Sian Griffiths presentation WSPCR 2010

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  • 1. Public Health and Primary care: a shared agenda? Challenges for integrationSian GriffithsProfessor of Public HealthDirector of the School of Public HealthChairman, Department of Community and Family MedicineThe Chinese University of Hong KongAPACPH 20088th November 2008
  • 2. ChongqingCUHK Cardiff MOU november 3 2010 2
  • 3. november 3 2010 3
  • 4. Public Health and Primary CareBackground : Common agenda : Social determinants WHO report: Now More Than Ever Lancet Sept 13 new agendaLessons from Health care reform: China : Deepening the healthcare system reform China 2020 Hong Kong: Better Health november 3 2010 4
  • 5. Social Determinants of HealthThe World Health Organization (WHO) Commission on Social Determinants of HealthPhoto Source: WHO november 3 2010 5
  • 6. “Social and economic conditions and theireffects on people’s lives determine their riskof illness and the actions taken to preventthem from becoming ill or treat illness with itoccurs. Within countries, the evidence showsthat in general the lower an individual’ssocioeconomic position the worse theirhealth. This is a global phenomenon.” november 3 2010 6
  • 7. •  Concerns about the affordability of health care, with an ever expanding menu of newer drugs and procedures, are near universal, whether driven by the demands of an ageing population and increasing chronic diseases, by the persistence of infectious diseases and maternal, newborn, and child health conditions, or by challenges that have emerged since 1978, such as HIV/AIDS.•  The current crisis in health, with increasing demand, rising costs, and a return towards curative and hospital care, makes re-exploration of the Alma-Ata principles timely and relevant.” november 3 2010 •  Lawn 2008 Lancet 7
  • 8. Values of Alma-Ata•  Equity, social justice, and health for all•  Community participation•  Health promotion•  Appropriate use of resources•  Intersectoral action november 3 2010 8
  • 9. Health policy today•  “Health is a universal aspiration and basic human need. The development of society , rich or poor, can be judged by the quality of its population’s health, how fairly distributed across the social spectrum and the degree of protection provided from disadvantage due to ill health. Health equity is central to this premise” Marmot 2007. Lancet 370:1153 november 3 2010 9
  • 10. november 3 2010 10
  • 11. The PHC reforms necessary to refocus health systems towards health for all november 3 2010 11 The World Health Report 2008
  • 12. The World Health Report 2008 12 november 3 2010
  • 13. Rationale for the benefits for primary care for health1.  Greater access to needed services,2.  Better quality of care,3.  A greater focus on prevention,4.  Early management of health problems,5.  The cumulative effect of the main primary care delivery characteristics [5Cs]6.  Reducing unnecessary and potentially harmful specialist care. november 3 2010 13
  • 14. november 3 2010 14
  • 15. Integrating primary care and public health•  Better alignment of a public-health approach with personal health services will achieve a better balance, but the balance since Alma-Ata has tilted towards personal health care at the expense of population health •  van Weel 2008 Lancet november 3 2010 15
  • 16. •  It is time to integrate personal health care and public health, and organise primary care on the principle of care for individuals in the context of an identified population over time.•  The future of primary care, and health care in general, will depend on how effectively primary practices achieve this community-oriented primary care approach and contribute to equity and social cohesion november 3 2010 16 »  Van weel et al Lancet
