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Alternative health care delivery models deserving consideration

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     ALTERNATIVE DELIVERY AND RE_IMBURSEMENT MODELS

International analysis of Primary Care Delivery models in lower income settings:


                                Table of Contents


1. WHO Alternative health care delivery models deserving consideration……2

2. Incentives with Primary Care Physician Payment Systems…………………3

3. Telemedicine Clinic in Cambodia…………………………………………...4

4. The Canadian Forces (CF) Primary Care Renewal Initiative (PCRI)……….7

5. Shared Care in the Primary Health Care Sector (UK)………………………9

6. Suburban Primary Health Care Council (USA)…………………………….12

7. Lesotho Health Service Area Model………………….…………………….15




                                                                                   1
               1. Alternative health care delivery models deserving consideration

     Source: WHO Health Action in Crisis
                 www.who.int/entity/hac/techguidance/ tools/disrupted_sectors/module_07.pdf


   Dimension                 Possible Options                                                     Remarks
                       Public, paid for by tax and custom      The dominant model (at least in terms of aspirations) in most post-colonial
                       revenues                                countries. Its goal of universal, free coverage materialised only in few fairly
                                                               wealthy and well managed health sectors.
                       Public, paid for by international aid   Pattern prevailing in many transitional situations. Political considerations and
                                                               media coverage may induce sudden inflows of abundant funds, with
                                                               accompanying waste, such as Kosovo and East Timor. The aid management
                                                               instruments established to channel external funds determine their
                                                               effectiveness.

                       Public/Private, paid for through        Private contributions are often implemented by public subsidies or employer
                       compulsory health insurance             payments. Demanding fairly sophisticated management systems, they are
                                                               mainly adopted in middle-income countries.
Financing                                                      Funds are channelled through international NGOs, missions, support groups.
                       Private, paid for by voluntary
                       contributions in rich countries, on     Given the dispersion of this financing source, it is difficult to track.
                       charity, religious or solidarity
                       grounds.
                       Private, paid for by voluntary          Situation common to many countries, attained by default, because of the
                       insurance or out-of-pocket              inability of a declining public sector to fulfil its stated role. Usually reluctantly
                       contributions                           acknowledged and under-estimated in official statistics. The quality of
                                                               commoditised health care may be dismal.
                       Private, channelled through             Often successful when introduced on a small scale and promoted by aid
                       community pre-paid schemes              subsidies (explicit or not). Expanding promising pilots to cover large
                                                               populations is usually difficult.
                       Public, through a National Health       Aggressively criticised during the 90s for its inefficiencies and ineffectiveness.
                       Service, usually, part of the civil     More resilient than expected, after more than a decade of health sector
                       service                                 reform. Model retaining its appeal, on grounds of simplicity, predictability, and
                                                               fairness. In the eyes of many health cadres in the developing countries, it
                                                               remains the central delivery model, to be reinstated as soon as possible, once
                                                               a crisis is overcome.

                       Public autonomous providers, often      Linked to de-centralization-oriented reforms. To work, it demands a robust
                       part of local government,               political, administrative and regulatory set-up.
                       sometimes separate from the civil
                       service.
Provision              Private not-for-profit providers,       The standard project arrangement, shaping the aid industry for decades. The
                       funded by donor agencies, through       dominant provision model in failed states.
                       grants.
                       Private providers contracted by         In poor countries, mainly charities and NGOs. A mainstay of reforms inspired
                       public financiers (usually donor        by the so-called New Public Management thinking. Despite the obvious
                       agencies), under the oversight of       conceptual appeal of this approach, results have been mixed. Promising
                                                               findings have emerged from pilots carried out in Cambodia. Being introduced
                       the recipient government
                                                               on a large scale in Afghanistan. For a brief discussion on the contracting
                                                               approach and a selection of key related references, see Annex 7.

                       Private providers paid for by           Usually poorly regulated, mainly concentrated in large towns. Private and
                       employers or customers                  para-statal firms may be the main contributors.

