Revitalizing Primary Health Care to Achieve the Millennium Development Goals

Transcription

1 Revitalizing Primary Health Care to Achieve the Millennium Development Goals By Prof. Doyin Oluwole, Director, Africa s Health in 2010/AED Keynote Address at the ECSACON 9 th Scientific Conference and the 3 rd Quadrennial General Meeting Lusaka, Zambia, August 2010 PROTOCOL Today, I am honored to address a group of professionals for whom I have great respect nurses and midwives. I am privileged to have been born, raised and educated by a mother who was a nurse/midwife. She served humanity for over 50 years, until she was 80 years old. Her passion, dedication, love and compassion for the pregnant women, children and families in her community in Nigeria was unparalleled. Hundreds of professors, engineers, nurses, midwives, teachers and other professionals in that community were delivered in her private Nursing/Maternity Home. It was these qualities that informed my decision to pursue the medical profession and become a pediatrician. I salute all nurses and midwives in this room, and thank you for the opportunity given me today to share some thoughts on the theme: revitalizing primary health care to achieve the MDGs. The Millennium Declaration and the Millennium Development Goals (MDGs) of 2000 represent an unprecedented commitment by world leaders to comprehensively address peace, security, development, human rights and fundamental freedom. In adopting the Millennium Declaration, the international community pledged to spare no effort to free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty. The MDGs encapsulate the development aspirations of the world, but also encompass universally accepted human values and rights such as freedom from hunger, the right to basic education, the right to health and a responsibility to future generations. We are now five years away from the target date 2015 by which the Millennium Development Goals are to be achieved. We have made important progress towards all eight goals, but we are not on track to fulfill all our commitments. Today I want to talk to you about great progress that has been made, great challenges that remain, and the great role African nurses will play in meeting those challenges. What progress has been made to date? Globally, recent assessment shows some key successes. The single most important success to date has been the unprecedented breadth and depth of the commitment to the MDGs a global collective effort that is unsurpassed in 50 years of development experience. For example, in May 2009, the US Government announced a $63b over 6 years for Global Health Initiative (GHI). More recently, the government has developed a strategy to meet the MDGs. It is not only governments of developing countries and the international community that have adopted the MDGs as their framework for international development cooperation, but also the private sector and, critically, civil society in both developed and developing countries. Besides being advocates for the MDGs, private foundations in the developed countries have become an important source of funding for a wide range of activities intended to achieve them. NGOs in developing countries are increasingly engaged in undertaking these activities, as well as in monitoring the outcomes. This global collective effort is yielding results. Despite the many and varied challenges, there has been sound progress in some MDG areas, and a number of targets are expected to be reached by 2015: Deaths of children under five declined steadily worldwide to around 9 million in 2007, down from 12.6 million in 1990; Measles deaths worldwide fell by 78% between 2000 and 2008, from an estimated 733,000 in 2000 to 164,000 in About 80 per cent of children in developing countries now receive a measles vaccine; 1

2 Primary school enrollment and completion rates have increased substantially across the developing world. In 2007, the primary school completion rate reached 86 percent for all developing countries in the aggregate, which means that over 40 million more children were in school in 2007 than five years before; Almost two!thirds of developing countries have met the goal of eliminating gender disparity in primary education. The goal of doing so in secondary education by 2015 is within reach; Over 1.6 billion people gained access to improved sources of drinking water between 1990 and If current trends persist, the target of halving the proportion of people without access to sustainable sources of safe drinking water will be met by 2015; Due to successful HIV/AIDS prevention, treatment, and care programs, AIDS!related mortality has decreased, and more than four million people in the developing world are receiving antiretroviral treatment; Thanks to malaria!prevention initiatives such as the widespread use of bed nets, a third of the 108 countries in which malaria is present reported a drop of at least 50 percent in the number of cases in the past decade; Tuberculosis incidence rates have declined in all nine epidemiological subregions, putting the world on track to achieving the MDG target of halving tuberculosis prevalence and mortality Where is Sub-Saharan Africa in this global progress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hese successes should be celebrated, encouraged, and supported. Though much has been achieved, much remains to be done. Important obstacles remain to meeting the health!related MDGs. Newborn and infant mortality is still unacceptably high, in Sub!Saharan Africa. 2

