AFR/RC56/12 17 June 2006
REGIONAL COMMITTEE FOR AFRICA Fifty-sixth session Addis Ababa, Ethiopia, 28 August–1 September 2006 Provisional agenda item 8.6
ORIGINAL: ENGLISH
REVITALIZING HEALTH SERVICES USING THE PRIMARY HEALTH CARE APPROACH IN THE AFRICAN REGION Report of the Regional Director EXECUTIVE SUMMARY 1. Implementation of Primary Health Care (PHC) in the Region initially led to improvements in the health of the people. The subsequent decline in performance of PHC was associated with a number of constraints in relation to intersectoral collaboration, community participation, human resources development, managerial capacity, resource mobilization, information base and research capacity. However, a review of PHC 25 years after Alma-Ata revealed that the strategy is still relevant. 2. Universal access requires well-functioning district health systems that are able to deliver essential interventions to communities, families and individuals timely and at an affordable cost. The Primary Health Care strategy, adapted to the current and anticipated environment, provides an appropriate framework for universal access to essential health care. 3. The approach proposed in this document is aimed at revitalizing health services using Primary Health Care based on priority interventions to enhance community participation, strengthen managerial capacity, improve generation and use of evidence, strengthen collaboration and partnerships, and improve quality and coverage of essential health services. 4. The Regional Committee is requested to consider and adopt the orientations proposed in this document and the attached resolution.
CONTENTS Paragraphs INTRODUCTION……………………………………………………………………………..……1–7 SITUATION ANALYSIS……………………………………………………………………..…..8–27 APPROACHES TO REVITALIZING HEALTH SERVICES……………..……………...…….28–36 ROLES AND RESPONSIBILITIES………………………………………………………...…...37–39 MONITORING AND EVALUATION………………………………………………...….……..40–41 CONCLUSION……………………………………………………………………………...…....42–43
AFR/RC56/12 Page 1 INTRODUCTION 1. There is a global commitment to achieving internationally-agreed health-related goals, including the Millennium Development Goals, four of which are health-related. In the African Region, countries need to accelerate towards universal access to essential health interventions in order to achieve the goals. Such access will be facilitated by well-functioning district health services that are able to deliver essential interventions to communities, families and individuals timely and at an affordable cost. 2. The Thirtieth World Health Assembly in 1977 identified the attainment by all peoples of the world by the year 2000 of a level of health that would permit them to lead socially and economically productive lives as a main social target of governments, international organizations and communities. This was reaffirmed by the International Conference on Primary Health Care (PHC) at Alma-Ata in 1978 which adopted PHC as the strategy for attaining the target. 3. The ideology behind Primary Health Care is based on the recognition that health promotion and protection are essential for sustained economic and social development and contribute to better quality of life. PHC is a cost-effective approach and its principles include social justice, equity, human rights, universal access to services, community involvement, and priority to the most vulnerable and underprivileged. 4. Since Alma-Ata, countries worldwide have made considerable efforts in trying to bring health to all through national health policies and plans based on Primary Health Care principles. Although countries in the African Region indicated their commitment to PHC implementation and adopted the health district as the basic unit for delivery of essential health services, they encountered various problems. These included weak structures, inadequate attention to PHC principles, declining financial resources allocated to health, the impact of the HIV/AIDS epidemic, economic crisis and civil strife, and, in most cases, inadequate political will. 5. The commitment to global improvements in health was renewed by World Health Assembly Resolution WHA51.7 (1998) in which Member States reaffirmed their intent to ensure availability of the essentials of Primary Health Care as defined in the Alma-Ata Declaration and set out in the Health-for-All policy for the twenty-first century.1 6. A meeting on future strategic directions for Primary Health Care held in Madrid, Spain (2003) called for a consideration of incomplete PHC implementation, new health challenges, social and political factors that influence health, and crises such as epidemics and emergencies that have reversed earlier gains.2 Consequently, with appropriate adaptation to the current and anticipated environment, the PHC strategy offers a good framework for universal access to essential health care. 7. This document analyses the health service situation in the Region, identifies challenges and proposes ways of revitalizing health services using the Primary Health Care approach to strengthen delivery of essential health interventions.
