sian griffiths presentation wspcr 2010
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Public Health and Primary care: a shared agenda?
Challenges for integration
Sian Griffiths Professor of Public Health Director of the School of Public Health Chairman, Department of Community and Family Medicine The Chinese University of Hong Kong APACPH 2008 8th November 2008
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Chongqing
CUHK Cardiff MOU november 3 2010
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Public Health and Primary Care
Background : Common agenda : Social determinants WHO report: Now More Than Ever Lancet Sept 13 new agenda
Lessons from Health care reform:
China : Deepening the healthcare system reform China 2020
Hong Kong: Better Health
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The World Health Organization (WHO) Commission on Social Determinants of Health Photo Source: WHO
Social Determinants of Health
november 3 2010
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“Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them from becoming ill or treat illness with it occurs. Within countries, the evidence shows that in general the lower an individual’s socioeconomic position the worse their health. This is a global phenomenon.”
november 3 2010
• Concerns about the affordability of health care, with an ever expanding menu of newer drugs and procedures, are near universal, whether driven by the demands of an ageing population and increasing chronic diseases, by the persistence of infectious diseases and maternal, newborn, and child health conditions, or by challenges that have emerged since 1978, such as HIV/AIDS.
• The current crisis in health, with increasing demand, rising costs, and a return towards curative and hospital care, makes re-exploration of the Alma-Ata principles timely and relevant.”
• Lawn 2008 Lancet 7 november 3 2010
Values of Alma-Ata
• Equity, social justice, and health for all • Community participation • Health promotion • Appropriate use of resources • Intersectoral action
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Health policy today
• “Health is a universal aspiration and basic human need. The development of society , rich or poor, can be judged by the quality of its population’s health, how fairly distributed across the social spectrum and the degree of protection provided from disadvantage due to ill health. Health equity is central to this premise”
Marmot 2007. Lancet 370:1153
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The World Health Report 2008
The PHC reforms necessary to refocus health systems towards health for all
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The World Health Report 2008 12 november 3 2010
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Rationale for the benefits for primary care for health
1. Greater access to needed services, 2. Better quality of care, 3. A greater focus on prevention, 4. Early management of health problems, 5. The cumulative effect of the main primary
care delivery characteristics [5Cs] 6. Reducing unnecessary and potentially
harmful specialist care.
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Integrating primary care and public health
• Better alignment of a public-health approach with personal health services will achieve a better balance, but the balance since Alma-Ata has tilted towards personal health care at the expense of population health
• van Weel 2008 Lancet
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• It is time to integrate personal health care and public health, and organise primary care on the principle of care for individuals in the context of an identified population over time.
• The future of primary care, and health care in general, will depend on how effectively primary practices achieve this community-oriented primary care approach and contribute to equity and social cohesion
» Van weel et al Lancet 16 november 3 2010
Reforms in China
Historical perspective on PH and PC 3 phases of reforms :
– Planned economy – Marketisation – Current reforms [social harmony ]
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Phase 1 : 1949-1977
Focus on preventive services
Focus on dissemination of health education “Patriotic health
campaigns” Initiated “Barefoot doctors
program” 18
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Primary Care
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Public Health :patriotic health campaigns
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“Eradicate pests and
diseases and build
happiness for ten thousand genera5ons”
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Phase 2 The market reforms
• Reduced investment from the central government;
• Increased local funding responsibility (through local taxation)>greater inequities;
• Privatization of health facilities; • Introduced price regulation system and
modified salary system for health professionals;
• Cooperative Medical System (primary care) dismantled with loss of universal coverage ;
• Decentralized the public health system and subsequent deterioration eg of immunisations
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Impact of market Reforms • Increased inequity rural:urban health status
• Decreased access to services ,with diminished government power to intervene
• Price regulation unintentionally increased sale of high tech interventions/expensive drugs in its attempts to control salaries etc
• Dismantling communes destroyed bare foot doctors system and removed rural safety net.As a result primary care in the community was decimated
• • Public Health system less effective
• Blumenthal D and Hsiao W NEJM 353:11 Sept 15 2005
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Decreased share of govt. exp. And increased share of out-of-pocket (1990-2004)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
% o
f tot
al h
ealth
exp
endi
ture
Govt. Exp. Soc. Exp. Out-of-Pocket
(Source: Chinese Health Statistic Yearbook 2006)
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The existing problems (3) Rapid increase in health care expenditure (NHE)
(1978-2004)
(Source: Chinese Health Statistic Yearbook 2006)
0
1
2
3
4
5
6
19781980198219841986198819901992199419961998200020022004
%
0
100
200
300
400
500
600
700
Yuan
NHEpercapita NHEas%ofGDP
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Disparity of health resource allocation between urban and rural per capita NHE
1262
159
302
390
200
400
600
800
1000
1200
1400
199019911992199319941995199619971998199920002001200220032004
yuan
urban rural
(Source: Chinese Health Statistic Yearbook 2006)
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Coverage of Cooperative Medical System in rural China
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big city middle-sized city
small city
rural 1 rural 2 rural 3 rural 4
inpatient
1993 34.09 33.87 53.47 47.95 63.15 61.14 67.72
1998 53.12 58.43 70.77 63.80 54.12 70.26 69.38
2003 64.4 35.6 74.8 77.6 74.9 75.5 73.6
Outpatient
1993 3.21 2.40 9.58 15.10 21.36 19.55 24.42 1998 36.69 23.48 42.96 30.09 31.67 42.29 38.72
2003 30.8 32.7 47 29.2 33.9 41.2 49.1
(Source: The national health service survey, 1993, 1998, 2003)
% of people who should see a doctor choose NOT to do so because of the cost
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‘China’s health system has changed greatly
and made great progress since the reform and opening up, but the problems are also
serious. Overall speaking, the reform was unsuccessful’ -- Development Research
Centre of the State Council. Assessment and
recommendations of health care system reforms in
China. August, 2005 -- 国务院发展研究中心课题组“中国医疗卫生体制
改革的评价与建议”. 2005.08
The overall objective is to establish a basic health care system covering both rural and urban people, as well as to provide safe, effective, convenient and affordable health services to all people.
