Transcript Primary Health Care

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GLOBAL PRIMARY HEALTH CARE
PUBHLTH 350
Deepti Bettampadi, MBBS, MPH
November 16, 2015
PRELIMINARY ETHICAL CONSIDERATIONS
Health and human rights
Health system goals and levels
Public and private approaches to health systems
Challenges in global health systems
 Responding to health inequalities
 Increasing uptake of health insurance
Research ethics
Skolnik. Global Health 101.
HEALTH AND HUMAN RIGHTS
According to the WHO constitution, the enjoyment of the highest attainable standard
of health is one of the fundamental rights of every human being
Since 1958, more than 20 multilateral treaties about the right to health have been
formulated
 The International Covenant on Economic, Social, and Cultural Rights
 Focuses on ‘positive rights’ such as right to work, to a living wage, to form a trade union etc.
 Signed, but not ratified by the US
 The International Covenant on Civil and Political Rights
 Focus on ‘negative’ rights i.e. those not requiring governmental actions
 Ratified by the US more than 20 years later in 1992
Skolnik. Global Health 101.
CIVIL RIGHTS VS. POLICE POWERS
Powers exercised by the states to enact legislation and promulgate regulations to
protect the public health, to ensure welfare, and promote the common good
Examples
 Childhood vaccinations as a condition for school entry
 Isolating and treating persons with tuberculosis
Parens patriae: When an individual cannot or will not take adequate care of
themselves, the state is obliged to take protective action
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State guardianship
Helmet or seat belt laws
Civil commitment; mental health
Obligatory treatment, TB
Children and elderly; health neglect
GOAL OF A HEALTH SYSTEM
What level of prevention should be provided? (primary, secondary, or tertiary)
To respond to acute conditions or chronic conditions?
To provide care to those who can pay, or to everyone?
To reduce health disparities?
DIMENSIONS OF HEALTH SYSTEMS
Provision of personal and public health service
Healthcare workforce
Access to essential medications and technologies
Health information system
Health financing system
Oversight
Jacobsen. Global Health 2nd Ed.
FRENK FRAMEWORK: EXPANDING OUR VIEW ON
HEALTH SYSTEMS
Health systems components:
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Human resources
Financing
Hospitals and clinics
Technologies
Interactions of these components
Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089
FRENK FRAMEWORK: EXPANDING OUR VIEW ON
HEALTH SYSTEMS
Both supply (institutional) side and demand side have to be considered
Population should not be viewed as just an external beneficiary, but also an essential
part of the system:
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Patients requiring care
Consumers with expectations about treatment
Source of financing as taxpayers
Citizens who believe health care is a right
Co-producers of health care, being compliant with prescriptions, and not harming the health of others
Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089
FRENK FRAMEWORK: EXPANDING OUR VIEW ON
HEALTH SYSTEMS
Goals of a health system
 Traditional: improve health
 More modern: increase health equity
 Secondary goals:
 Enhance responsiveness of health system to expectations of populace
 Respect dignity of persons and promote patient satisfaction
 Have fair financing (provide financial protection against costs of ill-health)
Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089
FRENK FRAMEWORK: EXPANDING OUR VIEW ON
HEALTH SYSTEMS
Function of health system:
 Not only direct provision of health services
 Also: stewardship, financing, resource generation (including of the health workforce)
Health system strengthening should also be accompanied by an effort to generate a
process of shared learning among countries.
Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089
TYPICAL HEALTH SYSTEM SERVICES IN LOWINCOME COUNTRIES, BY LEVEL
Skolnik. Global Health 101.
INTEGRATION OF HEALTH CARE SYSTEMS
Vertical integration: A health care organization offers, directly or through others, a
broad range of patient care and support services, operated in a functionally unified
manner
Horizontal integration: Coordination of functions, activities, or operating units that are
at the same stage in the process of delivering services
Diagonal integration: ‘Explicit intervention priorities drive the required improvements
into health systems, dealing with such generic issues such as human resource
development, financing, facility planning, drug supply, rational prescription, and
quality assurance’
HEALTH SYSTEMS FINANCING
Most high-income countries have a government sponsored healthcare system
The US has (mostly) privately-sponsored healthcare system
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Medicare
Medicaid
Veterans Affairs
Indian Health Services
Obamacare
Low-income countries have a mix of public and private providers that require out-ofpocket payment at the time of service
Jacobsen. Global Health 2nd Ed.
Jacobsen. Global Health 2nd Ed.
SIMPLIFIED CATEGORIZATION OF APPROACHES
TO SELECTED HEALTH SYSTEM ISSUES
Skolnik. Global Health 101.
Jacobsen. Global Health 2nd Ed.
Jacobsen. Global Health 2nd Ed.
OVERALL HEALTH SYSTEM PERFORMANCE
RANKING, SELECTED COUNTRIES
Skolnik. Global Health 101.
