PRIMARY HEALTH CARE REFORM FOR 21ST CENTURY IN SOUTH ASIAN REGION

1. PRIMARY HEALTH CARE REFORM FOR 21ST CENTURYIN SOUTH ASIAN REGION Sujan B. Marahatta M. Sc (Tropical Medicine) Dip in Int�l Health PhD WHO/TDR-Fellow Assistant Professor KUSMS/Kathmandu University

2. ESSENCE OF HEALTH SYSTEM Lives of the vast numbers of people lie in the hands of health system From safe delivery of a healthy baby to the care with dignity of the frail elderly, health systems have a vital and continuing responsibility to people throughout the life span. Health system is crucial to the healthy development of individuals, families and societies everywhere.

3. What is health system? Health system is defined as comprising all the organizations, institutions and resources that are devoted to produce health actions whose primary purpose is to promote, restore or maintain health. Improving health is the primary objective of the health system, it is not the only one. Objective of Health system is two fold: best attainable average level-GOODNESS and smallest feasible difference among individuals and group-FAIRNESS.

4. EVOLUTION OF HEALTH SYSTEM Today health system in all countries, rich or poor, play a bigger and more influential role in people�s lives than ever before. Health system of some sort have existed as long as people have tried to protect their health and treat diseases. Traditional practices, often integrated with spiritual counseling and providing both preventive and curative care have existed for thousands of years and often coexist today with modern medicine.

5. Health system have undergone overlapping generations of reforms in the past 100 years including the founding of national health care system and extension of social insurance schemes.

6. The quest for greater efficiency, fairness and responsiveness to the expectation of the people that system serve have brought about three generations of health system reforms in the twentieth century. The first generation saw the founding of national health care systems and extension to middle income nations of social insurance systems in the 1940s and 1950s.

7. By the late 1960s the rising costs of hospital based care, its usage by better off, inaccessibility by the poor and rural population of even the most basic services heralded second generation reforms promoting primary health care as a means of achieving the affordable universal coverage.

8. In 1978 PHC was adopted as the strategy for achieving goal of Health for All by 2000. The promotion of primary health care as a route to achieve affordable universal coverage of the goal �HFA Primary health care became the hub of national health system in many countries, with establishment of primary health care units generally employing mid level health workers. PHC is a blend of activities, approach and level of health care. It had eight elements, known as basic health care, to be conducted on the basis of equity, community involvement, appropriate technology and multisectorial approach.

9. Philosophy of PHC Universality Quality Equity Efficiency Sustainability

10. Five components andvalues of primary health care active community participation, and joint monitoring and control over the content and implementation of primary health care; social relevance, with western medicine complementing local systems; involvement of other sectors, including education, water and sanitation, and agriculture; health service provision and health promotion; use of appropriate and effective technologies.

11. The health system based on primary health care focuses on improving the overall health of the population rather than just the treatment of disease. The original eight primary health care ELEMENTS considered essential were: E: Health Education, L: control of Locally endemic diseases E: Expanded program on immunization M: Maternal and child health care E: provision of Essential drugs N Nutrition T: Treatment of common diseases and injuries and provision of S: Safe water and basic nutrition

12. WHAT IS THE REASON BEHIND FAILURE OF HFA?

13. LACK OF COMMUNITY PARTICIPATION: a result of conviction that the state is responsible for providing the totality of health services. In addition, the civic infrastructure and civic organizations are not well developed. LACK OF INTERSECTORAL COLLABORATION: limited intersectoral cooperation for health development. LACK OR MISUSE OF HUMAN RESOURCES AND MATERIAL RESOURCES. inappropriate human resources policies and planning, leading to imbalances between the number of health professionals in different disciplines and categories and to inequitable geographical distribution. As well, in some countries working conditions of health workers are unsatisfactory, with low salaries, poor living conditions and inadequate career structures. CONCENTRATION ON SOPHISTICATED TECHNOLOGY: Inappropriate use of medical technology and inequitable and insufficient resource allocation, with limited resources for promotive and preventive activities and programmes. MISMANAGEMENT. A major reason was weaknesses of national health systems with respect to policy analysis and formulation, coordination and regulation. Weak managerial capabilities at all levels of care have hindered the effective and efficient implementation of health programmes. Weak management also caused poor organization and delivery of health services at all levels including ineffective referral systems. The weakness of health information systems at central and peripheral levels has resulted in difficulties in collecting and using information to measure performance of health facilities. LACK OF INTER COUNTRY COLLABORATION AND LACK OF OPERATIONAL RESEARCH.

