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PHC & UC What do we mean by “primary health care” in the 21 st century? Wim Van Lerberghe SDC HEALTH NETWORK FACE 2 FACE MEETING 7. - 11. APRIL 2014.

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Presentation on theme: "PHC & UC What do we mean by “primary health care” in the 21 st century? Wim Van Lerberghe SDC HEALTH NETWORK FACE 2 FACE MEETING 7. - 11. APRIL 2014."— Presentation transcript:


2 PHC & UC What do we mean by “primary health care” in the 21 st century? Wim Van Lerberghe SDC HEALTH NETWORK FACE 2 FACE MEETING 7. - 11. APRIL 2014

3 Language matters “à toutes fins utiles, cet hôpital universitaire portera le nom de centre de soins de santé primaires” (1980) WVL - PHC - Boston 2

4  The origins of universal coverage  The roots of PHC  Between faith, confusion and disillusion  Crowding and fragmentation  The renewal of health for all: changing expectations  PHC in the XX st century  Definitions  Is this too much to aim for? WVL - PHC - Boston 3

5 1. The origins of universal coverage WVL-PHC-Boston 4

6 XIXth century doctors in Europe  Face-to-face remains the norm until mid- 19th century, but  In emerging cities independent doctors are not the only model  With the public health reforms come public health officers who also care for the poor PP&R, wvl 2001 5

7 The birth of the modern hospital  Number increases after 1830  Become effective (science, labs, techniques, Florence Nightingale [1820-1910])  Come under control of doctors  Repositories of science  New prestige (WW1) PP&R, wvl 2001 6

8 Workers movement: demand and expectations ↑  Hospitals loose stigma of charity  Effectiveness attracts paying patients  A favour to the poor becomes a right for the workers  Doctors want clients who can pay PP&R, wvl 2001 7

9 8 Bismarck’s response  1883: Compulsory sickness insurance  Management by local organisations  Employers (2/3) and employees (1/3) contribute, state not  Free choice, fee for service plus capitation  1911: covers 77% of employees plus dependants  1919: France imitates Germany;  1920s: UK reluctantly follows but moves to tax funding in 1930s;  the American 1910-20 campaign is defeated

10 PP&R, wvl 2001 9 The modern hospital: scientific, symbolic and expensive  “Modern” and distinct from other care since 1920:  Central & symbolic  in perception of users  in career of doctors  in income of doctors  compared to individual practitioners  in expenditure on health  More expensive: reliance on fees and donations is not enough  WWII: Europe: hospitals forced to co-operate with governments

11 Coverage expands and the state’s role becomes central  Bargains on everything  Involvement becomes natural  Instrument for redistribution  “ How to provide care to the destitute?” becomes “ Who has right to care, in what quality and quantity?” PP&R, wvl 2001 10

12 2. The origins of PHC WVL-PHC-Boston 11

13 The colonial legacy  Health care as integral part of colonization  « Lutte contre les grandes endémies » (F) Urban Hygiene Campaigns and national programmes  A network of services (E, B) Success of ‘ European curative care ’: injections, surgery Hospitals plus improvised network of dispensaries  At independence health care is  free,  public or quasi-public (little or no "private")  institutional (no family doctor)  Managed by public sector administrators  At independence the role of state is not challenged, but new actors shape reality

14 The urban elites medicalise …  "Africanisation" = access to technology:   medicalisation (specialists)   curative bias (preventive neglected)   hospitalcentrism (investments, budgets, personnel…)  … with support of the medical civil service  Budgets go to large hospitals, cities, elite  Rural areas are neglected

15 … the politicians get worried…  Contradictions between the discourse of independence & rural reality  Contrasts between regions and rural - uran  Persistence of mass disease delegitimises political powers

