WPRl2009IDHS/04/HSD-E Report Series No.: RS/2009/GE/27(PHL)
English only
REPORT MEETING ON WHO ACTION IN PRIMARY HEALTH CARE AND HEALTH SYSTEMS STRENGTHENING
Convened by: , " f
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC ,
•
Manila, Philippines 14-15 April 2009
Not/or Sale Printed and Distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines
December 2009
WHOIWPRO LIBRARY
MANILA. PlULiPPINF..S
1 9 FEB 2010
NOTE
The views expressed in this report are those of the participants in the Meeting on WHO Action in Primary Health Care and Health Systems Strengthening and do not necessarily reflect the policies of the World Health Organization.
This report was prepared by the World Health Organization Regional Office for the Western Pacific for governments of Members States in the Region and for the participants in the Meeting on WHO Action in Primary Health Care and Health Systems Strengthening held in Manila, Philippines from 14 to 15 April 2009.
CONTENTS SUMMARy ............................................................................................................ I 1. 2. 3. BACKGROUND .................................................................................................. . INTRODUCTORY SESSION ............................................................................... 2 TECHNICAL SESSIONS ..................................................................................... 4 3.1 3.2 3.3 3.4 Country Overviews (Session 2) .................................................................... 5 Improving Maternal, Newborn and Child Health/Reproductive Health (Sessions 3 -4) ........................ ................... .................................................... 5 What can and should WHO do? (Session 5) ............................................... 6 WHO/WHO Regional Office for the Western Pacific Action on PHC and HSS (Sessions 6-7) ........... ............... ........................... ............. 7
ANNEXES: ANNEX I ANNEX 2 ANNEX 3 TIMETABLE ............................................................................................ 15 LIST OF TEMPORARY ADVISERS AND SECRETARIAT ................ 17 POWERPOINT SLIDES OF PRESENTATIONS AND CONCLUSIONS ...................................................................................... 25
Key words:
IHealth systems / Primary health care
ACRONYMS
HMIS HSS ICT MCH MDG
MNCH PHC
Health management information system Health systems strengthening Information and communication technology Maternal and child health Millennium development goals Maternal, newborn and child health Primary health care
SUMMARY
Primary health care (PHC) and health systems strengthening (HSS) have become more prominent on the international health agenda for multiple reasons. One is that progress towards achieving the Millennium Development Goals (MDGs) by 2015 is behind schedule in many countries despite major increases in overseas aid. This is particularly true for MDG 5, which calls for reducing maternal mortality by three quarters and providing universal access to reproductive health, which is lagging. Weak health systems are viewed as a one of the sources of this problem. A response has been a call to build stronger health systems based on the values of PHC. This has given impetus to a process of PHC renewal. The PHC renewal process has been marked by a series of international meetings and by the launch of The World Health Report 2008: Primary Health Care, Now More Than Ever at an international conference in Almaty held 30 years after the original Alma-Ata Declaration on Primary Health Care. Several technical documents and resolutions have been produced to guide WHO's work on health systems and PHC. The Regional Committee of the Western Pacific Region has called for the Secretariat, in consultation with Member States, to formulate a regional strategy on HSS based on the principles and core values of PHC. As part of this process, a meeting of expert advisers was convened from 14 to 15 April 2009. The objectives of the meeting were to provide guidance on the following three strands of WHO work: (l) formulating a regional strategy on PHC and health systems; (2) enhancing the contribution of the continuing process of strategy formulation related to health systems and; (3) recommending potential actions WHO could take in cooperation with Member States to strengthen health systems and PHC. The meeting brought eight temporary advisers from seven countries to interact with the WHO Secretariat. The discussions included updates on the PHC renewal and HSS processes within WHO. Country overviews from Papua New Guinea, Cambodia and the Lao People's Democratic Republic were presented and discussed. These countries were selected because of their high maternal mortality rates. A presentation also was made on possible activities to decrease maternal mortality and improve reproductive health. The remainder of the meeting was spent brainstorming about possible actions based on the country overviews, what role WHO can and should play and making recommendations for action on PHC and health systems by WHO Headquarters and the Western Pacific Regional Office. A wide variety of recommendations to be considered during the consultation with Member States on the regional strategy was discussed. The highest priority issues identified by the participants were human resources, leadership and governance, management, fragmentation, political commitment and establishing a long-term coII11Ilitment. Participants will be considered part of the consultation process on the regional strategy and their opinions and recommendations will be sought throughout.
1. BACKGROUND Primary health care (PHC) and health systems strengthening (HSS) have become more prominent in the international health agenda for multiple reasons. They include progress towards achieving the Millennium Development Goals (MDGs) by 2015, which is behind schedule in many countries. This is particularly true in those countries most dependent on external aid in the health sector and for those MDGs related to maternal and child health. Major increases in international assistance to the health sector have occurred, and there have been benefits from this aid. However, the increase in aid has contributed to increasing fragmentation of the health sector. There is also a growing sense that the health outcomes achieved may not have been proportionate to the funds invested. Weak health systems are identified as a source of this problem. One response has been a call to build stronger health systems based on the values ofPHC. WHO Headquarters has produced a technical document, Everybody's Business: Strengthening Health Systems to Improve Health Outcomes -- WHO's Framework/or Action, I to guide its work in health systems. The WHO Secretariat in the Western Pacific Region also has produced a Strategic Plan/or Strengthening Health Systems in the WHO Western Pacific Region 2 to guide its work. These provide a basis for health systems work within the WHO Secretariat. The Director-General of WHO, Dr Margaret Chan, has made the renewal of PHC a cornerstone of WHO's programme. This was reiterated at the "International Conference Dedicated to the 30th Anniversary of the Declaration of Alma-Ata" held in Almaty, Kazakhstan, from 15 to 16 October 2008. The World Health Report 2008: Primary Health Care, Now More Than Ever, 3 was released at this conference. The report marshals the evidence for the need for PHC renewal. As a follow-up, the WHO Executive Board (EB) passed a resolution (EBI24.R8) on "Primary Health Care, including health systems strengthening", in January 2009. 4 The resolution was to be considered further by the World Health Assembly in May 2009 that was to define furtherWHO's commitment to the renewal ofPHC. The Regional Committee of the Western Pacific Region passed a resolution (WPRlRC59.4) on "Health Systems Strengthening and Primary Health Care" in 5 September 2008. The recommendations from this resolution included items pertaining to (1) increasing support in PHC to Member States; (2) increasing WHO's capacity to provide technical assistance; (3) aligning WHO's programme with national health plans and the Paris Declaration on Aid Effectiveness; (4) the establishment of an increased health systems analytic capacity through a health systems observatory; and (5) formulating in consultation with Member States a regional strategy for health systems strengthening based on the principles ofPHC.
1 http://www.wpro.who.intINRirdonlyres/5BASOB95-DCIF -4427 -SESB-OD9B
I E9 AF776/0/EB
http://www .wpro. who.intlNRlrdonlyresIDB6927F6-7697 -4EAF -80D4067CFB7757B6/0/StratPlan2.pdf 3 http://www.who.int/whr/200S/whr08_en.pdf 4 http://apps.who.int/gb/ebwhaJpdCfilesIEB 1241B 124_8-en.pdf 5 http://www.wpro.who.intINRirdonlyres/3EASOB45-B766-4E82-BE75CE564D62FIE7/0/wpr_rc59 J04.pdf 2
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The regional strategy is to be presented to a high-level meeting, possibly ministerial, and to the Regional Committee in 2010. The consultation on PHC and health systems will include continuing work on strategies for health financing, essential medicines, traditional medicine, human resources and health laboratories. Dr Shin Young-soo, the Regional Director of the Western Pacific Regional Office, has expressed a need to review WHO's programme of action in PHC. There is particular interest related to strengthening engagement with several of the nations in the Region most at risk for not meeting the MDGs. An expert meeting was held from 14 to 15 April 2009 in Manila, Philippines, to discuss WHO's programme in PHC and HSS. The meeting provided ideas for possible WHO action in relation to PHC, HSS and achieving the MDGs. The objectives of the meeting were to provide guidance on the following three strands of WHO work: (l) formulating a regional strategy on PHC and health systems; (2) enhancing the contribution of the continuing processes of strategy formulation related to health systems; and (3) recommending potential actions WHO could take in cooperation with Member States to strengthen health systems and PHC.
