WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fifty-eighth session Jeju, Republic of Korea 10–14 September 2007 Provisional agenda item 14
WPR/RC58/11 23 July 2007 ORIGINAL: ENGLISH
PEOPLE AT THE CENTRE OF CARE INITIATIVE
Health care quality and patient satisfaction are enormous concerns globally, and are the focus of the health agenda of a growing number of governments, professional organizations, health care institutions and health-oriented groups. Beyond the basics of access and coverage, health care quality and responsiveness to multidimensional needs, legitimate demands and expectations of patients significantly impact health. But global and regional trends indicate that current health systems and services need to be reoriented to promote and preserve health in its fullest sense: "complete physical, mental and social wellbeing and not merely the absence of disease or infirmity". Pursuant to Regional Committee resolutions calling on WHO to support Member States in ensuring that the formulation of health policies gives due consideration to the broader psychological, cultural and social determinants of health, the WHO Regional Office for the Western Pacific embarked on the People at the Centre of Care Initiative, in collaboration with the Regional Office for South-East Asia. A draft policy framework has been developed to provide policy directions and practical guidance to Member States in reorienting their health systems to provide balanced, holistic and people-centred health care. The Regional Committee is requested to review and endorse the draft PeopleCentred Health Care: A Policy Framework.
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1. CURRENT SITUATION
Modern medicine has made impressive progress over the last century, but surveys show that about half of patients are dissatisfied with current health care, and roughly the same proportion see no significant improvement over a five-year horizon according to the International Alliance of Patients’ Organizations. This state of affairs is evident even in developed countries. To Err is Human, a watershed report by the Institute of Medicine of the United States National Academies of Science brought home the sobering fact that practically one in every two patients in the United States is subject to unsafe and poor quality health care, and ends up unnecessarily worse off for the experience. It is clear that more than 20 years after the landmark Alma-Ata Declaration, health systems are still struggling with issues of quality, safety and responsiveness to patient needs, legitimate demands and reasonable expectations. Economic, demographic and social forces have increasingly put
pressure on health systems not only to provide universally accessible, effective and scientifically sound health care, but also to ensure that services are designed and delivered in ways that respect patients' rights and suit their needs and preferences for information, psychosocial support and participation in decision-making for their own care. The need for innovative, balanced, holistic and people-centred approaches to health care has become a matter of urgency for countries and health systems worldwide. Concerned about these worrisome developments, Member States of the WHO Western Pacific Region have adopted various resolutions addressing broader issues and determinants of health as they significantly impact health care, health outcomes, satisfaction with care, and overall population health and well being. The Regional Committee, in resolution WPR/RC55.R1, requested the WHO Regional Office for the Western Pacific to work with Member States, the WHO South-East Asia Regional Office and relevant experts to produce a health situation report covering Asia and the Pacific, paying due attention to the special circumstances of small island countries and to streamline data requirements to ensure efficient collection and analysis in preparation of the report; to produce, in collaboration with Member States and the WHO South-East Asia Regional Office, a draft policy framework reflecting the significance of psychosocial factors affecting health outcomes; and to present the health situation report and the draft policy framework to the Regional Committee at the appropriate time.
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In resolution WPR/RC54.R2, the Committee requested WHO to support Member States to improve the quality of health care and ensure that broader psychological, social, ethical and cultural determinants of health are taken into account. The Regional Committee, in resolution WPR/RC53.R6, requested WHO to work with countries to encourage the integration of principles of equity and fairness into health policies and to ensure that the development of WHO programmes is firmly grounded on ethical principles. In relation to the strengthening of essential public health functions, the Committee in resolution WPR/RC53.R7 also requested WHO to promote the reorientation of health professionals, managers, policy-makers and government institutions in the Region towards public health. It is notable that WHO's strategic objectives for 2008–2013 include, among other goals, achieving universal access to services through health systems oriented towards equitable gains that respond to people's needs, legitimate demands and expectations. Resolution WPR/RC55.R1, adopted by the Regional Committee in September 2004, prompted the WHO Regional Office for the Western Pacific to embark on the People at the Centre of Care Initiative as a biregional effort with the Regional Office for South-East Asia, with strong support from the Government of Japan. The initiative produced a document outlining the pertinent issues and providing a solid basis for the draft policy framework on people-centred health care, the formulation of which was founded on an analysis of health development patterns and trends, including current evidence and practice. The process included a reference group of experts who met twice, in July 2006 and in March 2007, as well as stakeholder consultations in selected countries in the South-East Asia and Western Pacific Regions, namely, Bhutan, Malaysia, the Republic of Korea and Thailand.