                       Hospital, providing mainly high-        Often the dominant if unplanned model, usually reinforced by protracted
                       tech, inpatient sometimes referral      crises. In urban settings, mainly for profit, or public but largely financed by
                       care                                    user fees. Not-for-profit large and fairly sophisticated hospitals are sometimes
                                                               run charities, missions, and NGOs in rural areas.
                       PHC facility, providing mainly low-     An appealing model, which has proved more difficult than expected to implant
                       tech , outpatient care, of high         and to expand.
Level and
localisation of care   theoretical effectiveness
                                                               PHC-oriented cadres have been trained in some health sectors. Otherwise,
                                                               PHC is provided by mainly hospital-oriented medical doctors and nurses.
                       Community/house, provided by            House care is often provided privately and informally by health professionals
                       professionals (PHC-oriented or not)     officially belonging to the public sector.

                       Community/house, provided by            Enjoyed enormous popularity in the 80s, but fell progressively out of grace


                                                                                                                                           2
   Dimension                      Possible Options                                                        Remarks
                           CHWs                                         afterwards, as the limitations of the approach emerged.

                           Mobile (in most cases providing              Usually very expensive and demanding on staff and equipment. For sparsely
                           selected services)                           settled communities, it may represent the only option realistically on offer.

                           Comprehensive package addressing             Usually including special programmes often disconnected from mainstream
                           most conditions (up to the                   services. Frequently a theoretical construction, not translated into widespread
                           affordable technical limits)                 practice.

                           Selective package of priority                Usually financed by donors. Strongly advocated by influential international
                           interventions (disease control,              institutions, it is rarely if ever implemented in its pure form. The priority-
                           special-group programmes etc.)               setting process is often driven by political, rather than technical rationale. It
                                                                        may provide effective, but rarely efficient nor equitable, health services. In
Content of care                                                         resource-starved health sectors, it may represent the only realistic option.

                           Emergency health care, targeting             Financed by international donors, charities and private contributions, and
                           severely distressed populations              mainly delivered by NGOs, some of them highly specialised. It has evolved
                                                                        over time, establishing its on methods and technical standards.
                           Unplanned, demand-driven                     It tends to translate into high-tech, hospital-centred health services, mainly
                           predominantly curative health care           used by affluent urban groups. Soaring costs against poor and inequitable
                                                                        public health outcomes are the common result of this approach.

                           In most situations, formal preserve          In practice, neglected by many MoHs. Where public sector is competing with
                           if the public sector                         private providers for resources and customers, conflicts of interests arise.

                           An autonomous body, recognized               More often, the regulatory mandate is limited to discrete components of the
                           by all stakeholders, regulates the           sector (health professions, drug market etc.).
Regulation
                           health sector
                           Indirect, through regulatory                 Examples include the accreditation of health professionals, or the quality
                           provisions enforced abroad                   checks drugs must pass to be supplied by firms based in well-regulated
                                                                        contexts (like the EU).



                     2. Incentives with Primary Care Physician payment systems:

    Source:
    Impact of payment method on behaviour of primary
    Journal of Health Services Research & Policy Vol 6 No 1, 2001: 44–55 .The Royal Society of Medicine Press Ltd 2001
    care physicians: a systematic review
    Toby Gosden, Frode Forland, Ivar Sonbo Kristiansen, Matthew Sutton, Brenda Leese,
    Antonio Giuffrid, Michelle Sergison, Lone Pedersen.


    CAPITATION                          SALARY                              FEE FOR SERVICE                      TARGET PAYMENT
    1. Contain costs (personal          1. Contain personal costs           1. Contain costs (personal           1. Contain costs (personal
    and financial) per patient by:      during working hours by:            and financial) per item of           and financial) of achieving
        Selecting low-risk patients        Selecting low-risk             service                              target by:
        (`cream-skim’)(if can                patients (`cream-skim’)        2. Induce demand (if marginal                  Providing target level
        refuse                               (if can refuse patients)       cost is less than marginal                      of care only
        patients or fee is not risk         Using other services           income) when:                                  Providing no care if
        adjusted)                            (e.g. referral/prescription)        Uncertainty exists about                  there is a
        Using other services               Minimising number of                 appropriate treatment                     risk of not meeting
        (e.g. referral/ prescription,        consultations                       Workload is low                           target
        if not at financial risk)                                                Supply of PCPs is high
        Providing preventative                                                   (income maximising
         care                                                                     PCPs only)
        Pooling risk (e.g. group                                                Fees fall (PCPs with
         practice)                                                                target income only)
                                                                            3. Increase quantity of care as
    2. Attract and retain patients                                          long as fee is greater than
    by:                                                                     marginal cost
     Price or non-price (quality                                           (income maximizing PCPs
          of care) competition                                              only) by:
                                                                                 Attracting patients
                                                                                 Working longer hours
                                                                                 Concentrate on profitable
                                                                                  fee-paying services only




