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Report on the public consultation to inform development of the Framework on integrated peoplecentred health services
Service Delivery and Safety department
June 2016
Report on public consultation Framework on integrated people-centred health services
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Contents
1. Background ............................................................................................................................ 3 2. The public consultation process ............................................................................................ 3 3. Participation ........................................................................................................................... 4 4. Summary of participant input ................................................................................................ 5 4.1. Level of agreement with proposed statements .............................................................. 5 4.2. Level of agreement with strategic directions ................................................................. 5 4.3. Missing strategic directions............................................................................................. 6 4.4. Improvement of the five strategic directions ................................................................. 6 4.5. Level of agreement with proposed approaches ............................................................. 7 4.6. Suggestions of the key stakeholders ............................................................................... 7 4.7. Barriers to implementation ............................................................................................. 7 4.8. Promoting sustainability ................................................................................................. 8 5. Annex 1 .................................................................................................................................. 9
WHO/HIS/SDS/2016.4 © World Health Organization 2016. All rights reserved.
Report on public consultation Framework on integrated people-centred health services
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1. Background At the 62nd Session of the World Health Assembly (WHA), WHO Member States adopted a resolution aimed at developing plans to put people at the centre of service delivery. The WHO Programme Budget for 2014-2015 requested the development of a global strategy on integrated, people-centred service delivery, to achieve universal health coverage in a continuum from health promotion to palliation. Following the WHA resolution and in response to this request, WHO drafted a global strategy on integrated people-centred health services (IPCHS). The final draft of the strategy is the result of input gathered through peer reviews and technical consultations involving more than 140 experts representing research organizations, ministries of health and academia, among others. The strategy has been further enriched and enhanced through additional contributions from stakeholders. Two kinds of consultations were undertaken. On the one hand, Member States made contributions through the Regional Committees of their WHO regional offices. On the other hand, the wider public representing a variety of entities (both individuals and organizations) with an interest in people-centredness and integrated health services were invited to join a public consultation process through the website of the Service Delivery and Safety (SDS) department. Over 800 individuals/organizations were targeted through an e-mail invitation. Additionally, given existing language and technological barriers in the WHO African Region, an offline consultation process involving individuals and organizations from this region also took place. The input resulted from this consultation process has been used to improve the document that was finally submitted for discussion at the 138th meeting of the Executive Board and the 69th session of the World Health Assembly in 2016. Among the relevant changes that resulted from the consultation period, the name of the document was modified to “Framework on integrated people-centred health services”. This title will be used hereinafter. This report contains a summary of the public consultation process, an overview of participation in the consultation, and of the major themes that emerged from it.
2. The public consultation process As far as the online consultation process is concerned, the SDS department launched a web page in English. This web page described the context of the Framework, contained a link to the full draft and provided access to a questionnaire to be completed. Contributions to the online consultation were received over a six-week period, from 8 June to 13 July 2015. Regarding the offline consultation in the WHO African Region, the questionnaire was translated into French in order to encourage contributions from Francophone countries. A database with individuals and organizations with a potential interest in IPCHS was created, potential respondents were approached by the WHO Regional Office, and questionnaires were gathered during a six-week period, from 7 September to 12 October 2015. In both cases, participants were encouraged to focus on the following areas:
Report on public consultation Framework on integrated people-centred health services
4 Agreement with the proposed vision Agreement with definitions of “people-centred health services” and “integrated health services” Relevance of the proposed five strategic directions Agreement with the implementation approach Barriers to implementation The role of key stakeholders Relevance of the monitoring and evaluation approach Proposals to successfully sustain implementation
The survey questionnaire is attached in Annex 1.
