AFR/RC65/5 24 November 2015
REGIONAL COMMITTEE FOR AFRICA Sixty-fifth session N’Djamena, Republic of Chad, 23–27 November 2015 Agenda item 9
ORIGINAL: ENGLISH
GLOBAL STRATEGY ON PEOPLE-CENTRED INTEGRATED SERVICES DELIVERY: CONTRIBUTION FROM THE AFRICAN REGION Report of the Secretariat CONTENTS Paragraphs BACKGROUND .......................................................................................................................... 1–5 ISSUES AND CHALLENGES .................................................................................................. 6–15 ACTIONS ................................................................................................................................ 16–18
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BACKGROUND 1. Health systems around the world have contributed significantly to improving health outcomes for many people. In the African Region, this has resulted in reduction in the incidence of malaria, new cases of HIV and child mortality.1 Despite these achievements, health systems are facing challenges as people experience difficulties in accessing the health services they need, when they want them. Available services do not always take account of perceived needs, and tend to be fragmented and disease-oriented with an over-emphasis on hospital-based curative care, thus hampering access to comprehensive and quality care services, especially for marginalized and vulnerable groups. These challenges are particularly significant in the African Region. 2. The World Health Report (WHR) 20082 and Resolution WHA62.12 on primary health care, including health system strengthening,3 call for service delivery reforms to make health systems and services more people-centred and integrated. People-centred health care is an approach to care that consciously adopts the perspectives of individuals, families and communities as participants in, and beneficiaries of, trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care. It is organized around the health needs and expectations of people rather than diseases.4 3. A call has been made by the global community towards Universal Health Coverage (UHC), defined as ensuring that all people can use the needed promotive, preventive, curative, rehabilitative and palliative health services of adequate quality, without being exposed to financial hardship.5 Progress in UHC will require integrated services which involve the management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services. This will be done through the different levels and sites of care within the health system, and according to their needs throughout the life-course.6 4. In 2013, WHO began the development of the Global Strategy on People-centred Integrated Services Delivery that will assist its Member States to achieve UHC with more people-centred and integrated health services. It builds on previous global commitments and strategies to reinvigorate primary health care and pursue UHC, as well as regional declarations on peoplecentred services and social determinants of health, including the Ouagadougou Declaration.7 The emphasis of the Strategy will be on how to effect health service delivery reform in both hospital and primary care settings. 5. The African Region made inputs to this global strategy. This paper seeks to: inform the Regional Committee of the development of the strategy; present an overview of the main issues, challenges, and actions proposed in the global strategy; and identify any areas relevant to the African Region that Member States should address in further consultations on the strategy.
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Atlas of Health Statistics of the African Region 2014, Brazzaville, World Health Organization, Regional Office for Africa, 2014. The World Health Report 2008: Primary health care now more than ever. Geneva, World Health Organization, 2008. WHA62.12. Primary Health Care, including health system strengthening. Geneva, 2008. National Ageing Research Institute, What is person-centered health care? , 2006, Victorian Government Department of Human Services: Melbourne. World Health Organization, Health Systems Financing: The path to universal coverage 2010, Geneva: WHO. Pan American Health Organization, Integrated Health Service Delivery Networks: Concepts, Policy Options and a Road Map for Implementation in the Americas, 2011, Pan American Health Organization: Washington, D.C. WHO, Ouagadougou Declaration on Primary Health Care and Health Systems in Africa: Achieving better health for Africa in the New Millennium, Brazzaville, Regional Office for Africa, 2008.
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ISSUES AND CHALLENGES 6. The main document consists of the following sections: making the case for the need to reorient service delivery; the current situation and service delivery challenges; setting a new vision for service delivery; the way forward; implementation and monitoring; learning and evaluation. The main issues and challenges were considered according to four domains, analysed according to different country contexts: fragile and conflict-affected states, low and lower middle-income economies, emerging economies, advanced economies, small island states and large federal states; and the underlying causes summarized. People-centred health services are generally lacking. Particular population groups such 7. as marginalized and vulnerable groups may be excluded. Furthermore, there is usually limited community engagement; health needs and/or expectations are not usually expressed or understood; there is lack of respect for patients; and the opening hours and waiting times may not be acceptable to people. There is a lack of integrated care. The donor-driven vertical disease programmes cause 8. fragmentation of services. Other causes include non-existent or weak referral systems across levels of care, poor coordination between public and private providers, and lack of continuous delivery across the life-course. Accessibility and availability of care is poor. This is due to staff shortages or 9. absenteeism, as well as lack of funding for medicines and other supplies. The other causes are inconvenient operational hours of health facilities and weak or non-existent institutional care. 10. Patients are provided with poor quality of care. The causes of poor quality of care include the lack of/weak health service regulation and enforcement health units; weak management of health facilities; substandard and counterfeit drugs. There is a disproportionate use of specialist and tertiary services as well as poor infrastructure and training which impede the ability to use new technological opportunities. 11. The underlying causes for these challenges can be summarized as follows: (a) Lack of empowerment among the people served by the health sector. The result is that these people are unable to make appropriate decisions about their own health and health care, or to exercise control over service providers. This problem is particularly acute among vulnerable and marginalized groups and further exacerbates existing inequities. Weak engagement of users and communities with health service providers. This means that service providers may be relatively unaccountable to the communities that they serve. Consequently, they have little incentive to provide responsive care that matches the preferences and needs of their clients. Weak prioritization and failure to support the implementation of proven costeffective strategies. Resources are often captured by more powerful and affluent groups, leading to a lack of transparency in resource allocation. In addition, there is excessive reliance on hospital services, and inappropriate resource distribution. Limited coordination across different levels and types of services. This is characterized by weak information flows and the fragmentation of services, particularly when funded by external donors, often leading to duplication and unnecessary provision of certain services.