2. INTRODUCTORY SESSION Dr Shin opened the meeting. He reflected on the importance of the MDGs, the large amount of financial resources flowing into health and the need to find sustainable mechanisms to improve health. He commented that there was limited interest in health systems throughout the 1990s but said that has changed. He noted that the three countries invited, the Lao People's Democratic Republic, Cambodia and Papua New Guinea, are lagging on MDG achievement and that WHO was interested in finding ways to help them improve their performance. A round of self-introductions was then conducted. Prof Masamine limba was elected Chairperson of the meeting. Dr Henk Bekedam, Director of Health Sector Development, reviewed the objectives of the meeting and encouraged the participants to discuss freely and openly. Dr Dean Shuey, Regional Adviser for Health Services Development, provided an update on PHC and HSS within WHO and the Western Pacific Regional Office. The presentation reviewed the process ofPHC renewal within WHO and the core documents and resolutions that provide the basis for PHC renewal and HSS within WHO and the Regional Office. The health systems framework of six system building blocks leading to outcomes for the health sector was presented as well as the schema from The World Health Report 2008, which shows the four areas of health sector reforms that are part ofPHC renewal and lead to improved health outcomes. The slides from the presentation are in Annex 3. Dr Willem van Lerberghe, Director of Health Systems Governance and Service Delivery at WHO Headquarters, presented the rationale for PHC renewal. PHC renewal was triggered by changing needs, frustration with fragmentation,
-3unequal results in the health sector and the financial and economic crisis. There is a move back to the basic values and principles of PHC with an emphasis on what people value. The importance of universal coverage, people-centred service delivery, public policy that protects the health of communities and more reliable leadership in the health sector were noted. Some emphasis was placed on the differences in the PHC renewal process, which built on lessons learned from early attempts to implement PHC. The slides from the presentation are available in Annex 3. A lively discussion ensued. A comment was made asking whether PHC renewal was a revival of the vertical-horizontal debate about health programming. It was felt that the World Health Report 2008 had been confusing and sometimes it was difficult to tell the difference between what is new and what was being revived and that it seemed too focused on primary medical care. Another participant felt that the delivery of services was neglected while looking at the other parts (building blocks) of health systems. Another participant asked whether management and leadership were considered the same and commented that, ultimately, individuals run systems. A response was that in business, management and leadership were considered different but that both were crucial to a health system. Another comment was that situations have changed in the last 30 years and the district health system model of primary health is not always viable, partiCUlarly for marginalized groups such as mobile popUlations. Some doubt was expressed that the inclusive values ofPHC are as widely accepted as implied in documents supporting PHC renewal. Another comment was made that the original definition of PHC from Alma-Ata still was valid but more work was needed to define the minimal package, as was done with essential drugs. The presenters responded that, overall, the horizontal and vertical debate should not be the focus. The focus should be on what works and produces the desired outcomes. The unregulated commercialization of the health sector was believed by one presenter to be a more significant problem than verticality. It was noted that in people-centred approaches, the health sector is also about what people want, not just what is needed from a technocratic viewpoint. The belief was expressed that values are changing and that the flow of history is moving towards more participatory approaches. It was agreed that service delivery may have been neglected and that the emphasis should be on universal coverage (or access) to quality services.
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3.
TECHNICAL SESSIONS
3.1
Country Overviews (Session 2)
Representatives from Cambodia, Papua New Guinea and the Lao People's Democratic Republic made presentation about the health situation. The three countries have the highest maternal mortality rates in the Western Pacific Region. Prof Dr Boungnong Boupha, Director of the National Institute of Public Health in the Lao People's Democratic Republic, spoke of the situation in that country based on information from the midterm review of the National Health Plan. He described core indicators, the service delivery model and the human resource base for health. The MDG progress report from May 2008 was reviewed. It showed declines in maternal mortality reduction (MMR) from 656 to 405 deaths per 100 000 live births and in the under-5 mortality rate from 170 to 98 deaths per 1000 live births between 1995 and 2005. Plans for scaling up interventions included: (1) promoting and expanding the health model villages concept; (2) promoting a maternal mortality reduction package; (3) promoting a child survival package; (4) promoting a nutrition package combined with disaster, epidemic and pandemic preparedness packages; (5) putting into effect plans drawn up for human resources for health; (6) strengthening the organization, regulation and working methods of the health sector; (7) promoting sustainable health financing; and (8) putting into effect the Vientiane declaration on aid effectiveness. There is a broadening partnership among the Ministry of Health and development partners with sectoral working groups. A new 5-year health plan during the period 2011-2015 probably will have an emphasis on maternal, newborn and child health (MNCH). The slides from the presentation are available as Annex 3. Dr Clement Malau, Secretary for Health, made a presentation on Papua New Guinea and also circulated an abstract of his presentation. The slides and the abstract are in Annex 3. The presentation reviewed some of the factors that are influencing the health sector, including global initiatives, numerous external agencies, global warming and the economic downturn. Dr Malau called for a focus on the district and local levels and emphasized the importance of managers at all levels. Improved accountability of managers focusing on service delivery was proposed. He acknowledged that the system has many problems and could be considered "broken". A process to formulate the next national health plan for the period 2011-2020 has begun. The focus will be on service delivery to the rural majority and the urban poor, centred on PHC. Reforms envisaged include defining national and local functions, improving governance at the central level, transforming multiple systems into a single system, greater focus on service delivery, formulation ofthe community health post concept and implementing the corporate plan. Dr Paul Weelen, Senior Health Systems Adviser, WHO Cambodia, gave a presentation on behalf of Dr Sin Somuny, who was unable to attend because of last minute travel problems. The core indicators, service delivery model and human
-5resource base were reviewed, all of which were problematic. Effective interventions were considered to be health equity funds, the contracting model, incentive mechanisms and some of the better practices by nongovernmental organizations (NGOs) on prevention, promotion and participation. Fragmentation was an issue, which is aggravated by the complex donor environment. The slides from the presentation are in Annex 3. The participants were asked to identify and discuss recurring themes in the presentations. Topics mentioned included management, decentralization, misalignment of plans and resources, human resource constraints with respect to both quantity and quality, lack of institutional capacity, the need to focus on communities and districts to contribute to national goals, challenges to service delivery due to remoteness, shortage of resources of many types, the need to improve efficiency, setting the correct priorities, how to monitor progress, the need for stronger governance, weakness in public sector management, lack of an evidence base for decision-making and the need for a sustainable architecture for adequate health care financing. Options for successful service delivery are needed. Human resources playa central role. Motivation, how to correctly remunerate and how to avoid dual roles and corrupting influences were discussed. Also mentioned was the need for sustainable health care financing with avoidance of overreliance on out-of-pocket expenditure and the need for aligning the partners with country plans rather than distorting the system with partner funds. One of the presenters encouraged WHO to take a central advocacy role in driving policy in these areas. A question was asked about why government spending in health was so low in Cambodia and the Lao People's Democratic Republic. It was felt that this makes health inequity more likely, increases donor dependence and fragmentation and therefore leads to inadequate implementation of national health plans. 3.2 Improving Maternal, Newborn and Child Health/Reproductive Health (Sessions 3-4)
Dr Narimah Awin and Mr Liu Yunguo, Regional Advisers for Making Pregnancy Safer and Reproductive Health, respectively, made a presentation on Improving MNCHIRH in the Lao People's Democratic Republic, Cambodia and Papua New Guinea. The experience of Malaysia in reducing maternal mortality was discussed, including the big decrease having occurred was before Malaysia became economically prosperous. It was attributed to the prudent use of resources and a focus on family planning, antenatal care, skilled birth attendance and essential obstetric care. Out-of-pocket financing was not allowed for maternal and child health. Traditional birth attendants were not rejected outright but were planned for replacement through obsolescence through attrition. The ideas for projects focused on PHC and districts using an HSS framework. Considerable discussion focused on what interventions would be effective and what should be WHO's role. One participant asked whether new ideas were needed or just improved implementation. Solving the human resource issue with respect to both quantity and quality was an issue and it would require a long-term view. Focusing on best buys might leave other aspects of the system unfunded and lead to unintended consequences. One comment was that the ideas seemed to be a move away from
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WHO's core role of technical cooperation and closer to implementation, a role that may not be to WHO's comparative advantage. A participant from Papua New Guinea expressed the idea that one needed to analyse why systems were broken. Poor governance evolves over a prolonged period, and concern was expressed about a narrow MNCH focus when a more systematic approach might be needed. Malaysia was noted to have the advantage of political stability and a treasury and finance department that was more supportive of the health sector. It was proposed that WHO be a more active advocate to the government in a cross-sectoral fashion (i.e. sectors other than health). Political commitment was deemed to be important but some doubt was expressed that WHO could create such commitment. It was expressed that WHO would need a clear position on some potentially difficult and controversial issues if it was to be an effective advocate. Some felt that advocacy, which depends on a combination of WHO's normative role and convening power more than money, could be WHO's biggest contribution on these issues. A view was expressed that WHO needs to have clear, forthright, evidence-based opinions that are not weak and timid. Several felt that WHO does have a role in applying pressure if WHO was sure of its facts and policies. The thought was expressed that maternal mortality needs to be considered an emergency in order to attract more attention. WHO can help with this. It was noted that maternal and child health (MCH) delivery, particularly the MMR, is a good indicator of universal coverage of a health care system. MCH was proposed as a good entry point for HSS. Other participants voiced caution about impatience for quick results. The issues of maternal mortality require patience, persistence and time. Caution was expressed to avoid making maternal mortality reduction or HSS into another fragmented, vertical programme. Some shorter-term strategies such as family planning and nutritional supplementation could have a more rapid impact but should not cause Member States to lose sight oflong-term vision, tailored to the needs of the individual country and persistently implemented, being needed ifthere are to be sustainable results. 3.3 What can and should WHO do? (Session 5)
The Chair opened the session by emphasizing that the day's sessions were focusing on the role of WHO. The Chair mentioned possible roles such as implementation, advocacy and harmonization. The comments in this session showed that there were a wide variety of opinions about WHO's role, not all of which were completely compatible. A comment was made that further work is needed on the priorities addressed the previous day. It was acknowledged that WHO's priorities need to be determined by country priorities. A country representative stated that other agencies, such as the United Nations Children's Fund (UNICEF), seem more bold and politically astute and encouraged WHO as the global expert on health to be bolder. Another country representative felt that WHO should concentrate on technical assistance, financial assistance, mobilization of other donors and use its influence for coordination, negotiation and explanation. This representative felt that WHO should act only when approved by the government.
