1. POPULATION HEALTH AND PRIMARY HEALTH CARE ACTION
Vivian Lin
Director, Health Sector Development
World Health Organization (Western Pacific Regional Office)
Professor Akira Ogawa, colleagues, ladies and gentlemen:
I am pleased to be in this beautiful campus to share with you WHO’s work in health. I would like to take this opportunity to thank Professor Ogawa for the invitation. I appreciate this special arrangement to deliver this lecture.

2. 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. 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

4. 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

5. 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

6. 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

7. 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

8. What is Universal Health Coverage (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

9. Three Dimensions of UHC

10. 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.

11. 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

12. Universal Health Coverage (UHC)
High quality people-centered and integrated interventions
Affordability
Accessibility
Acceptability
Availability
Financial protection
Equity
Quality
Services

13. COMMUNITY-ORIENTED PRIMARY CARE AT THE CORE
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
KEY PRINCIPLES
Use epidemiological and clinical skills
Address determinants and consequences of health and illness
Concern with environment/ family/ individual; with health services and behaviors

14. COPC= Partnership between Population Health and Clinical Services

15. INTERVENTIONS BY FUNCTION AND TARGET GROUP

16. A partnership-based PHC system
Community Nutrition
Environmental Health
Dietary Advice
Mental Health Promotion
Communicable Disease Control
Counselling
Clinical Care
Child Health
Early Childhood Development
Social Work
Community Nursing
Community Development
Home Support

17. 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

18. 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

19. 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

20. NEEDS ASSESSMENT Stakeholder consultation
Analyse information and confirm key issues
Collect quantitative data
Analyse problem and review evidence
Determine strategic issues and missing information
Collect qualitative data

21. A PLANNING TAXONOMY 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

22. Population Health Model
Care Coordinated
Self-managed
At Risk Population
Well Population

23. POPULATION HEALTH AND THE CARE CONTINUUM
Living with controlled chronic disease
Uncontrolled chronic disease
Well Population
At Risk
Community -based programs
Primary prevention
Screening
Early intervention
Secondary prevention
Self- management
Continuing care
Case- coordination
Complications management
Tertiary prevention & Disease management

24. Diverse patient journeys Falling through the cracks
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

25. Social Determinants of Health

26. 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

27. Essential Packages of Services - MCH
Pre-pregnancy  Pregnancy  Birth  Postnatal  Neonatal  Infancy  Childhood
Promoting breastfeeding
Promotion of healthy lifestyle (alcohol, diet, smoking, physical activity, etc.)
Antenatal
care
Safe
delivery
Postpartum
care
Management of childhood illness
Vitamin 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 27 27

28. Address service coverage gaps
Pre-pregnancy  Pregnancy  Birth  Postnatal  Neonatal  Infancy  Childhood
100 80 60 50 40 20
GAP
GAP
Improving maternal and child health requires coverage of high impact interventions all along the continuum of care. The Countdown to 2015 is an international initiative that advocates for and monitors coverage of effective interventions to reduce maternal and child mortality. Their latest report shows these coverage levels in the 68 high mortality countries monitored by the Countdown. Rates vary from a high for immunization to very low for newer interventions (insecticide treated bednets) and for those that depend on curative services (for diarrhoea, pneumonia, and malaria) and 24 hr. access to care (providing emergency child birth services such as cesarean sections).
Improved linkages are needed among the different components of care, often delivered by the same workers or through the same delivery channel. Many services can be delivered by workers selected and supported by the community. 28

29. Community and consumer/patient organisations
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

30. 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

31. 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

32. Organisational Shifts (Marquardt)

33. 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

34. CONCLUSION: THE UHC/PHC IDEAL