Health Systems Strengthening, Primary Health Care and · PDF fileHealth Systems Strengthening,...

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WHO Western Pacific Region

Health Systems Strengthening, Primary Health Care

and WHO

Dr Dean ShueyRegional Adviser

Health Services Development

26 January 2010


What is a health system?

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health

World Health Report 2000, WHOEverybody’s Business, WHO, 2007

(Health systems people - don’t own an organ or an organism)

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What is PHC?Declaration of Alma-Ata (1978)

“Health for All”

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 self-relianceand 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 all individuals, the family and the 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 .

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Why are Health Systems Important?

• Different societies spend vastly different amounts on health systems

• Different societies have vastly different health outcomes for the same amount of resources

• Those societies that organize their health systems according to PHC principles tend to get better health outcomes

• Not the only factor – many other determinants of health, but still an important one

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Correlation between expenditure on health and outco mes (2005)

R2 = 0.5886

40.0

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 5,500 6,000 6,500

Total expenditure on health (THE) per capita, US$

Life

exp

ect

ancy

(200

6 da

ta)

(num

ber

of y

ears

)

USA

LUXNOR

JPN

DNK

LKA

CUBISR

AUSNZLSGP

KOR

BRN

NIU

CHN

TUV

PLW

TON

MYS

BWA

ZAF

NRU

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HSS: WHO Framework for Action

Purpose The WHO Framework For Action concentrates on how the WHO secretariat can provide more effective support to Member States in strengthening their health systems to achieve better health outcomes.

http://www.who.int/healthsystems/strategy/everybodys_business.pdf

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4


AccessCoverage

QualitySafety

Goals/outcomes

Responsiveness

Social & financial risk protection

Improved health (level and equity)

Improved efficiency

- Priorities in each - Multiple, dynamic interactions

Service Delivery

System building blocks

Information

Health Financing

Leadership / Governance

Medical products, Technologies

Health Workforce

Health Systems framework with six building blocks

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Health Financing

• Huge variation in spending in the region –absolute and as % of national wealth

• High dependence on out of pocket (OOP)• Catastrophic expenditure as cause of poverty• Rational management of health services unlikely

if financial incentives for both providers and patients are irrational – e.g. pay workers through selling drugs or diagnostic tests, make more money at a training course than at work

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WHO Western Pacific Region5

Composition of health spending - 2001Data estimated unsing average annual exchange rate - Timor Leste not included

Source: NHA Unit, EIP/FER/RER, World Health Organization

0%

20%

40%

60%

80%

100%

AFR AMR -USA

EMR EUR SEAR WPR OCDE- USA

USA

Other private expenditure

Out-of-pocket spendingPrivate health insurance

Social health insurance

Taxes

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150 million people suffer financial catastrophe and 100 million people are pushed into poverty annually

due to health spending- WPR has the biggest problem

- 30,000 60,000 90,000

WPR

AMR

SEA

EUR

AFR

EMR

Number of people (1,000)

impoverishment

catastrophic

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Human Resources for Health

• Low-quality and sometimes costly health professional education

• High rural-urban and international migration of health professionals (low retention)

• Inefficient cadre mix and distribution – the health workers do not match the burden of disease in type, number, or location

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Human Resources - Health Workers Save Lives!

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5

Density (workers per 1,000, log)

Mor

talit

y (p

er 1

,000

, log

)

Maternal

Infant

Under-5

Anand and Barnighausen, 2004 13


Maldistribution

Health Care Worker Density vs. Burden of Disease

WHO regions

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30 35 40 45

% of global workforce

% o

f glo

bal b

urde

n of

dis

ease

Africa

South-East Asia

Eastern Mediterranean

Western Pacific

Europe Americas

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Information & Research

• Inadequate analysis/use of existing information and evidence

• Fragmentation and duplication • Not sufficient use of modern technologies • Research agenda not reflecting the

specific needs of the Region

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Medical Products, Vaccines and Technology

• Poor quality, counterfeits and fakes (majority of drugs in some countries), poor procurement and supply

