Primary care focus for International Health Ministers' Forum

Primary Health Care is top of the agenda at a forum for health ministers New Zealand is hosting this week.

Health Ministers and officials from seven countries, New Zealand, Sweden, Brazil, Canada, Chile, United Kingdom and Slovenia are in Wellington to attend the Third International Forum on Common Access to Health Care.

Sweden and New Zealand established the forum as a network of like-minded countries interested in the challenge of providing universal or common access to affordable health care.

"Primary care is the basis of a patient-centred health care system. It is the gateway to most other health services and it is the level of health care used most often by most people. As such it is key to equitable and affordable access to health care," the Ministers said in a programme statement issued at the end of today's meeting.

"Our meeting provided a valuable opportunity to discuss innovative approaches and solutions to areas of shared concern about access to primary care."

There is renewed interest internationally in primary health care, driven by the increase in chronic diseases or conditions in developed countries. "It is also driven by the proven effectiveness of primary care in delivering affordable, effective health care", the Ministers said in the programme statement.

The Ministers' discussions at Premier House today covered primary health's role in ensuring access, barriers to access, workforce issues, funding, access for indigenous people and approaches to access by illness. Several New Zealand Primary Health Organisation initiatives were featured in practical discussions during the meeting.

Ministers and officials will visit Primary Health Organisation sites in Porirua and Wellington tomorrow. They will see retinal screening and diabetes management services in action and visit marae-based health providers in Maori and Pacific Island community settings.

The first two meetings of the Forum were held last year in Stockholm (January) and London (May). For more information see the forum's website at www.social.regeringen.se/inenglish/forum

Details of participants and the programme statement issued at the end of the meeting follow.

Main Participants

BRAZIL Official Dr Santiago Alcazar - Health Minister's Chief of Staff, Head of the International Affairs Office

CANADA Official Dr Pierre-Gerlier Forest - G.D.W. Cameron Visiting Chair for Health Canada, Professor of Public Policy and Management with the Department of Political Science of Laval University.

CHILE Minister Pedro Garcia

NEW ZEALAND Minister Annette King

UNITED KINGDOM Minister Lord Warner of Brockley (Norman) - Parliamentary Under Secretary of State (Lords) for Health

SLOVENIA Minister Dusan Keber

SWEDEN Minister Lars Engqvist

An Australian official will attend as an observer.

Programme Statement

Third International Forum on Common Access to Health Care Wellington, New Zealand 28 - 30 January 2004

"Securing common access: Primary Health Care"

Primary care is the gateway to most other health services and it is the level of health care used most often by most people. As such, it should meet with people's needs and wishes within a framework of affordable access to health care, equitable utilisation, and good use of public money.

The International Forum on Common Access to Health Care provides a network for sharing progressive thinking and evidence on improvements in health care services. Our objectives are to continuously improve access to effective health care for everyone, and to achieve high quality services responsive to patient needs, with services funded and organised in an efficient and sustainable way.

The theme of primary health care was chosen for discussion by the Health Ministers because it is the gateway to most other health services and it is the level of health care used most often by most people. As such, it is a necessary base for any health care system and is key to the issues of equitable, affordable access to efficient health care.

A focus on primary care can support people's access to health care:

- There is potential to reduce inequalities in health through available, acceptable and affordable primary health care;

- A population health approach can be taken to service delivery, including health promotion activities;

- Linkages with public health actions - disease prevention and health promotion - can be reinforced in visits to the primary care practice;

- We can target resources to where they can impact earlier in treatment and care;

- Dealing with health problems early can improve the outcomes for patients and can help to achieve the best from available health resources, which are always finite, no matter how generous;

- Payment methods which support the formation of health teams will encourage flexible and responsive service delivery;

- Offering people a long-term, secure and safe relationship with the caring system can be facilitated by making the preferred provider, such as the family doctor, and the other members of the primary health care team the patient's advisor and guide within the health care system

- Personal choice can be improved through different models of organisation and service delivery.

While this meeting focused on primary care, Ministers also acknowledged the importance of specialist services, both within the hospital setting and through outreach services in primary care. Ministers recognised that better integration between service levels of primary and secondary care could improve continuity of care, better consideration of the total care needs of patients, and the delivery of the most effective and appropriate services or treatments to best meet patients' needs.

Discussions at the meeting covered 6 key areas in primary care: The role of primary care in ensuring access; Barriers to access; Workforce issues; Funding; Access for indigenous peoples; and Approaching access issues by illness.

The role of primary care

The Declaration at Alma-Ata in 1978 established fundamental principles for Health care systems - justice, equity, universal access, participation, and social determinants. They are an underpinning philosophy for the health system, and they are as relevant today as when first articulated.

There is renewed interest internationally in primary health care. This is being driven by the increasing burden of non-communicable disease - that is, the increase in chronic diseases or conditions. It is also driven by the proven effectiveness of primary care in delivering affordable, effective health care in both high and low resource settings. Initiatives to promote wellness and prevent disease, and changes in technology that enable us to provide more services at first point of contact also reinforce the importance of primary care.

