1. Public Health and Primary care:
a shared agenda?
Challenges for integration
Sian Griffiths
Professor of Public Health
Director of the School of Public Health
Chairman, Department of Community and Family Medicine
The Chinese University of Hong Kong
APACPH 2008
8th November 2008

2. Chongqing
CUHK Cardiff
MOU
november 3 2010 2

3. november 3 2010 3

4. Public Health and Primary Care
Background :
Common agenda : Social determinants
WHO report: Now More Than Ever
Lancet Sept 13 new agenda
Lessons from Health care reform:
China : Deepening the healthcare
system reform China 2020
Hong Kong: Better Health
november 3 2010 4

5. Social Determinants of Health
The World Health Organization (WHO) Commission on Social Determinants of Health
Photo Source: WHO november 3 2010 5

6. “Social and economic conditions and their
effects on people’s lives determine their risk
of illness and the actions taken to prevent
them from becoming ill or treat illness with it
occurs. Within countries, the evidence shows
that in general the lower an individual’s
socioeconomic position the worse their
health. 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 health
1. 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.
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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 China
Historical perspective on PH and PC
3 phases of reforms :
– Planned economy
– Marketisation
– Current reforms [social harmony ]
november 3 2010 17

18. Phase 1 : 1949-1977
Focus on preventive
services
Focus on dissemination of
health 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
04
19
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
25
Chinese 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 city
inpatient
1993 34.09 33.87 53.47 47.95 63.15 61.14 67.72
1998 53.12 58.43 70.77 63.80 54.12 70.26 69.38
2003 64.4 35.6 74.8 77.6 74.9 75.5 73.6
Outpatient
1993 3.21 2.40 9.58 15.10 21.36 19.55 24.42
1998 36.69 23.48 42.96 30.09 31.67 42.29 38.72
2003 30.8 32.7 47 29.2 33.9 41.2 49.1
(Source: The national health service 27

28. ‘China’s health
system has changed greatly
and made great progress
since the reform and opening
up, but the problems are also
serious. Overall speaking,
the reform was unsuccessful’
-- Development Research
Centre of the State
Council. Assessment and 28

29. Phase 3 :Healthy China
The overall objective is to establish a basic
health care system covering both rural and
urban people, as well as to provide safe,
effective, convenient and affordable health
services 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 objective
Establishing 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 healthcare
system:
 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 34
1. 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.

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35

36. Public Health Reforms
Strengthening the establishment of the public health
service 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. Fu
in many countries,traditional public health methods targeted at
individuals, such as vaccination and child and maternal care,
have been successfully relocated into the clinical sector,
most often primary care or general practice. Such individual
public health approaches to prevention are too important to be
neglected.
Although, in essence an individual approach, primary care
is where much of clinical medicine and many public health
practices 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