Primary Health Care, Objectives, Principles and Policy Directions

Connecting Health and Labour,

Role of Occupational Health in PHC

The Hague 2011

Primary health care: Objectives,

principles and policy directions

Dr Hans Kluge

Mrs Christine Beerepoot

Mr Rokho Kim

WHO Regional Office for Europe



The Hague 2011

Healthy ageing and the importance of

Primary Health Care

Fauja Singh,

UK, oldest

person ever

to run a

marathon.

Toronto

16 Oct 2011

aged 100



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What do we talk about when talking about

primary health care? An outline

• NCD burden

• Definitions

• Policy documents

• PHC Reforms

• Partnership Dutch

Government/WHO

• Conclusions



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Total deaths by broad cause group, by WHO Region,

World Bank income group and by sex, 2008



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Prevalence of multiple chronic conditions

increases steeply with age: Netherlands

Source: van Baal et al, 2011,

Co-occurrence of diabetes,

myocardial infarction, stroke,

and cancer: quantifying age

patterns in the Dutch

population using health survey

data, Population Health Metrics



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Public health and health systems

Other sectoral actors (beyond health

systems) with health generating activities

Agriculture

Tourism

Education

Transport

Health Systems

Curative

Health Care Services:

Primary, secondary, tertiary

Environment

Prevention, protection,

promotion Individual health services

Public

Health

Essential Public Health

Operations

Population-based health services

* Link to Health 2020, its governance, the whole-of-government

and the whole-of-society approach



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Operational approach to support Member States in

health system strengthening (WHO EURO)

Removal of health

system bottlenecks

Po

pu

lati

on

an

d in

div

idu

al

level

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ice d

eli

very

Go

vern

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Healt

h f

inan

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g

Reso

urc

e g

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tio

n

(Hu

man

reso

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es a

nd

tech

no

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y)

Core

services

Population level

Individual level

Population level

Individual level

Population level

Individual level

Population level

Individual level

Expected

results

Maternal and

child health

outcomes

Cardiovascular

health

outcomes

Tuberculosis

Etc.



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Primary Health Care a health reform movement launched at Alma Ata in 1978 to move towards health for all.

2008: a set of policy orientations and reforms needed to move towards health for all: moving towards

universal coverage; shifting service delivery to people-centred primary care; ensuring health in all

policies; promoting inclusive leadership and governance. (See Primary Health Care reforms)

1978: 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-reliance and self-determination. It forms an integral part of both the

country’s health system, of which it is the central function and the main focus and of the overall social and economic development of the

community.

1980s: The set of activities outlined in the Declaration of Alma-Ata: education concerning prevailing health problems and the methods of

preventing and controlling them; promotion of food supply and proper nutrition; an 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.

1990s: a level of care, that is the point of entry to the health services system (see: primary care).



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Alma-Ata Declaration. World Health Report

2008 “Now more than ever”

• Universal coverage reforms to

improve health equity

• Service delivery reforms to

make health systems people-

centred

• Leadership reforms to make

health authorities more reliable

• Public policy reforms to promote

and protect the health of

communities



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Efficiency gains are imperative

• Many effective policy instruments

to mitigate impact of crisis focusing

on cost reduction and efficiency

gains

◦ Hospital reconfiguration

◦ Increased focus on primary

health care

◦ Shift from inpatient to

outpatient care

◦ Rational use of medicines

◦ Reduced prices of medical

goods



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I. Universal coverage reforms to improve health

equity.

Ensure availability

Eliminate barriers to access

Organize social protection

• But that is not enough:

– mobilize beyond the health sector

– give visibility to inequalities

– reach the unreached



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Moldova: expansion of coverage towards

universality

• Expanded PHC to all

citizens regardless of

insurance status

• Expanded coverage of

health insurance program

to the poor

• Coverage funded by

pooled general tax and

payroll tax in mandatory

health insurance scheme

46.8

69.4

24.4

65.5

45.6

76

63.7

90.7

0

10

20

30

40

50

60

70

80

90

100

Employees insured Non-working insured Self-insured Uninsured

Any kind of medical services Inpatient care

Insured pay less out-of-pocket



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MOH/ WHO Mobile Health Team, Myanmar (2008)



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II. Leadership reforms – Inclusive leadership and

effective government

• Recognition of the key role &

responsibilities of government

• Inclusive leadership and policy

dialogue: from command-and-

control to steer-and-negotiate

• Matching growth in health

expenditure with massive

reinvestment in capacity for

leading and governing the health

sector



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The Tallinn Charter 2008:

Health Systems for Health and Wealth The Tallinn Charter has:

• inspired countries to act on

their values to improve health

and wealth;

• affirmed a value-based

approach to health system

strengthening; and

• empowered health ministries to

lead change for health

improvement.