3. Participation A total of 136 contributions were received: 83 responses from the online consultation and the remaining 53 from the offline consultation developed by the African Region. The consultation was successful in receiving input form a broad range of constituencies (see Figure 1), including ministries of health, health providers, civil society organizations, nongovernmental organizations, scientific and academic institutions, professional associations and networks. Submissions were received from all WHO regions, and from individuals in 38 different countries (see Table 1). Figure 1. Respondents’ profiles
Report on public consultation Framework on integrated people-centred health services
5 Table 1. Countries of participants Country Madagascar UK Cote d'Ivoire USA Comoros Netherlands Spain Switzerland Burkina Faso Ethiopia Australia Nigeria Belgium # 18 12 11 10 9 6 5 5 4 4 3 3 2 % 13% 9% 8% 7% 7% 4% 4% 4% 3% 3% 2% 2% 1% Country Canada Denmark India Italy Sweden Turkey Argentina Austria Cabo Verde Germany Egypt Finland France # 2 2 2 2 2 2 1 1 1 1 1 1 1 % 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% Country Gabon Gambia Georgia Greece Guinea Indonesia Ireland Jordan Philippinnes Romania South Africa Thailand Not specified # 1 1 1 1 1 1 1 1 1 1 1 1 13 % 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 10%
4. Summary of participant input In providing their contributions, participants were asked to focus on a set of specific questions. WHO received a wide range of insightful responses to the questions posed, which can be classified into two groups: direct questions regarding the level of agreement with specific statements stemming from the Framework, and open questions where respondents were asked to provide opinions and comments.
4.1. Level of agreement with proposed statements The level of agreement with the proposed vision and the definitions of “people-centred” and “integrated health services” was tested. As Figure 2 shows, there was a high level of agreement with these. Figure 2. Level of participants’ agreement with proposed statements
4.2. Level of agreement with strategic directions As indicated in Figure 3, the vast majority of respondents showed a high level of agreement with the proposed strategic directions of the Framework. However, although the five strategic directions were largely supported by participants, almost one out of three respondents felt that some strategic directions were missing and should be included, and almost half of them stressed the need to improve the proposed ones.
Report on public consultation Framework on integrated people-centred health services
6 Figure 3. Level of participants’ agreement with strategic directions
4.3. Missing strategic directions Participants stressed the need to improve the strategic directions in several ways, the most frequently cited being: Health professionals: in addition to pointing out that there is a lack of focus on the health-care staff performing health services and that health workforce well-being must be enhanced, the need for more emphasis on staff education in new skills, competencies and attitudes was frequently expressed by participants. Information systems: a need to stress the relevance of information, information systems and appropriate IT to support person-centred coordinated care. Aim to achieve intersectoral action and health in all policies.
4.4. Improvement of the five strategic directions The majority of respondents indicated that the proposed strategic directions were relevant, but proposals to modify them were nevertheless suggested. Strategic direction 1. Empowering and engaging people A frequent comment was the need to include the empowerment and engagement of informal caregivers, and to recognize the significant contribution of unpaid carers. Strategic direction 2. Strengthening governance and accountability Several respondents felt that “accountability and governance” should be considered part of strategic direction 5, “creating an enabling environment”. In addition, respondents generally stressed the need to include governance structures at ground level. Strategic direction 3. Reorienting the model of care The following were major themes that emerged: Strategic directions 3 and 4 overlap and could be combined More focus on health promotion and disease prevention is needed Health-care providers and their role should be explicitly included as part of this strategic direction The value of family medicine and the family approach should be more developed
Report on public consultation Framework on integrated people-centred health services
7 Strategic direction 4. Coordinating services Comments on this strategic direction mirrored those for strategic direction 3, suggesting that both strategic directions be merged. Furthermore, respondents frequently suggested that the importance of care coordinators and the role of nurses in coordination could be highlighted. Strategic direction 5. Creating an enabling environment Consistent with comments on strategic direction 2, respondents requested that strategic directions 2 and 5 be combined. Moreover, a stronger emphasis on health workforce education and motivation was requested, along with an increased focus on improving information systems.
4.5. Level of agreement with proposed approaches Participants were asked to show their level of agreement with the implementation, and the monitoring and evaluation approaches in the Framework. According to Figure 4, both approaches were supported by the majority of respondents. Figure 4. Level of participants’ agreement with proposed implementation and M&E approaches
4.6. Suggestions of key stakeholders A significant number of respondents (46%) recognized the need to take into account new key stakeholders in the Framework. Among the most widely stressed proposals were the need to include (1) the private sector, (2) training organizations, (3) civil society organizations, (4) professional organizations of providers, (5) student-based associations, (6) community, (7) regional and local bodies, (8) patients’ organizations.