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WHO was felt by some to have a role in identifying best practice and at times in creating best practice. Another representative noted that, in reality, WHO's mandate is wide but its resources are small. This participant emphasized the coordination role of WHO and stated that pure technical cooperation was not the beall and end-all and also noted that WHO sometimes tended to be reluctant to tackle difficult or controversial topics. One participant felt that integration of services was a priority and that PHC and HSS should be placed at the top of the agenda. Another participant enjoined that it was only in WHO where PHC was at the top of the priority list. A participant from a bilateral agency felt that money is important and that WHO should not try to compete in implementation. This participant felt that WHO could serve best in helping governments identify priorities and by asking the right questions. The participant then asked questions about the Asia Pacific Health Systems Observatory, and information about progress was given. The Chair emphasized the need for coordination. A comment was made in return that players often do not want to be coordinated and that stronger leadership was needed. It was also mentioned that coordination is the role of government and WHO's role is to assist government in fulfilling that role. It was expressed that WHO sometimes tries to be everything to everybody. This participant suggested that WHO should define what the minimum requirements for a PHC system would be, conduct an evidence-based audit of those systems, identify where health systems are failing and provide a roadmap on how to fix health systems. A comment was made that setting minimum standards is a risk because it can put PHC into the position of being identified as poor care for poor people in poor countries. A countervailing opinion was that essential minimum standards are needed and have been useful in programmes such as essential drugs.
The Regional Director commented that it is a new world in international health and development and that WHO must do something or be at risk of becoming less relevant. Maternal mortality is a problem but there are simple interventions to deal with infection and bleeding and something needs to be done. The Chair summarized the comments by saying that the strength of WHO was its country offices. He stated that the Group of Eight (G8) was looking at the MDGs and saw that MDG 6 had made significant progress while MDG 4 and MDG 5 had made less progress. The lack of progress was felt to be due to weak health systems, making the topic of these discussions particularly relevant. 3.4 WHO/Western Pacific Region Action on PHC and HSS (Sessions 6-7)
The following session moved towards the plans for formulation of a regional strategy on PHC and HSS as endorsed at the Regional Committee Meeting of September 2008. Dr Bekedam presented the three strands of work planned for the next 1Y, years, which are (1) formulating a regional HSS/PHC strategy; (2) reviewing and further formulating existing strategies in health care financing, human resources, traditional medicine, laboratory services and essential medicines; and (3) more specific in-country work on PHC/HSSIMCH, including work with public-private partnerships, operational districts and community fmancing. The proposed consultative process was explained, which is planned to culminate in a high-level
-8meeting in June 2010 and a regional committee resolution to be considered in September 2010. The presentation is in Annex 3. Updates on the process offormulation and implementation for the following five strategies were then given: (1) health care financing by Dr D. Bayarsaikhan; (2) human resources for health by Dr Z. Nukuro; (3) improving access to essential medicines by Dr B. Santoso; (4) strengthening health laboratory services by Dr G. Ghadiok; and (5) traditional medicine by Dr N. Samdan. A comment was made that this entire process might be too broad for PHC and HSS. It will be necessary to determine which would have higher priority and there is a need to respond to the emphasis that the international community has placed on the MDGs. Another participant asked if the strategies were understandable and if they would lead to action. It was noted by one participant that information and communication technology (lCT) did not feature as a cross-cutting theme. Another participant said that there was a mind-boggling range of activity and it was not completely clear how they would be linked. Efforts must be made to avoid silos and there should be an emphasis on integrated procurement and supply management as another cross-cutting theme. Another mentioned health information systems as a cross-cutting theme, linked to appropriate ICT. A response was that one of the purposes of the overall regional strategy for PHC/HSS was to link clearly all of the other strategies and to look at the health system holistically. The discussion then moved to advice on how a regional strategy might be constructed. One participant said that the regional strategy needs a first paragraph that grabs the interest of the reader and that the essence needs to be conveyed in one page. An example of a 37 -page policy brief was felt to be too long. Another participant said that there is a risk of "guideline and principles" fatigue. The document should have a clear link with outcomes. Another suggested a brief document that emphasized universal coverage, people-centred aspects ofPHC/HSS and public policy, with the details in annexes. Another stated that the focus needed to be moulding the opinions of managers and leaders, including those outside the health sector. It should not be targeted at health sector-strengthening specialists. Comments were made that specific country strategies need to link to national health plans. Equity, gender and human rights are of great importance and there is a need for collecting disaggregated data to assist in monitoring those issues. A lively discussion ensued on those items and priorities that should be considered by WHO for consultation with Member States. A set of slides was prepared that identified recurrent themes that had come from the discussions and are in Annex 3. Some of the recurrent themes were: • • • A long-term, consistent approach is needed. Evidence-based boldness is advised. Coordination - tailored to the situation, led by the country where possible but some risks that people, agencies or countries may not want it.
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•
Leadership, both inside and outside the Ministry of Health, especially in finance, planning and from the prime minister's office. Health public policy and cross-sectoral leadership is important. WHO as implementer. Different perspectives were expressed (will it hamper the honest broker and coordinator role?). Management as a recurrent cross-cutting theme - (leadership is choosing the right thing, management is doing the right thing right and the need to realize that HSS experts will not be present at all, if not most, levels). More focus on universal coverage and service delivery (noted that this might be more acceptable than PHC and HSS, which provoke some suspicion (allergy) from disease control programmes). Information clearinghouse (best practice - honest broker) - to facilitate, coordinate, synthesize and maintain observatory functions. Information systems (country - health management information system (HMIS) is cross-cutting). ICT (innovative and feasible uses to address obstacles is not an end to itself). Focus on outcomes - holistic - avoid unconnected pockets of policy or activity - help tie it up at the country level. o Human Resources for Health and Health Care Financing (HRH/HCF) - ,:omplex, interlinked and cannot be solved independently; and Drugs and technology/labs (HTL) - same interlinkage with HRHlHCF.
•
•
•
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•
•
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:)
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Defining a functioning PHC system (debate on minimum as a useful term or not - no consensus; do agree that PHC is not poor care for the poor). Integrated/comprehensive - priority setting (not clear whether this is the verticallhorizontal debate in other words).
•
The participants were asked to make comments or recommendations for specific topics to be included or emphasized according to the six building blocks of a health system as well as cross-cutting areas. One participant cautioned that the four PHC reforms are not equivalent to the six health system building blocks and that, particularly, participation and a focus on people should not be neglected. Some of the comments or interest areas to consider for inclusion follow: Human Resources for Health • Quality/standards for training.
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• • •
Incentives. Mentoring/supervision. Right people with right skills in right places tied up with financing and definition of service delivery model - development, deployment and retention strategies. Define categories of health workers by facility and position linked to a package of care (links with service delivery). More attention to private providers (regulation and governance). Skilled birth attendant for all pregnant women everywhere (urban and remote).
•
• •
Health Care Financing • Marketing and commercialization need to be recognized and managed. They go with leadership and regulation. Out-of-pocket spending to be addressed: the need to decrease out-ofpocket spending and increase sustainable pre-payment. Health care financing to focus on equity issues, safety nets and financing based on needs. New funding opportunities, which are said to have no intent for parallel systems but in practice they often are parallel. Costing of national health plans. Linking financing to health outcomes. Public health expenditure to increase. Sustainability - consider the role of community financing. Financial scenario planning (e.g. for aging, climate change, epidemiologic transition.
•
•
•
• • • • •
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Medical Products and Technology • • • •
Standards for equipment at each level, linked to financing. Appropriate and new technologies for remote and difficult settings. Maintenance. rCT.
•
Preferential use of generics and regulating incentives to health workers to use branded products. Traditional medicine in parallel with modernized medicine (also in service delivery).
•
Information • Improve the evidence base on programmes and on innovation, exchange information within and across regions, joint learning. Administrative (management) data part of information systems. Measure disparities in outcomes and access. Disaggregated data. Low-cost and technologically appropriate information systems. Health systems performance assessment is needed. Strengthening of research, Mexico commitments to be honoured.
• • • • • •
Service Delivery • Use a service delivery lens - scepticism about PHC and health systems - politicians interested in delivery - focus service delivery on MDG 4 and 5 (MNCH). Improve focus on prevention (service delivery, training and financing incentives) . Universal coverage of what needs to be determined, back to priorities. Overmedicalization. Quality needs to be emphasized as well as quantity. Patient-centred care, is it different? Yes, but how it is different needs to be defined, moves beyond consultation room, involves citizenry). Managers need to understand their roles (links with HR).
•
• • • •
•
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• • •
Rationalize incentives to encourage PHC and rational care. rCT - (e.g. mobile phones to link to services). Confront wmecessary interventions and product use (supplier-induced demand).
Leadership/Governance • Resources mismatched with needs - setting priorities; money mainly now for disease control, but that's not always the highest need. Regulation to be strengthened, although it is highly political. Medical tourism an issue in some settings. Management at each level - building capacities of local managers. Role of government to be defined and emphasized, especially if decentralization; inclusive stewardship role. Accountability to the people (democratization). Is this the same as people-centred? Policy dialogue - engaging people in policy debate and decisions. Accountability, zero-tolerance for abuse of public goods.
• • • •
•
• •
Cross-cutting • • • • • • • • rCT can help in many of the blocks (e.g telemedicine, HMIS). Equity. Inequality of outcomes, a cross-cutting focus. Adding efficiency to the system is the same as adding new money. Global warming. Global economic crisis is more than just a financing issue. Health as a human right. Universal coverage as cross-cutting issue.
There was discussion about whether a strategy could be relevant to all of the Member States in the Region. It was stated that this is the intention. PHC and HSS have relevance to all countries, although the most important decisions about implementation are made in countries. It was felt that clear guidance from WHO could help this process to be more rational.
