Priority for public health in Europe

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Priority for public health in Europe
Primary Health Care, A Solution? An Old Remedy?
Peter WS Chang, MD, MPH, ScD
Desiderius Erasmus Roterodamus 1469-1536
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Overview

• Before Alma-Ata/PHC/HFA
• What were in the Alam-Ata, what were not
• Why HFA did not deliver?
• Priority for public health in Europe
• What are needed beyond

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Reflections on health care, primary care

• Health care started from primary care.
• The healers received and examined, advised, then
  helped did not turn the patients away or
  referred to others.  
• Primary health care with advantage of providing
  continued care, fully satisfy patients need.
• New health care is fragmented.

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Dr. Halfdan Mahler, 1973-1988
"Methods of promoting the development of basic
health services" by WHO's Executive Board in
1973, co-sponsorship with UNICEF to convene "The
International Conference on Primary Health Care"
in Alma-Ata in 1978.
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Declaration of Alma-Ata

• A set of guiding values for health development, a
  set of principles for the organization of health
  services, and a range of approaches for
  addressing priority health needs and the
  fundamental determinants of health.
• Broadened the medical model to include social and
  economic factors, and acknowledged that
  activities in many sectors, including civil
  society organizations, shaped the prospects for
  improved health. Fairness in access to care and
  efficiency in service delivery were overarching
  goals.
• "It is the first level of contact of individuals,
  the family and community with the national health
  system bringing health care as close as possible
  to where people live and work, and constitutes
  the first element of a continuing health care
  process."

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When I took office in 2007, I made clear my
commitment to direct WHOs attention towards
primary health care
.. health systems had to be scaled up through
dynamic collaboration among governments,
international partners, non-governmental
organizations and the private sector .
combating disease and improving health in
developing countries is being enhanced by new
technologies, service-delivery mechanisms and
partnerships.
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World distribution of health workers
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Margaret Chan, Lancet 2008

• Primary health care increasingly looks like a
  smart way to get health development back on
  track.
• The Millennium Declaration and its Goals breathed
  new life into the values of equity and social
  justice, this time with a view towards ensuring
  that the benefits of globalization are more
  evenly distributed between countries.
• In August 2008, the Commission on Social
  Determinants of Health issued its final report.
  Its arguments make a compelling call for close
  attention to health in all government policies,
  in all sectors. the report champions primary
  health care as a model for a health system that
  acts on the underlying social, economic, and
  political causes of ill health.
• World Health Report on primary health care. Timed
  to commemorate the Alma-Ata anniversary, the
  report offers practical and technical guidance
  for reforms that can equip health systems to
  respond to health challenges of unprecedented
  complexity.

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• EXECUTIVE BOARD 124th Agenda item 4.5 EB124/8
  Jan. 2009
• Primary health care, including health system
  strengthening
• - renewal of primary health care
• recognize the potential of primary health care
  for providing a
• stronger sense of direction and unity in
  segmented and fragmented
• health systems
• - the framework integrates health into all
  policies
• need for improved health systems performance
  based on the values of
• primary health care
• Commission on Social Determinants of Health
  underlying social,
• economic, and political causes of ill health,
  and of the methods most
• likely to provide solutions
• - renewed focus on primary health care

How can political commitment avoid fail to
deliver?
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4 Broad Policy Areas for Essential Changes

• dealing with health inequalities by moving
  towards universal coverage
• putting people at the centre of service delivery
• integrating health into public policies across
  sectors
• - providing inclusive leadership for health
  governance

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Can primary health be a solution for all (health
system)?
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Can primary health be a solution for all (health
system)?
Can primary health care help health system
survive the financial crisis than the others?
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Priority for public health in the new Europe
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How does it work in Europe?

• One member country, one commissioner

enterprise and industry Günter Verheugen
consumer protection
Meglena Kuneva
healthy Androulla Vassiliou

environment Stavros Dimas


development humanitarian aids Louis Michel
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EU competences in health care system?