14. Despite its many virtues, a criticism of this route has been that it gave too little attention to people�s DEMAND for health care, and instead concentrated almost exclusively on their perceived NEEDS.

15. WHO states that community participation was one of the tenets of PHC, the movement focused almost exclusively on presumed health care needs of the people and did not emphasize enough attention to their demands. Therefore, the third generation of reforms now underway in many countries is driven by the idea of responding more to demand, assuring access for the poor and emphasizing financing rather than just provision within the public sector.

16. What should be the aims of HCR for 21st century in SEA? Changes in our life brought by urbanization, climate change, globalization, commercialization and information technology Nature of health problem is changing and growing inequalities between and within countries Health system have to meet challenges of the changing needs and reform to meet expectations of the people.

17. Health reform for 21st century aims to achieve HFA through PEOPLE CENTRED CARE, ensuring universal coverage and social protection eventually improving health status and equity Vision of health care reform is: healthier population with good living conditions, healthy living environment, suitable housing, good personal health practices and coping skills affordable health services accessible to all and prevention of illness, injury and prolonging of life.

18. PEOPLE CENTRED CARE

19. CHALLENGES FOR HEALTH CARE IN SOUTH EAST ASIAN REGION 26% global population 30% of the population in SEA are below poverty Faces double burden of disease and effects of climate change

20. MAJOR HEALTH CARE ISSUES 1. HIGH DISEASE BURDEN 2. WEAK & IN EFFICIENT HEALTH SYSTEM. 3. LOW HEALTH EXPENDITURE- PARTICULARLY PUBLIC HEALTH EXPENDITURE

21. 1. HIGH DISEASE BURDEN As of 2004 WHO estimates, SEA accounts for over 29% of the disease burden in terms of DALYS and over 26% of mortality worldwide. 41% of the burden is due to communicable disease, maternal and perinatal conditions and nutritional deficiencies (Group I condition) 45% due to communicable disease (Group II conditions) 14% due to injuries (Group III conditions)

22. Of the estimated deaths in 2004:37% were due to communicable diseases (Group I conditions) 50.4% due to non communicable diseases (Group II conditions) 25% due to injuries (Group III conditions)

23. 2. Weak Health system Weak public health services particularly in health promotion and primary prevention Mismatch of health work force Fragmented health service without referral backup

24. ICEBERG of Health Problems

25. 3. Imbalance in health expenditure Out of pocket constitute major share of health spending in this region. Private expenditure on health as % of total expenditure is about 66.4% as of 2006 and total expenditure as % of GDP is 3.4% (less than minimum of 5% of GDP recommended by WHO) Per capita government expenditure in health is $29 which is less than minimum recommended expenditure i.e $34 Health expenditure is more focused on medical care with less fund in public health programs.

26. REVITALISING PRIMARY HEALTH CARE: NEW NOTION FOR HFA!

27. KEY AREAS TO REVITALIZE PHC Leadership and governance Human resources Multisectoral collaboration Managing financial resources Knowledge generation

28. 1. Leadership and governance Strengthening PHC should be viewed as an integral part of overall development and central to equity and poverty alleviation. A high degree of political commitment is necessary to ensure equitable health care. This could be reflected by adequate and appropriate budgetary for health. The health system building blocks may be seen as effective entry points for non-state (private and non-profit) participation in the PHC effort; the regulatory and facilitatory role of government is important for this. Decentralization of health management (financial and administrative), in a country-specific context, with effective capacity building, should be considered as a part of revitalizing PHC

29. 2 Human resources Capacity building of all stakeholders in PHC at all levels needs re-emphasis, with a focus on first-level and community-level providers. Adequate and well-trained human resources are necessary. The role of CHWs and CHVs in the changed context needs to be revised and redesigned. Innovative ways are needed to reward and motivate CBHWs/CHVs. PHC principles must be integrated in the curricula of educational institutions- medical, nursing, midwifery and public health