                                                                                                                                                 3
                            3. Telemedicine clinic in Cambodia


Case Study:
A Model forRemote Health Care in the Developing World:The Markle foundation Telemedicine
Clinic in Cambodia.
Source:
Lygeia Ricciardi 2004.
www.markle.org/downloadable_assets/ telemedicine_clinic.pdf


Cambodia’s health situation is among the direst in the Western Pacific Region. Malaria,
dengue fever, diarrhea, tuberculosis, hepatitis, and HIV/AIDS are among the most
prevalent diseases affecting its population.
The United States-based Partners Telemedicine is an arm of the Partners HealthCare
System, a non-profit integrated health care delivery system founded by Brigham and
Women's Hospital and Massachusetts General Hospital, both teaching affiliates of
Harvard Medical School. Partners Telemedicine was established in 1995 and has
provided more than 10,000 specialty consultations, held 7,000 educational
videoconferences and numerous multimedia productions streamed via the Internet.
Telemedicine involves the exchange of medical information via information technology,
especially the Internet, to enable people to overcome the barriers of time and distance to
obtain better health care services. Telemedicine may involve the exchange of text, sound,
images, or even the remote operation of instruments. It has been used in a variety of
medical fields to aid in diagnosis as well as in direct treatment and follow-up care.
Although the use of telemedicine is expanding both in the developed and developing
worlds, it is still in a relatively early phase of adoption.




                                                                                             4
 SIHANOUK HOSPITAL
   CENTRE OF HOPE                           5
                              Doctors discuss diagnosis
                                  and course of treatment                         Partners
                                                                                Telemedicine

                              4                                 4
                                     Dedicated internet
                                               e-
                                         link: e-mail
                                       text & images
                                                                         6
                        6
                                                      Dedicated
                                                      satellite dish


                                                            3
           Nurse visits                                                                    7
           4 days per month
                                                     ic
                        2
                                        Mark le Clin


                                                 Patients go to Markle Clinic

                                                                    Remote Village In Ratanakiri Province
                                                        1                    14 AAFC Schools



1. About 80% of Cambodians live in rural areas, making the delivery of health care services
    all the more challenging. Ratanakiri Province , the location of the Markle Foundation
    Telemedicine Clinic, is 600 kilometers northeast of Cambodia’s capital,
   Phnom Penh. It borders Vietnam to the north and Laos to the east. It is among the poorest
   and most remote regions in Cambodia, and is populated in part by members of an ethnic
   minority who typically have even less access to health care services than do other
   Cambodians. The Markle Foundation and its partners chose Ratanakiri as the site for the
   telemedicine clinic based on the assumption that if it were able to function successfully in
   this extreme setting, it would be relatively easy to replicate it in less difficult circumstances.
2. A nurse from the Sihanouk Hospital Center of Hope visits the Markle clinic once a
   month for a four-day stay, during which he examines and photographs patients and measures
   their vital statistics.
3. The Markle clinic, like the one in Rovieng, uses an Internet link, transmitted via a dedicated
    satellite dish donated by Shin Satellite of Thailand, to send and receive
    e-mail text and images.
4. The resulting report is e-mailed to doctors at both the Sihanouk Hospital Center of Hope
    and Partners Telemedicine,

                                                                                                     5
    5. Partners Telemedicine, who collaborate with doctors in Ratanakiri on making a diagnosis
       and developing a course of treatment. In addition to supporting the physical plant and the
       acquisition of computer equipment, Markle Foundation funding contributes to the cost of
       AAfC staff time, the purchase of drugs, and transportation fees to the Sihanouk Hospital
       Center of Hope in Phnom Penh for those patients who require additional care.
    6. Patients are encouraged to return for follow up telemedicine check-ups as necessary.
    7. computer. While it would be prohibitively costly to dedicate satellite dishes
       to individual villages in this area, or to create a wire-based network among them, they are
       now being linked to each other and to the Internet wirelessly via a mobile send-and-receive
       system. Twice a day one of a small fleet of motorcycles is driven past each of 14 computer-
       equipped schools and the satellite hub, the Markle Telemedicine Clinic.
       Each motorcycle is outfitted with a wireless antenna and a data storage box (see
       photo, above). As it drives past a school, the motorcycle can transmit e-mails and
       information from web sites. This mechanism allows people to send e-mail and
       effectively surf the web in a time-delayed fashion. The schools, in addition to the
       clinic, are becoming community hubs from which villagers can send and receive
       questions and information about their personal health, regardless of whether they
       are able to travel to the Markle clinic, as well as communication on other topics.