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A list of recurrent topics raised was distributed and participants were asked to rank these as far as importance for WHO to address. The topics which the participants listed most commonly were: 1. Human resources (motivation, dual roles, corruption, living wage, capacity, shortages) - 13 mentions. 2. Leadership/governance/interlinkages - eight mentions. 3. Management/public sector management; fragmentation; political commitment; long-term commitment - six mentions each. The participants at the end of the meeting also were given a sheet that asked them to suggest normative statements in relation to health systems that they felt should be presented to Member States to consider for inclusion in the regional PHCIHSS strategy. Those comments have been included as part ofthe workshop report. It was suggested that there be a continuing dialogue with participants as the regional strategy process occurs. Dr Bekedam and Dr Shin closed the meeting with comments. The participants were thanked for their hard work and inputs into improving the quality of WHO's programme in this important area. They were assured that their recommendations would be considered and were of great value. They would be considered part of the network of people to be consulted throughout the formulation of the regional strategy and about future WHO plans in health systems and PHC.
MEETING ON WHO ACTION IN PRIMARY HEALTH CARE AND HEALTH SYSTEMS STRENGTHENING Manila, Philippines
14-15 April 2009 08:30
TIMETABLE
Session 1 - Introduction - Welcome, introductions, selection of chair (RD) - Objectives of meeting (HB) - Update on Primary Health Care and Health Systems Strengthening within WHOandWPRO(D~.
Session 5 - What can and sllOuld WHO do? Role of WHO vis a vis other actors at the multiple revels of WHO country, regional and global.
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10:00
I
Tea/coffee break
- PHC from HQ perspective (WvL) - Discussion
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10:30
09:45 10:00
Group Picture Tea/coffee break Session 2 - Coun Iry Overviews - Lao PDR - Prof Dr Boungnong Boupha - Papua New Guinea - Dr Clement Malau - Cambodia - Dr Paul Weelen - Discussion --Identification of common themes to discuss
10:15
Session 6 - WHO/WPRO Action on PHC and HSS • Update on current process ReM Resolution and Hi-level meeting (HB) Individual strategies (brief updates of core areas (HCF, TRM, PHA, LAB, HIID) - Comments on process - Brainstorming on normative guidance What can and should WPROIWHO say to Member States on PHC/HSS? What normative statements can and should WPRO make?
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VI
12:00 13:30
LUNCH
12:00 13:30
I LUNCH I Session 7 - WHO/WPRO Actiou on PHC/HSS Continued- block by block and reform by reform
3Overviews -MMR Reduction in Lao PDR - Discussion - Dr. Narimah Awin Possible topics for fUrther discussion: Remoteness Financial exclusion - out of pocket reliance Lac~ of clear service model Human resources - quality/quantity/locationlmotivation Private/Public Mix Fragmentation Gove.rnmentlAccountability Decentralization Aid effectiveness Vuln~rable groups
15:00 15:30 16:30 Session 4 - Discussions of issues and possible actions from Country Overview, . Continue (move progressively towards emphasis 011 WHOIWPRO action)
15:00 15:00
Tea/coffee break Session 8 - Recommended action for the future Group prioritizes recommended actions from the two previous sessions Concluding remarks - DHS and RD
~
'""'
-17ANNEX 2
LIST OF TEMPORARY ADVISERS AND SECRETARIAT 1. TEMPORARY ADVISERS Professor Dr Boungnong Boupba Director-General National Institute of Public Health Ministry of Health Vientiane Lao People's Democratic Republic Telephone: +85621216884 Fax: +85621 214012 Email: bboungnong@hotmail.com Ms Susan Ivatts Director, Health and HN Australian Agency for International Development (AusAID) GPO Box 887 Canberra ACT 2601 Australia Telephone: +612 6206 4199 Fax: +612 6206 4634 Email: susan.ivatts@ausaid.gov.all Dr Masamine Jimba Professor International Community Health Graduate School of Medicine University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo 113-033, Japan Telephone: +81 35841 3698 Fax: +81 3 5841 3422 Email: mjimba@m.lI-tokyo.ac.jp Ms Harumi Kitabayashi Human Development Department Japan International Cooperation Agency Shinjuku Maynds Tower Bldg. 2-1-1 Yoyogi, Shibuya-ku Tokyo 151-8558 Japan Telephone: +81-3-5352-5206 Fax: +81-3-5352-5320 E-mail: Kitabayashi.Harumi@jica.go.jp
-18Dr Cbang-yup Kim Professor School of Public Health Seoul National University 28 Yongon-dong, Chongno-gu Seoul 110-799 Republic of Korea Telephone: +82 2 740 8876 Fax: +82 2 762 9105 Email: cykim@snu.ac.kr Dr Clement Malau Secretary for Health National Department of Health P.O. Box 807, Waigani Papua New Guinea Telephone: +673 301 3601 Fax: +675 301 3604 Email: clementmaJau@health.gov.pg Mr William Parr Director - Social Resources Division Secretariat of the Pacific Community BPD5, 98848 Noumea Cedex New Caledonia Telephone: +687 260 III Fax: +687 263818 Email: billp@spc.int Dr Hilary Standing Visiting Professor BRAe University School of Public Health 66 Mahakhali, Dhaka 1212 Bangladesh Telephone: +880 171 540 3621 Email: h.standinguv.ids.ac.uk
2. WHOIHQ
SECRETARIAT Dr Willem Van Lerbergbe Director Health Systems Governance and Service Delivery WHO Headquarters Geneva Switzerland Telephone: +41 22791 2080 Fax: +41227914153 Email: vanlerberghew@who.int
-19-
WHOIWPRO
Dr Richard Nesbit Special Adviser to the Regional Director WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9921 Fax: (632) 521 10 36 Email: nesbitr@wpro.who.int Dr Henk Bekedam Director, Health Sector Development WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9951 Fax: (632) 521 1036 Email: bekedamh@wpro.who.int Dr Dean Shuey (Responsible Officer) Regional Adviser Health Services Development WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9805 Fax: (632) 521 1036 Email: shueyd@wpro.who.int Ms Laura Hawken Technical Officer Health Services Development WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9086 Fax: (632) 521 10 36 Email: hawkenl@wpro.who.int
-20Dr Momoe Takeuchi Technical Officer Health Services Development WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9084 Fax: (632) 521 1036 Email: takeuchim@wpro.who.int Dr Narimah Awin Regional Adviser Making Pregnancy Safer (MPS) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 5289876 Fax: (632) 521 1036 E-mail: awinn@wpro.who.int Dr Yunguo Liu Regional Adviser in Gender, Women and Reproductive Health WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9878 Fax: (632) 521 1036 Email: liuyun@wpro.who.int WHO/CAMBODIA Dr Paul Weelen Medical Officer Health Services Development No 177-179 comer Pasteur (51) and 254 P.O. Box 1217 Sangkat Chaktomouk Khan Daun Penh Phnom Penh Cambodia Telephone: (855) 23-216610 Fax: (855) 23-216211 Email: weelenp@wpro.who.int
-21WPROfDHS Dr Dorjsuren Bayarsaikhan Regional Adviser, Health Care Financing (HCF) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9808 Fax: (632) 521 1036 E-mail: bayarsaikhand@wpro.who.int Ms Anjana Bhushan Technical Officer, Health and Development WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9814 Fax: (632) 521 1036 E-mail: bhushana@wpro.who.int MrJun Gao Regional Adviser, Health Information (HIN) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9812 Fax: (632) 521 1036 E-mail: gaoj@wpro.who.int Mrs Rosebelle Azcuna Assistant, HIN WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9837 Fax: (632) 521 1036 E-mail: azcunar(a),wpro.who.int
-22Dr Gayatri Ghadiok Technical Officer, Essential Health Technologies WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9848 Fax: (632) 521 1036 E-mail: ghadiokg@wpro.who.int Dr Ezekiel Nukuro Regional Adviser, Human Resour.::es Development (HRD) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9816 Fax: (632) 521 1036 E-mail: nukuroe@wpro.who.int Ms Kathleen Fritsch Regional Adviser, Nursing (NUR) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9804 Fax: (632) 521 1036 E-mail: fritschkialwpro.who.int Dr Rodel Nodora Technical Officer, HRD WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 98029 Fax: (632) 521 1036 E-mail: nodorar@wpro.who.int
-23Dr Budiono Santoso Regional Adviser, Pharmaceuticals (PHA) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9846 Fax: (632) 521 1036 E-mail: santosob@wpro.who.int Dr Reijo Salmela Medical Officer, Situation Analysis for Policy (SAP) WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9835 Fax: (632) 521 1036 E-mail: salmelar@wpro.who.int Dr Narantuya Sam dan Regional Adviser Traditional Medicine WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9844 Fax: (632) 521 1036 E-mail: samdann@wpro.who.int Ms Mitra MotJagh Technical Officer Equity, Gender and Human Rights WHO Regional Office for the Western Pacific Manila Philippines Telephone: (632) 528 9883 Fax: (632) 521 1036 E-mail: motJaghro@wpro.who.int
-25ANNEX 3
POWERPOINT SLIDES OF PRESENTATIONS AND CONCLUSIONS Session 1. Introduction. Update on PRe and RSS within WHO and WPRO
PHC Renewal Primary Health Care and Health Systems Strengthening WPROMIHO Dean Shuey 14-15 April 2009 Manila DG of WHO - election manifesto - driven by discussion with countries while campaigning WHO Regional Strategies - AMRO, EURO 2007/2006 - Series of meetings - PAHO, AFRO. EURO.SEARO.EMRO WPRO - China, Malaysia. WPRO (Aug 2008) Almaty - October 15-16. 2008 - 30 years World Health Report - 2006
tir
",,*,', l
','JHO Western P.1ClftC Reg"," - Meeting on V.HOActlon In PHCIHSS
~,
\.',HD V,,,"te"n Pacll
RClloDn- Mer
~n3 on WHO Action In PIiC/IlSS
""
Declaration of Alma-Ata (1978) "Health for All" Primary health care is essential health care based on practical, scientifically sound and socialty acceptable methods and technology made universally accessible to Individuals and families in the community through their fuH participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and determination. It forms an integral part both of the country's health system, of which it is ttle central function and main focus, and of the overa!t social and economic development of the community. It is the first level of contact of a/l individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing
health care process. ,:;};~ ... HO V.""tcm P"aflc Reg on - M"dlClQ
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C~ ,'mo Action I" PHCfH5S
Q. 5,
WHO \',,,,,t,,m P;le he
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Health Systems framework with six building blocks System buifding blocks Service Delivery Health Workforce Information Rosponslveness Social & financial risk protection Improved efficiency
Goals/outcomes Improved health (level and equity)
Medical producu, TechnDlogies
Health Financing Leadership I Governance - Priorities in each - Multiple, dynamic interactions ~!
