Expanding Primary Health Care

1. Expanding Primary Health Care Sam Adjei NHIA 10th Anniversary Conference

2. 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

3. 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

4. Definition and global commitment

5. Many definitions of PHC – here is the JLN’s 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 “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” 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.  First-contactaccess 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.

6. Global commitments to PHC repeated over time, but not realized in practice   1978 1986 2008   Countries still continue to struggle with issues of organizational structures, demand, and financing of primary health care

7. Ghana experience • Goals, organization

8. Goal, objectives and strategies of Ghana PHC • Goal: • Maximise total life of Ghanaians • Objectives: 1) Achieve basic and primary health care for 80 of people 2) Effectively attack the diseases problems that contribute 80 of morbidity and mortality • Strategies: • Improve accessibility-coverage of services • Improve quality of PHC • Improve and strengthen management capacity to support to the primary level

9. Organization of care POLICY - MOH AND GHS TERTIARY CARE Policy -MOH GHS NATIONAL SECONDARY CARE -REGIONAL HOSPITALS STRATEGY TRANSLATION -RHMT REGIONAL LEVEL 1ST REFERAL HOSPITAL PRIMARY HEALTH CARE DISTRICT LEVEL

10. District level organization 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.

11. 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

12. Ref Community Health Care District Hospitals District Health Management Team M&L Ref Sub-district health management team Planning, M&E Health Centres Ref Clinical Determinants Track Social Determinants Track CHPS Compound Service & Surveillance CHO Trad. Healers Ref Com. Dev. Officers CM TBA CP Prayer Camps Env. & Sanit. Officers C H Vs CHWS

13. Services/priority interventions

14. 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;

15. 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

16. Expressed Needs for Services at the Community level

17. Comparison of disease problems Top 10 conditions- 1977 Top 10 conditions-2003 Malaria Anemia Pneumonia Stroke Typhoid Fever Diarrhea HPTN Hepatitis Meningitis Sepsis • Malaria • Prematurity • Measles • Birth Injury • Sickle Cell Disease • Child pneumonia • Malnutrition • Dysentry • Neonatal tetanus • Accidents

18. Financing

19. Trends in resource allocation

20. Where is the money coming from

21. 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

22. Performance measurements

23. 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

24. 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

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 DEBRIEFING INDEPENDENT REVIEW TEAM

26. Challenges and way forward

27. 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

28. 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

29. Moving forwards-2ICT potential • Mobile Technology for Community Health (MoTeCH) • E-Blood Bank an electronic (web-based) blood tracking system • Community-based electronic registration System for EPI • DHIMS2 • E-Claim

30. 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.