One of the greatest applications of telemedicine is in building the skills and
expertise of health care providers. As mentioned previously, Cambodia lacks an adequate
number of trained health practitioners such as doctors and nurses; and, those who are in
practice often lack rigorous and extensive training. According to Dr. Gary Jacques,
Director of the Sihanouk Hospital Center of Hope in Phnom Penh, telemedicine enables
his staff (and volunteers at Partners Telemedicine) not only to reach distant patients, but
to train and mentor the health care providers based in the regional referral hospital where
the clinic is located. The telemedicine links enable otherwise isolated Ratanakiri doctors
to learn not only how to treat individual cases, but about the underlying methodologies
and mindsets on which their highly educated and experienced colleagues’ practice is
based. At the same time, volunteers in Phnom Penh and in the United States deepen their
understanding of medicine as practiced in a remote, resource-poor region
Also of value are the results of the patient survey on quality
of life, satisfaction, and willingness to pay for telemedicine
services. Forty-six percent of sixty-three patients of the Rovieng clinic responded that
they had been ―very satisfied‖ and 54% reported that they had been ―satisfied‖ with their experience
at the clinic. None reported being ―neither satisfied nor dissatisfied,‖ ―dissatisfied,‖ or ―very
dissatisfied.‖
In addition, the survey yielded positive results with regard to patients’ willingness to pay
for telemedicine consultations in the future—the majority of patients indicated that they
would. The median amount suggested by patients was $0.63. While this may sound low
relative to outside standards, it is important to consider that the average annual per capita
income in Rovieng is about $40




                                                                                                  6
    4. The Canadian Forces (CF) Primary Care Renewal Initiative (PCRI)
Case Study:
Canadian forces Primary Care Renewal Initiative. An innovative model for care.
Source:
http://www.forces.gc.ca/health/news_pubs/rx2000/engraph/HCReform_article04_e.asp?Lev1=4&L
ev2=6&Lev3=5

   1.   The Canadian Forces (CF) Primary care renewal initiative (PCRI) used a highly consultative
        approach to develop a clinic model for the delivery of in-garrison care that promotes continuity of
        care. This approach focuses on long-term wellness, and fosters an inter-disciplinary approach to
        patient care for CF members. All CF members will be enrolled into a Care Delivery Unit through a
        formalized rostering process. Rostering may be done by unit or by patient need (e.g. language,
        gender). Rostering an entire military unit to a Care Delivery Unit will facilitate a seamless transition
        when deploying the unit or portions of the unit. The CF medical staff who normally deploy with the
        unit will be layered into the military unit’s Care Delivery Unit when in-garrison. This process should
        greatly enhance continuity of care while maintaining unit affiliation for the military medical staff.
   2.   The PCRI clinic model is similar to civilian primary care delivery models, but it has been       adapted
        to the unique requirements of the Canadian Forces. It addresses the specific concerns relating to
        continuity of care such as the regional inconsistencies in the levels of service, timeliness and access
        to care, and the manner in which health care has been delivered.This initiative is trialing a primary
        care delivery model at pilot sites at Esquimalt, British Columbia; Edmonton, Alberta; Kingston,
        Ontario; and Bagotville, Québec.The PCRI clinic model serves as the CF member’s first point of
        entry into the CF health care system and, as the continuing focal point of all required health care
        services. Primary care providers take an holistic approach to promoting health, preventing disease
        and maintaining health. They will provide counselling, patient education, diagnosis and treatment of
        acute and chronic illnesses.
   3.   The key concept of the new model is a basic building block called the Care Delivery Unit. A Care
        Delivery Unit is an inter-disciplinary team of civilian and military primary care providers who work
        consistently with each other in a collaborative practice to provide the services that have, traditionally,
        been provided by physicians. A Care Delivery Unit core team consists of a civilian physician, a
        civilian nurse practitioner, a civilian nurse care coordinator, and military medical technicians plus
        civilian administrative support who not only work collaboratively with the patient to assess his/her
        needs, but provides and coordinates the care necessary to support the patient’s recovery to
        complete wellness. The care delivery unit team is supported by in-house physiotherapists,
        pharmacists and mental health professionals, who provide care either in collaboration with the team
        or through direct intervention. In the past, poorly managed health records throughout the health care
        system has jeopardized the continuity of care. The new clinic model is addressing this issue. Within
        the care delivery unit there will be an integral medical records cell that will provide the health care
        team with up-to-date records that have been maintained in a secure manner respecting an
        individual’s privacy. Confidentiality will be respected in all patient matters.