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-26-
WHR 2008 - PHC Renew al
Wrth goals of: better health,
less disease. greater equity, and better performi ng
health systems.
Resolutions Regional Committee and Executive Board W PRlRC 59.4 - Health Systems Strengthening and Primary Heatth Care - (5) to develop. through a process of consultation with Member States, a regional strategy for strengthening health systems, based on the guiding principles and core values of primary health care ....... present this Strategy in a high·level meeting in 2010 as well as to the Regional Committee in 20 10. 3 Strands of PHCIHSS Work
EB124.RB - Primary health care, including health system strengthening
Regional HSS/PHC Strategy
..
Objectives - provide guidance on : (1) developing a regional strategy on PHC and HSS (2) enhancing the contribution of the ongoing processes of strategy development in HCF, TRM , Ess Meds, Lab, and HRH to the overall regional strategy in PHC and HSS (3) identifying actions WHO could realistically take with Member States in PHC and HSS
-27-
Session 1. Introduction. PHC from WHO Headquarters Perspective
Why a renewal? • Changing needs and challenges • Global frustration with fragmentation and unequal results • Evolving demand • National frustration with mismatch expectations and performance • Financial and economic crisis
• 21 "-.,1._ ~. ~ -~ ~-
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A moving target
Convergence • Regional reviews and resolutlons
• Commissio n of sodal determinan ts • • W onies about MDGs Initiatives from civil society & academia
1 ----..,
~ gap gBrlEll'ation
ClOsng
"Back to the basic values and principles" • A
sense of direction for fragmented health systems
Starting from what people value • Health equity, solidarity, sodal exclusion
• Dealing with current and future challenges to health • While contributing to social values of equity, solidarity and social j ustice
• People-cen lered care • •
LIve in communities whose health is protected and promoted Health authoritles that can be relied on
• Respond to social expectations
•
Having 8 say in what affect their lives and that of their fammes
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-28-
4 + 1 ~o!!cy direct~ns to refocus health systems
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Addrft. hulth inequ.lities.nd flXcillllon by movinll towards unlwrJll coY~ • ImpllClitionllor e r;.ntmion d-.vie,
COftI: move 10000I'da unIv..-..J covelllge :
• ~ wffkient $uppty • ...mow /J«rffn /0 acetu • M.W. nJt:hJ hHIth ptOtKtJoo ~lpooIedpte~.
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Trandom conventional huJth care delNIf)' model. Into ptople-centred pt1m..-y en networts
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Transform eonventlonlt health CIII delivery modets
Into peopIt-cenhd primiry care nctwotb Key f _ 01 primety can:
II does not happen automatically
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- t:epfdy fo ~ {htitWonI. SIraItgic 1n~, _1rfdIJ - tepkJ response c.p«Ity
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Invest in inclusive leadershIp to govern the hllllth lector: From c:.om~d-&nck;ontrol to staer-and-negoti.att models
OI;enIEatiDn III ......
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FoeI4: def>oeron UJliverMI~ . • """P'~~.~"'. primary c.artI public poIieies; ~ ~1'It!Of stMI'fn; and MgGtiIIing R~tWty Clpdy WId InItMnentI to gowem proI'enli:l""
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-29-
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Buhd on partiel~on and civil society invo/vemltflt
Ensure health systems and wider govemment response takes Into accoont growing demand for improved: User partJelpatlofl . partieullrly In prtmary eire settings
- l ocal eommunlly moblliutJon ; COnsuml( empowerment
Ind protaction;
Where are we at this moment? • EB resolution • Planning implementation, reprilritizing, mainstreaming
• WHA • Reporting • Mobilizing: global, country • Crisis
-30-
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-31-
Session 2. Country Overviews. Papua New Guinea
"Health Systems in PNG" Refocusing on Primary Health Care and Service Delivery to rural majority and urban poor
Content of presentation - Back to basiCS • Global influences on local systems • call for improving capacity of health managers at all levels • PNGs reforms in health to improve service delivery • Focus at the district and local level
Dr. Clement Malau Secretary for Health
Global Initiatives Poverty (Make poverty history) Maternal health (Safe motherhood) " Interventions are up to each country or the donors interested in the country Newborn and child health (IMO) HIV (GF & various funds & initiatives) TB (Stop TB)
Malaria (Roll Back Malaria) Access to essential drugs
___ Global support for health II II
Numerous agencies support for health
Resources available for health is unprecedented • Economic down turn " Global warming • Shift from individualism to globalization
If global initiatives and resources are to make a difference Managers must play and important role at all levels to making a difference
-32-
.---
,
-
In PNG we want to improve management capacity at all levels therefore our focus on reforms is to address basic management issues.
--Our mission is to improve service delivery
___ Our accountability '.- . _.' 6,3 million and residents of PNG
-33-
"' ___ Acknowledged problems • Broken Health Systems • Lack of clarity in coordination at the national level • Lack of delineation of national and provincial functions • Poor Human Resources Management • Poor Assets Management • Poor Budget Management • Communications difficulties E Drug supply problems and governance issues
Health Corporate Plan 2009 2013 Human resources planning and management " Asset (infrastructure and equipment) planning and management " Information Communication Technology c Evidence based budget E
___ The national health plan , ~. 2011 - 2020 c Assess global and local situation I:l
Envision PNG of the future
c Assess provincial and local needs c Consultation and agreement on a single
So far our focus has been
vision c Address other factors that are beyond
health but affect health
Reforms in the health sector Service delivery to the rural majority and urban poor focusing on Primary Health Care • Central agency support and leadership is critical • At the sodal sector level "selling the human face of development" is critical • Health sectoral level we need to clearly articulate National Functions and Provincial Functions and manage systems better • Defining national and local function • Central level New executive team (retreats) - Improving governance - Making the system trustworthy • Multiple systems to a single system • Focus on service delivery • Development of community health post concept • Implementing the corporate plan
-34-
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ey Issues & lor th e ft u ure
• Avoid bottlenecks and ensure transparent and accountable financial processes for implementation of priority health interventions at the loca I level • Well costed budget and projections of health budget by 2013 Fve;\rBnt:tO-;ensu~ih;n""'-
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• Private public alliances • Private public partnerships • Enhance govemment commitment to health
"Clearly defining roles and responsibilities of systems and individuals in provision of health services in critical to identifying gaps in capacity so as to strengthen systems and individuals capacity to deliver health services at all levels; global, regional, national, and locaL"
---
---
-35-
Session 2. Country Overviews. Lao People's Democratic Republic
Director general of the President·of Admin.Council
Indicators • Population: 5,621,982 .. Life Expectancy: 61 -Males: 59 o Females: 63 -M:MR:
Service Delivery Model
",
IMR: 70 per 1000 Jive births • CMR: 90 per 1000 live birt:hs(2~Jjt1f~J "GDP/Capita: 810 (2008) to
• Village level: Drug kits: 5,561 (98%) (HWV) \ ", • Health centers: 789.ofwhich 10 are modernized ~'li.:.... by]lCA , delivered by MAlNurses ~l • District hospitals: 127 deliv by MD,MA . ~, o Provincial hospitals: 16 deliv.by MD, Specialists 4 deliv. By MD, Specialists • Central hospitals: • Specialized hospitals: 3 deliv.by Skills MD&Specialists • Private pharmacies: >1800 • Private clinics: >350 • Referral links: He-DH "PH'" CHiSH
Human Resources • Total: 11711 (femaJes:6751) • • • • • Post graduate: 582 Under graduate: 2,063 Middle level: 4,219 Low level: 4,707 No qualifications: 147 \
.)
Pharmaceutical/health Techn . • Improved facilities:laborarones,ulttasounds,fiuoroscopy,ECG,Cfs fibroscopy,cardio-sur.gery equipment • Essential drug policy, list • quality control system,drugs and equipements law available • Introduction and use intensive cares,eruiosurgery,trautnatology.neurosurgery,cardiovascuIar surgery,oncology surgery etc.. • Drugs&medical supply warehouses:J.centr,41'egions Uica) .. Domestic drug produ~on 62% market-screened medic.plants 15ooitems.pharm.factones 6 ( produced 880 items),med.equipment fac.l,traditional medic.labs 10 (28. items) . companies 40 ,private pharmacies
• Distribution issues: 1.8 per 1000 Pop • HR. priorities: (SBA,MA,FMA,FD,FSp) • High demand: Specialities( Enda-Surgery, • Neuro-surgery. Traumatology. Urology. • Cardia-vascular surgery, oncology.