1
Resolution WHA51.7, Health-for-all policy for the twenty-first century. In: Fifty-first World Health Assembly, Geneva, 11– 16 May 1998. Volume 1: Resolutions and decisions, and list of participants. Geneva, World Health Organization, 2005 (WHA51/1998/REC/1). 2 WHO, A global review of Primary Health Care: Emerging messages, Geneva, World Health Organization, 2003 (WHO/MNC/OSD/03.01).
AFR/RC56/12 Page 2 SITUATION ANALYSIS Issues 8. A number of measures were undertaken in the 1980s to strengthen health systems. These included decentralization and establishment of health districts, training of personnel for PHC management, creation of health or social welfare development committees, and integration of programmes (immunization, diarrhoeal diseases, essential drugs) within Primary Health Care. However, coverage of services remained limited. For example, twelve out of 32 countries, representing 54% of the population, had less than 50% population coverage of medical services.3 9. Initially, improvements were noted in some health trends but the pace of improvement has slowed down, as shown by current infant and child mortality rates. There has also been a regression as shown by the high maternal mortality rates and declining life expectancy at birth in some countries. For example, the average maternal mortality rate in the Region is 1000 deaths per 100 000 live births,4 while life expectancy at birth averages 40 years.5 10. The gap between countries in the African Region and those in other regions has continued to widen. In 1960, for example, life expectancy (40–50 years) in sub-Saharan Africa was similar to that in China, the eastern Mediterranean region and India; by 2000, life expectancy in subSaharan Africa was still much the same, but it had increased to 60–70 years in the other countries. 11. Monitoring and evaluation of the implementation of national health-for-all strategies were carried out in 1988, 1991 and 1994. The findings revealed that the implementation of the strategy had achieved some significant results; however, there were weaknesses in community participation; intersectoral cooperation; mobilization of resources; managerial performance, including planning for human resources in health development; information collection and analysis; and integration and application of research and appropriate technologies into the health development process.6 12. A review of Primary Health Care in the African Region7 showed that most countries made considerable achievements in developing health care systems based on Primary Health Care. A review of the national development plans of countries in the Region indicated that the countries had addressed most of the elements of PHC. Despite this effort, there was a discrepancy between the health-for-all policy and PHC implementation. Whereas all countries made considerable effort to integrate PHC principles and elements into their health systems, the broad approach with PHC as the central function and main focus of the health systems had been abandoned, in most cases, in favour of “selective PHC” in the form of vertical disease-specific programmes. However, these programmes provided important lessons for revitalizing health services.
3
WHO, Monitoring of strategies for health for all by the year 2000, Brazzaville, World Health Organization, Regional Office for Africa, 1988 (AFR/RC38/16 Rev.1). 4 WHO, The world health report 2005: Make every mother and child count, Geneva, World Health Organization, 2005. 5 UNDP, Human development report 2005: International cooperation at a crossroads—Aid, trade and security in an unequal world, New York, United Nations Development Programme, 2005. 6 WHO, Monitoring of strategies for health for all by the year 2000, Brazzaville, World Health Organization, Regional Office for Africa, 1988 (AFR/RC38/16 Rev.1); WHO, Second evaluation of the implementation of the strategy of healthfor-all by the year 2000 in the African Region, Brazzaville, World Health Organization, Regional Office for Africa, 1991 (AFR/RC41/8 Rev.1); WHO, Implementation of strategies for health-for-all by the year 2000 in the African Region of WHO, Brazzaville, World Health Organization, Regional Office for Africa, 1994 (AFR/RC44/4). 7 WHO, Report of the review of Primary Health Care in the African Region, Brazzaville, World Health Organization, Regional Office for Africa, 2003 (in press).