                                                                                                                   7
        Care Delivery Unit
                                           3
            Civilian physicians
            Civilian nurse coordinator
            Medical Technicians
            Civilian Admin Staff
            Mental health professionals
            Pharmacists
            Physiotherapists



Holistic approach to counseling, patient education,
 diagnosis, treatment of acute and chronic illness.


                       PCRI          2




    Patients split according to rostering

                        1




                                                      8
          5. Shared Care in the Primary Health Care Sector (UK)


                                 Clinical
                Remunerated      Governance    Owned

Supported                                              Competent




                 3            SHARED CARE



                               Specialist
Referral for:
                                  DR
  Co-
- Co-morbidities
                        2
- Complex Cases

- Child protection
                               Dedicated               Specialist
- Prescribing needs                                    Service
                              Drug Worker



         1                       GP

                            GPWSI
                       Primary Care led Team           Primary Care
                        Pharmacists                   Trusts
                        Primary Care Team
                        Reception and Admin




                                                                      9
Case Study:
Models of Commissioning and delivering Shared Care.(NHS) Jim Barnard              (Primary Care
Advisor SMMGP), Dr Nat Wright (GP Clinical lead NTA)
Source:
http://www.nta.nhs.uk/events/pdfs/15_Shared_care.pdf

   1. Community Treatment in Primary care has really developed rapidly.31% of GPs are now
      involved in community primary healthcare settings. This is now possibly the main venue
      for community prescribing .Shared care is now only a subsection of the range of treatment
      delivery models in primary care. Traditionally shared care schemes have developed
      idiosyncratically and models have varied widely. Developments such as co-coordinated
      commissioning structures and the new GP contract has created more homogeneity, but there
      are still wide variations. Basic principles of shared cared are that it is:
           Supported
           Remunerated
           Clinical governance/medico legal safety
           Owned
           Competent/fit for purpose
   2. GPs receive support from Primary care led team, led by a GPwSI. Teams usually employed
      by PCTs (primary healthcare trusts, sometimes non-state).GP’s with special interest’s
      (GPwSI) often also runs intermediate clinic, dealing with some more complex patients and
      those without a GP patients and those without a GP offering enhanced services.Other
      options for Primary care based treatment include:
      Personal medical services (PMS) and practices offering services to specialist populations.
      Low threshold, easy access, Employ own support staff.
      Some practices specially commissioned to treat drug users and employing own support
      Staff.The development, co-ordination and facilitation role is increasingly provided by PCTs.
      Responsibility to oversee local scheme.Ensure training strategy developed. Develop
      enhanced service specifications. Develop enhanced service specifications , ensure the
      development of robust clinical protocols. Work alongside, facilitate and act on behalf of the
      shared care monitoring group.Other important players
           Pharmacists
           Primary Health Care Team
           Reception staff
           Training increasingly available for all Training increasingly available for all these
   3. The specialist tier will support the GPwSI service and deal with more complex cases. E.g
      comorbidity, child protection, complex prescribing needs or cases.
      Specialist service (usually NHS, sometimes non -state) gives clinical support to General
      Practitioners via a dedicated drug worker under the supervision of a specialist Dr.
      Referral back to specialist if case is too complex for skills of the individual GP.
      The new GP contract which was entered into allowed for enhanced service under the
      contract. Many areas have commissioned Locally Enhanced Services to continue existing
      scheme’s. Some have commissioned only Nationally enhanced and some a mixture
      Some areas have found no change, however, in particular newer schemes, there has been a
      move towards tiered services.
                Level 1. GP treating their own patients with in particular newer schemes, there
                   has been a move towards tiered services e.g support, assessment, titration and
                   stabilisation often done by others. Less workload required. Training done by
                   others
                Level 2. GP treating their own patients (and GP treating their own patients (and
                   sometimes other practices) and able to initiate treatment where appropriate in

                                                                                                 10
    primary care. Still receiving support but expectation of higher levels of input and
    knowledge.
   GPwSI. Supporting GPs at other tiers, running intermediate clinics and
    developing local scheme and mentorship programme.




