Development cooperation in healthcare…

What about the patients perspective?

Overview of content

• Introduction• Healthcare needs in developing countries• The concept of Patient-centred Care• The Lucoma Project• Communication skills course for rural

healthcare workers

Introduction:

Does developmental aid meet the needs?

Development cooperation: what are the needs?

… And what is in the (Belgian) offer?

Gouvernmental cooperation BTC, Lowns, acquitation of debts,… 291.514.950€

Non-Gouvernmental cooperation VVOB, VLIR, Scientific institutions, local NGO's,… 233.032.467€

Multilateral cooperation UN-contributions, World Bank, … 442.193.581€

Others Humanitary aid, sensibilisation, support private sector 313.925.930€

Foreign Affairs B-Fast, humanitary aid, conflict prevention & diplomacy,… 97.802.431€

Total Belgian budget 2008: 1.378.469.359€

(Source: http://diplomatie.belgium.be/en/policy/policy_areas/index.jsp)

(Source: DGOS year report 2008)

Match or mismatch?• Not everything that counts can be counted and…

• Healthcare is only one part in a complex web of interrelated needs

• Equally complex landscape of development cooperation organisations

• Acute vs. long term needs

• This seminar focuses on “efficient cooperation for long term needs in healthcare”

Healthcare needs in developing countries

Ranking of selected risk factors: 10 leading risk factor causes of death by income group, 2004

Source: GLOBAL HEALTH RISKS, Mortality and burden of disease attributable to selected major risks. WHO, 2009.

Chronic and complex health problems

• Growing incidence in both high and low income countries

• Have significant influence on healthy life expectancy and quality of life

• Are not cured by standard procedures• Any cure:

– Is mostly focussed on keeping the situation stabile rather tan on healing

– Risk for noncompliance– Success is related to integration in patients

life (motivation!)

Healthcare in Western vs. developing countries

Core Health Indicators (WHO, 2004-2006) Belgium France UK USABurkina

Faso Mali EthiopiaDR

Congo

Life expectancy m/f 77/82 77/84 77/81 75/80 46/49 45/48 55/58 46/49

Healthy Life expectancy m/f 69/73 69/75 69/72 67/71 35/36 37/38 41/42 35/39

Per capita gouvernment expenditure on healthcare (Intl$) 2194 2646 2261 2862 51 31 12 6

Per capita total expenditure on healthcare (Intl$) 3071 3314 2597 6350 86 60 20 17

Per capita gouvernment expenditure on healthcare (%) 0,71 0,79 0,87 0,45 0,59 0,51 0,6 0,35

Physicians (/10000 population) 42 34 23 26 ? <1 <1 1

Nurses & midwifes (/10000 population) 142 80 128 94 ? 6 2 5

Criteria for effective rural healthcare

– Availability (distance, time)– Regional spreading– Regional cooperation & referral– Low cost – Government support– Healthcare staff skills– Integration of prevention in socio-cultural life(Source: Immpact, 2008)

In reality: if you get sick in rural Africa...

• See the village responsible or local healer• Can you afford professional healthcare?• Organise family and housekeeping• Travel to the nearest health facility

(community care centre)• See the nurse for clinical examination and

standard cure• Travel home

Health risks

• Traditional medicine• Lack of financial means• Loss of time• Limited & strongly standardised basic care:– Lack of physicians– Anamnesis & clinical examination based on algorithms– Treatment based on standard cures

• Noncompliance

Some examples: CMA Houndé (Burkina Faso)

Some examples: Dispensary just outside Houndé (Burkina Faso)

Some examples: CSCOM Koutienso, Mali

First conclusions so far...

Healthcare needs:• Mainly chronic diseases• Multi-problem

situations

Healthcare system:• Limited budget• Limited development

aid• Limited Infrastructure• Limited skills• Traditional medicine

Patient centered care

What patients really want... (Stewart, 2001)

1. Explore the patients' main reason for the visit, concerns and need for information

2. Seek an integrated understanding of the patients' world—that is, their whole person, emotional needs, and life issues

3. Find common ground on what the problem is and mutually agrees on management

4. Enhance prevention and health promotion

5. Enhance the continuing relationship between the patient and the doctor

Why Patient-centred care?• Biomedical model does not satisfy patients needs in complex and/or chronic

diseases-> Quality of life

• Investigate and treat the patient, not the disease!-> “shared decision making”

• Compliance with therapy:– Patients knowledge & motivation– Integration in patients life style and family life– Thrust in medical staff & therapy

(Stewart, 2001; Pruitt, 2005; Dolan, 2008)

• Efficient healthcare– Outcomes– Settings

(Bradley, 2005, Inui, 2007)

PCC and the millennium development goals

•Perinatal follow-up•Skilled birth attendance•Prevention from domestic violence•Prevention from arranged marriage and pregnancy in young age

•HIV•Malaria•TBC•Safe drinking water

•Substance abuse•Child labour

•Social promotion•Family planning•Female circumcision

•Immunisation•Neonatal care•Child nutrition•Primary health care

How to achieve patient-centred care?

• Skilled health-care provider:– Medical knowledge & skills– Family & life style anamnesis– Communication skills

• Time & motivation– Team support & counselling

(Source: Dunn, 2003)

The Lucoma project

Houndé, Burkina Faso

Communication skills course

Houndé, April 2009

Course content

• Part 1: General communication theory and skills training– Schröder model

• Part 2: patient anamnesis– Conversation structure– Gordon’s 11 Health patterns

• Part 3: Health education– Goals & means– Procedures

The model

1. Health perception & management pattern

2. Nutritional-metabolical pattern3. Elimination Pattern4. Activity-exercise pattern5. Sleep-rest pattern6. Cognitive-Perceptual pattern7. Self-perception/self-concept

pattern8. Role-relationship pattern9. Sexuality-reproductive pattern10. Coping-Stress tolerance pattern11. Value-Belief pattern

Pedagogic considerations

• Theoretical part:– Limited and understandable– Lectures and literature review– Local situation as a starting point

• Focus on applicability

• Interactive sessions:Presentations, discussions,

role-plays, exercises andtry-outs

Presentations & discussions

Role-play

Results of the pilot

PCC and the holistic model

Methods of communication and positive influences

New, difficult and important?

Discussion and conclusions

• Small survey• Social desired answering

• Limited knowledge on PCC• Training is important, but only 1 aspect of a complex

situation (time & motivation)• Additive & continued support:– Procedures and posters– Expert group– Coaching