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

1. The Renewal of Primary Health Care (PHC) in the Americas Pan American Health Organization (PAHO) World Health Organization (WHO)

2. Alma Ata 1978

3. WIDENING DISPARITIES RISING EXCLUSION GLOBALIZATION & New Economic Order DEMOCRATIZATION & decentralization Economic & State Reforms Health Sector Reforms Welfare State & Social Security Crisis MDG HFA 2000 1975 1990 2015 DEMOGRAPHIC TRANSITION: population growth, urbanization, population ageing EPIDEMIOLOGIC POLARIZATION:opposite risk & disease profiles coexisting ENVIRONMENTAL & ECOLOGICoverburdening impact 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

4. Primary Health CareAlma Ata Declaration “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”

5. The Journey of Primary Health Care Renewal in the Americas • Why renew? • Context • Initial stages • Road ahead

6. Why Renew? • Inequity • Persisting ill health • Overburdened health systems • Health and the development agenda

7. Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care • Clinical Appropriateness • and Need • Patient Preferences Non-Minority The Operation of Healthcare Systems and the Legal and Regulatory Climate Difference Quality of Health Care Minority Disparity Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Populations with Equal Access to Health Care Source: USA. IOM 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare.

8. Persisting ill health

9. Persisting ill health • Major Challenges Remain: • Communicable diseases (HIV/AIDS, Malaria, TB), • Chronic Non-communicable conditions (Obesity, Hypertension, Diabetes, Cancer), • Increased consumption of alcohol, tobacco and illegal drugs, • Accidents and Violence.

10. …. Emerging challenges • Population aging • Changes in lifestyle • Urbanization • Information revolution • Deterioration of social structures and support systems • Climate change & natural disasters • Environmental degradation

11. Challenges Faced by the Health SystemsOverburdened health systems • Institutional and Organizational Segmentation • Fragmentation • Weak Steering Role

12. Health Systems: New Challenges • Universal Coverage and Equitable Access • People Centered Health Services • Inclusive leadership and effective government • Health in All Policies (HiAP)

13. Health and the development agenda • Health, for its social, economic and political implications, is a developmental issue. • MDG’s ► agreed-upon development goals that: • Addresses the unfinished agenda/new challenges • Gives a new sense of urgency • A framework that transcends all sectors and addresses the social determinants of health • Health, Education and Environment as key areas for prime investments for poverty reduction and human development • Considers the PHC strategy as crucial to achieving the goals

14. PHC and sustainable human development Other developmental strategies PHC Sustainable human development Health system Health services 1st level of care Person, Family & Community

15. KEY MESSAGE Health is a social, economic and political issue and, above all, a fundamental right. Inequality, poverty, exploitation, violence, and injustice are at the root of ill-health and the death of poor and marginalized people. Approaches to improving health must address multiple health determinants in an integrated fashion.

16. The Journey of Primary Health Care Renewal in the Americas • Why renew? • Context • Initial stages • Road ahead

17. Context Progress – still persistent and growing inequalities • Maternal mortality, malnutrition, HIV/AIDS, TB • Gaps in life expectancy between the richest and the poorest, rural and urban, ethnic minorities (as much as nearly 30 years in some countries)

18. The benefits of PHC • Improved health outcomes at the population level • Improved equity in health outcomes and access to health services • Better efficiency of the health system as a whole, less costs (and out of pocket expenditure) • More satisfaction of users with health services

19. 10000 PYLL Low PC Countries 5000 High PC Countries PYLL=Potential Years of Life Lost (Measure of premature mortality) 0 1970 1980 1990 2000 Lost Premature Mortality and PHC Performance In 18 OECD Countries, 1970-1998 PHC’s Impact on Population Health • PHC was a significant contributor to improved population health in OECD countries Macinko et al., 2003

20. Infant Mortality Rate Infant Death Rate (per 1,000 Live Births) by Month and Year in Municipalities Participating in the Community Health Agents Program Ceará, Brazil, 1993-1998 PHC’s Impact on Population Health • The Community Health Agents program in Ceara (Brazil) was found to decrease infant mortality rates Svitone et al., 2004

21. –– With reform ++ Without reform For every 5 additional years after PHC reform, child mortality was reduced by 13% Trends in Under-5 Mortality in Districts With and Without PHC Reform Costa Rica, 1985-2001 PHC’s 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

22. Hospitals Uruguay PHC Trinidad Hospital Care spending is more pro-rich All Nicaragua Jamaica Honduras Guyana Public spending on health going to the poorest 20% Public spending on health going to the richest 20% Ecuador Costa Rica Columbia Chile Brazil Argentina -1 0 1 2 3 4 5 PHC’s 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

23. Stronger PHC UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR Weaker PHC Health Systems with Strong PHC Are More Efficient Starfield & Shi, 2002

24. 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

25. KEY MESSAGE A review of experiences over the past quarter-century shows that PHC has been interpreted and implemented in varying manners in the Americas, incorporating different points of view, being operationalized in different ways, and embracing diversity. Today, PHC is considered a regional priority and is widely viewed as a cornerstone of national and regional strategies to achieve equity and equitable gains in health and human development.