16 … and the technocrats panic  As development technicians  Shift efforts to disease control programmes : smallpox, trypanosomiasis, malaria...  "Scientific" and controllable  Mix of success and disappointments  As managers: « this is getting out of hand »  “we cannot afford those vertical programmes”  there is not enough money  1970 ’s: economic growth of < 1%/year  Oil crisis 72-74  Drought Sahel 68-74

17 PHC as “the” solution  1970s:  Persistence of mass disease, rural deprivation, hospital model unsustainable  Alternative approaches to meeting basic health needs in developing countries  From technology to health for the people, from health for the people to health by the people  Cold war  1978: Alma Ata: PHC as a movement to move towards health for all, underpinned by values of:  solidarity,  social justice,  the right to better health for all,  Access, resources, participation WVL - PHC - Boston 16


19 Multiple interpretations…  PHC = no more doctors, no more hospitals  PHC = programmes  PHC = the state no longer has to pay  PHC = participation = user fees  Harare: back to: PHC = district health care WVL - PHC - Boston 18

20 … and a harsh reality

21 The State disappears… Drugs budget(MUS$

22 … and the system starves Gvt funding of district health care: constant $/inh/yr

23 Amidst pauperisation and war, some districts thrive

24 But most dont


26 4. Crowding and fragmentation OF THE DANGER OF GOOD INTENTIONS WVL - PHC - SDC 25

27 BONO MSF 250 PPPH WEF PHA World Bank More and new players

28 ECC MOH (15 Staff) Damian Foundation Memisa Cordaid Oxfam GB Cemubac Int and Nat NGO's (Development and church related) NGO's (Emergency) Multilateral agencies MSF Belgium BASICS Caritas CRS Louvain development Bilateral Funding / Technical agencies Fometro World Vision BDOM Salvation army Asrames World bank More than 200 health partners State and Parastatal organisations Fonds Social de la République BCECO 13 MoH Departments 52 specialised programs 11 provincial management team 11 Provincial Ministries of Health Ministry of Finance Ministry of Education Faculties of Medicine Schools of Public Health Novib Merlin Sanru Gavi ECHO UNFPA UNAIDS UNICEF EU UNHCR WHO IMF Global Fund WFP 13 Donor Government program coordination committees Apefe PSF-CI GTZ SIDA ACDI BTC CTB USAID DFID BAD VVOB 13-9-13 WVL-ULB 27

29 And management becomes more difficult (logistics in Burundi) WVL - PHC - Boston 28

30 The focus on priorities starts ignoring legitimate demand Is it OK for someone to get a fatal preventable stroke as long as they don’t die of HIV? Is it OK to get a C-section, but no care after a car accident? A growing disconnect between global discourse and the field reality of providing care WVL - PHC - Boston 29

31 Results are uneven WVL - PHC - Boston 30

32 13-9-13 WVL-ULB 31

33 5. So why renew PHC (or, rather, health for all)? FRUSTRATION AND CHANGING EXPECTATIONS

34 WVL - PHC - Boston 33

35 13-9-13 WVL-ULB 34

36 Modernization & changing Values  Modernization: long-term increase of secular-rational and self-expression values  Confirmed by cohort differences in all cultural zones except Africa.  Mass attitudinal changes conducive to democracy  See,; a/o Inglehart, R. & Welzel, C. Changing Mass Priorities: The Link between Modernization and Democracy. 2010, 13-9-13 WVL-ULB 35

37 Pressure for more democratic relations Economic Development Emphasis on self- expression values Emphasis on desire to have a say in what affects your life 13-9-13 WVL-ULB 36

38 13-9-13 WVL-ULB 37

39 13-9-13 WVL-ULB 38

40 13-9-13 WVL-ULB 39

41 13-9-13 WVL-ULB 40

42 Frustration about inappropriate care WVL - PHC - Boston 41

43 Frustration about impoverishing care In ½ countries, user charges account for over half of all health expenditures 100 M pushed in poverty 150 M catastrophic expenditure 1300 M no access The huge blind-spot of unregulated commercial care in L & MIC WVL - PHC - Boston 42