3 Despite encouraging new data, reductions in maternal mortality and child under!nutrition rates have been much too slow. There is a wide variation in contraceptive prevalence rate (CPR) among currently married women in the region ranging from 75% to 5%. HIV continues to spread in many countries, and a significant gap remains between those who need treatment and those who can access it. Reducing the burden of disease in developing countries is frequently limited by the difficulty of scaling up interventions through weak health care infrastructure. Realizing the Millennium Development Goals and targets depends upon availability of adequate human resources for health, infrastructure, delivery mechanisms, and uptake to achieve universal coverage with critical interventions. Although alternative mechanisms are sometimes required, the primary health care system remains the major distribution channel for essential health services and interventions. Therefore, access to primary health care is crucial for effectively reaching those at risk. Many of the health challenges we face today, both in rich and poor countries, echo those that led to the meeting in Alma-Ata in 1978 when primary health care was born. Demographic and epidemiological transitions have strained health systems as new diseases have emerged, while the old remain. 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 aging 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 care, with increasing demand, rising costs, and a return towards curative and hospital care, makes re-exploration of the Alma-Ata principles timely and relevant. What is primary health care? Primary health care according to the Alma-Ata declaration is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. 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. Let us examine the seven characteristics of primary health care as enumerated in the Alma-Ata Declaration and how they are relevant to the attainment of the MDGs: 1. Primary health care reflects and evolves from the economic conditions and socio-cultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical, and health services research and public health experience. This means evidence-based health care customized to the needs of the people. 2. It addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly that is, a comprehensive, holistic approach to care that transcends the dichotomy of vertical versus integrated approaches, and either community or facility-based care; 3. PHC includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs that is to say: a minimum essential package of acceptable quality health care and services; 3

4 4. It involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications, and other sectors; and demands the coordinated efforts of all those sectors. This means a multisectoral approach with intersectoral coordination, collaboration and partnership for health; 5. It requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation, and control of primary health care, making fullest use of local, national, and other available resources; and to this end develops through appropriate education the ability of communities to participate. That says: community empowerment, ownership and full participation; 6. Primary health care should be sustained by integrated, functional, and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need i.e., pro-poor functional continuum of care that links households to the formal health system with an efficient referral system; 7. It relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community- that is, Working as a skilled team together for health. If we agree with the above seven characteristics of primary health care, I wish to submit that the quickest way to reach the Millennium Development Goals is to return to the values, principles, and approaches of primary health care, in which you, the nurses of Africa, will play a central role. Decades of experience tell us that primary health care is the best route to universal access, the best way to ensure sustainable improvements in health outcomes, and the best guarantee that access to care will be fair and equitable. How do we embark on this journey? WHO has identified five key reforms to revitalize primary health care: 1. First, universal coverage reforms that ensure that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection. This reduces exclusion and social disparities in health. It requires us to update our essential health care packages, identify health system requirements for expanded coverage of essential services, assess the capacity of the health systems, particularly at the operational level to deliver quality essential services and promote comprehensive integrated approaches. 2. Next, we have the service delivery reforms that reorganize health services as primary care, i.e., around people s needs and expectations, so as to make them more relevant and more responsive to the changing world while producing better health outcomes. This type of reform is characterized by person-centeredness, comprehensiveness and integration, continuity of care, and participation of individuals, families and communities. Services are brought as close as possible to the people and delivered by a multidisciplinary, skilled, equipped and motivated team that is responsible for a defined population. 3. Third, public policy reforms that secure healthier communities, by integrating public-health actions with primary care and by pursuing healthy public policies across sectors; essentially integrating health into all sectors. This reform promotes intersectoral collaboration and public-private partnerships, development of regulatory frameworks to govern partnerships, and a strengthening of linkages between central and local government. 4. Fourth, leadership reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems by pursuing collaborative models of policy dialogue a policy dialogue that results in the best strategies and governance structure to meet the demands of the population; and 4