• Alzheimer's disease and other dementias Health
  Security and Bio-terrorism
• Blood Tissues Cancer
• Communicable Diseases Cross-border Healthcare
• European Health Examination Surveys Extreme
  weather conditions
• Health Reports Health Indicators
• Health Environment Health Workforce
• HIV/AIDS Injury Prevention and Injury Database
• Major and chronic diseases Mental Health
• Nutrition Patient Safety
• Pharmaceutical Forum Rare Diseases
• Scientific Committees Tobacco

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European health agencies

• Governed by European public law has its own
  legal personality.
• European Centre for Disease Prevention and
  Control (ECDC) mobilise and reinforce the
  synergies between the existing national centres
  for disease control.
• provide authoritative scientific advice on
  serious health threats, recommend control
  measures, allow quick mobilisation of
  intervention teams, enable a rapid and effective
  EU-wide response. From early 2005
  onwards.European Environment Agency (EEA)
  collect, prepare and disseminate timely,
  targeted, relevant and reliable information on
  the state and trends of the environment. is open
  to countries that do not belong to the European
  Union but share its concern for the environment.
  co-operates actively with other relevant bodies
  and international organisations.European
  Monitoring Center for Drugs and Drugs Addiction
  (EMCDDA) collect and disseminate 'objective,
  reliable and comparable information' on the
  phenomenon of drugs and drug addiction in Europe.
  works in partnership with non-EU countries as
  well as with international organisations
• European Agency for the Evaluation of Medicinal
  Products (EMEA) protection of public and animal
  health. works as a network, bringing together the
  scientific resources of the EU and EEA-EFTA
  Member States, ensure the highest level of
  evaluation and supervision of medicines in
  Europe.
• European Agency for Safety and Health at Work
  (EU-OSHA) bring together and share the region's
  vast pool of knowledge and information on
  OSH-related issues, particularly preventative
  measures.European Food Safety Authority (EFSA)
  provide independent scientific advice on all
  matters with a direct or indirect impact on food
  safety. cover all stages of food production and
  supply, from primary production to the safety of
  animal feed,

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Overview of European health strategy (1)

• an important priority for Europeans
• (Europeans) expect to be protected against
  illness and disease
• bring up (our) children in a healthy environment
• demand workplace safe and hygienic
• travelling (within the European Union) with
  access to reliable and high-quality health advice
  and assistance

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Overview of European health strategy (2)

• Public authorities (in Member States) have a
  responsibility to ensure that these concerns are
  reflected in their policies.
• (The European Union) has a vital role to play
  through the obligations placed on it by the
  European Treaties.
• Cross-border health threats, influenza, free
  movement of patients and medical personnel

EU
individuals
community
States
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Overview of European health strategy (3)

• A coherent and coordinated approach to health
  policy first set out in the European Community
  health strategy in May 2000.
• A new Health Strategy 'Together for Health A
  Strategic Approach for the EU 2008-2013 adopted
  on 23 October 2007.

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4 principles and 3 strategic themes
Overview of European health strategy (4)

• taking a value-driven approach,
• recognising the links between health and economic
  prosperity,
• integrating health in all policies,
• strengthening the EU's voice in global health.

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Overview of European health strategy (5)

• 4 principles and 3 strategic themes
• Fostering Good Health in an Ageing Europe,
• Protecting Citizens from Health Threats,
• Dynamic Health Systems and New Technologies.

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The Strategy is supported by financial tools both
in DG SANCO and in other sectors, such as the 7th
Framework Programme for Research, and Regional
Policy funding. The Health Programme 2008-2013
Funding EUR 321,500,000
Overview of European health strategy (6)
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Overview of European health strategy (7)
To improve citizens health security
Developing EU and Member States capacity
to respond to health threats, health
emergency planning, preparedness measures
Actions patient safety, injuries and accidents,
risk assessment, community legislation on blood,
tissues and cells.
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Overview of European health strategy (8)
To promote health and reduce health
inequalities Action on health determinants
nutrition, alcohol, tobacco, drug consumption,
social and environmental determinants
Measures on the prevention of major
diseases and bridging health inequalities
across the EU Increasing healthy life years
and promoting healthy ageing.
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Overview of European health strategy (9)
To generate and disseminate health information
and knowledge Action on health
indicators, disseminating information to
citizens Focus on Community added-value
action to exchange knowledge in areas such as
gender issues, childrens health or rare
diseases.
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Marc DanzonWHO Regional Director for Europe

• Europe is in a period of extensive innovation in
  primary care
• (Efforts) help close the gap between the
  expectations of health policy-makers about the
  major role that primary care should play, , and
  the day-to-day performance of real health systems
• how primary care can best be institutionalized
  within modern health care systems?
• whether primary care ought to be in the health
  systems drivers seat yet to be determined.

