population health and primary health care action vivian lin director, health sector development...

POPULATION HEALTH AND

PRIMARY HEALTH CARE

ACTION

Vivian LinDirector, Health Sector DevelopmentWorld Health Organization (Western Pacific Regional Office)

2 Universal Health Coverage

Providing an international perspective

• From PHC to UHC

• Post 2-15 Development Agenda and Universal health coverage (UHC)

• Reviewing Community-oriented Primary Care

• Population health planning for primary health care

• Moving to integrated, partnership-based approach

• Conclusion

3 Universal Health Coverage3

PHC–based health system

• an overarching approach to the organization and operation of the health system

• makes the right to the highest attainable level of health its main goal

• maximizes equity and solidarity


PHC–based health system

• Composed of a core set elements that guarantee universal access to services that are:– acceptable to the population – equity-enhancing

• Provides comprehensive, integrated, and appropriate care over time

• Emphasizes prevention and promotion, and assures first contact care

• Families and communities are its basis for planning and action


Experience says PHC works International evidence suggests that health

systems based on strong PHC orientation– have better and more equitable health outcomes

– are more efficient

– have lower costs

– achieve higher user satisfaction

than health systems with only weak PHC


PHC transformed into UHC?

• 2008 World Health Report – renewal of primary health care – need for health systems to respond better and faster to changing health challenges

• 2010 World Health Report – health financing – to achieve universal health coverage and improve population health outcomes


THE POST-2015 DEVELOPMENT AGENDA• High-level Eminent Persons Panel pillars for

development – leave no one behind, inclusive growth, sustainable development, good governance, quality of life

• Health related aspects:– Complete MDGs

– NCDs

– UHC


• Access to good quality of needed services

– Prevention, promotion, treatment, rehabilitation and palliative care

• Financial protection

– No one faces financial hardship or impoverishment by paying for the needed services.

• Equity

– Everyone, universality

What is Universal Health Coverage (UHC)?

Three Dimensions of UHCThree Dimensions of UHC


UHC contributes to good health and beyond…

• UHC improves or maintains health through coverage for needed services.

• UHC contributes to poverty reduction.

– Good health enables adults to earn income and children to learn, giving them more opportunities to escape from poverty.

• UHC is a vehicle to build social solidarity, national pride and trust in the government.

• UHC offers a way of sustaining gains and protecting investments in the current set of health-related MDGs.

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UHC – core to WHO work

• UHC in WHO’s history

WHO's constitution (1948) Alma-Ata Declaration (1978) WHR on Primary Health

Care (2008) WHR on Health Systems

Financing-The Path to Universal Coverage (2010)

Rio Declaration on SDH (2011)

UN High-level Meeting on NCDs (2011)

• Post-2015 Agenda

– All countries (rich or poor) can make progress

– Offers a way of sustaining gains and protecting investments of health-related MDGs

– Accommodates the changing agenda for global health and other internationally agreed health goals, such as NCDs

– Concerns health equity and the right to health

• Independent of post 2015 agenda, UHC remains core to WHO work

Universal Health Coverage (UHC)

Affordability Accessibility

Acceptability Availability

High quality people-centered and integrated interventions

Financial protection

Equity

ServicesQuality

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COMMUNITY-ORIENTED PRIMARY CARE AT THE COREKEY PRINCIPLES

• Use epidemiological and clinical skills

• Address determinants and consequences of health and illness

• Concern with environment/ family/ individual; with health services and behaviors

IDEAL FEATURES• Population - identified community

• Governance - allow community involvement

• Information - facilitate planning and evaluation

• Funding - incentives for cost-effective services

• Workforce - team-based, combine public health and clinical medicine skills

• Service - comprehensive, coordinated, consumer focused

COPC= Partnership between Population Health and Clinical ServicesTarget Type of Function (1)

Primary Secondary Tertiary

Generalised - population Pop Health Pop Health Pop Health

Generalised - individuals PH/ClinicalMed PH/CM PH/CM

Selective ? PH/CM PH/CM

Indicated PH/CM PH/CM Clinical Medicine

Source: Starfield (1996:1368)

PH = Public Health; CM = Clinical Medical Care

(1) Primary = intervention to prevent a problem from occurring; Secondary = intervention at a stage before a problem is manifested;

Tertiary = remediation to reverse manifestations of problem

INTERVENTIONS BY FUNCTION AND TARGET GROUP

Type of Function (1)Target

Primary Secondary Tertiary

Generalised -population

Environmentalplanning

Product safetymonitoring

Legal redress orsocial welfare

Generalised -individuals

Health education,immunisation

Breast andcervical cancerscreening

Surveillancesystems

Selective(population riskfactors)

?geneticengineering

Blood leadscreening

Home visiting

Indicated (knownpredisposition)

Prophylacticantibiotics

Follow-up afterdisease

Qualityassessment ofclinical services

Source: Adapted from Starfield (1998:328)

(1) Primary = intervention to prevent a problem from occurring; Secondary = intervention at a stage before a

problem is manifested; Tertiary = remediation to reverse manifestations of problem