2. ISSUES
WHO has published relevant studies and reports addressing the issues and challenges faced by today's beleaguered health care systems, particularly in relation to putting people at the centre of health care. Key considerations include the responsiveness of health systems (The World Health Report 2000), the importance of mental health issues (The World Health Report 2001), patientcentredness as a core competency of health workers (The Challenge of Chronic Conditions: Preparing a Health Care Workforce for the 21st Century, 2005), and being patient-centred as a key
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dimension of health care quality (Quality of Care: A Process for Making Strategic Choices in Health Systems, 2006). A literature review and consultations with stakeholders and experts clearly pointed to the need for health systems to move beyond the traditional models of providing health care and of measuring health system performance. A number of major gaps and weaknesses in current health systems have been highlighted: • Health systems and services have become overly biomedical oriented, disease focused, technology driven and doctor dominated. There is a need to restore balance in health care including the health system itself. • Health care financing mechanisms have not been optimal, pushing provider behaviour towards inadequate care: short consultations, lack of referrals, under- or overservicing in relation to financial incentives, inadequate case management and discontinuity of care. • Medical education has increasingly concentrated on body systems and disease conditions. The broader and important aspects of cultural context, psychosocial factors, medical ethics, and communication and relational skills, among others, have been neglected. There is a need to emphasize not only technical quality but also the experiential elements of care. Workforce development and policies should also be reviewed accordingly. • Specialization and weak referral systems have led to fragmentation and discontinuity of care, both within and between health care institutions, and between the formal health care system and other sources of care, such as support groups and the community. There is a need to adopt a team approach that involves specialists, general practitioners and other health workers across the spectrum of the health care delivery system, down to the caregiver at the household level. • There is little patient and family participation in health care, abetted by factors such as low levels of education and health literacy of patients, limited availability and sharing of understandable and culturally appropriate information and education materials, and short and hurried consultations.
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•
Although a people-centred approach to health care is predominantly focused on direct health care experience and on the provider-patient encounter, it needs to encompass all health care constituents. Even as it addresses the wider context of the patient and his or her environment, it also gives due consideration to the needs of the health care provider who should be enabled and supported to provide holistic care. Health care organizations and the larger health system must in the same manner be designed and developed to provide a conducive and supportive environment for people-centred health care.
•
While health systems have diverse socioeconomic, cultural and political contexts, a people-centred approach to health care is relevant to and needs to be adopted by all forms of health systems at all stages of their development. Good practices have come from both resource-rich and resource-challenged health systems, showing that positive changes can be achieved with the judicious and appropriate use of current capabilities.
A paradigm shift in health systems towards people-centred health care that restores internal harmony and balance to individuals, as well as harmony and connectedness between people and their environment, promises many potential gains. These include increased patient safety, improved
adherence to care plans, improved treatment and health outcomes, increased patient satisfaction with care, and improved quality of life for patients, their families, the community and society at large. The benefits of people-centred health care also spill over to the provider side in terms of provider satisfaction, patient trust and loyalty, good public reputation, and a cost-effective and sustainable health system resulting from appropriate health care use by empowered patients.
3. ACTIONS PROPOSED
The draft People-Centred Health Care: A Policy Framework cannot and does not exhaustively capture all possible policies and interventions that can potentially contribute to people-centred health care. It does, however, comprise four policy domains corresponding to key health constituencies where priority interventions could be identified. The framework envisions a paradigm shift to optimal, holistic and people-centred health care in the 21st century, driven and sustained by: (1) informed and empowered individuals, families and
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communities; (2) competent and responsive health practitioners; (3) effective and efficient health care organizations; and (4) supportive health systems. The Regional Committee is requested to review and endorse the draft People-Centred Health Care: A Policy Framework.
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PEOPLE-CENTRED HEALTH CARE: A POLICY FRAMEWORK (DRAFT)
1.