  • 17. Reforms in ChinaHistorical perspective on PH and PC3 phases of reforms : –  Planned economy –  Marketisation –  Current reforms [social harmony ] november 3 2010 17
  • 18. Phase 1 : 1949-1977Focus on preventive servicesFocus on dissemination ofhealth education “Patriotic health campaigns” Initiated “Barefoot doctors program” november 3 2010 18 18
  • 19. Primary Care november 3 2010 19 19
  • 20. Public Health :patriotic health campaigns “Eradicate  pests and diseases and  build happiness for ten thousand  genera5ons”   november 3 2010 20 20
  • 21. Phase 2 The market reforms•  Reduced investment from the central government;•  Increased local funding responsibility (through local taxation)>greater inequities;•  Privatization of health facilities;•  Introduced price regulation system and modified salary system for health professionals;•  Cooperative Medical System (primary care) dismantled with loss of universal coverage ;•  Decentralized the public health system and subsequent deterioration eg of immunisations november 3 2010 21
  • 22. Impact of market Reforms•  Increased inequity rural:urban health status•  Decreased access to services ,with diminished government power to intervene•  Price regulation unintentionally increased sale of high tech interventions/expensive drugs in its attempts to control salaries etc•  Dismantling communes destroyed bare foot doctors system and removed rural safety net.As a result primary care in the community was decimated• •  Public Health system less effective •  Blumenthal D and Hsiao W NEJM 353:11 Sept 15 2005 november 3 2010 22
  • 23. Decreased share of govt. exp. And increased share of out-of-pocket (1990-2004) 70.0% of total health expenditure 60.0 50.0 40.0 30.0 20.0 10.0 0.0 78 80 82 84 86 88 90 92 94 96 98 00 02 04 19 19 19 19 19 19 19 19 19 19 19 20 20 20 Govt. Exp. Soc. Exp. Out-of-Pocket 23 (Source: Chinese Health Statistic
  • 24. The existing problems (3)Rapid increase in health care expenditure (NHE) (1978-2004) NHE
per
capita
 NHE
as
%
of
GDP
 6 700 600 5 500 4 400 Yuan% 3 300 2 200 1 100 0 0 78 80 82 84 86 88 90 92 94 96 98 00 02 0419 19 19 19 19 19 19 19 19 19 19 20 20 20 24 (Source: Chinese Health Statistic
  • 25. Disparity of health resource allocation between urban and rural per capita NHE 1400 1262 1200 urban rural 1000 800 yuan 600 400 302 159 200 39 0 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 25Chinese Health Statistic Yearbook 2006)
  • 26. Coverage of Cooperative Medical System in rural China 26
  • 27. % of people who should see a doctor choose NOT to do so because of the cost big city middle- small rural 1 rural 2 rural 3 rural 4 sized city cityinpatient1993 34.09 33.87 53.47 47.95 63.15 61.14 67.721998 53.12 58.43 70.77 63.80 54.12 70.26 69.382003 64.4 35.6 74.8 77.6 74.9 75.5 73.6Outpatient1993 3.21 2.40 9.58 15.10 21.36 19.55 24.421998 36.69 23.48 42.96 30.09 31.67 42.29 38.722003 30.8 32.7 47 29.2 33.9 41.2 49.1(Source: The national health service 27
  • 28. 




‘China’s healthsystem has changed greatly and made great progresssince the reform and openingup, but the problems are also serious. Overall speaking,the reform was unsuccessful’-- Development Research Centre of the StateCouncil. Assessment and 28
  • 29. Phase 3 :Healthy ChinaThe overall objective is to establish a basichealth care system covering both rural andurban people, as well as to provide safe,effective, convenient and affordable healthservices to all people. november 3 2010 29
  • 30. Why ?•  Politics of change•  Costs escalating•  SARS showed the deficiencies in the public health system•  Increasing affluence spread unevenly across the country >potential for social unrest november 3 2010 30
  • 31. New health system reform plan: one building, four girders and eight pillars Overall objectiveEstablishing a basic health system covering both urban and rural people, promoting health for all.
