The Primary Care Assessment Tool in Health Systems Strengthening

Transcription

1 FACULTY OF HEALTH SCIENCES UNIVERSITY OF CAPE TOWN The Primary Care Assessment Tool in Health Systems Strengthening Dr Graham Bresick cutting edge research world class training and education partnering for patient-centred health services

2 Health Systems Strengthening What is a Health System? WHO Building Blocks What is Health Systems Strengthening? Support vs Strengthening Obstacle Disease / Service Specific Response vs Health System Strengthening

3 WHO Health System Framework Source: World Health Organization. Everybody s Business: Strengthening health systems to improve health outcomes WHO s Framework for Action. Geneva: WHO, 2007, page 3.

4 The 7 th Building Block PATIENT (PEOPLE) Individuals, households, and communities as: Civil society Consumers Patients Payers Producers of health through knowledge, attitudes, behaviours, and practices Graphic: Bob Emrey, USAID

5 When a patient is sick Treat patient s symptoms? Strengthen the patient s health?

6 The truth about health system strengthening Not prescriptive Objective, evidence-based and tailored to the country Indirect link between HSS and health outcomes Attribution difficult Few photo ops Coordination REALLY matters Long-term process

7 Primary Care in Health Systems Strengthening University of Cape Town Faculty of Health Sciences

8 Primary care Distinct from other clinical disciplines and levels of care Complex: has to respond to the interaction between clinical, personal and contextual factors Cost-effective when provided by trained primary care practitioners in a unified public health system Meets most health-related needs most of the time University of Cape Town Faculty of Health Sciences

9 Primary care defined Care provided by primary care practitioners trained to meet most health-related needs most of the time by: first contact person-focused (not diseased orientated) ongoing care (care over time) referring appropriately (only conditions too uncommon to maintain competence) coordinating care (integrates care with other service levels) University of Cape Town Faculty of Health Sciences

10 Strong evidence for primary care outcomes i.e. where essential elements of primary care are accessible to users and applied to their care Improved health in individuals and areas staffed with well-trained primary care practitioners Lower costs Reduced inequity Increased satisfaction University of Cape Town Faculty of Health Sciences

11 Essential elements of cost effective primary care core domains & derivative subdomains First contact care access & utilization Continuity of care (ongoing care) Comprehensiveness available & provided Coordinated care & information systems Family centeredness Community orientation Cultural competence Definition for each domain / subdomain University of Cape Town Faculty of Health Sciences

12 Measuring primary care (essential elements) Primary Care Assessment Tool (PCAT) Ability to measure primary care has been validated Each element (domain) is measured on 2 levels: presence (access) utilization (application) A measure of service organization (structure) and performance (process) for each element University of Cape Town Faculty of Health Sciences

13 HSS Building Block Tower (Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 Building Blocks of High- Performing Primary Care. Ann Fam Med 2014; ; WHO) 6 HS building blocks (WHO) 10 Building blocks of highperforming primary care University of Cape Town Faculty of Health Sciences

14 The PCAT and the Building Blocks University of Cape Town Faculty of Health Sciences

15 Health care axis / cascade PCAT Financing Equipment Work force Infrastructure Leadership & management Training CNP/Dr - Pt interaction (consultation) PHC team care Referral to next level of care Family & Community involvement in care Contextual challenges Follow up University of Cape Town Faculty of Health Sciences

16 Report-back on the Primary Care Assessment Tool study Where do we stand ito delivering primary care in the CWD? University of Cape Town Faculty of Health Sciences

17 Western Cape Primary Care Assessment Tool (PCAT) Study A Baseline Measure of Primary Care Organisation & Performance in Western Cape District Health Services 2013 CAPE WINELANDS DISTRICT RESULTS Anova-Cape Winelands Health Systems Strengthening Workshop July 2014 Study Team PI: Graham Bresick; Co-investigators: Cynthia Le Grange; Rauf Sayed; Nayna Manga; Deon September; Susheela Bhagwan; Derek Hellenberg Division of Family Medicine School of Public Health & Family Medicine, University of Cape Town & Western Cape Province District Health Services

18 PCAT 2013 STUDY PURPOSE Improve health outcomes by strengthening primary care organization and performance Support current efforts to improve primary care delivery in the Western Cape Province Obtain a baseline measure of primary care prior to major reform Provide district level managers & practitioners with a tool for ongoing monitoring & evaluation

19 PCAT 2013 Essential elements of cost effective primary care (core & derivative domains) First contact care access & utilization Continuity of care (ongoing care) Comprehensiveness available & provided Coordinated care & information systems Family centeredness Community orientation Cultural competence PHC team (added in validation process by local expert panel) (Definition for each domain / subdomain)

