1. Expanding Primary Health Care Sam Adjei NHIA 10 th Anniversary Conference

2. Outline Introduction Definitions of PHC Global evolution of PHC Goal, objectives and strategies Ghana’s organization of PHC Package of services Financing of services Assessing performance Moving forwards

3. Introduction Evolution of health delivery systems 20yr cycle 1957- Basic health care – Emphasis on infrastructure 1977/78- Health for All based on PHC – Emphasis on rapid expansion of services 1997- Health sector Reforms and SWAP – Health systems strengthnening and MDGs 2015- Post MDG

4. Definition and global commitment

5. Many definitions of PHC – here is the JLN’s Primary care is the level of a health services system that provides entry into the system for all new needs and problems, provides person- focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and coordinates or integrates care, regardless of where the care is delivered and who provides it. Essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination First-contact access for each new need; long-term person-based care (not disease-oriented), comprehensive care for most health needs, and coordinated care when it is sought elsewhere. “The provision of outpatient non-secondary and non- tertiary preventive and curative care, with a particular focus on ensuring the quality delivery of health interventions prioritized by both countries and the global health community against the highest disease burdens”

6. Global commitments to PHC repeated over time, but not realized in practice Alma Ata (WHO members) Recognized PHC as an essential right, and committed governments to launching and sustaining PHC as part of a national health system Haikko Declaration (40 member countries) Reaffirmed Alma Ata 198619782008 Ouagadougou Declaration (All African region members) Reaffirmed Alma Ata Birchwood Declaration (South Africa members) Reaffirmed Alma Ata Americas Region Declaration (All Latin American members) Reaffirmed Alma Ata Countries still continue to struggle with issues of organizational structures, demand, and financing of primary health care

7. Ghana experience Goals, organization

8. Goal, objectives and strategies of Ghana PHC Goal: – Maximise total life of Ghanaians Objectives: 1) Achieve basic and primary health care for 80 of people 2) Effectively attack the diseases problems that contribute 80 of morbidity and mortality Strategies: 1.Improve accessibility-coverage of services 2.Improve quality of PHC 3.Improve and strengthen management capacity to support to the primary level

9. Organization of care NATIONAL Policy -MOH GHS POLICY - MOH AND GHS TERTIARY CARE REGIONAL LEVEL STRATEGY TRANSLATION -RHMT SECONDARY CARE -REGIONAL HOSPITALS DISTRICT LEVEL PRIMARY HEALTH CARE 1 ST REFERAL HOSPITAL

10. District level organization LevelNamePopulationHuman Resources ACommunity200-5000TBA, CFHW, CEDW BSub district5-10,000CHN, MIDWIFE, PA CDistrict175-24,000DHMT-DDHS, DMOH, DPHN, DNTO, DHI The community level was problematic: there was little evidence that their training and deployment effectively affected morbidity and mortality. The MOH therefore took a decision to replace them with trained staff. Hence the Community-based Health Planning and Services-CHPS Initiative which uses CHO.

11. What is CHPS Stands for Community-based Health Planning Services Involves relocating a CHN (CHO) into community with defined population (zone) Works with volunteers Supported by community through CHC Has a set of functions to perform Supervised by sub district team

12. Community Health Care District Health Management Team District Health Management Team Clinical Determinants Track CHO CM TBACP Social Determinants Track CHWS Prayer Camps Trad. Healers Env. & Sanit. Officers Com. Dev. Officers C H Vs CHPS Compound Health Centres District Hospitals Ref M&L Planning, M&E Service & Surveilla nce Sub-district health management team

13. Services/priority interventions

14. Health services-for PHC in 1978 education concerning prevailing health problems and the methods of preventing and controlling promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;

15. Priority interventions-1996 Immunization Reproductive health programs Prevention and control of epidemics Health promotion Micronutrient deficiency control and prevention Management of locally endemic diseases – Malaria, TB, HIV, Oncho, filariasis etc Emergency care for accidents and trauma

16. Most PopularPopularLeast Popular Family Planning CounselingCare for neonates (0-7 days) Road Traffic Accidents (care of victims/casualties) Defaulter tracing and continuing drug replacement Antenatal Care Services on expectant mothers Hypertension Management ARI in ChildrenAntenatal Education in Groups Ulcer Management Immunization and Vaccination Services Dispensing of AntibioticsDispensing Class C Drugs School Health ServicesInsertion and Removal of Family Planning Implants Minor Surgery (eg., Incision and Drainage) Malaria case managementTB TreatmentDiabetes Management Nutrition Advisory Services and Product Distribution HIV/AIDS TreatmentDispensing of approved traditional Medicines Growth MonitoringDelivery Care of Children (1-59 months)Yaws, Elephantiasis, Schistosomiasis Care of Infants (7-28 days)Injuries and Poisoning Diarrheal Disease ManagementObesity Management Distribution of contraceptive pills and condoms Post-delivery care of Mothers Expressed Needs for Services at the Community level

17. Comparison of disease problems Top 10 conditions- 1977 Malaria Prematurity Measles Birth Injury Sickle Cell Disease Child pneumonia Malnutrition Dysentry Neonatal tetanus Accidents Top 10 conditions-2003 Malaria Anemia Pneumonia Stroke Typhoid Fever Diarrhea HPTN Hepatitis Meningitis Sepsis

18. Financing

19. Trends in resource allocation YearPer Capit Govt Expend HeadquartersTertiarySecondaryPrimary or district 1976$3-5-404515 1996$6-728311723 2001$10-1216192342 2012$30-5042-50

20. Where is the money coming from

21. NHIS a major player Contributes to 70-80 per cent of facility IGF Contributing now 30-40 per cent of income DWHIS focuses on the district Capitation is for primary health care Selection of PPP can be skewed to lower level Potential of capitation for preventive care not yet explore Can be considered in national roll out

22. Performance measurements

23. Measuring performance Data sources include – Routine administrative data – Program statistics – Surveys by GSS- MICS,GDHS, GLSS – Demographic surveillance centre – Other research studies – Composite assessment- Holistic Assessment Joint MOH-Partners Summit for policy/ strategy New Performance League table can be examined

24. Organization of assessment BMC Review and performance hearing Interagency performance review In-depth review of key areas of concern Independent Sector Review Report to Parliamentary Select Committee on health Annual Joint MOH-partner Summit

25. Areas of assessment Goal 1: Mortality changes Goal 2: Reduce excess morbidity Goal 3: reduce inequality in service SOB 1: Human Resources XXX SOB2: Health, reproduction and nutrition SOB3: Capacity Development SOB4: Governance and Financing 1/04/2010DEBRIEFING INDEPENDENT REVIEW TEAM25

26. Challenges and way forward

27. Some challenges The capacity of DHMTs, sub district and community teams Public private partnership Package of interventions Decentralization Financial strategies Evidence base for decision including Mand E

28. Moving forwards -1 Influencing factors Demographic transition – Aging population, urbanization Economic transition – Low to middle income Changing disease burden – Double burden of diseases Financing changes – The rise of NHIS, fragmented donor sources

29. Moving forwards-2 ICT potential Mobile Technology for Community Health (MoTeCH) E-Blood Bank an electronic (web-based) blood tracking system Community-based electronic registration System for EPI DHIMS2 E-Claim

30. Conclusion A lot has changed since 35 years Post MDG discussions affords opportunity for a major thrust to rekindle PHC globally Because more than ever PHC is needed to address equity issues and link services to financial risk protection Opportunity to enhance quality in PHC Advances in technology mist be maximised Performance system that compares where countries are will be an advantage.