                                                                                     11
                         6. Suburban Primary Health Care Council

Case Study:
Suburban Primary Health Care Council:Access to Care Cook County, Illinois, USA
Source:
http://www.sphcc.org/
2004 Annual Report: PHCC


    1. Access to Care is a primary health care program for low-income, uninsured residents of
       suburban Cook County and residents in Chicago that live west of Cicero Avenue AND north
       of North Avenue. The program provides a health care "safety net."
    2. The medically indigent are widely dispersed throughout an area with poor public
       transportation making it important that local care is available. There is an annual enrollment
       fee of $20 for one person, $40 for two people, or $50 for a family of three or more. Patients
       pay $5 per visit to their Access to Care doctor. Prescriptions are available for $10 (generic),
       $20 (preferred brand) and $30 (non-preferred brand) and laboratory and radiology tests for
       $5 per test or specimen drawn. Eligibility for the Access to Care program is determined by
       the following criteria: 1) The family or individual lives in suburban Cook County, or west of
       Cicero Avenue AND north of North Avenue in Chicago. 2) Family income is below 200%
       of the federal poverty level, 3) The family or individual does not have private health
       insurance or has an annual deductible of $500 or more per person and is ineligible for
       Medicare, Medicaid or KidCare Assist. The fees paid by the patients are as follows:

Fee Paid               Service Received
$20 per annum          Enrollment fee for one adult
$40 per annum          Enrollment fee for two adults
$50 per annum          Enrollment fee for a family of 3 or more
$5 per visit           Patient visit to their Access to Care doctor
$10 per prescription   Generic medication
$20 per prescription   Preferred brand
$30 per prescription   Non Preferred brand
$5 per test or
                       Radiology and pathology tests performed
specimen drawn




    3. Access to Care links community-minded physicians with individuals and families in
        need of affordable primary health care services. The program is a partnership of
        the public and private sectors working together to make primary health care
        available to eligible individuals for small co-payments to service providers. The
        public/private partnership is formed from public funding and discounts given by
        private providers




                                                                                                   12
       Suburban Primary Health Care Council
                 Access to Care




                     1


                 County Run:
                 Access to Care

                                                    Public
                                                    Private
                 2                                  Partnership

                                                      3


                                             Community Minded
    Indigent Patients
                                                Physician




Access to Care served nearly 12,000 individuals in 2004. Thanks to an increase in funding from
Cook County and the State of Illinois, the program provided affordable primary health care to over
3,000 additional patients than were served in 2003. Since the program’s inception in 1988 over
77,000 people have received primary health care services through Access to Care.

The Access to Care client population has aged. In addition to a continued decrease in the number of
children, the number of clients over age 34 has increased from 48% in 2000 to 64% in 2004.




                                                                                                 13
2004 Statistics:

Age of     Most            Most            Most frequently
patients   frequent        frequently      ordered
serviced   diagnosis       ordered lab     radiology
                           procedures      procedures
<19yrs –   Essential       Lipid panel     Mammogram
1417pts    hypertension
           – 9%
19-24 -    Diabetes –      Comprehensive   Chest X-Ray
1030pts    7%              metabolic
                           panel
25-34 -    Disorders of    Thyroid         Spine X-Ray
1894pts    Lipid           stimulating
           metabolism –    hormone
           7%
35-44 -    Respiratory     Hemoglobin,     Knee X-Ray
2246pts    and chest       glycated
           symptoms –
           4%
45-54 -    Depression      Complete        Foot X-Ray
2568pts    and anxiety –   blood count
           3%
 55-64 -
2349pts


>65 yrs
- 464pts




                                                             14
                          7. Lesotho Health Service Area Model:

Case Study:
Lesotho HSA model
Source:
“Health for All” in a Least-Developed Country.
Aderibigbe M.O. Shonubi, MB, BS, FMCS, FWACS; Olatunde Odusan, MB, BS, FWACP;
David O. Oloruntoba, MB, BS, FWACS; Solomon A. Agbahowe, MB, BS, FWACP; and
M.A. Siddique, MB, BS, FRCS.
Journal of the National Medical Association.




