Population and International Health PIH 30 - Health Systems International

HEALTH SYSTEMS and SERVICES: A Global & Developing Country perspective

Prof Ruair Brugha Dept Epidemiology and Public Health Medicine

RCSI Medical Graduate profile

The RCSI doctor:
4.3 Understands the characteristics of a range of health systems and population health responses and the merits and problems associated with each. 4.3.1 Understands the principles, values and strategies that underpin the population health and different health systems approaches to controlling the major burden of disease in wealthy and poor countries 4.3.2 Understands how health systems and services are organised, financed, managed, staffed and delivered in ones own country and the main models used in other high, middle and low-income countries.

Health Systems: Learning

Outcomes students will be able to

1. Explain, with examples, the inter-sectoral nature of health systems, including

the broader actions that contribute to health The basic primary health care interventions that benefit populations most

2. Define what is meant by the health system and list its goals, components and levels 3. Discuss the origins and global variations in health systems 4. Explain Patient referral pathways through the different levels of the health system
Primary (health) care (specialist) care Secondary (hospital) care Tertiary

5. Describe global health worker distribution and responses to the health workforce crisis 3

Millennium Development Goals 1: Eradicate extreme poverty and hunger

2: Achieve universal primary education 3: Promote gender equality and empower women 4: Reduce child mortality 5: Improve maternal health 6: Combat HIV/AIDS, malaria and other diseases 7: Ensure environmental sustainability 8: Develop a Global Partnership for Development
See http://www.un.org/millenniumgoals/pdf/mdgs_glance_factsheet.pdf
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Impact of AIDS in 1990sand then?

Anti retrovirals in 2000s
Life expectancy progress from 1960 to 2010 Life expectancy at birth, total (years) 66 years 1990

56 years 2007

51 years 2000
Botswana 1960

Botswana 2001

What is the triple burden of AIDS on the health system?

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MDG 4: reduce child mortality by 2/3rds,

1990-2015

What 3 interventions will prevent most deaths?

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Health action goes beyond Health Services

water, food, work, sex, travel, cooking investment in health, the economy and an equitable society as well as investing in health services environmental problems need to be tackled because they impact on health the health system is about more than just health services or health is too important to be left to doctors alone Q?What are the causes of the high burden of HIV and AIDS in southern Africa? What population measures will prevent HIV?
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Example: Maternal Health

MDG 5: reduce maternal mortality ratio by three quarters (1990-2015) Safe Motherhood strategy components?: Community education Antenatal care: e.g. nutritional supplements, blood pressure and infectious disease screening, Post partum care Skilled assistance at delivery Interventions to manage obstetric complications & emergencies What else . . . .? Transport ! in many poor countries, facilities for managing complications exist but people cannot reach them Trained health workers often lost to rich countries, e.g. Ireland New technologies mobile phones
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1. 2. 3.

From health services to health systems definitions

1. the resources, organisation, financing and management that go into the delivery of health services to the population the means whereby programmes and interventions are planned and delivered the institutions and individuals that combine to determine how goods and services are delivered, whose principal intended function is to improve human health

2.

3.

Apart from meeting the health & health care needs of populations, what is the other big role of Health Services ? they employ people !
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Health Systems components

1. Health Services types, levels, target groups Preventive and curative personal health services Primary, secondary and tertiary services (appropriate levels of care) Services for specific population groups, e.g. children, mental illness, People living with AIDS, disability, etc. Resources needed Trained staff, commodities (drugs), facilities (hospitals and clinics) a) Organisation and b) Stewardship a) Ministries of health, private sector, voluntary sector b) Planning, Management, Regulation, Legislation Financing mechanisms Tax, insurance, user (patient) fees . . . . more later
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2.

3.

4.

