
and Andhra Pradesh - 85% of the
households in Gujarat and 74% of those in
AP health expenses was the main reason
for their economic decline.
• World Bank estimates that OOP pushes
2.2 % health users in poverty and 1in 4
among those hospitalised.
Catastrophic Health Expenditure
• A adverse health condition that necessitates more
than 10% of the household income in medical
expenses (Pradhan 2002)
• Illness leads to loss of income and significant
extra expenditure. The combination pushes
people in to poverty.
• 9% of households in India experience
catastrophic health expenditure
• Catastrophic health expenditure is more common
in the low income group, but it can also effect the
middle income group.
Access to Essential / Life Saving
drugs
• WHO lists 270 drugs as essential – take care of
95% of the health problems.
• 60,000 to 80,000 brands of various drugs in India
• 10 of the top 25 drugs sold in the Indian market
are non essential, irrational or hazardous.
• 56% of the people in India still do not have access
to essential drugs (WHO 2004)
• Deregulation of drug price control has led to
spiralling of costs with profit margins being
increased to 75-100%
Price variations in drugs
Price in
INR
Medicine
Brand
Company
Ofloxacillin 200
mg
ZO
FDC
3.2
Tarivid
Aventis
31
Levoflox
Cipla
Levofloxacillin
500 mg
Amlodepine 5
mg
Travanic Aventis
Amoloda
c
Zidus
Amlogar
d
Pfizer
Difference
969%
6.82
95
1392%
1.51
6
397%
Income Inequalities
Disparities across income
groups
Health Status
Indicator
Poorest
Quintile
Richest
Quintile
Poor/ rich
risk ratio
Infant Mortality
109
44
2.5
Under 5 Mortality
155
54
2.8
Childhood
Underweight
60
34
1.7
Total Fertility Rate
(births/woman
age:15-49)
4.1
2.1
2.0
Social Disparities: IMR & U5MR
Impact of Climate Change
• Migration of families
in search of
livelihood.
• Increase in natural
disasters
Impact on the programs
• Health disparities: Averages cannot the only way
to summaries data and it is important to look at
the data in different groups.
• Hospitals need to synchronize with community
based initiatives. Joint planning
• Good quality health care is an important adjuvant
to community programmes
• Engage with Government programmes
• Establish linkages with Government programme
and to access available resources – privatepublic partnerships.
Can the principles of Primary
Health Care be incorporated in to
hospitals to synchronize them with
community based programmes?
Applying the Principles of “Primary
Health care” to hospitals
• Demystifying medicine – strengthen patient
education. Using patients to educate others in
the community.
• Participation of the family and the larger
community (volunteers) in caring for the patients.
• Using the community as gatekeepers for
directing services.
• Community advisory committee in hospitals
• Making healthcare affordable.
• Vertical equity – differential pricing / cross
subsidization
Applying the Principles of “Primary
Health care” to hospitals
• Rational drug therapy
• Use of only appropriate/ cost-effective
technology.
Conclusions
• Hospitals can be a good launch pad for
community based health programmes
• There are potential synergies in having
community health programmes
Thank you for listening