AFR/RC56/12 Page 3 13. A number of recent strategies and initiatives have led to increased service coverage. The implementation of Reach Every District has contributed to increased immunization coverage, for example regional average diphtheria-pertussis-tetanus 3 coverage increased from 54% in 1995 to 66% in 2004. Increased coverage of directly-observed treatment short-course services in 41 of the 46 countries in the African Region has led to remarkable improvements in case notification of tuberculosis. Antiretroviral therapy roll out programmes under The 3 by 5 Initiative and the multisectoral AIDS programmes have improved coverage of HIV/AIDS prevention, treatment and care in the Region. Opportunities 14. Efforts to revitalize health services can build on the lessons and successes of on-going programmes and initiatives such as Integrated Management of Childhood Illness, Reach Every District, directly-observed treatment short-course, antiretroviral therapy, polio elimination and guinea-worm disease eradication, etc. 15. Decentralization to the districts, currently being implemented through health sector reform, provides an opportunity to promote bottom-up approaches and contribute to the mobilization of additional resources for Primary Health Care. 16. The Commission on Macroeconomics and Health has recommended an annual minimum per capita investment of US$ 34 for delivering an essential health package. This provides an avenue for advocacy for increased health financing in countries. 17. The on-going work of the Commission on Social Determinants of Health will provide useful information and recommendations to address challenges arising from social determinants. The implementation of these recommendations will improve the effectiveness of health interventions. 18. The poverty reduction strategies currently being undertaken in countries provide a favourable framework for integration and funding of health objectives and key health interventions in the context of national development agendas. 19. In the recent past, a number of global health initiatives have recognized the need for strengthening health systems to facilitate delivery of priority interventions. The Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization are providing significant resources to strengthen health systems. 20. The Fifty-sixth World Health Assembly requested WHO to continue to incorporate the principles of Primary Health Care in all of its programme activities in order to attain the Millennium Development Goals. This inclusion offers a springboard for reintroduction of PHC in health programmes. 21. The document, Strategic orientations for WHO action in the African Region 2005-2009,8 presents five orientations, one of which is strengthening health policies and systems to improve capacity for delivering health care at local levels. This priority for the African Region for the 5year period will require adequate attention and resources.
8
WHO, Strategic orientations for WHO action in the African Region 2005-2009, Brazzaville, World Health Organization, Regional Office for Africa, 2005.
AFR/RC56/12 Page 4 Challenges 22. One of the major challenges is improving community participation. Participation of communities in planning, monitoring and evaluation of health services has diminished. Community management structures have broken down or are non-existent; the link between health delivery systems and the community they serve has disappeared. In most countries, community health workers and extension workers are no longer in place. There is need to strengthen capacity of communities in improving the quality of health services. 23. Availability of resources is crucial to the provision of health services. Poor resource allocation; inadequate government health financing; health personnel shortages; lack of basic equipment, logistics, essential medicines and other supplies; and poor infrastructure have contributed to the decline in Primary Health Care performance. 24. There is a need to improve managerial performance to overcome inadequate capacity at country level, especially at operational level, in planning and management, including financial management. 25. Strengthening capacity to generate and use evidence for decision-making will also revitalize health systems. The national health information systems are weak in most countries, particularly at operational level. The capacity to generate evidence through operational research has tended to decline over the years. 26. Another major concern is increasing access to essential health interventions and improving the quality of health services. The coverage of health services has not kept pace with, among other things, the high rate of population growth, leading to declining population service coverage. 27. Strengthening coordination and collaboration between the various partners and stakeholders is essential. Intersectoral collaboration, though often discussed, has not happened. Involvement of the private sector and civil society remains limited. Very few countries have defined clear policies, mechanisms and procedures for collaboration with the private sector in health service delivery in general and in the application of Primary Health Care in particular. APPROACHES TO REVITALIZING HEALTH SERVICES 28. The approaches to revitalizing health services will focus on the challenges identified and applying Primary Health Care principles in the process. Objectives 29. The overall objective is to improve equity and access to quality health services in the context of Primary Health Care for better health outcomes. Specific objectives are: (a) (b) (c) (d) (e) to strengthen community participation in health service delivery; to improve resource availability and allocation at operational level; to strengthen the managerial capacity of the district and subdistrict health teams; to strengthen capacity for generation and use of information for decision-making; to improve health service quality and coverage;
AFR/RC56/12 Page 5 (f) to strengthen coordination and partnerships among all stakeholders, especially publicprivate partnerships.
