1. Prescribed Minimum Benefits and Primary Care
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the Circle
Session: address the necessity to review the PMB’s to include primary care
Address specifically the ‘norms and standards’ within the district health system
Examine basic packages which prevail in other countries
By Professor Shan Naidoo
Adjunct Professor and Chief Specialist
School of Public Health
University of the Witwatersrand
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

2. This Analysis from a Public Health vantage point.
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the Circle
The value of a public health approach:
Addresses all levels of prevention, treatment and rehabilitation
It promotes the individuals welfare by fostering healthy, strong and safe families, communities and workplaces
It views the individual within a social milieu and explores the influence of cultural, family, and community values on behaviour.
It also looks at organizational and political behaviour
It examines public policy (e.g. On income, education, health care and employment)
It views behaviour along a health related continuum (health enhancing to illness producing)
It also emphasises an integrated approach and a systems view
It addresses opportunities as well as constraints
The public health perspective allows for a comprehensive analysis of the biological, behavioural, social and economic determinants of health and ill health
It also leads to multiple strategies and points of intervention!
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

3. What is Public Health
Public Health is the process of mobilizing local, state, national and international resources to ensure the conditions in which people can be healthy.(Oxford Textbook of Public Health)
The Four major public health strategies :
Preventing disease and promoting health
Improving medical care
Promoting health enhancing behaviour, and
Controlling the environment.
The BHF Southern African Conference July’07 Sun City

4. What is Health:
Health is not merely the absence of disease or infirmity but the presence of physical, mental and social well being (WHO, 1974).
The BHF Southern African Conference July’07 Sun City

5. What is Health..
Health is your adaptive capacity for becoming ‘whole’.
Healing is regaining that adaptive capacity.
Concept of ‘WHOLON’.
Health and Development often used interchangeably.
The BHF Southern African Conference July’07 Sun City

6. What is development: Improving the quality of life of people,
To uproot poverty,
To promote well-being…..
The BHF Southern African Conference July’07 Sun City

7. Strategies for Development:
Education
Job Creation
Housing
Primary Health Care
Social Welfare
The BHF Southern African Conference July’07 Sun City

8. Introduction to Primary Health Care
The Declaration of Alma Ata:
Primary Health Care 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 a spirit of self-reliance and self determination.
The BHF Southern African Conference July’07 Sun City

9. Primary Health care cont…
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.
The BHF Southern African Conference July’07 Sun City

10. Principles of PHC: Equity Community Involvement Focus on Prevention
Multisectoral Approach
Appropriate Technology.
The BHF Southern African Conference July’07 Sun City

11. The Elements of Primary Health Care Includes at least:
Education concerning prevailing health problems and the methods 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,
Immunisation against major infectious diseases,
Prevention and control of locally endemic diseases,
Appropriate treatment of common diseases and injuries, and
Provision of essential drugs.
The BHF Southern African Conference July’07 Sun City

12. How to define a basic package of health services?
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the Circle
How to define a basic package of health services for a tax funded or social insurance based health care system?
Editorial: F.Rutten & J. van Bussbach
Criteria used by countries include the effectiveness and cost-effectiveness of treatments, the necessity of treatment for the individual, the severity of the disease, the collective versus the individual responsibility, and the efficiency of insuring the service.
They argue that what is needed is an ethical framework suggesting criteria and values to be used systematically in priority setting.
They also suggest that more transparency in priority setting in health care will contribute to a wider support in society for the difficult choices in health care which are inevitable!
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

13. Defining the “ Health Benefit Basket” in nine European Countries
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the Circle
Evidence from the European Union Health BASKET Project
Original Papers: J.Schreyogg, T.Stargard, M.Velasco-Garrido & R.Busse (Eur J Health Econom Suppl 1, 2005)
This article identifies and analyses the framework for health baskets, the taxonomy of benefit catalogues for curative services, and the criteria for in- or exclusion of benefits in nine EU member states ( Denmark, England, France, Germany, Hungary, Italy, The Netherlands, Poland and Spain).
Note the distinction between benefit basket and benefit catalogue!
Main Findings are that the criteria are often not transparent and are varied.
There may be scope for a European core basket?
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