 Public health Medical service Medical insurance Drug production and service system system system supply system
 Management system Information system Monitoring system Operation system Human resources Price forming system Input system legislation Collecting extensively people’s comments and suggestions on deepeningnovember 3 2010 and health medical 31 reform
  • 32. 4 systems for establishing a basic universal healthcaresystem:  Public health services including primary care  Medical services including primary care  Health insurance to cover primary care  Medicine supply system to cover primary care november 3 2010 32
  • 33. Primary care in China •  CHS first announced as the future direction for urban healthcare reform in 19971 –  borrowed much from the UK. •  Primary care is provided by community health service (CHS) via community health centres (CHCs) PHDs TCM physici •  Public Health and primary care GPs ans integrated Multi- Allied healthcar skilled e nurses personnel 1.  “Decision on Development of Urban Health Care System”. CCP Central Committee and State Council. Jan 15, 1997.Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/wsb/ pM30115/200804/18540.htm.2.  “城市社區衛生服務機構設置原則及指導標準”. Establishing community health services in the urban areas of China. Division of Primary and Women’s Health, Ministry of Health. MOH. No.467 november 3 2010 document. Dec 29, 2000. Accessed on http://www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/pfybj/200804/18182.htm. 33
  • 34. Community Health Services (CHS)•  Basis of urban public health system & basic medical services Treatment & Referral Rehab Health Six-in-one Health Maintenance comprehensive Education care package1 Family Prevention Planning november 3 2010 341.  Division of Primary and Women’s Health, Ministry of Health – “Opinions on Development of Community Health Services in the Cities”. MOH .No.326 document. Jul 16, 1999. Accessed on http:// www.moh.gov.cn/publicfiles/business/htmlfiles/mohfybjysqwss/pfybj/200804/18183.htm.
  • 35. november 3 2010 35 35
  • 36. Public Health ReformsStrengthening the establishment of the public healthservice system:  build up sound public health networks of  disease prevention,  health education,  maternal and child health care,  mental health,  first aid,  blood collection and supply,   health supervision,  family planning.  november 3 2010 36
  • 37. Observation•  Language is confusing•  Much of what is labeled public health can be regarded as primary care•  Those providing primary care have public health responsibilities•  Therefore Van Weels terminology /concept is more helpful to achieve healthcare reform ; community-oriented primary care approach november 3 2010 37
  • 38. Hong Kong november 3 2010 38
  • 39. Market based Primary care in Hong Kong•  Fragmented•  Uncoordinated•  Mainly out of pocket•  No clear clinical standards•  Doctor shopping•  Generalist /specialist issues•  No register of primary care practitioners•  No comprehensive data system november 3 2010 39
  • 40. Hong Kong Primary Care : the reform challenge •  Participants who did not currently have a family doctor and were mainly of lower socioeconomic status than those with a family doctor saw a family doctor as something of a ‘luxury item’ for the wealthy and not within the financial reach of the bulk of the population in Hong Kong. •  There is a need to make primary care acceptable, accessible, and affordable to all, especially those in need. november 3 2010 40(Source: Mercer et al., BMC Public Health 2010)
  • 41. Way forward: enhance primary care •  New funding mechanisms•  Promote the family doctor concept which emphasizes continuity of care, holistic care and preventive care. –  register •  Put greater emphasis on prevention of diseases and illnesses through public education and through family doctors. -guidelines •  Encourage and facilitate medical professionals to collaborate with other professionals to provide coordinated services. -  new models of care november 3 2010 41
  • 42. CUHK response•  Build on SARS report•  Increase the profile and capacity of public health•  Increase the profile and capacity of primary care•  Create an integrated approach –combining public health and primary care :SPHPC november 3 2010 42
  • 43. School of Public Health and Primary Care The Chinese University of Hong Kong november 3 2010 43
  • 44. The challenges of public health education with a particular reference to China S.M. Griffiths L.M. Li , J.L. Tang , X. Ma, Y.H. Hu, Q.Y. Meng H. Fuin many countries,traditional public health methods targeted atindividuals, such as vaccination and child and maternal care, have been successfully relocated into the clinical sector,most often primary care or general practice. Such individualpublic health approaches to prevention are too important to be neglected.Although, in essence an individual approach, primary careis where much of clinical medicine and many public healthpractices meet, and recognition of this interface is extremely important for building a seamless framework for improving the health of the population. november 3 2010 44
  • 45. •  The future of primary care, and health care in general, will depend on how effectively primary practices achieve this community- oriented primary care approach and contribute to equity and social cohesion »  Van weel et al Lancet 2008 november 3 2010 45
  • 46. november 3 2010 46