A partnership-based PHC system

Clinical Care

Clinical Care

Communicable Disease Control

Dietary Advice

Environmental Health

Community Nutrition

Counselling

Mental Health

Promotion

Child HealthEarly

Childhood Development

Social Work

Community Development

Community Nursing

Home Support


HEALTH NEEDS – Central to population health planning and prevention

• Groups! – health is not randomly distributed

• People live, work and play in context – demographic, social, economic, cultural factors matter

• Objective measures + subjective status – perceptions are realities

• Health hazards and risks – present and future

• Relativities - comparison with peer communities/population groups


PLANNING FOR POPULATION HEALTH

• Starting points:– Health: diseases and conditions (eg diabetes, cancer,

mental health), risk factors (eg alcohol, tobacco, physical inactivity), protective factors (eg social support)

– People: children, older people, ATSI, CALD communities, homeless

– Places and settings: localities, schools, workplaces

• Outcomes: health improvement; disease prevention; health maintenance; quality of life

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CONTRASTING MODELS OF HEALTH PLANNING

Population-based

1. Select health issue

2. identify risks

3. evaluate population risk level

4. compared need with current program

5. adjust resources

6. evaluate

Institution-based

1. Select health service

2. determine current demand

3. forecast future demand

4. compare demand with current capacity

5. adjust resources

6. evaluate


NEEDS ASSESSMENT

Stakeholder consultatio

n

Analyse information and confirm key issues

Collect quantitative

data

Analyse problem and

review evidence

Determine strategic

issues and missing

information

Collect qualitative

data

LIFE COURSE

Health promotion

Disease prevention

Early detection and intervention

Episodic and acute care

Sub-acute care and rehabilitation

Long term care

Palliative and terminal care

children

youth

Young adult

Middle aged

Older adults

A PLANNING TAXONOMY

Population Health Model

Care Coordinated

Self-managed

At Risk Population

Well Population


POPULATION HEALTH AND THE CARE CONTINUUM

Well Population

At Risk

Living with controlled

chronic disease

Uncontrolled chronic disease

• Community -based programs

• Primary prevention

• Screening • Early

intervention

• Secondary prevention

• Self-management

• Continuing care

• Case- coordination

• Complications management

Tertiary prevention &Disease management


UTLISATION AND SERVICE SYSTEMS – understanding from population perspective

• Diverse patient journeys

• Falling through the cracks

• Parallel primary care systems

• Financial, cultural, psychological barriers to care seeking

• Level of health literacy


Social Determinants of Health


DEVELOPING STRATEGIES AND SELECTING INTERVENTIONS

• Ottawa Charter a useful checklist:

– Healthy public policy

– Supportive environment

– Community action

– Personal skills

– Health services

• Review evidence and consider applicability, gaps in current system, and scale needed to effect change (population strategy vs individual strategy)

• Weigh up options using multiple criteria, ensuring acceptability, feasibility, and cost-effectiveness (or return on investment) are considered

• Use multi-voting amongst stakeholders

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Essential Packages of Services - MCH

Promotion of healthy lifestyle (alcohol, diet, smoking, physical activity, etc.)

Promoting breastfeeding

Antenatal care

Safe delivery

Postpartum care

Management of childhood illnessVitamin A,

micronutrients

Deworming

Immunization

Insecticide-treated nets and indoor residual spraying

Improved sanitation, Better nutrition and food access, and Health protection

Housing, Education, Employment, Early childhood development,Empowerment of women and gender equity

Pre-pregnancy Pregnancy Birth Postnatal Neonatal Infancy Childhood

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Address service coverage gapsPre-pregnancy Pregnancy Birth Postnatal Neonatal Infancy Childhood

100

80

60

50

40

20

0

G

A

P

GAP


PARTNERSHIPS – Coordinated service delivery and action on social determinants of health

• Health services

• Social services

• Local government

• Community and consumer/patient organisations

• Private sector

• Frontline staff


Need for Integrated/Coordinated Service Delivery

• People experience multiplicity of issues - multiple determinants have multiple outcomes, and clustered in localities and populations

• Shared interests and objectives at service delivery level (operational/informational needs, common clients and partners)

• Co-benefits across service providers and sectors


Possible approaches for coordination and integration • Clustering of health issues

• Linking of service providers

• Settings as basis for intervention

• Population groups as frame of reference

• Clinical care and public health partnership

Organisational Shifts (Marquardt)Dimensions Bureaucratic Network

Structure Hierarchical Teams andalliances

Managementstyle

Command andcontrol

Participative

Culture Compliance Outcomes

Boundaries Fixed Permeable

Focus Institution Client


GOVERNANCE – Managing the networks and the course of events• Participation ladder: information – consultation –

collaboration – ownership

• Who participates – advisory or decision-making? Who decides in the first place? Accountability to whom? And how?

• Successful partnerships – safe environment, clear decision-making procedures, focus on joint priorities, win-win, draw on complementarities, share the credit

CONCLUSION: THE UHC/PHC IDEAL

population health and primary health care action vivian lin director, health sector development...

Documents

good health

health challenges

universal health coverage

universal health coverage

health systems financing

population health outcomes

phcbased health system

current set of health