Patient-Centered and Integrated Services (PCIS): Is it Primary Health Care (PHC) by another name?

This morning, October 1, 2014, a panel that was moderated by Edward Kelley, Director for Service Delivery and Safety at the WHO, introduced and explored the rationale and strategic directions outlined in a new WHO strategy on People-Centered and Integrated Health Services. The strategy outlines four core priorities for health systems: empowering users and population groups; strengthening engagement and accountability; coordinating services and setting and implementing system priorities. The principles that underpin the strategies include: country led and owned process; equity focused; people’s voices are heard; recognition of interdependence of different levels of health system; learning and action cycles.

A provocatively interesting question from the audience was: what is the difference between PCIS and PHC? And what have we learned from the failures of PHC to make the new PCIS strategy successful. Part of the solution lies in the ability of the research and policy community to use evidence to articulate a compelling case on the need for change – basically demonstrate that the current models of care are fragmented and are excluding many people and creating a culture of “us” and “them”. It also emerged that the narrative for change should not necessarily be premised on cost-containment but bringing people to the center of the health system, with strong emphasis on responsiveness and people’s perspectives. Once a coalition of support has been established, the next step is to invest in implementation know-how and the governance infrastructure that is required to make it happen, and to understand what works by doing.

Posting and transfer practices among health-care workers: neglected but crucial in people-centered health systems

The severe shortage of human resources for health (HRH) in some low- and middle-income countries (LMIC) is primarily driven by inadequate training facilities, unattractive terms and conditions of service and the inequitable distribution of health care workers (HCW). However, the processes by which health workers are recruited, posted, and assigned transfers are important contributors to inequitable distribution and the erosion of morale and trust of HCW in the health system itself.

On September 30, during the Third Global Symposium on Health Systems Research in Cape Town, I was asked, at very short notice, to speak briefly on a panel hosted by Columbia University, Averting Maternal Death and Disability Program and Public Health Foundation of India.

The discussion that ensued was rich and insightful. It emerged that although nearly all countries have good policies regarding recruitment, posting, and transfers for health workers and health service managers, the practice often deviates significantly from policy. Depending on the context, these deviations can undermine the stated goals of the health system, including Universal Health Coverage (UHC). Poor practice occurs when existing systems are distorted and health care workers are not posted or transferred to the areas where they are most needed, when they are posted or transferred in a disrespectful or punitive way, or when they are denied opportunities for growth and self-determination.

Additionally, poor posting and transfer practice can be driven by the personal wishes of the transferee or the transferor, or stem from overall weaknesses in the human resource management system. Transferees may have a preference in where they work, and thus use social or patronage networks or bribery to get what they want. Transferors may respond to these requests, or they may generate a transfer for their own reasons, including dissatisfaction with health care worker performance.

The state of Tamil Nadu in India has managed to streamline its posting and transfer policies and practices and make them responsive to the needs of service delivery and population health goals.

Kenya, Malawi, Senegal and Namibia have also tried to implement various forms of emergency programs and special measures to create fair, transparent and fit for purpose systems to post and transfer HCW. In the long term, however, a comprehensive national level reform is required. This reform should be implemented in phases and guided by tools of political economic analysis and qualitative analysis on the governance challenges that are often co- associated with posting and transfer practices.

Ummuro Adano is the Global Technical Lead for Human Resources for Health (HRH) at MSH.