Introduction In recent years, within the World Health Organization and among its many partners in health,
there has been increasing interest in the patient's perspective of health care and how health systems can better respond to the needs of patients and other health care consumers and constituencies in a holistic manner. Previous recommendations of Member States through the WHO Regional Committees for the Western Pacific and South-East Asia reflect the need to pursue work in the following: equity and fairness into policies; the development of programmes firmly grounded in ethical principles; the quality of health care and patient safety; human dignity, patients' rights and needs, and the role of families, culture and society; the broader psychosocial and cultural determinants of health; and ethics related to medical practice, research and education. These issues have widespread relevance and significance. Improving health care quality and safety and enhancing the patient's experience of care require attention not only to health system design but also to the focus and process of patient care. How to best use information about the needs and expectations of patients and other health stakeholders as a set of organizing principles for the design of health care systems is a shared challenge across countries in the Asia Pacific region. A people-centred approach to health care is largely focused on the patient and his or her direct care experience, which is largely shaped by the provider-patient encounter. But it also encompasses all health stakeholders. Even as it addresses the needs of the patient in the broader context of his or her environment, it also gives due consideration to the needs of the health care provider who should be enabled and supported to provide holistic care. Health care organizations and the larger health system must in the same manner be designed, developed and managed to provide a conducive and supportive environment for delivering people-centred health care. People-centred care is a choice. All health stakeholders are jointly claim holders and duty bearers. In an economic sense, a state of equilibrium is attained and optimal societal benefit is achieved if both the supply and demand sides of the health care system are satisfied in their dealings with others in the system—policy-makers, health care managers, health practitioners and other health
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workers on the supply side, as well as patients, their families, the community and society at large on the demand side. Any of these health constituencies can play multiple roles in this dynamic system. 2. Rationale for people-centred health care and health systems The achievements of modern medicine over the last century are impressive. Advances in diagnostic procedures, non-invasive interventions, pharmaceuticals, and effective health promotion and prevention strategies have greatly improved the ability of health practitioners to diagnose, manage and treat numerous health conditions. However, health systems have reached an important turning point. Globally, population health patterns and outcomes are changing as the burden of disease shifts from infectious diseases to chronic diseases. Diabetes, depression, cardiovascular disease and
disabilities now account for over half the burden of disease globally and in the Western Pacific and South East Asia Regions. This trend is expected to continue, representing a major challenge to today’s health systems, particularly as the shift in the burden of disease increases the need for people to have continuing contact with multiple practitioners in the health system. At the same time, higher levels of education, increased availability of information, rising consumerism and greater access to goods and services are altering community expectations of health care delivery. With basic health infrastructure and essential health services in place, people now expect health systems, health care organizations and health practitioners to move to a higher level of performance and adopt a more humanistic and holistic approach to health care, where the patient is viewed and respected as a whole person with multidimensional needs. This people-centred approach is increasingly recognized as the future of health care, because it addresses key global health issues of interest to patients and health consumers. It is well established that people are dissatisfied with health care as it generally fails to meet their needs, preferences and expectations. According to the International Alliance of Patients'
Organizations, a cross-country comparison of the perceptions of health care quality revealed that overall, about half of patients are dissatisfied with current health care and roughly the same proportion see no significant improvement over a five-year horizon (A Survey of Patient Organizations' Concerns: Perceptions of Healthcare 2006). Patient safety is a global issue. The World Alliance for Patient Safety reports that the risk of health care-associated infection in developing countries is 2 to 20 times higher than in developed
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countries. In some, the proportion of patients affected by a health care-acquired infection can exceed 25%. At any time, over 1.4 million people worldwide are suffering from infections acquired in hospitals, and up to 10% of patients admitted to modern hospitals in the developed world acquire one or more infections. The persistence of such high levels of unsafe care, which is largely avoidable, is alarming. Responsiveness of care is another important issue. It is one of three key measures of health systems performance identified in The World Health Report 2000, Health Systems: Improving
Performance. It addresses people's non-medical expectations and comprises: respect for people, which covers respect for dignity, confidentiality and autonomy; and client orientation, which covers prompt attention, quality of amenities, access to social support networks and choice of provider. The World Health Report 2000 noted that poor populations receive the worst levels of responsiveness and emphasized that "recognizing responsiveness as an intrinsic goal of health systems establishes that these systems are there to serve people, and involves more than an assessment of people's satisfaction with the purely medical care they receive." These are important aspects that are clearly beyond the realm of biomedicine and specialized models of care, where other factors such as psychosocial, cultural and broader environmental determinants of health are unduly neglected. The need for patient-centredness has become an important global issue, having been identified by the Institute of Medicine of the United States National Academies of Science as one of six attributes of health care quality, the others being safety, timeliness, effectiveness, efficiency and equity. The literature is replete with studies using various operational definitions of patient-centred care, but in addition to the features included under WHO's definition of responsiveness, other common themes are emerging, including but not necessarily limited to the following: listening and communicating, emotional empathy and support, information sharing and health education, coordination and continuity of care, transparency, accountability, cultural appropriateness, and participation in decision-making and care. The International Alliance of Patients' Organizations, the Picker Institute, the International Diabetes Federation, and the British National Health Service, as well as the Commonwealth Fund and the Institute for Healthcare Improvement in the United States of America, among others, have been in the forefront of patient-centred care initiatives, and have noted that gaps in patient-centredness are found in varying degrees in various health systems and settings, even in the Asia Pacific region where cultural and traditional moorings are relatively strong.
