Expanding Primary Health Care

Sam Adjei
NHIA 10th Anniversary Conference
 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
 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
Definition and global commitment
 Many definitions of PHC – here is the JLN’s

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
“The provision of outpatient
non-secondary and non-
tertiary preventive and
curative care, with a
Primary care is the level of a health services system that provides entry
into the system for all new needs and problems, provides person- particular focus on ensuring
focused (not disease-oriented) care over time, provides care for all but
very uncommon or unusual conditions, and coordinates or integrates
the quality delivery of health
care, regardless of where the care is delivered and who provides it. interventions prioritized by
both countries and the global
health community against
the highest disease burdens”
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.
Global commitments to PHC repeated over time, but not
realized in practice
Haikko Declaration Ouagadougou Declaration
(40 member countries) (All African region members)

Reaffirmed Alma Ata

 Reaffirmed Alma Ata


1978 1986 2008

Alma Ata Birchwood Declaration Americas Region Declaration

(WHO members) (South Africa members) (All Latin American members)

Recognized PHC as an essential

right, and committed
Reaffirmed Alma Ata Reaffirmed Alma Ata

governments to launching and
sustaining PHC as part of a
national health system

Countries still continue to struggle with issues of organizational

structures, demand, and financing of primary health care
 Ghana experience
• Goals, organization
 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
 Organization of care
POLICY
Policy TERTIARY
NATIONAL - MOH AND
-MOHGHS CARE
GHS

STRATEGY SECONDARY
REGIONAL LEVEL CARE
TRANSLATION
-RHMT -REGIONAL
HOSPITALS

DISTRICT LEVEL PRIMARY 1ST REFERAL

HEALTH CARE HOSPITAL
 District level organization
Level Name Population Human Resources
A Community 200-5000 TBA, CFHW, CEDW
B Sub district 5-10,000 CHN, MIDWIFE, PA
C District 175-24,000 DHMT-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.
 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
 Ref Community Health Care
District District
Hospitals Health M&L
Management Team

Ref

Sub-district health Planning,

Health management team M&E
Centres

Clinical Determinants Track Social Determinants Track

Ref

CHPS Trad. Com. Service &

Compound Ref
Healers Dev. Surveilla
CM CHO TBA CP Officers nce
Prayer Env. &
Sanit. C H Vs
Camps
CHWS Officers
Services/priority interventions
 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;
 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
 Expressed Needs for Services at the Community level
Most Popular
Family Planning Counseling
Defaulter tracing and continuing
drug replacement
ARI in Children
Immunization and Vaccination
Services
School Health Services
Malaria case management
Nutrition Advisory Services and
Product Distribution
Growth Monitoring
Care of Children (1-59 months)
Care of Infants (7-28 days)
Diarrheal Disease Management
Distribution of contraceptive pills
and condoms
Post-delivery care of Mothers
Popular Least Popular
Care for neonates (0-7 Road Traffic Accidents (care of
days) victims/casualties)
Antenatal Care Services Hypertension Management
on expectant mothers
Antenatal Education in Ulcer Management
Groups
Dispensing of Antibiotics Dispensing Class C Drugs
Insertion and Removal of Minor Surgery (eg., Incision
Family Planning Implants and Drainage)
TB Treatment Diabetes Management
HIV/AIDS Treatment Dispensing of approved
traditional Medicines
Delivery
Yaws, Elephantiasis,
Schistosomiasis
Injuries and Poisoning
Obesity Management
 Comparison of disease problems
Top 10 conditions- 1977 Top 10 conditions-2003
• Malaria • Malaria
• Prematurity • Anemia
• Measles • Pneumonia
• Birth Injury • Stroke
• Sickle Cell Disease • Typhoid Fever
• Child pneumonia • Diarrhea
• Malnutrition • HPTN
• Dysentry • Hepatitis
• Neonatal tetanus • Meningitis
• Accidents • Sepsis
Financing
 Trends in resource allocation
Year Per Capit Headquarters Tertiary Secondary Primary or
Govt district
Expend
1976 $3-5 - 40 45 15
1996 $6-7 28 31 17 23
2001 $10-12 16 19 23 42
2012 $30-50 42-50
Where is the money coming from
 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
Performance measurements
 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
 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
 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

1/04/2010 DEBRIEFING INDEPENDENT REVIEW TEAM 25

Challenges and way forward
 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
 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
 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
 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.