Guiding principles 30. Revitalizing health services will be guided by a set of principles aimed at ensuring fair and appropriate health services to all in the context of Primary Health Care. They include: (a) Human rights. All persons have the right to health, including access to basic quality care and services. Every person should have access (physical, financial, cultural, etc) to a defined minimum (essential) package of acceptable quality health care and services. Efficiency and effectiveness. All health interventions should be efficient and effective. The best possible use of resources should achieve the desired results of the given interventions. Responsiveness. The services should be tailored to the expectations of the clients, including social and human rights expectations. Participation. Primary Health Care depends very much on community participation and people’s involvement and ownership of health programmes. Intersectoral collaboration and partnership development. Given the multisectoral nature of determinants of health and the increasing number of stakeholders in health, it is critical to strengthen collaboration between health and other sectors and build partnerships with relevant stakeholders.
(b)
(c) (d) (e)
Priority interventions 31. Community participation will be enhanced through: (a) (b) (c) (d) 32. establishing and strengthening community and health service interaction to enhance needs-based and demand-driven provision of health services; empowering communities and strengthening community management structures, consumer activities and linkages to health service delivery systems; providing guidelines for strengthening community participation; reorienting the health service delivery system, including health staff, to reach out and support communities.
Availability of human, financial and material resources will be improved through: (a) (b) increasing availability and skills of human resources for health for delivery of quality health services; incorporating community health workers into the human resources for health development agenda of the country, in general, and districts, in particular, and providing appropriate professional back-up through training, mentoring and support supervision; providing performance-based incentives and improving the work environment; mobilizing and allocating more resources at operational level to improve financing of health services delivery and thus respond to identified needs;
(c) (d)
AFR/RC56/12 Page 6 (e) (f) 33. developing and supporting health infrastructure development plans; strengthening estimation, procurement and supply of basic equipment, logistics, essential medicines and other commodities.
Managerial capacity will be strengthened through: (a) (b) (c) assessing capacity-building needs in leadership and management within district and subdistrict health teams, and providing necessary skills and support; reviewing the functions of the different health structures, including hospitals and health facility management committees, in health service delivery at lower levels; establishing and providing support to multidisciplinary teams at the national and intermediate levels that will provide policy and technical guidance, support planning and implementation, monitor and evaluate the performance of the health services at the operational level (districts); providing technical and logistic support to enable effective monitoring and support supervision and quality assurance at all levels; building capacity of health service delivery structures at all levels in financial management, including budgeting and accountability.
(d) (e) 34.
Generation and use of evidence will be strengthened through: (a) (b) improving health information systems, especially at the peripheral health facility and community levels; strengthening capacity of district and subdistrict health teams in operational research and utilization of research results in improving health service delivery.
35.
Quality and coverage of health services interventions will be improved through: (a) (b) (c) (d) defining and updating essential health care packages; identifying health system requirements for expanded coverage of essential health services; assessing the capacity of the health system, particularly at operational level, to deliver the essential health services; promoting integrated and harmonized delivery of health interventions using existing programmes as entry points.
36.
Collaboration and partnerships will be strengthened through: (a) (b) (c) (d) building mechanisms for strengthening coordination and partnerships, including intersectoral collaboration and public-private partnerships; developing regulatory frameworks to govern partnerships; reviving the network of community extension workers from relevant sectors; reviewing and strengthening linkages between central government and local governments.