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WHO has published relevant studies and reports addressing the issues and challenges faced by today's beleaguered health care systems, particularly in relation to putting people at the centre of health care. Key considerations include the importance of mental health issues (The World Health Report 2001), patient-centredness as a core competency of health workers (The Challenge of Chronic Conditions: Preparing a Health Care Workforce for the 21st Century, 2005), and being patientcentred as a key dimension of health care quality (Quality of Care: A Process for Making Strategic Choices in Health Systems, 2006). If health systems are to move beyond the traditional models of providing health care and of measuring health system performance, greater attention to health system design, financing mechanisms, and the focus and process of care is required. A number of major gaps and weaknesses in current health systems that need attention have been highlighted: • Health systems and services have become overly biomedical oriented, disease focused, technology driven and doctor dominated. There is a need to restore balance in health care including the health system itself. • Health care financing mechanisms have not been optimal, pushing provider behaviour towards inadequate care – short consultations, lack of referrals, under- or overservicing in relation to financial incentives, inadequate case management, and discontinuity of care. • Medical education has increasingly concentrated on body systems and disease conditions. The broader and important aspects of cultural context, psychosocial factors, medical ethics, and communication and relational skills, among others, have been neglected. There is a need to put emphasis not only on technical quality but also on the experiential elements of care. Workforce development and policies should be reviewed accordingly. • There is little patient and family participation in health care, abetted by factors such as low levels of education and health literacy, limited availability and sharing of understandable and culturally appropriate information and education materials, and short and hurried consultations. • Specialization and weak referral systems have led to fragmentation and discontinuity of care, both within and between health care institutions, and between the formal
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health care system and other sources of care, such as support groups and the community. There is a need to adopt a team approach that involves specialists, general practitioners and other health workers across the spectrum of the health care delivery system, down to the caregiver at the household level. Traditionally, the focus has been the supply side of the health equation—the biomedical, technological, provider and delivery system side of health care. It is time to pay more attention to the demand side—patients and other health consumers. It is time to consolidate and build on the groundswell of ongoing work and champion these efforts so that they are taken to scale, more strategically and more widely, and adopted by governments as a matter of policy. Across the Region, basic health infrastructure and essential health services are in place and socioeconomic conditions are improving. Strengthening and reorienting health systems to provide people-centred health care should now be on the health agenda. 3. Vision for people-centred health care The overall vision for people-centred health care is one in which individuals, families and communities are served by and are able to participate in trusted health systems that respond to their needs in humane and holistic ways. The health system is designed around stakeholder needs and enables individuals, families and communities to collaborate with health practitioners and health care organizations in the public, private and not-for-profit health and related sectors in driving improvements in the quality and responsiveness of health care. People-centred health care is rooted in universally held values and principles which are enshrined in international law, such as human rights and dignity, non-discrimination, participation and empowerment, access and equity, and a partnership of equals. It aims to achieve better outcomes for individuals, families, communities, health practitioners, health care organizations and health systems by promoting the following: (1) Culture of care and communication. Health care users being informed and involved in decision-making and having choices; providers showing respect for their privacy and dignity and responding to their needs in a holistic manner. (2) Appropriate service approaches. Designed around a person's health needs, recognizing psychosocial dimensions, providing continuity of care through team work and partnership with families, communities and other support groups.
