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http://kff.org/uninsured/report/the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-the-era-of-health-reform/ GLOBAL PRIMARY HEALTH CARE PUBHLTH 350 Deepti Bettampadi, MBBS, MPH November 16, 2015 PRELIMINARY ETHICAL CONSIDERATIONS Health and human rights Health system goals and levels Public and private approaches to health systems Challenges in global health systems Responding to health inequalities Increasing uptake of health insurance Research ethics Skolnik. Global Health 101. HEALTH AND HUMAN RIGHTS According to the WHO constitution, the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being Since 1958, more than 20 multilateral treaties about the right to health have been formulated The International Covenant on Economic, Social, and Cultural Rights Focuses on ‘positive rights’ such as right to work, to a living wage, to form a trade union etc. Signed, but not ratified by the US The International Covenant on Civil and Political Rights Focus on ‘negative’ rights i.e. those not requiring governmental actions Ratified by the US more than 20 years later in 1992 Skolnik. Global Health 101. CIVIL RIGHTS VS. POLICE POWERS Powers exercised by the states to enact legislation and promulgate regulations to protect the public health, to ensure welfare, and promote the common good Examples Childhood vaccinations as a condition for school entry Isolating and treating persons with tuberculosis Parens patriae: When an individual cannot or will not take adequate care of themselves, the state is obliged to take protective action State guardianship Helmet or seat belt laws Civil commitment; mental health Obligatory treatment, TB Children and elderly; health neglect GOAL OF A HEALTH SYSTEM What level of prevention should be provided? (primary, secondary, or tertiary) To respond to acute conditions or chronic conditions? To provide care to those who can pay, or to everyone? To reduce health disparities? DIMENSIONS OF HEALTH SYSTEMS Provision of personal and public health service Healthcare workforce Access to essential medications and technologies Health information system Health financing system Oversight Jacobsen. Global Health 2nd Ed. FRENK FRAMEWORK: EXPANDING OUR VIEW ON HEALTH SYSTEMS Health systems components: Human resources Financing Hospitals and clinics Technologies Interactions of these components Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089 FRENK FRAMEWORK: EXPANDING OUR VIEW ON HEALTH SYSTEMS Both supply (institutional) side and demand side have to be considered Population should not be viewed as just an external beneficiary, but also an essential part of the system: Patients requiring care Consumers with expectations about treatment Source of financing as taxpayers Citizens who believe health care is a right Co-producers of health care, being compliant with prescriptions, and not harming the health of others Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089 FRENK FRAMEWORK: EXPANDING OUR VIEW ON HEALTH SYSTEMS Goals of a health system Traditional: improve health More modern: increase health equity Secondary goals: Enhance responsiveness of health system to expectations of populace Respect dignity of persons and promote patient satisfaction Have fair financing (provide financial protection against costs of ill-health) Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089 FRENK FRAMEWORK: EXPANDING OUR VIEW ON HEALTH SYSTEMS Function of health system: Not only direct provision of health services Also: stewardship, financing, resource generation (including of the health workforce) Health system strengthening should also be accompanied by an effort to generate a process of shared learning among countries. Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089 TYPICAL HEALTH SYSTEM SERVICES IN LOWINCOME COUNTRIES, BY LEVEL Skolnik. Global Health 101. INTEGRATION OF HEALTH CARE SYSTEMS Vertical integration: A health care organization offers, directly or through others, a broad range of patient care and support services, operated in a functionally unified manner Horizontal integration: Coordination of functions, activities, or operating units that are at the same stage in the process of delivering services Diagonal integration: ‘Explicit intervention priorities drive the required improvements into health systems, dealing with such generic issues such as human resource development, financing, facility planning, drug supply, rational prescription, and quality assurance’ HEALTH SYSTEMS FINANCING Most high-income countries have a government sponsored healthcare system The US has (mostly) privately-sponsored healthcare system Medicare Medicaid Veterans Affairs Indian Health Services Obamacare Low-income countries have a mix of public and private providers that require out-ofpocket payment at the time of service Jacobsen. Global Health 2nd Ed. Jacobsen. Global Health 2nd Ed. SIMPLIFIED CATEGORIZATION OF APPROACHES TO SELECTED HEALTH SYSTEM ISSUES Skolnik. Global Health 101. Jacobsen. Global Health 2nd Ed. Jacobsen. Global Health 2nd Ed. OVERALL HEALTH SYSTEM PERFORMANCE RANKING, SELECTED COUNTRIES Skolnik. Global Health 101. HEALTHCARE SYSTEM IN INDIA Public health sector was established by the Government of India after independence from British rule Private health sector, which was already dominant at the time of independence, has grown exponentially, and has become a default option for middle and upper income classes Reddy, K. S., Patel, V., Jha, P., Paul, V. K., Kumar, A. K. S., & Dandona, L. (2011). Towards achievement of universal health care in India by 2020: a call to action. Lancet (London, England), 377(9767), 760–8. http://doi.org/10.1016/S0140-6736(10)61960-5 PUBLIC PRIMARY HEALTH CARE Primarily funded by central and state health governments The hierarchy of institutions is as follows: Subcenters: Cover three or four villages Primary health centers (PHCs): Cover a population of 30000 (or 20000 in remote or rural areas), operated by auxiliary nurse midwife Community health centers: 30 bed hospitals which are