-36-
• At National level: Department of statistic (MOI&P) • At Ministerial level: Depannent of statistic unified Iverticalized(reporting monthly, yearly) • NCs,NHS ( every 5 years) • NR,H&HR policies available • So far 4-5 year NHRMP Implementation (2007.2011)focusing on the strengthening of the quality ofMCH and access to rural poor, thus to strengthen the NHRSS in LAOPDR
• Total Health Expenditure (lHE)3.6 % ofGDP:11.5 S/capita: • Out of pocket 79.8% of TIlE ,OOP payment for drug, 48,3%,inpat =e 2S,2%,traditional healm 1O.4%,outpatient care 9,8%(LHS20 . Donor. 113% ofTHE - Domestic Gov. : 8.9"/. of THE • GGEonHea1tb :4.6%, • GGE on Health ofnIE: 202% • Social secwity fund of GGHE: 11.2% • Peroenta.gt of HE DD drugs 5% in the past.so tar subsidiu: with DRF • Hospital financial manapmeut system are being reformed lIS part of the "'good. gOvmwlce" effort:s of the govcmtnentIMOH, but iu also need to be integmed Into a broader information system to ensure timely. evidencebased decision making.
Health Financing • Health care fmancing includes the administration of revenue and expenditure within a system provided for by law and regulation for the purpose of ensuring for the population fair and equitable access to health care and to a better state of health. • HCF derived from: • State budget • Direct payment by patients • HI funds (CBHI, CSHI, comp HI,privau: HI,public Insurance or equity fund) • Social contribution • ContnbutioD from internat orgBllliOl!iI,ns,fon'in!:.couotri~
.nnitv
Issues
• Health care law approved by NA since 2005, determines the principles, regulations, different measures relating to the operations and urgent control of health care activities to ensure high quality and equitable health care services for all citizens, families and co=unities, so that they may enj oy a satisfactory state of health, to protect the right and the fairness interest of health care professionals
Challenges:in addition with 5 health -related MDGs by 2015 • Development ofHRFH & HRFHR both in quantity ,and quality
based examples of PHCIHS S that contribute to MDG achievement • The ~gresa I'q)ort prepared bytbe Lao government 'Nlth support from the UN In May 2008, surnrnarizcd ofbea.1th related to MD(], 15 follow: ~~~~;;~:,,';;_=46% to 33% (1992-2000) nWnutnrion rmWns a $I; attefttioo by both governmc:m IDd the
• Fwl PHe ,or;i~, rom.., & m • Strengthening MIS,DSS coverage ~ ' . • Sustainable health care financing,& univ -. coverage ofR! scheme -~• Community's ownership in health promotion, disease prevention as well as in health development
oq"'"
.BI
-37-
To scaling up effective intervention through "moving down" to grass-roots"from central, regional, districts. Strongly promoting/expanding healthy model villages. 2. Strongly promoting MMR reduction package 3. Strongly promoting child survival package 4. Strongly promoting nutrition package combining with disasters, epidemic, pandemic preparedness. 5. Strongly implement the DHR capacity 6. Strengthening organization ,mechanism, regulation and working methodologies. 7. Promoting sustainable health financing 8. Vientiane declaration on aid effectiveness implementation package j
• In addition, with the broadening partnership among the MOR and development partners, the sector working group for health have concentrated on respecting and strengthening MOR ownership and leadership, intensiiYing communication among the MOR and DPs, . and building consensus on various plans and strategies developed under SWGs through sector working coordination towards SWApproaches in the future.
-38-
Session 2. Country Overviews. Cambodia
Core Indicators Country Presentation Country: Cambodia Presenter: Dr. Sin Somuny Meeting on WHO Action in Primary Health Care and Health Systems Strengthening Manl!a - 14-15 Aptf 2009
Population: Life Expectancy: -Male: -Female:
Matemal mortality ratio: • I nfant mortality rate: Child mortality rate: GDP/Capita:
14.3 million 60-65 60 65 472/100,000 66/1000 LBs 83/1000 LBs US $419
Service Delivery Model - Who, what services, and how many facilities? Point of first contact: drug sellers/pharmacies, traditional healers, private clinics Village level: 2VHSGs/SD Households Health centers: 967 Primary hospitals: 30 Secondary hospitals: 28 Tertiary hospitals: 18 +
Human Resources Health workers1100D: 1.39/1 DOD (18592113.4 million population) Nurses (8720)/Midwives (3322) /Combination: 12,042 Doctors (2196) and medical assistants (1258):
3454 Distribution issues: remote areas vs. urban Quality issues: quality of SD & pre-service training HR priorities: Technical Skills & competency, remuneration, quality of work, distribution and retention
B National Hasps M~~k,g on \',HD ;.rtbn In "HC/H~'>
et? 'LJ
Referral links: HCs to RHs & RHs to NHs ,',flO
V.~I!:m PndfTc fl~
on-
Pharmaceutical/Health Technology Pharmaceuticals - Essential drug policy and list: Y - Quality control systems: Y (Pre-inspection shipment and post-inspection) - Private or public? Ministry of Health has more power to deal with the private sector - % of health expenditure on drugs: 33 %
I nformation and Research Briefly describe HMIS - Unified or verticalised: integrated but not completed - Routine reporting: • Regularity: Computerized monthly basis from 00 level • Compleleness:
only main core indicators
- Surveys Number. once very five year. CDHS by the NIS of Mol' Periodicity: Other surveys by dH'rerent national programs
Laboratory - Policy and regulations: Y
Health care technology - Policy and regulations: N
Research (NIPH: Operational Research) - Policy and Plan? DPHl's function but not it is more money-driven research topiC.
{tty
.VIIO
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on- M~[
Un~ on WilD Action In I'HC/lt55
-39-
Health Financing Total Health Expenditure (THE) $9/capita: ',.2 % of GOP: Government Health Expenditure 1.2 % of GOP: 12% of govemment expenditure: $9/capita: Private Health Expenditure Out of pocket -66 % of THE: Donor contribution 23% of govemment expenditure:
Health Sector Governance Describe briefly health govemance system - Predominantly public, private, or mixed Mixed but most people are using private sector, especially the non-formal one. - CentralizedlDecentralized Responsibilities More decentralized where the PHOs/Ods are responsible for service provision - Accountability mechanisms to the pUblic Mechanism exists but not well funtions - Aid effectiveness/Sector wide approaches
~
WilD Wc.Jt.em PoIIcllkRegJfln-Meel:ing onV.HO.r.etlon In J>iIC{ltSS
Inequitable health outcomes Cambodia: Under.S Mortalrty Rates by WHlth Qulntile, 2005
Primary Health Care/Health Systems Major Challenges HR: Skills, distribution, retention, and dual practices, leadership and management Logistic Management System: Procurement of drugs: excessive and shortage Health Care Financing: Require a mechanism which will promote equity and efficiency in a low in-come country Governance system requires active community participation
140,---",------;,.__-----------,
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Ride for 1O-yearl)eriod preced.,,, ltIe survey_ Souree: CDHS. 2!l05.
®
WHO Wate'l1 P.IIClrtc
fteg\cn-MeeUl"~ NI\I,'I\OActJonill PHt/HSS
Evidence based examples of effective interventions in PHC/HSS that contribute to MDG achievement Health Equity Fund Contracting Incentive Mechanism to health staff (MBPI, PMG) NGOs' best practices on preventive and promotive interventions at community level and promoting good governance by raising awareness on clients' rights and making them actively partiCipate for better services ~ WHO Wffiem P.ldlic RegIon - M"'cltna on WHO Actio" In fiNe/US!>
Requirements for and Obstacles to Scaling up Effective Interventions Supply side • capacity building • More resources are needed • The change in leadership and management Demand side • Capacity building for grassroots/local NGOslCSOs in both skills and institutional development (leadership, advocacy, and facilitation skills) • Resources to strengthen community structure strengthening.
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WIlO WCliIc.m P.1Cfjc:
R~ (111- Mt~!m!J(;~ WilD A~'m Or"! PHC/tISS
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Session 3. Discussion of issues and possible actions from Country Overviews
MAKING PREGNANCY SAFER (MPS)
MUONG PREGNANCY SAFER. (MPS)
Meeting with RD (4th Feb 2009) Improving MNCHIRH in LAO, CAM, PNG through
• Proposal (Road Map) • Situational analysis (Laos) • Contacted Laos (CO) "One size does not fit all': but there are commonalities in the three countries
Strengthening Health Systems
MUONG PREGNANCl' SAFER (MPS)
MAKING PREGNANCY SAFER (MPS)
Key principles for the ROAD MAP HS Strengthening PHC focus District focus (to support PHC)* Uses proven experience * Can be made LINEAR ROAD MAP Research on ~Role of District Hospital as First Level Referral for PHC'
MUONG PREGNANCl'SAFER (MPS)
MUilN'G PREGNANCY S.4.FER (MPS)
4 Pillars of HSS • relevant Pillar 1 Pillar 2 ~ WHO at cOuntry
F/wprK with 6 building
PrOg. to'NorK tog, to produce results
Experience of Malaysia & Sri Lanka The FACTORS leading to poor status (see slide #3) are seen in LINEAR way as a "ROAD MAP" in phases
blocks
Pillar 4 WHOlniern8tl6nal agenda
(the foundations) We are doing this in this imp, plan!!
(in many sub-phases)
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M,-Ua:NG pJt EGNA.NCYSAFER (MPS)
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, r>hase I \. ~
\ lo. _Ph~."