• Irrational use of drugs and technology• Inefficient and poor quality and

management of laboratory services• High levels of obsolete, inappropriate and

non-functional medical technology 16

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Health Service Delivery

• Inequitable access and utilization • Inadequate planning and management• Fragmentation• Low quality• Incentives do not encourage rational

service delivery

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Leadership and Governance

• Role of state not well articulated and sometimes not accepted

• Weak accountability and regulatory capacity

• Unclear role of the state in the health sector

• Limited planning and management capacity• Inefficient aid coordination leading to

inefficient and fragmented assistance18

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Overseas Development Assistance in Health (Health ODA)

Just one aspect of health – most important in low income countries

Fragmented cooperation an obstacle to good results

Good intention do not always yield the best results

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Significant increase in funding for health – good news

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Varied Donors – New Donors –Good news

• USA $ 3.636 billion • Japan $ 1.156 billion• Gates Foundation $ 0.895 billion• UK $ 0.729 billion• Germany $ 0.593 billion• France $ 0.394 billion• Canada $ 0.318 billionA good thing, but a hint of problems

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Donor proliferation and aid fragmentation

Source: Kaul and Conceicao (2006).

Number of official donors > Number of recipient countries Number of financing mechanism is even greater

Gates bigger than all but two bilaterals

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New foundations: from 2000…


Figure 5

MOH MOEC

MOF

PMO

PRIVATE SECTORCIVIL SOCIETYLOCAL GOVT

NACP

CTUCCAIDS

INT NGOs

PEPFAR

Norad

CIDA

RNE

GTZ

SidaWB

UNICEF

UNAIDSWHO

CF

GFATM

USAID

NCTPNCTP

HSSPHSSP

GFCCPGFCCPDAC

CCM

T-MAP

3 by 5

SWAPSWAP

UNTG

PRSPPRSP

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WHO Western Pacific RegionIs this “let a thousand flowers blossom”?

WHO Western Pacific Regionor a piece of abstract art?

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• Paris declaration (with Accra follow-up) – a pledge by both donors and recipients for better behaviour– Country ownership, alignment, harmonization,

managing of results, mutual accountability• Sector-wide approaches coordinating domestic

and donor support • More adherence to national planning

processes• A renewal of Primary Health Care and its

values

Global Response

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WHR 2008http://www.who.int/whr/2008/en/

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World Health Report 2008 Organized around 4 areas of reform

LEADERSHIP REFORMS

PUBLIC POLICY

REFORMS

to make health authorities more

reliable

to promote and protect the health of communities

SERVICE DELIVERY REFORMS

UNIVERSAL COVERAGE REFORMS

to improve health equity

to make health systems people-

centred

With goals of: better health, less disease, greater equity, and better performing health systems.

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Ongoing Work of WPRO

• Development of Regional Strategy on PHC and HSS

• Sub-sectoral strategy development and implementation

• Country support– Op trials PHC/MCH emphasis – PNG, LAO, CAM – Public private partnership - PNG, Malaysia– National Health Planning (multiple countries)– Aid effectiveness/Donor coordination/SWAps– Global Health Initiative support – synergies– Quality assurance/Patient Safety

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Fragmentation:High Income Countries Also

Better results at lower cost if organize health services along PHC principles, e.g.– Specialist-generalist/PHC mix appropriate– Health care teams – ‘medical homes’ –– Logical referral patterns – Incentives for health (prevention, promotion)– Universal access with pre-payment, risk

pooling– Patient centred systems – not physician

centred 33


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Websites for Documents

Everybody’s Business….http://www.wpro.who.int/sites/hsd/documents/Everybo dys+Business.htm

Regional Strategies of WPRO/WHO.... http://www.wpro.who.int/sites/dhs/

MAKER – (website with management related documents)…..http://www.who.int/entity/management/en/

Disease Control Priorities in Developing Countries …..http://www.dcp2.org/page/main/Home.html

WHO | Primary health care ….www.who.int/topics/primary_health_care/en/

WHO | Health systems strengthening based on primary health care... www.who.int/healthsystems/en/

WHO Toolkit for Monitoring Health Systems Strengthe ning (Indicators…http://www.who.int/healthinfo/statistics/toolkit_h ss/en/

Paris Declaration on Aid Effectivenesshttp://www.oecd.org/dataoecd/11/41/34428351.pdf

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