14. A Basic Package of Health Services for Afghanistan
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the Circle
March 2003/1382
Main purposes are:
1. To provide a standardised package of basic services which forms the core of service delivery in all primary health care facilities and
2. To promote a redistribution of health services by providing equitable access, especially in undeserved areas.
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

15. Contents of the Basic Package of Health Services for Afghanistan
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the Circle
Maternal and Newborn Health
Antenatal Care, Delivery Care, Postpartum Care, Family Planning, Care of the Newborn
Child Health and Immunizations
EPI services (routine and outreach), IMCI
Public Nutrition
Micronutrient supplementation, treatment of malnutrition
Communicable Diseases
Control of Tuberculosis and Malaria
Mental Health
Community management of mental problems, health facility based treatment of out- and inpatients
Disability
Physiotherapy integrated into PHC services, Orthopaedic services expanded to hospital level
Supply of Essential Drugs
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

16. Primary health care in Africa
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the Circle
No real information on Africa re: basket of services.
A comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam
Roger Few, Trudy Harpham & Sarah Atkinson
Health & Place, 2003
This article compares attempts in two projects – in Zambia and Tanzania – to strengthen urban primary health care in the public sector and make it more inclusive.
Conclusions: similarity in findings. Most positive aspect was gains in capacity building( management training of staff). Also, given improvements in facilities, urban populations were readily prepared to utilise the primary health tier. Community participation in terms of community ownership was less clear.
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

17. World Health Organisation
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the Circle
Paucity of work
Emergency and Essential Surgical Care
Surgical Care at the District Hospital
The Integrated Management for Emergency and Essential Surgical Care toolkit
Primary Care in the Driver’s Seat
Essential Health Technologies
Management for Health Services Delivery
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

18. The Primary Health Care Package for South Africa
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the Circle
Norms and standards for health clinics
Norms and Standards for Community Based Clinic Initiated Services
Department of Health
Pretoria
March 2000
All the necessary components of a comprehensive primary care package are described and norms and standards for each component are described
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

19. The PHC package for South Africa – a set of norms and standards
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the Circle
A norm is defined as a statistical normative rate of provision or measurable target outcome over a specified period of time e.g. For PHC clinics – the clinic renders comprehensive integrated PHC services using a one stop approach for at least 8 hours a day, five days a week.
A standard is defined as a statement about a desired and acceptable level of health care e.g. Medicines for PHC services – medicines and supplies as per the EDL for PHC.
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

20. Core norms and standards for PHC Services
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the Circle
Women’s Reproductive Health
Integrated Management of Childhood Illnesses
Diseases prevented by immunisation
Adolescent and Youth Health
Management of Communicable Diseases
Cholera and Diarrhoeal Disease Control
Dysentery, Helminths
Sexually Transmitted Diseases (STD)
HIV/AIDS
Malaria, Rabies
Tuberculosis, Leprosy
Prevention of Hearing Impairment due to Otitis Media
Rheumatic Fever and Haemolytic streptococcal infection
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

21. Core norms and standards for PHC services cont..
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the Circle
Trauma and Emergency
Oral Health
Mental Health
Victims of Sexual Abuse, Domestic Violence and Gender Violence
Substance abuse
Chronic Diseases and Geriatrics
Diabetes and Hypertension
Rehabilitative Services
Community Level Water and Sanitation
Community Level Home-Based care
DOTS Strategy
Integrated Nutrition Programme
School Health Services
Community Based Rehabilitation
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

22. Critique
Confusion between basic benefit package and disease defined package.
The latter requires a diagnosis!
Argue that we define the basic benefit package as a basket of services that should be provided at PHC level followed by the detail as benefit catalogues perhaps
Current language used needs to be consistent with Primary Health Care philosophy.
The BHF Southern African Conference July’07 Sun City