Commendable initiative of LAOS, "Strategy & Planning F/work for the Integrated Package of MNCH service II .Phase III
2009-2015" / OBJECTIVES anJs STRATEGIES - WHOreO had asked for assistance from RO - -Inter dept and inter unit working together - continuum of care, social determinants, HSS
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"........
to use this as BASI,J; using the 3 STRATEGIC
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Appencflr;.2.: The trIIndafmatamal mDrtallty 1/1 Malaysl.,
frgm
111l3-199t1
MAKING PREGN.I\NC}- SAFER (MPS)
MAKING PREGNANCY S.u'Elt (MPS)
1_.Leade.r:ship,1
Governanee
IHe,~1th Illfo.fmation I i f:"Ie~lth woi-kfor<:e"Medical Product~
& .T~~tm9Jogv
,.- Su-pporHve
E!}_vltoS'lffl_l!:!Its
M.UUNG PREGNANCl.' SAFER (MPS)
MAKINGPREGNANCY.SAFER (lIfP6)
Therefore
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BSTRATEG/S .~ "
~
ATWST 190 Arni::ms to be ctJrrie<:/cut
Next steps ............ . How do we work from these 3 Strategic Objectives to fit into "Improving MNCH thru HSS", with a ROAD MAP? that focuses on • PHC
• District mgt
Almost ALL these are HSS activities
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MAKING PREGNANcY SAFER (MPS)
M.UilNG PREGNANm' SAFER (MPS)
or Uu Yunguo's suggestion 1. Blground
Presented to RD, Directors, DHS & DHP
4 PrOjeetCk!scription
2. Challenges 3. GoalslObj.
.S~~~U)Dn HIS at eiD5s~ts ,'"
·o,;ilvo~ I~~g~tcd MNCH packa9c ·Pro~ Coordination -!Ulds.~
5. Costtfinanclng G. Implinr~n1!'tion arnnge~nts 7. M&E 8, ~lsksIBenerrts
The assistance shall initially focus on two districts in a province has been selected, as a phased implementation of a plan and not as a pilot or demo project. Funding - assistance from Rep of Korea
We need to align these
to the existing Framewoi'k
M.UilNG PREGNANcY S.ti'ER (MPS)
Only certain limited endpoints/outputs/impact are expected to be visible by end of the year; not expected to show reduction in mortality rates. However, some morbidities may show visible change. J;> Process or service use indicators are expected to improve such as family planning, antenatal care and especially births attended by skilled birth attendant (SBA) J;>
,. Intensified TA from WHO to mange the project :> Repair of run-down infrastructure, purchase of supplies and equlpm.n~ can be carried out almost immediately. ~ Several hospitals are in dire need of service improvement, especially in emergency obstetric care which is central to MPS ;;.. A major and predictable pitfall is human resource - in terms of quantity, quality and distribution as revealed by the study by a consultan~ the Laos government is planning to take steps to improve the midwifery situation including remuneration .
. MAKING PREGNANCl" SAFER (MPS)
M.UilNG PREGNANCl" S.U'ER (MPS)
Immediate next steps 1. 2. 3.
4. 5.
Recruit the professional/manager Consult Laos Gov!. for selection of two districts in first phase Use the existing plan on integrated MNCH oackage which is based on HSS, and see the "best buys' that WHO technical assistance can offer Work out the detailed cost estimates use this for scalingup and expansion to other districts Involve Laos in all relevant intercountry activities being planned such as IFC workshop, needs assessment of EmOC, identifying costing tools, etc.
Government to provide - Management: to do things right - Leadership: to do the right things WHO to provide - TA (capacity building, HSS etc) - Evidence -Advocacy In all these - to work with partners
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Session 6. WHOfWPRO Action on PHCIHSS. RCM Resolution and Hi-level Meeting
Consultation on Regional PHC I HSS Strategy in preparation for the High level meeting, June 2010 Regional Committee, Sep 2010
ReM Resolution PHCfHSS Sept. 2008 - Mandate to WPRO Accelerate support in HSS/PHC Increase tech nical aSSistance • Adhere to Paris Principles of Aid Effectiveness Asia Pacific Observatory on Health Systems and Policies Regional HSS/PHC Strategy - to high level meeting (2010) and to RCM (2010)
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WIIO
W~tm PlldfieRCilICIl-Mcctlllll cnWIlOAct\gniM PHCfHSS
3 Strands of PHCIHSS Work
Getting to a Consensus Within division - Avoid health systems silos Across divisions - Finding the diagonal approaches with colleagues in WPRO and increased coherence of country programmes With partners - Incentives for a systems approach? With countries - What end produc:t? Broad enough for consensus. speCific enough to make a difference
Regional HSS/PHC Strategy
KO Actlolt In PjlC}HSS
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WHO Weril!t'Il P ...
dfleReC'I~-MDGl.inli[lnWHOActJOI1 In I'IlC/HSS
st
Draft strategy
Consultation processes • Part of planned meetings for substrategies: -Financing, Drugs, Lab services
• Written by WPRO secretariat • based on expert meetings (Aug 2008, April 2009), comments from ReM, and existing strategies and documents • by July 2009
• In-country consultations - 3rd and 4th quarters 2009 -Contract a researcher or institute -Guided, focused format - e.g. key informant interviews, focus groups and a validation round table
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Consultation processes (2) . • Collate findings • Revise draft early 2010 • High level meeting June 2010 • On agenda at RCM Sept 2010
Purpose of in-country consultation • Expose more people to the strategy • Obtain views from more people - 1 or 2 per country cannot validate an entire PHC/HSS strategy • Ensure participants at the HLM have at least heard about the strategy
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\'.HJ \'.cslun Plldllc RI'!J "n-"Meeting pn .'J/lOAetlcn In 'PIlC/IIS!>
Your role • Comment on feasibility of approach • Facilitate access to right people • Ideas on possible researchers • Ideas on key strategy statements
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WIlO ..·.C.Ii!cm PlIr;JncRClIlcn - Mec\ nil
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,',ttO ;.,\J:ln In PItCfllSS
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Session 6. WHOfWPRO Action on PHCIHSS. Health Care Financing
Meeting on WHO Action in PHC and HSS, 14-15 April 2009, WPRO
HCF Strategy review and update Bi-regional HCF Strategy (56th RCM in 2005). Midterm review in 14 countries (Jul-Oct 2008). • • • • • Progress report. Updated strategy for 2010-2015. Technical consultation (25-26 March, 2009). ConSUltation with countries (27-28 April, 2009). Submission to ReM (September 2009). ~ WIIO Wc:stcm
HCF Strategy update D. Bayarsaikhan, Regional Adviser, HCFMlPRO
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..
HlO We$lem p4>:ln, flOSlIarJ- MClltinll on V',IIDAttlon In PHC/IfSS
Plll;Jrr~ R~lon - M~ctJng On WHO AclJon In PIIC{HSS
Main issues High OOP - access, catastrophic spending, poverty and impoverishment Low levels of govemment health spending and investment Low coverage of SHI and financial protection. Absence of safety nets for the poor and vulnerable Efficiency: - resource a!!ocation and low priority to PHC, - budgeting and resource management practices, - use of medicine and diagnostic services, • health workforce and provider payments .
Strategy Strategy for 2010-2015: 1. 2. 3. 4. 5. 6. 7. Increase investment and public spending on health Increase prepayment and pooling Strengthen safety-net mechanisms Improve efficiency (purchasing methods) Improve aid effectiveness Improve evidence and information for policymaking Improve monitoring and evaluation of policy changes
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WHO WjUtem Plldflc Ite.glon-Hcu:Unll en WJlOA!;tlDn
In
PHC/"s.s
Guiding principles Universal coverage and access. Strengthening health systems based on PHC Application of health financing policy norms to reduce
OOP. Supporting evidence based policy and implementation. - Reduce the share of OOP below 30% of total health expenditure; - Attain over 90% population DDverage by various risk·pooling and prepayment arrangements - Increase public financing on health to reach 4-5 % of GOP with 50-70% share of total health expenditure;
Thank you
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WHO Western POlClJiC RCtJlan -Mcclinllcn WIIO ActiO'11O PHC/tfSS
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Session 6. WHOfWPRO Action on PHCIHSS. Traditional Medicine
Regional Sb'ategy for Traditional Medicine in the Western Pacific (2001 - 2010) Develop a national policy for TM Promote public awareness of and access to TM Evaluate economic potential of TM Establish appropriate standards for TM Encourage and strengthen research into evidence-based practice of TM • Foster respect for the cultural integrity of TM • Formulate polides on the protection and conservation of health recourses. • • • • •
What WHO is doing ~ Traditional Medicine N • Develop national policy and regulation on traditional medidne • Develop appropriate standards on traditional medidne • Establish and operate Regional Forum and network on traditional medidne • Stren~then the quality of academic education on traditional medidne • Strengthen safety, efficacy and quality of traditional medicme in the Region through evidence-based research • Promote rational use of traditional medicine through the dissemination of Information of treditional medidne for practitioners and consumers
. , Strategy review and .UPdate
Survey on Regional Strategy for Traditional Medicine
COuntry assessment on implementation progress of the strategy Expert consuttatlon to revieW and revise strategy Region~1 workshop to review draft: strategy Regional committee presentatlon Focus areas
To collect updated information on the implementation of the Regional Strategy for Traditional Medicine in Member States To identify specific needs of each Member States regarding capacity building on Regional Strategy for Traditional Medicine.