30. 3 Multisectoral collaboration  The health sector should play an important, proactive and sensitizing role in effecting intersectoral collaboration. The roles of the other sectors in health should be recognized, monitored and promoted using a common agreed framework and indicators. Avenues for an interface between the public and private (profit and non-profit) sectors need emphasis. Participation of civil society networks should be promoted so that they play an important role in revitalizing PHC. Innovative ways for community empowerment, especially of women, need to be explored and implemented. One way to do this is to give the community a role in monitoring and supervision. Governments should explore setting up an institutional mechanism to foster multisectoral collaboration at all levels; this will also facilitate effective community-based action.

31. 4 Managing financial resources Financial barriers are an important constraint for marginalized populations in accessing care. Government financing through general taxation is the most equitable mechanism to finance health. Social and community health insurance supplement tax-based financing. These are equitable mechanisms to finance health system in line with the PHC approach. Corporate social responsibility as a means to finance community empowerment should be explored. It is essential to effectively allocate, manage and utilize resources across different types of care (preventive, promotive, curative and rehabilitative) and all levels of care as well as sectors (health and health-related)

32. 5 Knowledge generation Health systems research needs to be strengthened to promote effective and efficient functioning of health systems based on PHC. Social determinants are important for equitable health. More research is needed to understand how the health sector can address the social determinants of health. Health impact assessments, as part of healthy public policy, need to be done at regular intervals. Research findings on health systems must be disseminated, and their link to policies and programmes strengthened.

33. KEY CHALLENGES KEY challenges that need to be addressed if we are to achieve health goals in general and health MDG in particular. Misinterpretations of the concept of Primary Health Care Burden of diseases Inequity in health Escalating health-care cost Trade agreements Interdependence of the world Inadequate performance or low efficiency of the health system Need for more research Financing the health system Need for integrated services Public-Private partnership Climate change

34. RECOMMENFATION TO SEAs Reaffirm their political commitment to PHC as an effective approach to address national health needs. Review health financing and expenditure Strengthen human resources and the service delivery system to support PHC Develop a strategy for improving health information systems that can better support setting of priorities and targets Establish mechanisms as well as strengthen capacity for health systems research

35. RECOMMENFATION TO SEAs Empower communities, especially women, to take an active role in ensuring responsiveness and accountability in PHC Strengthen the capacity of ministries of health in governance and stewardship to coordinates all health and health-related sectors and stakeholders Advance PHC by ensuring governance and stewardship which is critical for PHC to reorient the public sector towards PHC

36. Recent initiatives to revitalize PHC in Nepal As a signatory of Alma Ata declaration of 1978, Government of Nepal (GoN) has fully realized the importance of continued adherence to the PHC approaches for the development of coordinated quality health care services for the people living both in rural and urban areas.

37. FOCUS OF GON working to make essential healthcare services available to all people through primary healthcare centers, trying to decentralize health systems management to encourage greater people participation, trying to promote and facilitate public-private/NGO partnerships in the delivery of health services, and making efforts to improve the quality of healthcare through total quality management of human, financial and physical resources.

38. WAY FORWARD To strengthen on-going high priority EHCS and achieve MDGs in accordance with the principles of Primary Health Care, equity and social justice. To redesign health system to make people oriented, efficient and effective through reform in institutional management and health professional education. To ensure availability of good quality services and essential medicines to all at affordable prices. To strengthen public private partnership. To develop performance based planning and budgeting system. To strengthen financial information system including monitoring and feedback. To encourage the implementation of decentralization approaches in health service delivery system. To develop capacity of the health workers and stakeholders involved in health facility operation and management.

39. CONCLUSION Health care reform for the 21st century should aim to achieve health for all through people centered equitable care, ensuring universal coverage and social protection eventually improving health status and health equity. In other word the vision of health care reform is a healthier population with good living and working conditions, healthy living environment, suitable housing, good personal health practices and coping skills, affordable health services accessible to all, and prevention of illness, injury and death.