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Squaring

Squaring. Prescribed Minimum Benefits and Primary Care. the Circle. Session: address the necessity to review the PMB’s to include primary care Address specifically the ‘norms and standards’ within the district health system Examine basic packages which prevail in other countries

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Squaring

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  1. Squaring Prescribed Minimum Benefits and Primary Care the Circle • Session: address the necessity to review the PMB’s to include primary care • Address specifically the ‘norms and standards’ within the district health system • Examine basic packages which prevail in other countries • By Professor Shan Naidoo • Adjunct Professor and Chief Specialist • School of Public Health • University of the Witwatersrand The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  2. Squaring This Analysis from a Public Health vantagepoint. the Circle • The value of a public health approach: • Addresses all levels of prevention, treatment and rehabilitation • It promotes the individuals welfare by fostering healthy, strong and safe families, communities and workplaces • It views the individual within a social milieu and explores the influence of cultural, family, and community values on behaviour. • It also looks at organizational and political behaviour • It examines public policy (e.g. On income, education, health care and employment) • It views behaviour along a health related continuum (health enhancing to illness producing) • It also emphasises an integrated approach and a systems view • It addresses opportunities as well as constraints • The public health perspective allows for a comprehensive analysis of the biological, behavioural, social and economic determinants of health and ill health • It also leads to multiple strategies and points of intervention! The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  3. What is Public Health • Public Health is the process of mobilizing local, state, national and international resources to ensure the conditions in which people can be healthy.(Oxford Textbook of Public Health) • The Four major public health strategies : • Preventing disease and promoting health • Improving medical care • Promoting health enhancing behaviour, and • Controlling the environment. TheBHFSouthern African Conference22-25 July’07 Sun City

  4. What is Health: • Health is not merely the absence of disease or infirmity but the presence of physical, mental and social well being (WHO, 1974). TheBHFSouthern African Conference22-25 July’07 Sun City

  5. What is Health.. • Health is your adaptive capacity for becoming ‘whole’. • Healing is regaining that adaptive capacity. • Concept of ‘WHOLON’. • Health and Development often used interchangeably. TheBHFSouthern African Conference22-25 July’07 Sun City

  6. What is development: • Improving the quality of life of people, • To uproot poverty, • To promote well-being….. TheBHFSouthern African Conference22-25 July’07 Sun City

  7. Strategies for Development: • Education • Job Creation • Housing • Primary Health Care • Social Welfare TheBHFSouthern African Conference22-25 July’07 Sun City

  8. Introduction to Primary Health Care • The Declaration of Alma Ata: • 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 a spirit of self-reliance and self determination. TheBHFSouthern African Conference22-25 July’07 Sun City

  9. Primary Health care cont… • 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. TheBHFSouthern African Conference22-25 July’07 Sun City

  10. Principles of PHC: • Equity • Community Involvement • Focus on Prevention • Multisectoral Approach • Appropriate Technology. TheBHFSouthern African Conference22-25 July’07 Sun City

  11. The Elements of Primary Health Care Includes at least: • Education concerning prevailing health problems and the methods preventing and controlling them, • Promotion of food supply and proper nutrition, • An adequate supply of safe water and basic sanitation, • Maternal and child health care, including family planning, • Immunisation against major infectious diseases, • Prevention and control of locally endemic diseases, • Appropriate treatment of common diseases and injuries, and • Provision of essential drugs. TheBHFSouthern African Conference22-25 July’07 Sun City