How health systems evolved around the world

Pre-colonial
Informal traditional systems in Africa
Herbalists Spiritualists / fetish priests

Formal traditional systems in Asia

Ayurvedic medicine Homeopathy (also popular in Europe and USA) 1.There are more formally trained Ayurveds and Homeopathists in India than Allopaths (MB BS doctors) 2.Healers are the first port of call for 50% who seek care for HIV and sexually transmitted diseases in Africa 3.80% of people in Africa continue to visit traditional healers because of physical, mental and social ill health (see Wikipedia on traditional medicine)
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From colonial health to Primary Health Care

Health Services in Africa + much of Asia
Hospital focus no formal primary care service Urban concentration cities prioritised rural areas neglected Focused on needs of elite few

Primary Health Care Principles (Alma Ata 1978)

Universal accessibility and coverage Community participation Intersectoral action for health Appropriate (evidence-based) interventions Affordability and Sustainable systems
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Health System Structure: primary care

Aim of Primary Health Care:
to provide care as close to the community as possible, but safely & effectively

Primary Care: 1st level of formal care within the health system
- Ireland: GP, District Nurse, Pharmacist (Primary Care team, esp in UK) - Africa: Community health post, village health worker, traditional birth attendant - India: Rural areas: informally trained private provider practicing a mix of allopathy, homeopathy and ayurvedic medicine Urban areas: privately for profit GP trained in allopathy, or homeopathy or Ayurvedic medicine
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* Referral system in Ireland and the UK

The GP (General Practitioner) = gate keeper to The Hospital County or district (secondary care) Regional, voluntary & national specialist (tertiary care) Level of hospital care depends on Complexity of case and need for specialist investigation and specialist care Access (financial and physical)
* Student Notes Page include hyperlinks to Wikipedia for explanations of terms
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Referral system in India & Africa

Rural Africa and India Functioning public district hospital + district management are key
primary care services rudimentary patients directly access district hospital In a functioning system, cases requiring emergency care and major surgery are referred to district hospital + more complex cases referred onwards district management of preventive, treatment and care services

Urban Africa and India: Mix of public sector and private sector
private specialists working in small private hospitals and clinics large tertiary public hospitals providing basic and even primary care as well as tertiary specialties mixed public private practice common (e.g. Drs work in public sector in the morning and refer patients to their afternoon private clinics)
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http://www.gapminder.org/
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Human Resources for Health: a framework

1. Capacity
Basic and in-service training appropriate to disease burden To produce knowledge, skills, competencies, attitudes

2. Remuneration and other incentives

Financial: salary, pension, personal and family allowances Non-financial incentives: access to training

3. Organisational environment
Availability of facilities, drugs, equipment to deliver services Management / leadership Hongoro & Normand
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COST-Africa: a case study

1.
RCSI is partnering with the College of Surgeons of East, Central and Southern Africa (COSECSA) to train doctors to be specialist surgeons in 10 African countries on-line simulation methods and exams overseen by RCSI. Hypothesis: training African doctors as surgeons in-situ will mean they will continue to practice in these countries.

Problem: salary levels at 10% of Europe + US levels Doctors not employed at district hospitals ($) + doctors emigrate

2. Response: train non-medics (clinical officers 3 yrs training) to do major surgery

COST-Africa: an EU-funded cluster randomised controlled trial (RCT) to measure the health impact and cost-effectiveness of training clinical officers to do major surgery at the district level in Malawi and Zambia: 2011-15 Potential to save thousands of lives / ten thousands of DALYs New roles for surgeons as: (i) specialists, (ii) trainers, (iii) quality assurers a population approach to health workforce planning based on good evidence
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Global Code on the international recruitment of Health Personnel 1. Ethical international recruitment
Avoid active recruitment from countries facing critical shortages
Ireland recruited its nurses mainly from Philippines and India and now doctors from India and Pakistan is this ethical ?

2. Health workforce development and health systems sustainability

Member states should train and retain a health workforce appropriate to its needs HWs central to health systems
Ireland is good at training, but not at retaining its doctors and nurses

3. Fair treatment of migrant health personnel

Health workers have rights, including rights to emigrate, Rights to accurate information, and to equal treatment
researchable issues being researched by RCSI in 2011-15

Global Code on the international recruitment of Health Personnel 4. International cooperation

Destination countries encouraged to collaborate with source countries to maximise mutual benefits
Ireland (donors, practitioners and researchers) collaborating with African countries but what about our main source countries?? Support training, technology and skills transfer best practice is to support in-country training: RCSI COSECSA, COST, Medical Schools

5. Support to developing countries

Technical assistance and financial support (as above) Establish effective health personnel information systems Research programmes Share information and Report on implementation internationally

6. + 7 Data gathering, reporting, research