GHF2008 – PL02 – Primary Healthcare Revisited in a Multistakeholder Landscape

Session Outline

Plenary session PL02, Monday, May 26 2008, 14:00-15:30, Room 2
Chair(s): Bruno Gryseels, Director, Institute of Tropical Medicine, Belgium & John Martin, Adviser, Office of the Director General, WHO, Switzerland
The Role of Public Services
Gilbert Balibaseka Bukenya, Vice President of the Republic of Uganda
Communities and Social Movements: Key Players in Realizing the Right to Health
Thelma Narayan, Public Health Consultant, Centre for Health and Equity, Community Health Cell, Sochara, India 
Clinicians’ Role in Primary Healthcare
Jan de Maeseneer, Secretary General, The Network: Towards Unity for Health (TUFH), University of Ghent, Belgium

Session Documents

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Session Video

Part 1

Part 2

Session Report

Submitted by: Jay Wilson (ICVolunteers)

H.E. Gilbert Balibaseka Bukenya, Vice President of the Republic of Uganda, photo: V. Krebs,

John Martin, Adviser, Office of the Director General, WHO, Switzerland, opened the session stating that the purpose was to deliberate on what the world could do to improve the health care of its inhabitants. Despite progress in technology and treatments, why is the impact not substantial? He defined "global health" as encompassing all people on the planet, over and above individual nations. Health care centres cannot do the job alone - to face the challenge of gross social injustice requires a gross political response.

H.E. Gilbert Balibaseka Bukenya, Vice President of the Republic of Uganda, stated that the centre - or glue - of a Health System is Human Resources (HR), supported by: financing, infrastructure, technologies, drugs, knowledge and information. He pointed out that health care workers (HCW) are the most important component of any health care delivery system. They design, manage and deliver prevention and care services. One of the key health indicators is the HCW to population ratio; the global average is 4 HCWs:1000. The critical threshold according to WHO is 2.28 HCW:1000 and Uganda has 0.81 HCW:1000.

Mr. Bukenya continued that another issue is weak HR management. There is an inequitable distribution in favour of urban versus rural, especially for academic degree holders. There is poor retention and low productivity; people with degrees move away. Furthermore, there is little relationship between public and private sectors. Institutional agreements create a gap between the health delivery system and communities, such as housing, environment, water, sanitation, nutrition, education, etc. Mr. Bukenya wondered why these communities are managed by people outside of the health system. Why is there not a stronger link between political will, industries and HCWs? He also stated that HCWs, along with other stakeholders, should know the country's vision and its strategic priorities, along with understanding the needs of the society they serve and learning to work with others who are dealing with similar issues, in order to affect change in the community.

He concluded that health is imperative for economic productivity. Efforts should be made to expand HR in the health sector, especially in Africa, in order to meet the standard ratio of 2.28 HCW:1000 population. He also said we must debate the idea of compensation mechanisms for migrant health workers working in the developed countries. Base countries must be indemnified for the educational investment in their people, who now use their skills to benefit other countries. Likewise, there must be an appropriate technology (i.e. Information Communication Technology, cheap effective drugs, etc) transfer to Africa to help facilitate health systems.

Thelma Narayan, Senior Public Health Consultant of the Centre for Health and Equity, stated that the community has enormous strengths. Local health traditions developed over generations have placed women health workers and women in the communities as the bearers of health care for several thousands years. When communities are involved in the decision making process, changes made are of quality and character. In these communities, health means access to water and livelihood; whereas to professionals in developed countries, health means something else. She stated that health for all is a fundamental right of each citizen; communities are agents of change. She questioned, "As experts, are we problem-solvers or are we part of the problem due to our own self-interest?"

Dr. Narayan said that she has been involved in many projects in India which use a community based approach to addressing health determinants. Communities include health facilities, elected representatives, health workers, volunteers and practitioners. They have successfully organized health awareness events where people seriously discuss health issues and how they can fix problems themselves. They have also involved the government in order to effect policy change. Similarly, they engaged the human rights commission, reviewed violation of health rights, and took judicial action to ensure the right to health.

Jan de Maeseneer, Secretary General, The Network: Towards Unity for Health (TUFH), stated that the health care system is a social determinant for health. Through various networks (education, work, economy, housing, etc), social cohesion and empowerment, good primary health care (PHC) can be accessible to the people. Additionally, the involvement of civil society is important in changing the level of health care. Community-oriented primary care (including community diagnosis, inter-sector cooperation and a focus on individual behaviour and living conditions) must be established in order to lessen unhealthy inequalities.

Principles of PHC are equity/accessibility, comprehensiveness, continuity, cost effectiveness and patient participation. Enabling patients to see the same doctor over a long period is cost effective, gives continuity of care, takes into consideration patient's expectations, and empowers the individual. In various studies, Dr. Maeseneer has shown that training of health professionals is a crucial part of PHC. HCWs must have access to continuous development; they need guidelines and medical supervision to assure adequate health care. According to the World Health Organization, a five star doctor is one who: assesses and improves the quality of care, makes optimal use of new technologies, promotes healthy lifestyles, reconciles individual and community requirements, and works efficiently in teams.

Dr. Maeseneer continued that highly skilled HCWs are taken from primary health care to specialist care and from local health care systems to vertical disease oriented programmes. Additionally, an international brain drain exists where HCWs move from central to southern Africa, then from southern Africa to Europe, Australia and North America. This phenomenon weakens the already weak state of HCWs in the local communities of underdeveloped and developing countries.

The PHC context has changed since Alma Ata, 1978. New problems exist: civil society, vertical programmes, the manpower crisis, the magnitude of economic impediment, increasing privatization and IP issues, among others. Today, PHC needs to address issues that did not exist in 1978.

The issues must be localized, meaning they must address local problems. PHC needs to look at global issues in the context of local issues, in which it must operate and it must be in a position to operate in the given community.

Is compensation really the answer to brain drain? Mr. Bukenya claimed that approximately 10% of HWCs earnings must be given back to the origin country. A compensation mechanism has to be put in place so that HCWs can stay in their 'new' country. The host country must give a proportional remittance back to the country of origin that paid for most of the HCW's primary education. Will paying for professionals to migrate to other countries solve the problem or increase the inequality gap? According to Mr. Gryseels, it is a political responsibility to create feasible working conditions, in order to keep HCWs; individuals cannot be controlled, however, compensation is political.

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