  12. Squaring How to define a basic package of health services? the Circle • How to define a basic package of health services for a tax funded or social insurance based health care system? • Editorial: F.Rutten & J. van Bussbach • Criteria used by countries include the effectiveness and cost-effectiveness of treatments, the necessity of treatment for the individual, the severity of the disease, the collective versus the individual responsibility, and the efficiency of insuring the service. • They argue that what is needed is an ethical framework suggesting criteria and values to be used systematically in priority setting. • They also suggest that more transparency in priority setting in health care will contribute to a wider support in society for the difficult choices in health care which are inevitable! The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  13. Squaring Defining the “ Health Benefit Basket” in nine European Countries the Circle • Evidence from the European Union Health BASKET Project • Original Papers: J.Schreyogg, T.Stargard, M.Velasco-Garrido & R.Busse (Eur J Health Econom Suppl 1, 2005) • This article identifies and analyses the framework for health baskets, the taxonomy of benefit catalogues for curative services, and the criteria for in- or exclusion of benefits in nine EU member states ( Denmark, England, France, Germany, Hungary, Italy, The Netherlands, Poland and Spain). • Note the distinction between benefit basket and benefit catalogue! • Main Findings are that the criteria are often not transparent and are varied. • There may be scope for a European core basket? The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  14. Squaring A Basic Package of Health Services for Afghanistan the Circle • March 2003/1382 • Main purposes are: • 1. To provide a standardised package of basic services which forms the core of service delivery in all primary health care facilities and • 2. To promote a redistribution of health services by providing equitable access, especially in undeserved areas. The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  15. Squaring Contents of the Basic Package of Health Services for Afghanistan the Circle • Maternal and Newborn Health • Antenatal Care, Delivery Care, Postpartum Care, Family Planning, Care of the Newborn • Child Health and Immunizations • EPI services (routine and outreach), IMCI • Public Nutrition • Micronutrient supplementation, treatment of malnutrition • Communicable Diseases • Control of Tuberculosis and Malaria • Mental Health • Community management of mental problems, health facility based treatment of out- and inpatients • Disability • Physiotherapy integrated into PHC services, Orthopaedic services expanded to hospital level • Supply of Essential Drugs The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  16. Squaring Primary health care in Africa the Circle • No real information on Africa re: basket of services. • A comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam • Roger Few, Trudy Harpham & Sarah Atkinson • Health & Place, 2003 • This article compares attempts in two projects – in Zambia and Tanzania – to strengthen urban primary health care in the public sector and make it more inclusive. • Conclusions: similarity in findings. Most positive aspect was gains in capacity building( management training of staff). Also, given improvements in facilities, urban populations were readily prepared to utilise the primary health tier. Community participation in terms of community ownership was less clear. The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  17. Squaring World Health Organisation the Circle • Paucity of work • Emergency and Essential Surgical Care • Surgical Care at the District Hospital • The Integrated Management for Emergency and Essential Surgical Care toolkit • Primary Care in the Driver’s Seat • Essential Health Technologies • Management for Health Services Delivery The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  18. Squaring The Primary Health Care Package for South Africa the Circle • Norms and standards for health clinics • Norms and Standards for Community Based Clinic Initiated Services • Department of Health • Pretoria • March 2000 • All the necessary components of a comprehensive primary care package are described and norms and standards for each component are described The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  19. Squaring The PHC package for South Africa – a set of norms and standards the Circle • A norm is defined as a statistical normative rate of provision or measurable target outcome over a specified period of time e.g. For PHC clinics – the clinic renders comprehensive integrated PHC services using a one stop approach for at least 8 hours a day, five days a week. • A standard is defined as a statement about a desired and acceptable level of health care e.g. Medicines for PHC services – medicines and supplies as per the EDL for PHC. The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  20. Squaring Core norms and standards for PHC Services the Circle • Women’s Reproductive Health • Integrated Management of Childhood Illnesses • Diseases prevented by immunisation • Adolescent and Youth Health • Management of Communicable Diseases • Cholera and Diarrhoeal Disease Control • Dysentery, Helminths • Sexually Transmitted Diseases (STD) • HIV/AIDS • Malaria, Rabies • Tuberculosis, Leprosy • Prevention of Hearing Impairment due to Otitis Media • Rheumatic Fever and Haemolytic streptococcal infection The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  21. Squaring Core norms and standards for PHC services cont.. the Circle • Trauma and Emergency • Oral Health • Mental Health • Victims of Sexual Abuse, Domestic Violence and Gender Violence • Substance abuse • Chronic Diseases and Geriatrics • Diabetes and Hypertension • Rehabilitative Services • Community Level Water and Sanitation • Community Level Home-Based care • DOTS Strategy • Integrated Nutrition Programme • School Health Services • Community Based Rehabilitation The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  22. Critique • Confusion between basic benefit package and disease defined package. • The latter requires a diagnosis! • Argue that we define the basic benefit package as a basket of services that should be provided at PHC level followed by the detail as benefit catalogues perhaps • Current language used needs to be consistent with Primary Health Care philosophy. TheBHFSouthern African Conference22-25 July’07 Sun City

