European Forum for Primary Care: "Twinning Population Health and Primary Care" Barcelona, Spain, 1-2 September, 2014 WHO Strategy on People-Centered and Integrated Health Services (PCIHS) Hernan Montenegro Coordinator Services Organization and Clinical Interventions Service Delivery and Safety (SDS)

Content Rationale Strategy analytical framework Strategic directions on PCIHS Strategy implementation Next steps

Ongoing challenges for health Access – 1/3 of people with mental health disorders in HICs receive treatment, as low as 2% in LMICs Availability – 58% of countries have any palliative care program Acceptability – delivering women experience verbal abuse, condescension, intimidation and even physical abuse Quality of care – international survey of clinical practice for heart failure found only 59% of quality of care indicators achieve, under clinical trial conditions

Emerging challenges for health services Non-communicable diseases: multiple-morbidities long-term, continuous care Service fragmentation Existing and growing inequities Recognition of the significant challenges to reforming health service delivery systems

Ongoing challenges for health Lack of coordination Coordination Of Care, Medical Errors, And Safety Among Sicker Adults In Eleven Countries, 2011

Emerging challenges and opportunities Demographic and Epidemiological Transition Socio-political factors: concerns about health care costs, and cost-efficiency Increasingly active and organized consumers Technological advances: Patient self-monitoring and self- management Linkages between health care providers (e.g. electronic medical records) Globalization: Export of unhealthy lifestyles Medical tourism

Building on Global Commitments Reinvigorating Primary Health Care (WHR 2008) Health systems strengthening (Everybody’s Business 2007) Universal Health Coverage (WHR 2010) Rio Declaration on social determinants (2011) Prevention and control of NCDs (UNGASS 2011) Multiple regional reports Growing global commitments– but can service delivery systems deliver?

Source: WHO, Primary Health Care- Now More than Ever, World Health Report, 2008

Understanding People Centered and Integrated Health Services Universal Health Coverage People Centered Care Integrated Health Services People centered and integrated care to support UHC -The best case scenario-

Proposed analytical framework

Core principles guiding People-Centered and Integrated Care Comprehensive Equitable Sustainable Co-ordinated Continuous Holistic Preventative Empowering Co-produced Respectful Rights and responsibilities approach Collaborative care Shared accountability Evidence-informed Whole-systems thinking Comprehensive - a commitment to universal health coverage to ensure care is comprehensive and tailored to the evolving needs and aspirations of people Equitable – care that is accessible and available to all Sustainable – care that is both efficient, effective and contributes to sustainable development Co-ordinated – care that is integrated around people’s needs and effectively coordinated across different providers and settings Continuous – continuity of care and services that are provided across the life course Holistic - a focus physical, socio-economic, mental, and emotional wellness Preventative - tackles the social determinants of ill-health through intra- and inter-sectoral action that promote public health and health promotion Empowering – supports people to manage and take responsibility for their own health 9.Co-produced – through active partnerships with people and communities at an individual, organizational and policy-level 10.Respectful - to people’s dignity, social circumstances and cultural sensitivities 11.Rights and responsibilities approach 12.Collaborative care - that supports relationship-building, team-based working and collaborative practice across primary, secondary, tertiary care and other sectors 13.Shared accountability - between care providers for quality of care and health outcomes to local people 14.Evidence-informed 15.Whole-systems thinking

Examples of interventions for each Strategic Action Empowering and engaging people Health literacy Access to personal health records Self-management & care Patient/family involvement in clinical decision making Development of community organizations, etc. Strengthening governance & accountability Decentralization & devolution Performance based-contracting & financing Provider report cards, patient reported outcomes & surveys Registration with specific provider(s) Patient charters, etc. Reorienting the model of care Strengthening primary care through family/community practice models Expand ambulatory, community & home-based care Comprehensive benefits plans Health technology assessments Outreach services for marginalized communities, etc. Coordinating services Integrating vertically oriented services into primary care services Information systems Inter-professional collaboration Referral systems Inter-sectoral partnerships, etc. Creating an enabling environment Leadership and development of shared vision Inclusion into national health policies, strategies & plans Dedicated resources Changing organizational culture Reorienting the health workforce, etc.

Strategy implementation Country context Low income countries Middle income countries High income countries Some special cases: Fragile/conflict affected states Small island states Large federal states

Strategy implementation Country-led Equity-focused Ensuring that people’s voices are heard Recognizing interdependence Sharing knowledge Learning/action cycles

Strategy implementation Some key issues for health workforce (HWF) HWF planning and skills mix Capacity gaps and distribution New roles and functions (e.g. network planning and management; clinical integration) Regulation (e.g. certification, re-certification, flexibility to relocate) Teamwork, multi-disciplinary teams and inter-professional collaboration Organizational culture Innovation and learning with bottom-up approaches Performance assessment and mutual accountability Co-production of health Compensation, incentives and motivation In service training and career development path Competencies (e.g. systems thinking, teamwork, negotiation, conflict resolution) Inter-professional training Interim short training courses to compensate for lack of specialists

Next steps Refine, publish and disseminate two versions of the Strategy: Shorter version for policy-makers Larger version for broader technical audience Mobilize resources in support of Strategy Start rolling out implementation of Strategy jointly with other partners during 2nd semester of 2014