Regional Family Medicine Development - and Challenges for Thailand Dr Garth Manning Primary Health Care Adviser Health Care Reform Project

“By 1990 all member states, through effective community representation, should have developed health systems that are based on primary health care and supported by secondary and tertiary care, as outlined at the Alma Ata conference in 1978” WHO Target: 1985

Why is primary care important? Better health outcomes Lower costs Greater equity in health

Primary care oriented countries have: Fewer low birth weight infants Lower infant mortality, especially post- neonatal Fewer years of life lost due to suicide Fewer years of life lost due to all causes except accident and injury Higher life expectancy at all ages except at age 80

World Health Report 2008 Universal coverage reforms Service delivery reforms Public policy reforms Leadership reforms

China

Vietnam

Philippines

Brunei

Singapore

Sri Lanka

India

Bangladesh

Pakistan

Primary care – key facts

What we already know A primary care oriented system is important for: Improving health (improving effectiveness) Keeping costs manageable (improving efficiency)

Key Elements Primary Personal Continuing Comprehensive Coordinating

PC 4181 First contact avoids unnecessary specialist visits. Person-focus over time avoids disease-focused care (makes care more effective). Comprehensiveness avoids referrals for common needs (makes care more efficient). Coordination avoids duplication and conflicting interventions (makes care less dangerous).

Did you know…..in USA An estimated one third of health interventions (surgical and medical) are unnecessary. Studies have shown that the third leading cause of death in the United States, after heart disease and cancer, is medical intervention, including both tests and therapies.

Did you also know…. Areas with high use of resources and greater supply of specialists have NEITHER better quality of care NOR better results from care Baicker & Chandra, Health Aff 2004; W4: Wennberg et al, Health Aff 2005; W5:

…areas with better primary care have better health outcomes, including total mortality rates, heart disease mortality rates, and infant mortality, and earlier detection of cancers such as colorectal cancer, uterine/cervical cancer, breast cancer, and melanoma. The opposite is the case for higher specialist supply, which is associated with worse outcomes. Sources: Starfield et al, Milbank Q 2005;83: Macinko et al, J Ambul Care Manage 2009;32:

Does primary care reduce inequity in health?

Source: Shi et al, Soc Sci Med 2005; 61(1): In the United States, an increase of 1 primary care doctor is associated with 1.44 fewer deaths per 10,000 population. The association of primary care with decreased mortality is greater in the African-American population than in the white population.

In 35 US analyses dealing with differences between types of areas (7) and 5 rates of mortality (total, heart, cancer, stroke, infant), the greater the primary care physician supply, the lower the mortality for 28. The higher the specialist ratio, the higher the mortality in 25. Controlled only for income inequality Source: Shi et al, J Am Board Fam Pract 2003; 16:

What is the appropriate role for primary care and specialist physicians? Primary care –person-focused care over time, first contact access, ongoing care of all but uncommon problems, coordination of care Specialist care: Short term consultation for diagnosis or initiation of management Concurrent consultation for advice on continuing management Long term referral for management of unusual conditions

Good primary care requires Health system POLICIES conducive to primary care practice Health services delivery that achieves the important FUNCTIONS of primary care

Challenges to development Improved incentives and career structure Increased professionalism of the specialty (and removal of hospital specialists from FM) Increased financial support for training Strategic leadership from MOPH (including a rational postings policy) Enhanced role for nurses Financing reforms Increasing primary care research

“ Today we’re not just challenged to provide universal care at all levels, but also better quality care, better organised and integrated services. People expect much more of us now “ Dr Christina Luna