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III. Service delivery reforms

• Putting people first: four features of good care

• Person-centeredness

• Comprehensiveness and integration

• Continuity of care

• A personal relationship with well-identified, regular and

trusted providers

• Organizing primary care networks accordingly

• Shifting the entry point: bringing care closer to the people

• Shifting accountability: responsibility for a well-identified

population

• Shifting power: the primary care team as the hub of

coordination



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PHC as a hub of coordination between

hospitals and community care



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Partnership Ministry of Health the Netherlands and WHO

Regional Office for Europe on Primary Health Care



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The benefits of Primary Health Care

• Improved health outcomes at the population

level

• Improved equity in health outcomes and

access to health services

• Better efficiency of the health system as a

whole, less costs

• More satisfaction of users with health services



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Modernize PHC within the healthsystem



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1 2

Integrated Care : Simultaneously Managing

Crisis & Transformative Change

Short term strategy

Crisis management

Drugs: Brand to Generic

Human Resources: Salaries

Tecnologies: Desinvestment…

Long term strategy

Reforming Delivery

Chronic Diseases Agenda

Integrated Care

SUSTAINIBILITY?

&

Primary

Prevention Early

Management Acute

Management

Rehabilitation

& secondary

prevention



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Tools for Integration Help to move

towards a “System” Perspective

risk stratification…

case nurses…

routine clinical reminders…

continuum of care…

activated patient…

Regular telemonitoring …



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IV. Public policy reforms to promote and protect the health

of communities: national health policies and strategies

System-wide analysis and frameworks are more important than ever

Resources are scarce, improved efficiency is needed

Support Member States

1. Defining priorities informed by high-quality analysis and evidence

2. Convening many actors of the health system

3. Facilitating cross-country sharing and learning



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Coverage of OHS in 21 countries

9590

86

80 80

70 70

60

50 50 50 5048

39

34

3028

15

10

54

0

10

20

30

40

50

60

70

80

90

100

NET FIN SVN BEL FRA SWE JAP HUN DEN NOR POR ITA TUR POL UNK BUL GRE EST CHI KEN SVK

OHS can be provided to

Under-served population

through PHC system



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WHO position: universal coverage of OHS

• WHO Constitution: Health as a fundamental human

right

• Alma Ata Declaration (1978): Health care closer to the

places where people live and work

• Global Strategy on Occupational Health for All (1996),

and Global Plan of Action on Workers’ Health (2007):

– Occupational health services should be provided for all

workers including migrant workers, workers in small industries

and in the informal sector, and other occupational groups at

high risks and with special needs, including child workers and

farmers.



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Stage I Starting level

Stage II Basic Service

Stage III International Standard Service

Stage IV Comprehensive Service

Field nurse Safety agent

Physician and nurse with short special training

Multidisciplinary team with special training

Multidisciplinary specialists' team

•Advice in OH •Accidents and ODs •Acute ill-health •PHC

•PHC Infrastructure

•Basic OHS content

•Toolboxes

•OHS Infrastructure

•ILO No. 161, 155

•Multidisciplinary content •Prevention plus curative services

•In-company or external

special OHS units •Comprehensive content:

prevention, curative and promotion & development services

Objective for all!

SMEs,SSEs,SEs,IFS SMEs,SSEs,SEs,IFS Starting point for Big industries and well organised SMEs

Big industries and Big OHS Centres

A stepwise strategy for occupational health services



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Conclusion

• Commitment of member states for the need for change

towards integrated health care with PHC at the heart

• Redefine the role of hospitals

• Involvement of community care and patient empowerment

• Transformative education, role of nurses and paramedics

• Increase efficiency and reduce costs protecting the

vulnerable

• Exchange best practices

• ONE SIZE DOES NOT FIT ALL

• WALK THE TALK: TAKE CARE OF OURSELVES !



The Hague 2011

-From Values

to Action -

Division of Health Systems

and Public Health Thank You

Primary Health Care, Objectives, Principles and Policy Directions

Health & Medicine

universal

connecting

occupational

care

health

alma

prevention

community