Organizational reform in European primary
care Richard B. Saltman, Ana Rico, Wienke
Boerma Open University Press, 2006
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• 24 November 2008
• Home care in Europe the solid facts

Quality in Primary Care 2008
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The PHAMEU projectPrimary Health Care Activity
Monitor for Europe

• coordinated by NIVEL and a network of
  institutes organisations in EU - to establish
  a sustainable health information and knowledge
  system on the state and development of primary
  care systems in Europe.
• - monitor the degree of development of primary
  care systems by means of a measurement instrument
  applicable to all national situations in Europe,
  able to capture the essential elements of primary
  care. 
•  Expect a primary care monitoring instrument
  providing country descriptions, international
  comparisons, trends in primary care, implications
  for primary care policy.
• Duration from 1 November 2007 until 1 November
  2010.

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GP density/ Role of GPs as doctor of first
contact with health problems
http//www.phameu.eu/

• Heterogeneity and distribution in Europe

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What are the problems?

• In-suf?cient coherence and coordination
• Character and conditions of primary care so
  diverse
• Constantly rising health expenditures, the health
  needs of growing subgroups of the population,
  such as the chronically ill, the elderly and
  those in need of hospice services in their homes,
  are not well met (McKee and Healy, 2001)
• Unmet needs, unnecessary treatments,
  medicalization, other threats to patients safety
• side effect of specialization and
  sub-specialization in health care, by which
  professional inward-directedness tended to grow
  at the expense of attention to integration with
  other disciplines

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Expanded horizon of health care services

• Problems of coordination are likely to arise at
  key interfaces between primary and secondary
  care, between curative care and public health
  services, and between specialities within
  particular subsectors
• Growing importance of anticipatory medicine and
  prevention.
• Poor communication between primary care,
  hospitals, and medical specialists has been well
  documented in many health care systems

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Why PHC preferred?

• Relationship between strong primary care systems
  and health outcome measures (Starfield,1992).
• The strength of primary care systems in countries
  related to cost-containment and health outcomes
  (Starfield 1994 Delnoij et al. 2000 Shi 2002
  Macinko et al. 2003).
• If more health care providers were directly
  accessible in a country, patients showed a higher
  satisfaction with general practice than in
  countries where more referrals were required
  (Madelon W. Kroneman et al, 2006)

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• strong primary care system is the linchpin of
  effective health care delivery and can help
  resolve the lack of continuity and responsiveness
  in health care in general (Saltman and Figueras,
  1997 WHO, 2002).
• strong primary care based systems are cheaper to
  operate than more open systems, health outcomes
  are better (Star?eld, 1994 Doescher et al.,
  1999 Shi et al., 2002 Macinko et al., 2003).
• only a few OECD countries have been able to
  improve essential features of primary care since
  1970 (Macinko et al. 2003)

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Other disciplines in primary care

• Nursing, community nurses
• Pharmacist
• Physiotherapist
• Midwife
• Other home helpers
• How to integrate these resources?

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Time to develop new players and indicators

• Considering the population distribution, health
  care provider distribution, transportation/communi
  cation, availability of GP, other helpers

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Factors in new indicators for PHC

• Disease incidences
• Hospitals, specialties,
• Health professionals
• Ambulance
• Transportation

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New players for PHC to join? When?

• eBusiness/ eHealth model?
• Internet
• Email
• Google-messenger/video-MedWeb? (ebanking?)
• Skype-video

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• Thank you for your attention.

Dr. and Mrs. Landsborough (1913)
John Snow 1813-1858
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Almere health care experiment

• 1978, first Dutch model of PC
• Suburb of Amsterdam, 165,000 population, 6500
  increase each year
• Design a well-developed coherent system of
  primary care, with a minimum amount of secondary
  level facilities.
• A foundation was created to employ all GPs,
  physiotherapists, pharmacists, dentists, midwives
  and auxilliary staff, social workers and
  community nurses
• The goal reduce referrals to medical
  specialists.
• Reduce use of antibiotics particularly by
  children, as were tonsillectomies.
• At least one female GP in every health centre,

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• Coordination, teamwork, integration
• - offers diagnostic, curative, rehabilitative
  and palliative services in response to the bulk
  of these problems
• - offers prevention to individuals and groups at
  risk in the population served
• - takes into account the personal and social
  context of patients
• - is provided by a variety of disciplines,
  either within primary care, secondary care or
  related sectors
• - assures patients continuity of care over time
  as well as between providers.