Phase 3 :Healthy China
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Why ?
• Politics of change • Costs escalating • SARS showed the deficiencies in the
public health system • Increasing affluence spread unevenly
across the country >potential for social unrest
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New health system reform plan: one building, four girders and eight pillars
Collecting extensively people’s comments and suggestions on deepening medical and health
reform
Overall objective Establishing a basic health system covering both urban and rural people, promoting health for all.
Public health service system
Medical service system
Medical insurance system
Drug production and supply system
Managem
ent system
Operation system
Input system
Price forming system
Monitoring system
Hum
an resources
Information system
legislation
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4 systems for establishing a basic universal healthcare system: Public health services including primary care
Medical services including primary care
Health insurance to cover primary care
Medicine supply system to cover primary care
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Primary care in China
• CHS first announced as the future direction for urban healthcare reform in 19971
– borrowed much from the UK. • Primary care is provided by community health
service (CHS) via community health centres (CHCs)
• Public Health and primary care integrated 1. “Decision on Development of Urban Health Care System”. CCP Central Committee and State Council. Jan 15, 1997.Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/wsb/
pM30115/200804/18540.htm. 2. “城市社區衛生服務機構設置原則及指導標準”. Establishing community health services in the urban areas of China. Division of Primary and Women’s Health, Ministry of Health. MOH. No.467
document. Dec 29, 2000. Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/pfybj/200804/18182.htm.
TCM physici
ans GPs
PHDs
Multi-skilled nurses
Allied healthcar
e personnel
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• Basis of urban public health system & basic medical services
Community Health Services (CHS)
1. Division of Primary and Women’s Health, Ministry of Health – “Opinions on Development of Community Health Services in the Cities”. MOH .No.326 document. Jul 16, 1999. Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/pfybj/200804/18183.htm.
Six-in-one comprehensive care package1
Prevention
Treatment & Referral
Health Maintenance
Health Education
Family Planning
Rehab
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Strengthening the establishment of the public health service system: build up sound public health networks of
disease prevention, health education, maternal and child health care, mental health, first aid, blood collection and supply, health supervision, family planning.
Public Health Reforms
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Observation
• Language is confusing • Much of what is labeled public health can
be regarded as primary care • Those providing primary care have public
health responsibilities • Therefore Van Weels terminology /concept
is more helpful to achieve healthcare reform ; community-oriented primary care approach
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Hong Kong
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Market based Primary care in Hong Kong
• Fragmented
• Uncoordinated
• Mainly out of pocket
• No clear clinical standards
• Doctor shopping
• Generalist /specialist issues
• No register of primary care practitioners
• No comprehensive data system
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Hong Kong Primary Care : the reform challenge
• Participants who did not currently have a family doctor and were mainly of lower socioeconomic status than those with a family doctor saw a family doctor as something of a ‘luxury item’ for the wealthy and not within the financial reach of the bulk of the population in Hong Kong.
• There is a need to make primary care acceptable, accessible, and affordable to all, especially those in need.
(Source: Mercer et al., BMC Public Health 2010) november 3 2010
Way forward: enhance primary care
• New funding mechanisms
• Promote the family doctor concept which emphasizes continuity of care, holistic care and preventive care. – register
• Put greater emphasis on prevention of diseases and illnesses through public education and through family doctors. -guidelines
• Encourage and facilitate medical professionals to collaborate with other professionals to provide coordinated services. - new models of care
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CUHK response
• Build on SARS report • Increase the profile and capacity of public
health • Increase the profile and capacity of
primary care • Create an integrated approach –combining
public health and primary care :SPHPC
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School of Public Health and Primary Care The Chinese University of Hong Kong
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The challenges of public health education with a particular reference to China
S.M. Griffiths L.M. Li , J.L. Tang , X. Ma, Y.H. Hu, Q.Y. Meng H. Fu
in many countries,traditional public health methods targeted at individuals, such as vaccination and child and maternal care, have been successfully relocated into the clinical sector, most often primary care or general practice. Such individual public health approaches to prevention are too important to be
neglected. Although, in essence an individual approach, primary care is where much of clinical medicine and many public health practices meet, and recognition of this interface is extremely important for building a seamless framework for improving the health of the
population. november 3 2010
• The future of primary care, and health care in general, will depend on how effectively primary practices achieve this community-oriented primary care approach and contribute to equity and social cohesion
» Van weel et al Lancet 2008 45 november 3 2010
46 november 3 2010