  23. Squaring The District Services Package according to the norms and standards document the Circle • Three important aspects characterise the DHS: • District hospitals are integrated with the PHC clinics and Community Health Centres and they provide a comprehensive package of health care delivery for the full range of medical disorders. • The DHS is embedded in the community it serves and should be integrated with home-based care and the Community Health Worker programme. • The DHS is integrated with community governance structures. It is through this that the tenet of community participation of the PHC approach is realised. • Critique is that it is maybe its again too medical and perhaps too vague. No norms and standards have been defined. The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  24. Squaring International Review of Basic Benefit Packages and a proposal for a South African Benefit the Circle • Discovery Health: 2005 • Definition of a Basic Benefit Package – is a health insurance plan determined and mandated by the government to provide the population with access to equal, basic health care at an affordable cost. • Used 5 categories and 150 variables • Looked at Argentina, Brazil, Chile, Mexico, Netherlands, Australia, Switzerland, USA and Taiwan The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  25. Squaring Consultative Investigation into Low Income Medical Schemes the Circle • Final report • 7 April 2007 The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  26. Squaring Establishment of a new prescribed minimum benefit for LIMS Schemes the Circle A. GP Consultations. B. Pathology and radiology investigations ordered by GP - subject to a defined formulary. C. Dental Consultations D. Optometry E. Medicines - based on DOH EDL for primary care suitably supplemented F. Emergency Transport • What about Maternity Care and inpatient care for LIMS members??? The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  27. Squaring Development of an Essential Health Care Package proposal for Medical AID Schemes in South Africa’s transition towards SHI the Circle • Prepared for Board of Healthcare Funders of Southern Africa • February 2007 • Informed by the policies of the NDOH, existing legislation, the Health Charter, scientific literature and work done by the private sector to date. • Draws an important distinction between an essential care package and an insured package: • Essential care packages are public health need and benefit driven whereas insurance is individual patient and disease driven. The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  28. Squaring Development of an Essential Health Care Package proposal for Medical AID Schemes cont. the Circle • An essential healthcare package can be defined as a plan that provides a minimum compulsory set of benefits that all health insurers should cover. • It is a set of basic entitlements to services that must be funded and provided for the benefit of all. • The EHP generally includes a primary care component (focussing on preventative programmes, mother and child care, oral health, etc.) and a hospital component sometimes differentiated by hospital level. • The inclusion and exclusion criteria for developing countries is guided by need firstly and then by cost-effectiveness. (NB principle) The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  29. The process of setting an Essential Health Care Package • Could follow two tracks: • 1. Defining broad categories of services such as consultation, medicine (EDL), pathology, etc. NB in equity. And/or, • 2. Specifying all the diseases, with inclusion and exclusion criteria that must be included on the list of benefits such as the DPT/CDL. Potentially inequitable. • I suggest that we start with 1. but may need to consider 2. if we looking at supplementary insurance? • Compare with EU benefit package and catalogues! TheBHFSouthern African Conference22-25 July’07 Sun City

  30. Squaring What are the recommended benefits? the Circle • Primary Care Benefit GP consultations – exclusions questioned (mental health) Maternity Care Services Pathology and Radiology – Medicross formulary Dental Consultations – dental procedure formulary Optometry – makes reference to LIMS Medicines – hospital level of EDL • Emergency Transport – extremely important! • Hospital Inpatient care Benefit – based on BOD? • Public Sector – unrestricted. 100% UPS fees. • Private Sector – inpatients. Listed conditions. DOH reg. fees! The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  31. Squaring The way forward! the Circle • A substantial amount of good work has already been done – need to use this! • Can use NDOH norms and standards as a basis. • BHF together with the NDOH, Treasury and Civil Society need to finalise this asap. • Challenge is to incorporate more of the PHC principles (equity, multisectoral approach, appropriate technology, focus on prevention) and the Health Charter requirements into the scheme. • Don’t forget the management challenges! The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

  32. Squaring Thank You! the Circle The BHF Southern African Conference 22-25 July’07 Sun City TheBHFSouthern African Conference22-25 July’07 Sun City

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