(b)
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Issues and challenges pertinent to the African Region needing more emphasis in the Global Strategy 12. The continuing heavy toll of communicable diseases, particularly the frequent occurrence of epidemics and their devastating effects on health systems and the entire socioeconomic fabric of societies and entire countries, has not been given prominence. The resources needed to control these epidemics significantly reduce what is available to address people-centred integrated services. This has been brought to the fore by the recent Ebola Virus Disease epidemic in West Africa. 13. Inadequate investment in basic inputs for service delivery has been mentioned but not been given enough priority. These inputs are so important that they should be considered as a prerequisite for the development of people-centred integrated health services. 14. The importance of emphasizing health promotion and prevention as well as the social determinants of health, the means of reducing the disease, thus lightening the workload for already understaffed health systems. This will enable service providers to devote more time and attention to people, thus contributing to more people-centred services. 15. Health systems across the world need to move towards providing people-centred, integrated services, through service delivery reforms. The Global Strategy on People-centred Integrated Services Delivery seeks to contribute to a vision of people-centred and integrated health services in support of progress towards UHC. In order to realize this vision, a number of actions are proposed to address the underlying causes mentioned above. ACTIONS PROPOSED 16. The global strategy proposes that Member States should: (a) Empower and engage people with the information, skills and resources they need to make effective decisions about their own health; engage and enable communities to become actively engaged in co-producing healthy environments, providing care services in partnership with the health sector and contributing to healthy public policy. Strengthen health literacy awareness through the use of local languages. Strengthen governance and accountability by promoting transparency in decisionmaking and creating robust systems for the collective accountability of health providers and health system managers that align governance, accountability and incentives. Reorient the model of care so that efficient and effective health care services are made available and provided through models of care that prioritize primary and community care services and the co-production of health. This encompasses a good balance between inpatient, ambulatory and outpatient care, and the need for a fully integrated and effective referral system. It requires investment in holistic care, including health promotion and ill-health prevention strategies that support people’s health and well-being. It will create new opportunities for intersectoral action at the community-level to address the social determinants of health and make the best use of scarce resources. The role of multiple sectors operating in an integrated manner is particularly critical for risk management of health. Define the package of essential health services and identify factors that would facilitate scale-up, including the monitoring and evaluation framework needed to implement the strategy at different levels of the health system.
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(e)
Strengthen overall governance and coordination, and reinforce the management of services by promoting transparency and accountability in health system management, in a bid to ensure value for money in the drive towards universal health coverage. Coordinate services around the needs of people at every level of care, promote activities to integrate different health care providers and create effective networks of health and other sectors. Reorganize services to improve patient experience through the creation of multidisciplinary teams. Work to overcome the fragmentation in care delivery that can undermine the ability of health systems to provide safe, accessible, high quality and cost-effective care in order to improve care experiences and outcomes for people. This entails the integration of key public health functions, including surveillance, early detection and rapid emergency response capacity, into the health service delivery system to address emergencies resulting from any hazard faced by the system. Create an enabling environment that brings together the different stakeholders to undertake the transformational change needed. This involves making changes in legislative frameworks, financial arrangements and incentives, and reorienting the workforce and public policy-making. Consider the role of telemedicine and new technology, as well as training, research and media involvement in the implementation of primary health care.
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The Secretariat requests Member States of the African Region to: (a) participate in the consultations on the draft strategy development which will include the online consultation, the 138th session of the Executive Board in January 2016 and the World Health Assembly in May 2016. They should propose inclusion of the issues and challenges that they consider important for the African Region; emphasize the important role of communities in service provision as proposed in the primary health care approach, and recently demonstrated in the management of the Ebola epidemic. They should emphasize, in the actions proposed, investments for the provision of basic services to communities, including remote and marginalized communities, as an essential prerequisite for effective people-centred integrated health services; understand the possible implications of the strategy on their respective health systems, when implemented. Particular attention should be paid to the existing access/availability gaps; the training, capacity building and supervisory aspects; the need for investment in infrastructure, equipment and human resources to move forward and flexibility and adaptation to local needs. In addition, health professionals should be trained to use a more ethical and human approach when working with individuals and communities; reinforce the health district as the operational unit for implementation of peoplecentred and integrated health services based on the primary health care approach. They should strengthen the leadership of district health management teams who should implement a comprehensive package of essential health services which should include health promotion and prevention, and strengthen the complementary capacities of the different levels of care.
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18.
The Regional Committee considered and adopted the actions proposed in this document.