5 5. Finally, what I call partnership reforms that increase stakeholder participation for improved leveraging and maximization of synergies, with due recognition that no one government, agency or group can reach the desired goal working independently. The implementation of these reforms will doubtless set us on the path to a second primary health care revolution. What role can ECSACON play? A CHARGE TO ECSACON Cognizant of the fact that Sub-Saharan Africa has only 4% of the health workforce but 25% of the global burden of disease (GBD), and that doctors, nurses and midwives constitute the backbone of the health workforce, I urge you to actively promote intensified quality capacity-building and personal professional development efforts to reduce the gap in the nurse/midwife to population ratio in the region in the next 5 years. This will require you to develop, together with the appropriate government and stakeholder bodies, relevant training, retention, management, recruitment, deployment and support policies and strategies including monitoring and evaluation frameworks to document progress. It also calls for you to work in a collaborative, interdisciplinary, complementary and not competitive context with other health care providers such as doctors, allied health professionals and community health workers to enable effective responses to people's health needs. The results will include: a revitalized recruitment to get workers with the right skills to the right place at the right time and improved social compatibility between workers and clients; supportive, firm and fair supervision to improve the competence of individual health workers. Recognizing that the health status of communities is both a function and a reflection of development in those communities; that the locus of control is important in PHC; and that health services should reflect local needs and involve communities and individuals at all levels of planning and provision of services, I challenge you to engage in researchbased assessments of health and service needs of people and communities of the ECSA subregion, in partnership with communities and other stakeholders. Nurses are known for their human understanding of their patients; I urge you to join that human touch with a data-based understanding of the community's overall needs and priorities. Convinced that the provision of comprehensive primary health care services including promotive, preventive, curative, and rehabilitative services, linked to effective referral systems, delivered through an integrated and continuum of care approach will achieve universal coverage, I charge you to review and update pre-service and in-service training curricula for nurses and midwives to address the need and demand of people for broadened nursing/midwifery functions at all levels of care. Bear in mind that in-service training is most likely to change behavior and performance when it is interactive, based on real-life problems and coupled with continuing, intermittent support. Mindful of your commitment to the Florence Nightingale Pledge (for those who took it and value it), I urge you to intensify personal and corporate efforts to respect, protect and promote the health of individuals and communities you serve, maintain and elevate the standard of your profession, and work together towards achieving universal access, greater equity and improved health outcomes, including achievement of Millennium Development Goals, particularly the health-related MDGs. Persuaded that nurses and midwives represent the voice of the many voiceless women and children particularly in Africa, I urge you to continue to advocate for improved resource mobilization, allocation and release, health systems strengthening based on the primary health care approach, as well as, development of an appropriate and sustainable national health financing mechanism for accelerated progress towards universal access to quality health services and achievement of MDGs. Noting that the majority of health workers are women, ECSACON should continue to advocate for keeping health work as a career of choice for women. More attention must be paid to their safety including protection against violence, and more flexible work arrangements and promotions to senior positions. Taking into account that what gets measured gets done, I urge you to strengthen documentation of good and promising practices, information and knowledge sharing, culture of follow-up, monitoring and evaluation and performance indicators with a focus on both process and impact. In conclusion, I wish to remind us that the operationalization of universal coverage, service delivery, public policy, leadership and partnership reforms cannot be implemented as a blueprint or as a standardized package. It needs to be tailored to the needs of each community and country and be people-centered. Health ministries must be strengthened to 5

6 provide inclusive, transparent and accountable leadership of the health sector and to facilitate multisectoral action as part of primary health care. Millennium Development Goals 4 and 5 are still achievable by 2015 but only a dramatic acceleration of political commitment and financial investment can make it happen. I know that whatever gains are made, nurses will be central to those gains. Wherever morbidity goes down, wherever mortality goes down, wherever communities take steps to prevent disease, nurses and midwives will be key players in this progress. I salute your commitment. Together, we must maintain our commitment, determination, and above all, our sense of urgency for a large unfinished agenda that of achieving the Millennium Development Goals. References 1. The World Health Report 2008: Primary Health Care now more than ever. Geneva, World Health Organization, Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva, World Health Organization, 2008: nd World Health Assembly, May 2009: 4. Florence Nightingale Pledge 1893: 5. Dr Joy E Lawn MRCP [Paeds], Jon Rohde MD, Susan Rifkin PhD, Prof Miriam Were DrPH, Prof Vinod K Paul MD, Mickey Chopra MSc. Alma-Ata 30 years on: revolutionary, relevant, and time to revitalize. The Lancet, Volume 372, Issue 9642, Pages , 13 September Countdown to 2015: Decade Report. Taking stock of maternal, newborn and child survival Global measles deaths drop by 78%, but resurgence likely: 8. The Millennium Development Goals Report 2009: 9. The World Health Report working together for health: 6