   Health Service Area
   (HSA) model: LESOTHO
                                                           8




                               Specialist Hospital
                                                 7

                                             Ambulance
        LFDS          6                      Evacuation
 remote mountainous areas

                                                                     1
                                                                   Implement PHC
                                     HSA                           and Govt Policies


                                                Referral

                                      2              5                   Clinics
    Health Centres                          PHC                3
                           4                 Nurse Clinician
                                               Nurse Assistant
                                               Traditional Birth Attendant
                          1-
                     Max 1-2 hour
                     walk




Inadequacy and inaccessibility of health facilities to the poor and underserved, and the ever-
increasing problem of shortage of a skilled workforce in the health sector are crucial problems
facing most developing countries including Lesotho. This problem is further aggravated by medical
professionals emigration to the moreaffluent developed countries of the world. The integrated
health system of Lesotho
                                                                                               15
embraces the elements of preventive, rehabilitative and curative services. Infrastructural issues
include lack of transportation to healthcare facilities and lack of means to communicate with
healthcare providers.

   1. Lesotho has 19 HSAs, 10 of which are supervised by government hospitals and nine by
        mission hospitals. Secondary level healthcare is provided by medical officers, registered
        nurses/midwives and nurse assistants as well as visiting consultants of various
        specializations.Radiographers and laboratory technicians offer additional basic radiological
        and laboratory services. Pharmacy technicians provide pharmaceutical services. The
        secondary level of care caters to family health needs, including intermediate surgical
        procedures; cases beyond the limits of the facilities at this level are referred to the tertiary
        center
   2.   Each HSA hospital, a secondary level facility, supervises all the health centers and clinics
        under it, provides basic hospital services and implements primary healthcare as well as all
        other government policies
   3.   Staffed by nurse clinicians and nurse assistants, they provide community and primary
        healthcare services to the people. There are also the traditional birth attendants (TBA),
        whose services have been effectively integrated into the healthcare system at the primary
        level and have been instrumental to successes recorded in health education, improved
        sanitation and the expanded immunization programs.
   4.   At the primary level, the health centers/clinics, each serving between 6,000–10,000 people,
        are located so that they are accessible to the people within 1–2 hours’ walk.
   5.   Difficult cases at this level are referred to the next level of health facilities, the district
        hospitals. Each district hospital, acting as a secondary level facility, has 100–250 beds. It is
        equipped with laboratory and radiological facilities to offer basic hospital services to
        function as a full-fledged hospital. There is also an integrated mental observation and
        treatment unit. Regular visits by consultants from the national referral hospital are provided,
        and cases needing further specialist care are sent to the appropriate referral center
   6.   The Lesotho Flying Doctors Service (LFDS) unit serves the very remote clinics in the
        mountainous areas, which are normally inaccessible by road.
   7.   . Each district hospital has ambulance services for prompt patient evacuation to the specialist
        hospitals. To enhance communication between the health center/clinics and the hospitals, a
        one-way radio communication facility (referred to as ―Roger-Roger‖), is provided in places
        where telephone services are not available.
   8.   The national referral hospital has facilities for computerized axial tomography (CAT) scan,
        echocardiography, endoscopies, operative laparascopy and basic radiological contrast
        studies. At this tertiary level of care, the health team consists of specialist consultants in the
        major discipline of pediatrics, obstetrics and gynecology, medicine, psychiatry, surgery and
        the laboratorysciences. There are also specialty trained nurses, nurse assistants and
        laboratory scientists. Services at this level are mainly curative and rehabilitative.
        Furthermore, patients requiring more exhaustive and highly specialized interventional
        management are referred to the Universitas Academic Hospital, Bloemfontein, Orange Free
        State in the neighboring Republic of South Africa.

The structural arrangement of healthcare services in Kingdom of Lesotho demonstrates that the
government has put in place a system of healthcare geared towards some specific objectives,
namely:

           Stimulating a high level of community participationin promoting and maintaining a
            healthy life,


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          Ensuring easy access by the nationals to good healthcare facility regardless of
           socioeconomic status, residence or nature of illness,
          Ensuring that vulnerable and disadvantaged groups in the society receive adequate
           attention.

The government of Lesotho has effectively taken health to the people by:
       encouraging community participation at the primary care level,
       integrating traditional birth attendant practicesinto primary healthcare,
       ensuring that individuals accept responsibility as custodians of their medical history,
       providing appropriate, easy-to-maintain technology for effective transportation and
          communication at all levels.




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