HEALTHCARE SYSTEM IN INDIA
Public health sector was established by the Government of India after independence
from British rule
Private health sector, which was already dominant at the time of independence, has
grown exponentially, and has become a default option for middle and upper income
classes
Reddy, K. S., Patel, V., Jha, P., Paul, V. K., Kumar, A. K. S., & Dandona, L. (2011). Towards achievement of universal health care in India by 2020: a call to
action. Lancet (London, England), 377(9767), 760–8. http://doi.org/10.1016/S0140-6736(10)61960-5
PUBLIC PRIMARY HEALTH CARE
Primarily funded by central and state health governments
The hierarchy of institutions is as follows:
 Subcenters: Cover three or four villages
 Primary health centers (PHCs): Cover a population of 30000 (or 20000 in remote or rural areas),
operated by auxiliary nurse midwife
 Community health centers: 30 bed hospitals which are referral centers for 3 or 4 PHCs each
 Taluk or district level hospitals: Higher-order public hospitals situated at each taluk or district
PHCs and subcenters form the basis of India’s primary health care system
Each PHC is charged with providing promotive, preventive, curative, and
rehabilitative care
Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May).
http://photos.wikimapia.org/p/00/03/13/42/58_full.jpg
NATIONAL RURAL HEALTH MISSION
Aims at ‘establishing a fully functional, community owned, decentralized health
delivery system with inter-sectoral convergence at all levels, to ensure simultaneous
action on a wide range of determinants of health such as water, sanitation, education,
nutrition, social, and gender equality
Launched in 2005
Accredited Social Health Activists (ASHAs):
 Community health volunteers who will create awareness on health, and will mobilize the community
towards increased utilization and accountability of existing health services, and local health planning
 Women residing and planning to residing in the village for foreseeable future aged between 25-45
years, has class 8 education or higher, preferably married, widowed or divorced
Courtesy: Brad Carlson and Amy Sarigiannis
Courtesy: Brad Carlson and Amy Sarigiannis
THE KERALA PARADOX
Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May).
HEALTHCARE BY PUBLIC SECTOR
Why is it needed
Reasons for its poor performance
Affordable
Bureaucratic approach to health care provision
Availability for preventive, curative, and
rehabilitative services under one roof
Better coverage in rural areas, which house
majority of population in India
Needed to provide healthcare to urban
poor (ex: slum dwellers) who cannot afford
private services
 Rigid PHC structure
 Focus on inputs rather than outputs
 Lack of public health management capacity and
partnerships with private sectors
 Vacancies in PHCs for long periods
Lack of accountability: No incentive to treat
citizens as clients
Incongruence between budgets and commitments
 Lack of medicines
 Limited doctor salaries
 Poor condition of PHC infrastructure
Ridwan, I. (2005). India - Private Health Services for the Poor
Policy Note. HNP Discussion Paper, World Bank, (May).
PRIVATE HEALTH CARE
Includes for-profit and not-for-profit providers, nongovernmental organizations, missionary
hospitals, private pharmacies, blood banks and unqualified informal providers
Private sector providers can be divided into following groups:
 Rural medical providers (RMPs)
 Most of them are unqualified, especially in rural areas
 Vast majority practice allopathic medicine, though some of them are qualified in Indian Systems of medicine
 Have good public standing, available at convenient hours, and known to treat patients equally
 Not-for-profit sector
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Non-governmental organizations
Religious-based facilities
Often provide good quality of care because they are not motivated by profit
Willing to take health care challenges that for-profit sector is not willing or not able to take on
 Corporate, or for-profit sector
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Most of them general hospitals (71%), while few focus on maternal and child health (26%)
Tend to charge more than not-for-profit sector
Tend to be clustered in few urban centers
Provide majority of institutional deliveries and high percentage of antenatal care (40-60%)
Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May).
HEALTHCARE BY PRIVATE SECTOR
Why is it needed
Disadvantages
Provide high quality of care
Top-level hospitals are focused almost
entirely on tertiary care, and do not cater to
the health care services of the poor
More accessible to urban population (rural
population in case of RMPs)
Non-for-profit sector can provide high
quality of care at low cost
NFP fills the gaps in services provided by
public and for-profit private sectors
Even the moderate costs of private clinics
and nursing homes can plunge poor
households into poverty
Parts of for-profit sector involved in
unnecessary procedures such as caesarian
sections
Has grown without any oversight or
regulation from the public sector
Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May).
HEALTH CARE REFORM IN INDIA
Problems
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50% of household poverty from health expenditures
Imbalanced resource allocation
High out-of-pocket health expenditures
Health-spending inflation
Potential solutions
 Adoption of equity metrics in monitoring, evaluation, and strategic planning
 Investment in knowledge-base of health systems research
 Redefinition of the specific responsibilities and accountatbilities of key actors
Balarajan. Lancet. 2011 February 5; 377(9764): 505–515
HEALTH CARE REFORM IN CHINA
Early Communist Period (1950s-1970s)
 Development of rural insurance program
 Training of “Barefoot doctors” to focus on poor, rural peasants
Economic Reform (late 1970s-1990s)
 Fee-for-service replaced barefoot doctors
 Government share of health spending fell from 32% to 15%
Current reform efforts
 Public Health Insurance covers 95% of population: reimburses health care expenditures (up to 70% of
inpatient costs, depending on level of health system accessed)
Eggleston. Asia Health Policy Program Working Paper #28
IMPROVING HEALTH SYSTEMS: LIST
Leadership
 Train people with strategic vision, technical knowledge, political skills, and ethical orientation
Institutions
 Ministry of Health: should be sensitive to local realities but have level of technical proficiency
Systems Design
 Timely conjunction of human, financial, technological, and knowledge resources
Technologies
 Appropriate interventions
 Expanding supply of drugs, vaccines, bed nets, etc.
Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089
HEALTH SYSTEM CHALLENGES
How to cope with an aging population
Quality of governance
Number, quality, and distribution of health care personnel
Mobilization of sufficient financial resources for the health sector
How to provide health care at an appropriate level of quality
How to ensure access to and equitable provision of services
Creation of mechanisms to provide poor with protection from the costs of health
services
Skolnik. Global Health 101.
QUESTION OF THE DAY
As developing countries build up their health infrastructure, what developed country
should they look to as a model for health care?