44 43 People care about health but there are things they don’t like Inverse care Fragmented care Impoverishing care Unsafe care Wasted money 2012-01-24 wvl 2013

45 Frustration about slow response to new challenges Climate change, urbanization, aging, globalization, chronic diseases, multi-morbidity, inequalities… Mismatch between expectations and performance in dealing with the 3 transitions: demographic epidemiologic demand WVL - PHC - Boston 44

46 6. “PHC” in the XXI st century WVL - PHC - Boston 45

47 Everybody is unhappy (except the development set)  Politicians: the disconnect between discourse and performance is dangerous  Policy makers: this gets out of hand, we need more value for money  Professionals: this is not what we studied for  Citizens: we’re not getting proper care and we’re being ripped off wvl 2013 46

48 It is not about poor care for poor people in poor countries WVL - PHC - Boston 47

49 Start from what people value and expect you to provide  Having a say in what affects their lives and that of their families  Health equity, solidarity, social inclusion: hence UC  Universal access + financial protection;  Redistribution through pooling; social legitimacy  Living in communities where health is protected and promoted: hence Social Determinants  Sources of ill-health (E)  Sources of inequalities (LA)  Good care: hence PC-PC  Health authorities that can be trusted WVL - PHC - Boston 48

50 PHC as a set of interlocked reforms Shifting to primary care has to go along with: Ensure UC: access plus social health protection Integrate public health actions with primary care and pursue healthy public policies Replace command & control and laissez-faire disengagement with inclusive, negotiation- based leadership. WVL - PHC - Boston 49

51 It doesn’t come automatically  Shifting to primary care requires major changes to HRH, payment, incentives, financing, division of tasks between hospital and community...  This is bound to create resistance WVL - PHC - Boston 50

52 The sustainability argument: PC as a managerial response to the challenges of ageing, technology and demand EC: “Contain spending pressures through efficiency gains, to ensure fiscally sustainable access”: reduce unnecessary use of specialist and hospital care while improving primary care services EC (DG ECFIN) report, 2010 MoU Greece & Portugal: gate-keeping, referral, primary care; monitoring and feedback to providers; rationalization of hospital networks WVL - PHC - Boston 51

53 People-centered Primary Care WVL - PHC - Boston 52 Entitlements: Access Quality User voice Five desirable features of care: Effective Safe Comprehensive and integrated Continuous Person- centered An organization where form follows function: Close-to-client, personal relation Explicit responsibility for a defined population Networked: point of entry, gatekeeper, back-up Coordination of care

54 People-centered? WVL - PHC - Boston 53

55 7. Definitions WVL - PHC - Boston 54

56 Check the date!!!  1978: PHC =A movement to get to Health for All by focusing on “Essential” health care  1980s: divergent interpretations  in LIC: PHC = A package of 8 components; interpretations;  in Europe: primary care and determinants  1990s: PHC = Primary Care:  The point of entry level of care (HC, GP, FD, VHW), >> District Health Care  LIC: replaced by disease control  M/HIC: accelerated focus on primary care  Mid 2000: convergence: PHC = a set of reforms to steer health systems towards health for all WVL - PHC - Boston 55

57 Primary care the part of a health services system that assures  Person focused care over time to a defined population,  Comprehensiveness: only rare or unusual manifestations of ill health are referred elsewhere,  Coordination of care such that all facets of care (wherever received) are integrated,  Continuity of care  Quality: effective, safe, parcimonious, people-centred. the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community WVL - PHC - Boston 56

58 8. Is this too much to aim for? wvl 2013 57

59 Brazil: wvl 2013 58

60 Thailand: wvl 2013 59

61 China: wvl 2013 60

62 Portugal:  Effective and efficient  Improved user satisfaction  Improved professional satisfaction wvl 2013 61

63 A personal relation wvl 2013 62

64 Thank you for your patience WVL - PHC - Boston 63

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