referral centers for 3 or 4 PHCs each Taluk or district level hospitals: Higher-order public hospitals situated at each taluk or district PHCs and subcenters form the basis of India’s primary health care system Each PHC is charged with providing promotive, preventive, curative, and rehabilitative care Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May). http://photos.wikimapia.org/p/00/03/13/42/58_full.jpg NATIONAL RURAL HEALTH MISSION Aims at ‘establishing a fully functional, community owned, decentralized health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social, and gender equality Launched in 2005 Accredited Social Health Activists (ASHAs): Community health volunteers who will create awareness on health, and will mobilize the community towards increased utilization and accountability of existing health services, and local health planning Women residing and planning to residing in the village for foreseeable future aged between 25-45 years, has class 8 education or higher, preferably married, widowed or divorced Courtesy: Brad Carlson and Amy Sarigiannis Courtesy: Brad Carlson and Amy Sarigiannis THE KERALA PARADOX Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May). HEALTHCARE BY PUBLIC SECTOR Why is it needed Reasons for its poor performance Affordable Bureaucratic approach to health care provision Availability for preventive, curative, and rehabilitative services under one roof Better coverage in rural areas, which house majority of population in India Needed to provide healthcare to urban poor (ex: slum dwellers) who cannot afford private services Rigid PHC structure Focus on inputs rather than outputs Lack of public health management capacity and partnerships with private sectors Vacancies in PHCs for long periods Lack of accountability: No incentive to treat citizens as clients Incongruence between budgets and commitments Lack of medicines Limited doctor salaries Poor condition of PHC infrastructure Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May). PRIVATE HEALTH CARE Includes for-profit and not-for-profit providers, nongovernmental organizations, missionary hospitals, private pharmacies, blood banks and unqualified informal providers Private sector providers can be divided into following groups: Rural medical providers (RMPs) Most of them are unqualified, especially in rural areas Vast majority practice allopathic medicine, though some of them are qualified in Indian Systems of medicine Have good public standing, available at convenient hours, and known to treat patients equally Not-for-profit sector Non-governmental organizations Religious-based facilities Often provide good quality of care because they are not motivated by profit Willing to take health care challenges that for-profit sector is not willing or not able to take on Corporate, or for-profit sector Most of them general hospitals (71%), while few focus on maternal and child health (26%) Tend to charge more than not-for-profit sector Tend to be clustered in few urban centers Provide majority of institutional deliveries and high percentage of antenatal care (40-60%) Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May). HEALTHCARE BY PRIVATE SECTOR Why is it needed Disadvantages Provide high quality of care Top-level hospitals are focused almost entirely on tertiary care, and do not cater to the health care services of the poor More accessible to urban population (rural population in case of RMPs) Non-for-profit sector can provide high quality of care at low cost NFP fills the gaps in services provided by public and for-profit private sectors Even the moderate costs of private clinics and nursing homes can plunge poor households into poverty Parts of for-profit sector involved in unnecessary procedures such as caesarian sections Has grown without any oversight or regulation from the public sector Ridwan, I. (2005). India - Private Health Services for the Poor Policy Note. HNP Discussion Paper, World Bank, (May). HEALTH CARE REFORM IN INDIA Problems 50% of household poverty from health expenditures Imbalanced resource allocation High out-of-pocket health expenditures Health-spending inflation Potential solutions Adoption of equity metrics in monitoring, evaluation, and strategic planning Investment in knowledge-base of health systems research Redefinition of the specific responsibilities and accountatbilities of key actors Balarajan. Lancet. 2011 February 5; 377(9764): 505–515 HEALTH CARE REFORM IN CHINA Early Communist Period (1950s-1970s) Development of rural insurance program Training of “Barefoot doctors” to focus on poor, rural peasants Economic Reform (late 1970s-1990s) Fee-for-service replaced barefoot doctors Government share of health spending fell from 32% to 15% Current reform efforts Public Health Insurance covers 95% of population: reimburses health care expenditures (up to 70% of inpatient costs, depending on level of health system accessed) Eggleston. Asia Health Policy Program Working Paper #28 IMPROVING HEALTH SYSTEMS: LIST Leadership Train people with strategic vision, technical knowledge, political skills, and ethical orientation Institutions Ministry of Health: should be sensitive to local realities but have level of technical proficiency Systems Design Timely conjunction of human, financial, technological, and knowledge resources Technologies Appropriate interventions Expanding supply of drugs, vaccines, bed nets, etc. Frenk. PLoS Medicine. January 2010 | Volume 7 | Issue 1 | e1000089 HEALTH SYSTEM CHALLENGES How to cope with an aging population Quality of governance Number, quality, and distribution of health care personnel Mobilization of sufficient financial resources for the health sector How to provide health care at an appropriate level of quality How to ensure access to and equitable provision of services Creation of mechanisms to provide poor with protection from the costs of health services Skolnik. Global Health 101. QUESTION OF THE DAY As developing countries build up their health infrastructure, what developed country should they look to as a model for health care?