4.7. Barriers to implementation WHO asked for participants’ insights into the barriers to implementation of the Framework. There was an outstanding demand among participants to select “culture” as one of the main barriers to be addressed. Lack of political leadership and commitment along with financial restrictions were other factors mentioned by respondents. Regarding health professionals, concerns about their unwillingness to collaborate, lack of skills and negative attitudes towards change were raised. Other factors included the lack of communication, existing and competing interests among stakeholders, the generally low level of health education among the population and payment models.
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4.8. Promoting sustainability As a supplement to the information provided on barriers to implementation, participants were asked to suggest the best way to promote implementation of the Framework in a sustainable way. A significant number of suggestions were gathered, including: the need to emphasize knowledge generation and dissemination; strengthening monitoring and evaluation; investment in capacitybuilding and guidance; funding assurance; and the involvement of policy-makers, providers and users at all levels.
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5. Annex 1 Survey questionnaire Draft WHO global strategy on integrated people- health services (IPCHS) A new vision for service delivery (Main document pp 9-13) The WHO global strategy on integrated people-centred health services (IPCHS) presents a vision for the future that is based on the delivery of people-centred and integrated health services. The vision is stated as: “A future in which all people have access to health services that are provided in a way that responds to their preferences, are coordinated around their life course needs and are safe, effective, timely, efficient and of acceptable quality”. 1. Do you agree with the proposed vision? □ I disagree strongly □ I disagree □ I slightly disagree □ I agree slightly □ I agree □ I agree strongly If you don't agree, please provide your comments on how the vision can be improved. ________________________________________________________________________________ ________________________________________________________________________________ “People-centred health services” are defined as an approach to care that consciously adopts the perspectives of individuals, families and communities, and sees them as participants, as well as beneficiaries, of trusted health systems that respond to their needs and preferences in humane and holistic ways. “Integrated health services” are health services that are managed and delivered in a way that ensures people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, at the different levels and sites of care within the health system, and according to their needs throughout their life course. 2. Do you agree with the definitions of “people-centred health services” and “integrated health services?” □ I disagree strongly □ I disagree □ I slightly disagree □ I agree slightly □ I agree □ I agree strongly If you don't agree, please provide your comments on how these definitions can be improved. ________________________________________________________________________________ ________________________________________________________________________________
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The five strategic directions (Main document pp 20-33; Technical document pp 11-35) The strategy on IPCHS proposes five strategic directions for health service delivery to become more people-centred and integrated. These strategic directions are: 1) empowering and engaging people; 2) strengthening governance and accountability; 3) reorienting the model of care; 4) coordinating services; 5) creating an enabling environment. It also presents evidence on interventions and looks at examples from around the globe, in different country contexts, and identifies some models of good practice and lessons learnt. 3. Do you agree with the five proposed strategic directions? □ Yes □ No
If NO, which strategic directions you think should not be included? Why? ________________________________________________________________________________ ________________________________________________________________________________ 4. Do you think there are any missing strategic directions that should be added? □ Yes □ No
If YES, please specify which strategic direction(s) should be added and give rationale for it. Could you also provide an example? _________________________________________________________________________________ _________________________________________________________________________________ 5. Regarding each of the five proposed strategic directions, do you think that any of them should be modified or improved? □ Yes □ No
If YES, please provide your proposals for the improvement of each strategic direction: Empowering and engaging people_______________________________________________ Strengthening governance and accountability _____________________________________ Reorienting the model of care__________________________________________________ Coordinating services_________________________________________________________ Creating an enabling environment ______________________________________________
6. Could you provide further examples of programmes, interventions or case studies of good PCIHS practice for any of the proposed strategic directions? (Attachments can be uploaded) Empowering and engaging people_______________________________________________ Strengthening governance and accountability _____________________________________ Reorienting the model of care__________________________________________________ Coordinating services_________________________________________________________ Creating an enabling environment ______________________________________________ Report on public consultation Framework on integrated people-centred health services