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(3)
Responsible, responsive and accountable services and institutions. Providing affordable, accessible, safe, ethical, effective, evidence-based and holistic health care.
(4)
Environmental support. Supportive health system environments, appropriate policies and interventions, positive care and work environments, strong primary care workforce, and stakeholders' involvement in health services planning, policy development and feedback for quality improvement.
4.
Domains and areas of reform for promoting people-centred health care The major challenge confronting health systems is the need to tip the balance away from health
services that are overly biomedical oriented, disease focused, technology driven and doctor dominated. There is a clear call to restore balance in health care and the health system itself. There is demand for more to be done and there is an evidence base to justify a framework for strategic action. The Policy Framework charts pathways for balancing health systems in the Western Pacific Region and achieving the desired reorientation to optimal, holistic and people-centred health care in the 21st century. This involves comprehensive and positive changes spanning four key policy and action domains, corresponding to key health care constituencies that will continue to drive and sustain the paradigm shift: (1) informed and empowered individuals, families and communities; (2) competent and responsive health practitioners; (3) effective and efficient health care organizations; and (4) supportive health systems. The individuals, families and communities domain represents the health care experience. The health practitioners domain is the interface where patients and clinicians and other health practitioners meet, where the process of health care delivery is implemented. The health care organizations domain represents the facilitator of processes, creating the conditions that enable health practitioners to deliver health care. The health systems domain represents the facilitator of facilitators where decisions or policies have far-reaching consequences for the entire system. The interrelatedness of these four domains necessitates mutually reinforcing changes in all parts of the health system if real transformation is to occur. Leadership within and across all domains will be the ultimate enabler of change. In recognition of the different levels of health systems development in the Region, the Policy Framework is non-prescriptive and is intended as a guide only. It is comprehensive but not
exhaustive, providing Member States with an indicative list of evidence-based policy measures that
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can be utilized in placing people at the centre of health care and health systems. Member States can adopt an appropriate mix of reforms and interventions based on their own unique needs and circumstances. 4.1 Individuals, families and communities Holistic and compassionate health care requires an effective partnership between people who need care and people who provide care. To achieve this, action is required to support capacitybuilding for better informed and more empowered individuals, families and communities who are able to actively participate in health care and in health systems development. Strategic responses could include: (a) Increasing health literacy • • • community and mass media education campaigns; skills-oriented health education programmes in schools; written information in conjunction with verbal information in clinical consultations; and • (b) evidence-based health education through the web.
Providing communication and negotiation skills that lead to meaningful participation in decision-making • personalized and comprehensive decision-making aids, including computerbased and web-based health education packages; and • access to health records, including audio recordings and written summaries of clinical consultations, as appropriate.
(c)
Improving capacity for self-management and self-care • • • chronic disease management training programmes; computer or web-based targeted health education programmes; referral to appropriate patient or peer support groups; and
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•
interventions that promote patient adherence to medication regimes, e.g. providing explicit written instructions about taking prescribed medicines.
(d)
Increasing capacity of the voluntary sector, community-based organizations and professional organizations to extend mutual assistance • • • volunteer training and support programmes; funding for self-help programmes; and funding mechanisms for nongovernmental organizations.
(e)
Promoting social infrastructure that supports community participation in health services planning and facilitates greater collaboration between local governments and communities • participation and collaboration mechanisms for local governments, communities, health-oriented groups and consumer organizations; and • funding and training for consumer organizations and their representatives.
(f)
Developing community leaders who advocate and support community involvement in health service delivery • • • identification of suitable leaders in local communities; leadership development programmes; and mechanisms for participation in hospital boards, health care advisory panels and community health programmes.