Barriers to access

Affordability of primary health care is a key factor impacting on timely and equitable access to both primary and secondary services. Other barriers can include the ability to communicate and to be listened to, the geographical location or lack of services in an area and / or the lack of workforce, lack of transport, understanding of cultural and health beliefs, lack of personal choice because of inadequate information, the appropriateness of services and whether people feel comfortable using them, availability of diagnostic and treatment services, the rapid development of new technologies, including specialist services, the presence or size of co-payments, and indirect costs to individual patients.

We agreed that services must be affordable, available equitably, and therefore be more accessible, so that people do not delay when they need treatment or care. Services also need to be more flexible, responsive to individuals and delivered at the right time by an appropriate member of the health care team. We agreed on the importance of offering continuity in care which includes health promotion and disease prevention. This could be achieved, for example, through secure (or ongoing) contact with a family doctor and members of his or her team. We also agreed it was important to encourage a stronger patient voice by supporting patients with the right information at the right time.

Changes to primary care organisation and payment methods can help to achieve many of these results.

Workforce issues

To provide the most effective primary care services, the primary care workforce needs to be patient-centred, high performing and responsive, up-to-date and flexible.

Working in teams can improve the coordination of services, the provision of preventive measures and the local management of chronic illness, leading to reduced rates of hospitalisation and ensuring people don't "fall through the cracks" between one service provider and the next. Teamwork can also improve retention of staff by increasing support and providing more varied career opportunities.

Challenges for achieving these goals can include shortages in parts of the primary care workforce, an appropriate distribution and mix of practitioners, the willingness of professionals to expand their roles or learn new roles, low numbers of trainees, and changing workloads due to demographic changes and increases in chronic diseases.

As the amount of day surgery increases and the length of stay in hospitals reduces, a vital function for primary care teams is to co-ordinate and explain care (including secondary and tertiary services) for the patients they care for in the community on an on-going basis.

We will support health care staff in meeting these new and expanded tasks through training and research, making primary health care an appealing workplace, capable of attracting young doctors, nurses and other staff members.

Funding

To improve access to primary care services, ensuring adequate and sustainable levels of funding is critical. It is also important to balance investments for the future through prevention and wellness programmes with the demands for care and treatment services now.

One way to improve access to primary health care services would be to extend public health funding of services and ensure that any out-of-pocket payments are affordable.

Changes to payment methods (fee for service/salary/capitation) can also improve access. However, the incentives created by different payment approaches need to be oriented towards ensuring the continuity of care so that there are no interruptions or gaps, no duplications or inefficiencies, and the right kinds of services are provided at the right time.

Access to care for indigenous peoples and specific population groups

While significant gains in life expectancy and lower infant mortality have been made in recent years, health improvements are not shared equally across all population groups. Economically deprived groups experience higher levels of ill-health and avoidable mortality. Indigenous people can fall disproportionately in groups with the highest level of need.

Disparities in health status need to be reduced. Resources should be targeted to health promotion and prevention activities as well as initiatives to reduce current inequities.

Further, it is important that the services that are provided are appropriate to cultural needs. Culturally appropriate services can be delivered through mainstream services or services specifically tailored for particular groups (there are good examples of this, such as 'by Mäori for Mäori' services in New Zealand).

Approaching access issues by illness

The prevalence of chronic conditions such as diabetes, cardiovascular disease, depression and conditions such as cancer, is increasing in all countries. Improved care for people with chronic conditions can be achieved through shifting the focus of the health sector from individuals to populations, reinforcing the importance of evidence based medical care programmes, and moving from competition to collaboration in service delivery.

To reduce the incidence of chronic conditions, reducing smoking, reducing obesity, improving nutrition and increasing physical activity are critical. Payment for primary care services must be oriented to encourage prevention and wellness as well as treatment. The population approach in primary care, supported by funding mechanisms, can increase disease prevention and health promotion initiatives with patients and patient groups.

With the current emphasis in New Zealand on primary health care, a number of initiatives were featured in discussions during the meeting, as examples of ways to make service delivery models acceptable to consumers. Ministers will also observe services in action - for retinal screening and diabetes management - and they visited marae-based health providers in a Mäori and Pacific Island community setting.

Looking forward

This Forum is constituted of a diverse group of countries that share in common the challenge of providing universal access to affordable healthcare. Our meeting provided a valuable opportunity to discuss innovative approaches and solutions to areas of shared concern in relation to access to primary care services.

Looking forward, it was agreed that the Forum website should be used to share evidence and information between meetings. The website can be a 'clearing house', profiling the latest innovations in Forum countries and making new developments available for a wide audience.

The next forum is to be held in Slovenia in May 2004 where ministers will discuss "Better health outcomes through public health approaches in primary health care".

ENDS

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