•
Recognizjng TM as one of the recourses of PHC services Increasing availabfJlty and affordability ofTM Proper use ofTM Safety, efficacy of TM Evidence based approach
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Beijing Declaration Adopted by the WHO Congress on TM, Beljing~ China, a November 2008
• Respect, pneserve, promote of TM • Formulate national policies, regulations, standards as part of national health systems to ensure appropriate , safe and effective use of TM • Integrating TM into their national health systems • Establish system for the qualification, accreditation or licensing of TM practitioners • Establish appropriate training programmes for health professionals, medical students and relevant researchers
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Session 6. WHOIWPRO Action on PHCIHSS. Pharmaceuticals
-i
Regional Strategies for Medical Products and He~lth Technologies
~
I Essential Medicines in the Western Pacific '& Region (2005 -2010) - functions & process • Guide for actions in improving access to essential medicines for • Member States • WHO
Regional Strategy for Improving Access to
• Pharmaceutical program • Regional Strategies for Improving Access to Essential Medidnes in the Western Padfie (2004 - 2010)
• Traditional medidnes • RegiOnal Strategy on Traditional Medidnes for the Padfic (2001- 2010)
• Consultattve process invoMng experts: from wit,in and outside WHO and Member States. • Endorsed by WHO Member States during the RegionaJ COmmittee meeting in September 2004.
western
• Health technology Asia Padfic strategy for Strengthening Health Laboratory Services (2010 - 2015)
• The implementation wO'Jld also depend on the exiSting hearth system cllnd taking into account the national priorities, legislation and administrative framework. and resources
Regional Strategy for Improving Access to ESsential Medidnes in the Westem Padfic Region (2005 -2010) - technical contents Issues & challenges and the recommended strategies & actions 1. Rational selection 2. Rational use 3. Affordable price 4. TRIPS/trade globalization 5. Sustairlable financing 6. Reliable supply 7. Quality & combating counterfeits 8. Monitoring
..... WHO actions? Country technical supports to improve access to good quality essential medicines and their rational use by providers and consumers National medicines policies de"eIopment, monitoring. evaluation
• =~~;a~~rt':"TRIPS, prtlcurementand ~
Medicines regul9tDry system, q~lIlJty tiStJJ'a11IE &. combating counterfeits • Rabonal use &. safe use of medicines Good governance in medICines I0pid Alert: System on cvull~mediclnes &. Enforcement operatiOn Regimal price information exchange
Inter country supports &. information exchange mechanism
Inter CDuntry meetings to sha~ experiences Newsletter, electronic: dlsr;uss:ion network for PIes
- . Current review and revision • Survey to identify actions undertaken by member states • In depth analysis of strengths and weaknesses in some selected cDuntries; cambodia, Laos, MalaYSia, Mongolia, China, the Philippines • ReYisiOfl of the draft st::n5tegies based on the findings
.. ExPert consultation 1D review the draft revision • RegiO/"lal inter--country consultation to review the draft revision • Presented during the ReQionai COO1mittee Meetit\9 in 2010
• Development of implementation plan
New focus
• Effective financing mechanism • Consumer empowerment • InteractlnQ wft'1 p~ sectors
• Innovation &. appropriate technologies to improve access
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Session 6. WHOIWPRO Action on PHCIHSS. Health Laboratory Services
Total population; 1.76 billion (27% of the worlds' population) MA.POP' THE ~RN PACIFIC REGION
Asia Pacific Strategy for Strengthening Health Laboratory Services (2010-2015)
Dr.Gayatri Ghadiok
WPR - situation analysis** -_ _ •__ -
Challenges In almost all the developing countries, the issues being faced by laboratories are same - their complexity and spectrum may vary but essentially the chaDenges are the same. Various units within WHO (dealing with laboratories) have been wor1dng independent of each other and to some extent in isolation.
Low national priority No labontory pollcv &Jor plan, focal point (., the NloH)
_ Multiple proWlers
- Inadequate resowces :
_
l...ek of coordination I.nd planning: public, priY8te and
._:_---_:_--._,---._,--
leads to duplication of efforts and rescurces ~_
t:Ontrol prtlgfmTll:
How to align with natiDnal pclicy ? Adc1ress the fragmentation and integration issues across the GHI How to coordinate donor aid (eg.GFATM)
-
\/Veale quality and ufety systems
_ RagtJIlitory ~.ms ineffective
Goal of Strategy To provide comprehensive laboratory support to public health and curative services leading to improved health in Asia Pacific. This is a guidance document and will be used for undertaking advocacy with the national authorities Assist them in developing their own national strategies And plans for strengthening health laboratories
Objectives 1. 2. 3. 4. 5. 6. 7. National coherent framework Sustainable Financing Building Capacity Assure Quality Promote Rational Use Improve Safety Support Research
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Issues narmonization with _ PriVatelle~r
Role of WHO Perform normative and technical support function for implementation of the strategy Assess current status using a standardized methodology iquestionnaire Develop appropriate documents - how to develop policy, plans, standards, network etc
Iabo~tories
in other s-ectol'S
_ -
Re.se.ar<;h.nd tsachini InsliUtioni <ertiaryeat. f'lDspitals
Integration of laborstories dedicated to vertical programs Better CDordl~ation. c:ommunication.
Uni<.s to other programs - MeH, NCO Address ditf8l'ent levels offunctions Mana!lement ,procurement attd logistics issues :Jonoraid coordination
Financing met;henisms thlllere sustainable at'Id acceptable Monitoring mechanism
• Assist countries in implementing these.
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WHOfWPRO Action on PHCIHSS. Human Resources for Health
Key Result Area
Strategic Objectives .H\V planning & development is an integra! part of national development planning and responsive to population and service needs -HW size, skill mix and distribution -HW needs and support to ensure optimal retention and participation .Quality of education and training • Policy and regulation
I
Meeting on WHO Action in PHC and HSS
1. Health workforce response to population needs (demand) 2. Health workforce development,
Session 6 Regional Strategy on Human Resources for Health (2006-2015)
deployment and retention (supply) 3. Health workforce governance and
-Leadership and management .Nationalleadership and coordination -Advocacy for political commitment & resources allocation -Partnerships and Alliances.
management Support for Strategy implementation.
Provess " Outeoma (Oct.Z006 to March 2009)
Notes The strategy guides WHO Collaboration with Member States and provides policy options and strategic actions that Member States could consider in addressing their national health workforce needs WHO support and collaboration has been flexible to meet emerging needs /priorities Meeting on how to accelerate implementation planned for August 2009 evaluation of progress in 2010
RqW04l -MirWDwn dataset foI" DU!SI:S lmidwives; T=nplm for country HRH profiles; Simplified wod:fan:c pWmiaa tool:
IIJrc-/m-collntry
l~
• S1rengtbcc bwth w~rkforcc databases (> 10 cowm:ies) .Development ofnational HRH policy fr2mewcrk and stmegic ~oas (5 c:oUIltrics) oE4ucation md tn.ining ofbealtb worlam (most wamrics.and areas) oI>cvclopmcot amd delivery of oolilte health courses tbrOllgh POUiN (l2 PIC) oClmicula reviews iUld support for faculty development (3 coWllries)
Tcc:ba.ical support h HRH sitl.:IiDlUll cW)'Iis Jassw;mcms. _Quality rwun:nec Md SIaDdards iD bcahh pro{ess:iODS cducatiou; Cani..w. rievelopmcDl: iIldudiq COR c:ornpctcllcie:s;
'"for
Support for education and ~ (FeJlowrrups); Guidance oaHRH pJarmiDg
·Cock ofpRCtiec for ~ ofhea1tb workctr. Tcdmical NpPOrt b' hiah level. eousult:atian£ 011. ~ Nu.rsiDi l.ca&cnhip
ChaD&c programme.
.Pacmc Code of Practice for ~itrnaI: of Health Wcri:eB: High level COII!uIu.tions 0!1 HRH (4 CDUDtricu); Gr01lp traming in health bdcnhip and management (4 coulltriet) ofR.CB QD. HRH in Mongolia.; o Pacific Human Resources for Health Alliance (pHRHA)
oPaei6c Hcaltb. Minislen: Mc:crina on HRH
agtIId& items; ColJabomicm with the Asia paQfic Aaion AlliaDcc on HRH
Points raised in 2008 meeting Importance of primary care workers and Family Physicians; multi-skilled teams; fair remuneration flncentives; performance & retention; quality data, eVidence, innovative strategies; partnerships Quantity and quality of HW
Global level action EB124.R8: Urge Member states to train adequate numbers of health workers, able to work in a multidisdplinary context, in order to respond effectively to people's health needs WHO Guidance /recommendations on increasing access to health workers in remote and rural areas through improved retention
WHO support Iroles: Knowledge base (evidence, good practices) HRH planning Standards !Guidelines Managing migration & advocate for ethical recruitment
Fadlitate policy dialogue & partnerships
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Session 6. Recurrent Themes for Strategic Choices for WHO
Recurrent Themes Recurrent Themes for Strategic Choices for WHO Long term, consistent - permanent • Need for evidence based boldness • Coordination - Tailored to situation - Support to country, in some situations leading - Do people/agencies/countries really want it? Leadership - to levels outside MOH - Finance/planning/Prime Minister - Healthy public policy - sectoral/cross-sectoral
Recurrent Themes WHO as implementer - different perspectives expressed (implications on honest broker role, coordination role) Management - cross-cutting - Leadership - choosing the right thing - Management - doing the right thing rightly • Managers needed at all levels • HSS expertise, not necessarily experts at all levels More focus on service delivery
Recurrent Themes • Information clearinghouse - best practice (honest broker) - Facilitate/coordinate access - Synthesis of multiplicity of gUidance - Observatory functions Information systems - (country) - (HMIS - cross-cutting) leT (innovative uses to address obstacles)
Recurrent Themes Focus on outcomes - holistic - avoid unconnected pockets of policy or activityhow to tie it up at country leVel - HRH/HCF - complex, interlinked - cannot solve independently - HTL (Drugs and Technology/Labs) - ditto
Recurrent Themes Define a functioning PHC system - (debate on minimum as a term or not - PHC is not poor care for the poor) - Evidence based audit (HSPA is our jargon) - Develop a road map (normative + country specific) - Monitor progress Integrated/Comprehensive - Priority setting (Is this vertical/horizontal debate in other words?)