4.2
Health practitioners Competent health practitioners are required to deliver health care that is responsive to the
needs, preferences and expectations of people accessing health services. The most effective and appropriate intervention in this domain is appropriate education and training of health practitioners. Strategic responses could include: (a) Increasing capacity for holistic and compassionate care
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• •
identification of core competencies of people-centred health practitioners; promotion and integration of core competencies in all education and training programmes for health practitioners; and
•
development of comprehensive, harmonized medical, nursing and allied health curriculum (including undergraduate, postgraduate and continuing professional development) and community-based training that: ►
are skills-oriented; emphasize bio-psychosocial and spiritual factors; include humanities-based subjects (such as medical ethics) in addition to the clinically oriented subjects;
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cover communication skills, building trust and developing tailor-made interventions;
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increase cultural competency; facilitate understanding of psychosocial dimensions of health and illness and of the role of traditional medicine in health care;
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promote evidence-based practice; feature a balance of family medicine and specialities; use role models to instil in students the values of people-centred health care;
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bring medical, nursing and allied health students together during clinical training in order to allow students to develop skills necessary for working in a multidisciplinary team;
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inculcate a culture of reflective practice; encourage life-long learning, personal growth and development; instil the importance of taking care of one’s health and well-being; utilize a variety of teaching and learning strategies; and provide continuing professional development for health practitioners in a number of forms (i.e. Internet, professional associations and journals).
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(b)
Enhancing commitment to quality, safe and ethical services • formation and reinforcement of people-centred values in the curriculum and in continuing education, professional codes of conduct, and workforce development and regulation policies; and • recognition of and support for clinical educators and role models who espouse professionalism and humanism in health care and transfer values to trainees through active modes of instruction.
4.3
Health care organizations The way health care delivery is organized and managed can provide incentives for the delivery
of quality health care, as well as address the fragmentation of care resulting from numerous health providers offering services from different, limited specialty perspectives or programme areas. At the institutional level, there is a need to adopt measures that respond to the needs of patients, health practitioners and other staff. Effective interventions at the organizational level specifically relate to physical environments; service coordination and continuity of care; multi-disciplinary collaboration and partnerships; patient education and counselling; models of care; incentives for safe, quality and ethical services; and leadership capacity. Strategic responses could include: (a) Providing a conducive and comfortable environment for people receiving health care and for health practitioners • health care environment designed for comfort, safety and functionality, providing access to social, emotional and spiritual support for patients and their families, as well as for staff of the facility; • • appropriate and flexible visiting policies; risk management policies (i.e. infection control guidelines) that protect the public, patients and staff; and • use of waiting rooms and other public spaces within the premises of health care facilities and organizations for opportunistic health education. (b) Ensuring effective and efficient coordination of care
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•
transparent, accessible and understandable service protocols that improve patient flow;
• • •
appropriate scheduling of appointments; reminder notices for specific interventions; public announcements, loose or wall-mounted printed materials and signage to guide health service navigation;
• • (c)
hand-held patient health records (electronic or hard copy); and protocols for discharge and referral.
Establishing and strengthening multidisciplinary care teams • detailed job descriptions for each health worker, incorporating duties and responsibilities as a team member; • support for team development and effective team work (e.g. training on group dynamics, communication and negotiation skills and conflict resolution); and • communication protocols across disciplines.
(d)
Strengthening the integration of patient education, family involvement, selfmanagement and counselling into health care • concise, simple, harmonized and effective communication and counselling protocols for health practitioners; and • educational guides and sessions on self-care and home care for patients and their families, with appropriate illustrations and demonstrations.
(e)
Providing incentives for safe, quality and ethical services • • staff salary levels that provide financial security; performance-based incentive packages, including public acknowledgement of model staff;
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•
opportunities for continuing professional development and competency-based skills training; and
•
targeted monitoring and evaluation of individual and team performance for continuous quality improvement.
(f)
Introducing and strengthening models of care • continuing development of new models of care across all service areas and settings (e.g. outreach clinics, nurse-practitioners, psychosocial interventions including group therapies, and shared care including community-based care).
(g)
Enhancing leadership capacity of health services managers in championing peoplecentred health care • capacity-building to enhance leadership, managerial and organizational development competencies; • • creation of inter-professional leadership teams; and leadership training programmes.
4.4
Health systems Policies relating to the organization, delivery and financing of health care have not been
optimal. It is imperative to involve stakeholders not only in the health sector, but also in other sectors whose work impacts health outcomes and health status. A supportive health system will ensure that interventions implemented at the organizational, health practitioner and health consumer levels are effective. Strategic responses could include: (a) Developing and strengthening primary care and the primary care workforce • human resource planning that places due emphasis on primary care and provides for balanced geographical distribution of primary care practitioners; • participation of professional bodies in setting standards for education and practice and in raising the profile of family medicine; • networking and referral systems between primary care and higher levels of care;
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•
selection criteria for education and training that explicitly consider the needs of disadvantaged and cultural communities;
• • (b)
standards of practice for traditional medicine, where appropriate; and link with and access to accredited traditional medicine practitioners or facilities.