26. The Journey of Primary Health Care Renewal in the Americas • Why renew? • Context • Process • Road ahead

27. Initial Stages • 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

28. Regional Declaration on the New Orientations for Primary Health Care (MONTEVIDEO-2005) • Countries committed to: • Facilitate social inclusion and equity in health • Promote PHC-based health systems • Re-orient to health promotion and comprehensive and integrated care • Foster intersectoral action • Orientation toward quality of care and patient safety • Strengthening of human resources in health • 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.

29. Main Approaches to PHC *Adapted from Vuori, 1984

30. PRIMARY HEALTH CARE: THE STRATEGY • Strategy for Organizing Health Systems • First level of care, integrated and comprehensive, community participation, intersectorial coordination • Philosophy permeating health and social sectors • Health as a human right, addresses broader social and political determinants of health

31. PHC: A renewed definition • Health systems as a whole • Highlights Equity and Solidarity • Human rights approach • Discards the notion of PHC as: • Defined set of services or level of complexity • Defined types of health personnel • Poor health for poor people in poor countries • Guides the transformation of Health Systems to achieve goals • Introduces functional and organizational elements than can be measured and evaluated • Is not just the provision of health services but encompasses all health systems functions and other social processes

32. What is a PHC-based Health System? • …an overarching approach to the organization and operation of health systems that makes de right to the highest attainable level of health its main goal while maximizing equity and solidarity. • PAHO, 2005.

33. Provide the bases for health policies, legislation, evaluation, and resource generation and allocation Framework Social Values: Provide a moral anchor for policies and programs enacted in the public interest Structural and functional basis What is a PHC-based Health System? Elements Values Principles

34. 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 Government accountability Equity 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

35. The Journey of Primary Health Care Renewal in the Americas • Why renew? • Context • Process • Road ahead

36. 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

37. Learning from Experiences Making it work • Challenges to effective PHC implementation • Enabling factors to effective PHC implementation

38. Effecting PHC Renewal PHC based health systems • PHC competencies for personnel • Methods for eliminating fragmentation of health services – Integrated Health Services Delivery Networks • Building the evidence on best practices of PHC in the Americas • Accreditation and performance evaluation systems for primary care • Mainstreaming PHC across programs • Essential Public Health Functions and PHC

39. Health for all… How? • The proposed mechanism for PHC renewal is the transformation of health systems so that they incorporate the PHC strategy as their basis.

40. Renewing PHC through 4 areas for reform PARTICIPATION

41. Universal coverage reforms Addressing the equity agenda • Moving towards universal coverage is the core of the reform: Ensure availability + Eliminate barriers to access + Organize social protection • But that is not enough: • mobilize beyond the health sector • give visibility to inequalities • reach the unreached

42. Three ways of moving towards universal coverage

43. Service delivery reforms Shifting to equitable, comprehensive and integrated care • Putting people first: four features of good care • Person-centeredness • Comprehensiveness and integration • Continuity of care • A personal relationship with well-identified, regular and trusted providers • Organizing primary care networks accordingly • Shifting the entry point: bringing care closer to the people • Shifting accountability: responsibility for a well-identified population • Shifting power: the primary care team as the hub of coordination

44. Trust and rights: Explicit entitlements User voice Beyond minimum packages Key features: Effectiveness Safety Comprehensiveness and integration Person-centeredness Continuity (in synchrony with human life cycle) Organizational frameworks(moving away & beyond levels of care): Entry point through close-to-client networks of primary care teams / districts A personal relation between services and users Explicit responsibility for all members for a defined population Coordinate/mobilize inputs from other levels of care (and from social services) Transform conventional health care delivery models into people-centred primary care networks

45. Transform conventional health care delivery models into people-centred primary care networks • Desired straight through changes do not happen automatically (because of strong supply side distortions) • Avoiding current diversionary trends has implications for health programs - different profiles, changed behavior etc.

46. Public policy reforms Health in All Policies (HiAP) • Health systems (e.g. health workforce – education, work conditions, retention; essential medicines – R&D, manufacture, procure, supply chains) • Public health (e.g. iodine fortification, tobacco taxation/advertising) • Cross-government (e.g. employment, housing, nutrition, trade, urban development)

47. Leadership reforms Inclusive leadership and effective government • Recognition of the key role & responsibilities of government • Inclusive leadership and policy dialogue: from command-and-control to steer-and-negotiate • Matching growth in health expenditure with massive reinvestment in capacity for leading and governing the health sector

48. Remember, PHC… …is NOT about …. (poor) care for poor people in poor countries …BUT It is about …. putting people at the centre of health & development in the whole world

49. Remember: The Key Actors

50. A Call To Action! • “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