20 Method and Overall Results CTN Metro + CWD PCAT 2013 Adapt the ZA PCAT (Expert panel; Delphi & NGT methods) 4 Districts; 9 sub-districts;13 CHC/CDCs (sampling frame) 1432 patients (100+ per CHC/CDC) All consenting Drs & CNPs in 12 CHC/CDCs (100) All consenting facility managers in 9 sub-districts (64) Analysis (PCAT manual) 3 CWD Sub-district manager NGT groups (top 5 challenges) 3 Informant Groups Users (1432 patients) Providers (100 practitioners) Facilities (64 managers)

21 2013 CWD Results PCAT 4 CHCs (4 Sub-districts) 435 patients (100+ per CHC) 20 Drs & CNPs (4 CHCs) 22 CDC Op. Managers & Deputies 3 NGT groups (CWD only; CDC managers consensus on top 5 challenges)

22 CWD Patient Gender Distribution by CDC PCAT CWD Gender distribution (%) by Facility Male Female Wellington Ceres Worcester Montagu Total

23 PCAT CWD Patient Age Distribution by CDC Age distribution of patients (%) < Wellington Ceres Worcester Montagu Total

24 Practitioners(PE) who rated performance as good (>= 3) (METRO+CWD)

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26 CWD PCAT 2013 Patients(AE), Managers(FE), Providers(PE) scoring domains as "good" performance (>= 3) PRIMARY CARE SCORE FIRST CONTACT ACCESS(C) 100.0% 80.0% ONGOING CARE (D) AE PE FE PRIMARY HEALTH CARE TEAM(P) 60.0% 40.0% 20.0% CO-ORDINATION - E CULTURALLY COMPETENT(K) 0.0% COORDINATION (INFORMATION SYSTEMS)(F) COMMUNITY ORIENTATION(J) FAMILY-CENTEREDNESS (I) COMPREHENSIVENESS(SER VICES PROVIDED)(H) COMPREHENSIVENESS(SER VICES AVAILABLE)(G)

27 PCAT 2013 (METRO + CWD) Percentage PATIENTS (AE) scoring domains as "good" performance (>= 3) by District/Substructure S/W N/T PRIMARY CARE SCORE FIRST CONTACT ACCESS(C) % 80.00% ONGOING CARE (D) K/E RURAL PRIMARY HEALTH CARE TEAM(P) 60.00% 40.00% 20.00% CO-ORDINATION - E CULTURALLY COMPETENT(K) 0.00% COORDINATION (INFORMATION SYSTEMS)(F) COMMUNITY ORIENTATION(J) FAMILY-CENTEREDNESS (I) COMPREHENSIVENESS(SER VICES AVAILABLE)(G) COMPREHENSIVENESS(SER VICES PROVIDED)(H)

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32 Patients(AE) CWD PCAT 2013 Patients responses to selected questions

33 Patients reported waiting time (hrs; median) (C9b) CWD PCAT Median waiting time Median Wellington Ceres Worcester Montagu

34 Patients preferred waiting time (hrs; median) (C9c) CWD PCAT Median preferred waiting time Median Wellington Ceres Worcester Montagu

35 CWD Facility Managers Consensus on Top 5 Resources Needed 22 Managers; 3 Sub-districts Nominal Group Technique (NGT) process conducted with CWD Facility Managers in response to PCAT Q10: We are aware that funding streams and staff shortages may be the main resources that need to be addressed. Other than money and staff, what else do you need as a facility manager / practitioner to ensure appropriate primary care for the communities you serve

36 CWD Nominal Group Technique with CDC managers (N 22) RANK Managers Top 5 rated challenges / needs by sub-district SUB-DISTRICT A B C 1 High CNP Workload High CNP Workload (Management vs clinical tasks) & poor clinical support Infrastructure - inadequate & problematic 2 Repair of equipment & maintenance of buildings lengthy process Programmes operating in silos Transport of patients 3 HR: Staff feel unappreciated Need for levels of care (PHC) to be defined Inadequate security of facilities 4 HR: specific needs (Pharmacy, IM, help-desk) HR - Absenteeism HR: staff feel unsupported 5 Infrastructure - inadequate & problematic Infrastructure - inadequate &problematic Repair of equipment & maintenance of buildings lengthy process

37 PCAT 2013 CWD Practitioners (PE) list of Top 5 resources needed (other than more staff and money) 1. Out-Reach Programme (working closely with NGO s & CHF) 2. Patient Education (taking responsibility for their health) 3. Staff Support (by top management) 4. Time Management (clinicians spending more time doing admin work; limited time with patients) 5. Co-ordination (improve referral systems)

38 RECOMMENDATIONS and WAY FORWARD Build strong PHC stakeholder partnerships: user-providermanager Facilitate discussion: interpretation of results Generate & formulate recommendations/interventions Choose intervention pilot site (Wellington CDC) Customise PCAT for DHSs Train DHS staff to use PCAT in ongoing M&E (2014) Re-measure: determine impact of intervention(s)(2015)

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