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Leading and managing change towards PCIHS (Main document pp 34-38; Technical document pp 36-38) Reorienting health services toward a people-centred and integrated model is a fundamentally political act that questions existing interests. Moreover, a number of system-, people- and organizational-related challenges make it difficult to undertake the reforms needed for peoplecentred and integrated health. When moving this strategy forward, it is important to acknowledge that the successful reorientation of health services will most likely be a long journey requiring substantial political commitment and leadership for change. 7. Do you agree with the implementation approach? □ I disagree strongly □ I disagree □ I slightly disagree □ I agree slightly □ I agree □ I agree strongly If you don't agree, please provide your suggestions on how the approach can be improved. __________________________________________________________________________________ __________________________________________________________________________________ 8. In order to contribute to the strategy implementation, please provide tools, techniques and methodologies (such as research and assessment tools, guidelines, etc.) that can promote capacity building towards effective and sustainable country PCIHS performance. (Attachments can be uploaded) __________________________________________________________________________________ __________________________________________________________________________________ 9. From your perspective, what are the main barriers to implementation that should be considered? How can these be overcome? __________________________________________________________________________________ __________________________________________________________________________________
The role of key stakeholders (Main document pp 35-37) Moves towards people-centred and integrated health services need to be led at a country, regional or local level in a process of collaboration between health institutions, service providers and the users of these services. The role of governments is essential in engaging all stakeholders and coordinating efforts to overcome challenges to implementation. In support of this, WHO and other national and international partners have important roles to play. 10. In addition to countries, WHO and national and international partners, are there any specific key stakeholders not mentioned in the draft that should be taken into account? □ Yes □ No Report on public consultation Framework on integrated people-centred health services
12 If YES, please suggest up to three key stakeholders and propose roles and responsibilities to be undertaken by them. __________________________________________________________________________________ __________________________________________________________________________________ 11. Regarding countries, WHO and national and international partners, please provide your suggestions on proposed roles and responsibilities that are missing in the draft to support broad dissemination and implementation of the strategy. __________________________________________________________________________________ __________________________________________________________________________________ 12. As far as national and international partners are concerned, are there specific health organizations or initiatives relevant to PCIHS that are not mentioned and should be engaged? □ Yes □ No
If YES, please suggest up to three key health organizations or initiatives and propose potential ways in which they could be involved and the roles to be developed. _________________________________________________________________________________ __________________________________________________________________________________
Monitoring, learning and evaluation (Main document pp 39-40; Technical document pp 39-41) A core requirement for strategies promoting people-centred and integrated health services to succeed will be gathering of evidence and learning to justify and support implementation. A key focus should be on the ongoing monitoring of progress within a framework that includes specific and measurable objectives. A key action for policy-makers will be to develop systems that monitor outcomes at the micro, meso and the macro level. 13. Do you agree on the monitoring and evaluation approach? □ I disagree strongly □ I disagree □ I slightly disagree □ I agree slightly □ I agree □ I agree strongly If you don't agree, please provide your suggestions on how the approach can be improved. __________________________________________________________________________________ __________________________________________________________________________________ 14. In order to facilitate the ongoing monitoring and evaluation of PCIHS strategies, please recommend tools, techniques and methodologies to support the gathering of evidence and learning. (Attachments can be uploaded) Report on public consultation Framework on integrated people-centred health services
13 __________________________________________________________________________________ __________________________________________________________________________________
The future (Main document p 41) Efforts are already underway in many countries to channel energy and resources into creating more equitable, accessible and sustainable health services that seek to better coordinate care around people’s needs and to secure improved health for individuals and populations. Being able to nurture and sustain these efforts over time will be key to the implementation success of the strategy. 15. From your perspective, what would be the best way to promote sustainability for the strategy implementation? __________________________________________________________________________________ __________________________________________________________________________________
Overall assessment 16. Please provide any additional comments on the draft strategy (including writing, wording, style etc.) __________________________________________________________________________________ __________________________________________________________________________________
About you (optional) Which of the following statements best defines your current position? You can check more than one box. □ I work as a clinician/health provider □ I am a national or regional programme manager/officer □ I work for a nongovernmental and/or civil society organization and/or community based organization □ I work at a university or academic institute □ I am involved in fundraising, a national or international donor agency, a development agency or advocacy □ I am a public health policymaker/manager Report on public consultation Framework on integrated people-centred health services
14 □ I work for a national or international public health organization/agency □ I work with communities and people living with and impacted by this issue □ I work for a private sector organization □ Other
Name: Organization: E-Mail: Country:
Report on public consultation Framework on integrated people-centred health services