AFR/RC56/12 Page 7 ROLES AND RESPONSIBILITIES Countries 37. Countries are primarily responsible for the revitalization of their district health services. They should: (a) (b) incorporate the priority interventions for revitalization of health services in their national and district health plans; ensure that an appropriate coordination mechanism is in place to harmonize the complementary roles of local, intermediate and central level structures and institutions; reorient their hospitals to function in support of district health services; mobilize and allocate resources, giving priority to health service delivery at the operational level; facilitate delegation of responsibilities and functions with commensurate resources; promote intersectoral collaboration and public-private partnerships; involve communities in resource mobilization, planning, implementation, monitoring and evaluation of health services.
(c) (d) (e) (f) (g)
WHO and partners 38. WHO should: (a) (b) (c) (d) (e) 39. provide technical guidance and support for the priority interventions aimed at revitalizing district health services; advocate for more resources for strengthening district health services; promote collaboration with other partners at global, regional and country level; monitor and report on district health service performance for the Region; promote intercountry exchange of experiences and dissemination of good practices.
Other partners, working with WHO, should : (a) (b) (c) harmonize support for strengthening district health services; provide resources for strengthening district health services; participate in joint performance reviews of district health services with leadership from the national authorities at country level.
MONITORING AND EVALUATION 40. At the country level, mechanisms will be put in place to promote technical peer review between districts and consumer evaluation of the health services within districts. Core indicators for district health performance will be adopted for the Region and used for routine monitoring and reporting on an annual basis. A regional consolidated report on performance of district health services in all countries in the Region will be made every three years. 41. A task force on Primary Health Care will be constituted in the Region to regularly review the progress made in the implementation of the key strategies for revitalizing district health services, identify major bottlenecks and advise the Regional Director, on an annual basis, on how to address them.
AFR/RC56/12 Page 8 CONCLUSION 42. Success in achieving the Millennium Development Goals and the overall goal of universal access to prevention, care and treatment is based on effective and fully-functional health services at the local district level. The principles of Primary Health Care are still relevant for strengthening health service delivery for the populations in the African Region, but they need to be adjusted in a country-specific context and adapted to new global challenges. 43. The Regional Committee is invited to consider and adopt the orientations proposed in this document and the attached resolution.
AFR/RC56/WP/4 9 June 2006
REGIONAL COMMITTEE FOR AFRICA Fifty-sixth session Addis Ababa, Ethiopia, 28 August–1 September 2006
ORIGINAL: ENGLISH
DRAFT RESOLUTION REVITALIZING HEALTH SERVICES USING THE PRIMARY HEALTH CARE APPROACH IN THE AFRICAN REGION (document AFR/RC56/12)
The Regional Committee, Recalling the 1978 Alma-Ata Declaration on primary health care; Mindful of resolution WHA51.7 (1998): Health-for-all policy for the twenty-first century; Concerned by the slow pace of progress being made by the majority of the countries of the Region towards the Millennium Development Goals; Noting that national health systems have deteriorated due to a number of challenges; Recognizing that universal access to essential health interventions requires efficient, well functioning district health systems; 1. ENDORSES the document entitled “Revitalizing health services using the primary health care approach in the African Region”; URGES Member States: (a) (b) to incorporate in their national and district health plans the priority interventions for revitalization of health services, based on the primary health care approach; to ensure that an appropriate coordination mechanism is in place to harmonize the complementary roles of local, intermediate and central level structures and institutions; to re-orient their hospitals to function in support of district health services; to mobilize and allocate resources giving priority to district health systems; to promote intersectoral collaboration and public-private partnerships; to strengthen community capacities and increase their involvement in planning, implementation, monitoring and evaluation of health services;
2.
(c) (d) (e) (f)
AFR/RC56/WP/4 Page 2
3.
REQUESTS the Regional Director: (a) (b) (c) (d) (e) (f) to provide technical guidance and support for implementing priority interventions aimed at revitalizing district health services; to continue advocating for more resources for strengthening district health services; to strengthen collaboration with partners; to facilitate intercountry exchange of experiences and dissemination of good practices; to establish a regional task force on primary health care; to report to the Regional Committee on performance of district health services in all countries of the Region every three years.