23. The BHF Southern African Conference 22-25 July’07 Sun City
The District Services Package according to the norms and standards document
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the Circle
Three important aspects characterise the DHS:
District hospitals are integrated with the PHC clinics and Community Health Centres and they provide a comprehensive package of health care delivery for the full range of medical disorders.
The DHS is embedded in the community it serves and should be integrated with home-based care and the Community Health Worker programme.
The DHS is integrated with community governance structures. It is through this that the tenet of community participation of the PHC approach is realised.
Critique is that it is maybe its again too medical and perhaps too vague. No norms and standards have been defined.
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

24. The BHF Southern African Conference 22-25 July’07 Sun City
International Review of Basic Benefit Packages and a proposal for a South African Benefit
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the Circle
Discovery Health: 2005
Definition of a Basic Benefit Package – is a health insurance plan determined and mandated by the government to provide the population with access to equal, basic health care at an affordable cost.
Used 5 categories and 150 variables
Looked at Argentina, Brazil, Chile, Mexico, Netherlands, Australia, Switzerland, USA and Taiwan
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

25. Consultative Investigation into Low Income Medical Schemes
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the Circle
Final report
7 April 2007
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

26. Establishment of a new prescribed minimum benefit for LIMS Schemes
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the Circle
A. GP Consultations.
B. Pathology and radiology investigations ordered by GP -
subject to a defined formulary.
C. Dental Consultations
D. Optometry
E. Medicines - based on DOH EDL for primary care suitably supplemented
F. Emergency Transport
What about Maternity Care and inpatient care for LIMS members???
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

27. The BHF Southern African Conference 22-25 July’07 Sun City
Development of an Essential Health Care Package proposal for Medical AID Schemes in South Africa’s transition towards SHI
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the Circle
Prepared for Board of Healthcare Funders of Southern Africa
February 2007
Informed by the policies of the NDOH, existing legislation, the Health Charter, scientific literature and work done by the private sector to date.
Draws an important distinction between an essential care package and an insured package:
Essential care packages are public health need and benefit driven whereas insurance is individual patient and disease driven.
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

28. The BHF Southern African Conference 22-25 July’07 Sun City
Development of an Essential Health Care Package proposal for Medical AID Schemes cont.
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the Circle
An essential healthcare package can be defined as a plan that provides a minimum compulsory set of benefits that all health insurers should cover.
It is a set of basic entitlements to services that must be funded and provided for the benefit of all.
The EHP generally includes a primary care component (focussing on preventative programmes, mother and child care, oral health, etc.) and a hospital component sometimes differentiated by hospital level.
The inclusion and exclusion criteria for developing countries is guided by need firstly and then by cost-effectiveness. (NB principle)
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

29. The process of setting an Essential Health Care Package
Could follow two tracks:
1. Defining broad categories of services such as consultation, medicine (EDL), pathology, etc. NB in equity. And/or,
2. Specifying all the diseases, with inclusion and exclusion criteria that must be included on the list of benefits such as the DPT/CDL. Potentially inequitable.
I suggest that we start with 1. but may need to consider 2. if we looking at supplementary insurance?
Compare with EU benefit package and catalogues!
The BHF Southern African Conference July’07 Sun City

30. What are the recommended benefits?
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the Circle
Primary Care Benefit
GP consultations – exclusions questioned (mental health)
Maternity Care Services
Pathology and Radiology – Medicross formulary
Dental Consultations – dental procedure formulary
Optometry – makes reference to LIMS
Medicines – hospital level of EDL
Emergency Transport – extremely important!
Hospital Inpatient care Benefit – based on BOD?
Public Sector – unrestricted. 100% UPS fees.
Private Sector – inpatients. Listed conditions. DOH reg. fees!
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

31. The BHF Southern African Conference 22-25 July’07 Sun City
The way forward!
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the Circle
A substantial amount of good work has already been done – need to use this!
Can use NDOH norms and standards as a basis.
BHF together with the NDOH, Treasury and Civil Society need to finalise this asap.
Challenge is to incorporate more of the PHC principles (equity, multisectoral approach, appropriate technology, focus on prevention) and the Health Charter requirements into the scheme.
Don’t forget the management challenges!
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City

32. The BHF Southern African Conference 22-25 July’07 Sun City
Thank You!
Squaring
the Circle
The BHF Southern African Conference July’07 Sun City
The BHF Southern African Conference July’07 Sun City