Putting in place financial incentives that induce positive provider behaviour and improve access and financial risk protection for consumers • evidence-informed purchasing arrangements and payment systems that consider quality and responsiveness; • performance evaluation systems and performance-based subsidies or grants (e.g. for improved service quality and more compassionate care); and • social health insurance schemes.
(c)
Building a stronger evidence base on ways to improve health care and the health system itself to achieve better health outcomes • funding for developing guidelines and undertaking research and development on innovative approaches and interventions that promote holistic and compassionate care, are culturally appropriate and address equity issues; and • monitoring and evaluation of health care reforms and interventions to guide the continuing health systems development process.
(d)
Ensuring rational technology use • technology assessment criteria that balance economic and social costs with expected positive impact on health care and health outcomes; and • participatory technology assessment processes.
(e)
Strengthening the monitoring of professional standards
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•
mechanisms to ensure adherence to standards of health professional education and practice; and
• (f)
public accountability for maintenance of professional standards.
Instituting public accountability measures for health services organization, delivery and financing • public reporting of performance of relevant health agencies and health care organizations, including specific services or departments in health care facilities; • careful consideration of the type of information to be released to minimize harm to the system; and • social preparation for public reporting of performance.
(g)
Monitoring and addressing patient and community concerns about health care quality • • • • • accessible and transparent system for the investigation of complaints; conciliation mechanisms for quicker resolution of disputes; independent party presence in dispute resolution; patient and public satisfaction surveys; and adverse events monitoring, including pharmaco-vigilance.
(h)
Assisting people who have experienced adverse events in the health system • • • access to medical records to support investigation; autonomous investigation of adverse events; and mechanisms of redress, including counselling and compensation, as appropriate.
(i)
Ensuring protection of patient information • legal protection of patient information;
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• •
privacy policies in health care organizations; and training for health care organization staff responsible for, or with access to, sensitive health care-related information.
5.
Conclusion It is clear that more than 20 years after the landmark Alma-Ata Declaration, health systems
continue to struggle with issues of quality, safety and responsiveness to patient needs, legitimate demands and reasonable expectations. Economic, demographic and social forces have increasingly put pressure on health systems not only to provide universally accessible, effective and scientifically sound health care, but also to ensure that services are designed and delivered in ways that respect patient rights and patient needs and preferences for information, psychosocial support and participation in decision-making for their own care. The need for innovative, balanced, holistic and people-centred approaches to health care has become a matter of urgency for countries and health systems worldwide. People-centred health systems embrace and promote a more positive approach to health care that gives due consideration to the multifaceted needs and responsibilities of all health constituencies and stakeholders. This results in empowered individuals, families and communities, as well as supported and effective health practitioners and health care organizations. While health systems have diverse socioeconomic, cultural and political contexts, a peoplecentred approach to health care is relevant to and could be adopted by all forms of health systems at all stages of their development. Good practices have come from both resource-rich and resourcechallenged health systems, showing that any health system can achieve positive changes and results with the judicious and appropriate use of current resources and capabilities. A paradigm shift in health systems towards people-centred health care that restores harmony and balance to individuals, as well as harmony and connectedness between people and their environment, promises many potential gains. These include increased patient safety, improved
adherence to care plans, improved treatment and health outcomes, increased patient satisfaction with care, and improved quality of life for patients and their families, the community and society at large. The benefits also spill over to the provider side in terms of provider satisfaction, patient trust and loyalty, good public reputation, and a cost-effective and sustainable health system resulting from appropriate health care use by empowered patients.
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The Policy Framework is designed as a menu of evidence-based interventions and best practices that promote people-centred health care and facilitate policy development and implementation at the country level. Countries and areas in the Western Pacific Region should take guidance from this Policy Framework according to their specific needs and situations. The Policy Framework will pave the way for cooperation and concerted action among all stakeholders at regional, subregional, national and local levels. The WHO Regional Office for the Western Pacific will take a leadership role in the further development and implementation of the Policy Framework through advocacy, technical support and assistance to countries and areas, and establishment of appropriate coordination, monitoring and evaluation mechanisms to sustain reforms and make people-centred health care a reality for all people in the Western Pacific Region and beyond.