SHARING BEST OF PRACTICES

PRIMARY CARE LEVEL IN MAURITIUS

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

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Y. RamfulLead Health Analyst

11 July 2019

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

• Population: 1, 265,309

• Gross Domestic Product: Rs 482.6 billion (US$

14.1 Billion)

• Economic Growth Rate: 3.8

• Per Capita Income: Rs 381,278 (US$ 11,074)

• Headline Inflation : 3.7%

• Unemployment Rate:7.1

• Human Development Index: 64

• Governance Index : 81.4

• E-Government Development Index: 58

• Leading Economic Segments: Financial

&Hospitality Services, Manufacturing & Trade,

Construction& Real Estate Activities, Agriculture

and Information & Communication

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Y. RamfulLead Health Analyst

19 June 2019

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

HEALTH

MISSION: Provision of universal, accessible and quality healthservices, free of any user cost, with emphasis on customersatisfaction.

VISION: A healthy nation with a constantly improving qualityof life.

Healthcare Financing

• MOH&QL BUDGET (FY 2019/2020): Rs 13.2 billion

National Health Accounts 2016

• Total Health Expenditure (THE): Rs 25.3 billion (US$ 735 Million)

• Household OOP Spending : Rs 11.9 billion (US$ 347.2 Million)

• Household OOP Expenditure on Health as a % of THE :47.23%

• Total Health Expenditure as a % of GDP: 5.83%

• General Government Health Expenditure as a % of GDP:2.61%

• Private Health Expenditure, including OOP expenditure as a % of GDP: 3.22%

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Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

Aim of the National Healthcare System,including Primary Health Care inMauritius:

TO BE

• ACCESSIBLE

• EFFECTIVE

• EFFICIENT

• SAFE

• PATIENT AND FAMILY CENTERED

• COORDINATED

• COMMUNITY ORIENTED, and

• ACT AS A STRONG GATEKEEPER

MECHANISM.

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Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

5

PRIMARY HEALTHCARE: EX POST FACTO HIGHLIGHTS

BRITISH RULE (1810-1968)

• Free healthcare services under the “Poor Law”• End of 1959: 48 Static Dispensaries, 4 Mobile Dispensaries, School Dental Services,

27 Estate Hospitals• Recommendations of the 1960 Report on Social Policies and Population Growth

include universal coverage of health services, the setting up of a National FamilyDoctor Service (NFDS) and the implementation of a Compulsory ContributoryHealth Insurance Scheme (CCHIS).

• The NFDS will provide ambulatory care services, offer patients a free choice ofdoctors, to support continuity of care at home and to reduce morbidity andpremature mortality from both vector borne diseases and NCDs.

POST INDEPENDENCE (1968)

• The NFDS and CCHIS were not implemented.• Inheritance of a frail health system from the British.• Free health care services sustained.• Dispensaries were upgraded into AHCs and CHCs.• Additional AHCs & CHCS were set up to strengthen universal coverage• Public Health activities were integrated in the PHC system• Master Plan on PHC

11/7/2019

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

PRIMARY HEALTHCARE: EX POST FACTO HIGHLIGHTS

POST ALMA ATA (1978)

• Golden age of PHC development was observed in the 2nd decade in which community participation and involvement in health were promoted.

• 50 CHCs in the main island of Mauritius and 5 in Rodrigues were constructed with community financing.

• The National Trust Fund for Community Health was enacted by Parliament to promote community participation in health.

• Local Health Committees were set up for constructing CHCs, managing them and for the organization of health promotion activiites.

• 2 AHCs with inpatient facilities for deliveries were set up with funding from the World Bank.

• These 2 AHCs were eventually converted into Mediclinics based on the South African Model and were fully computerized.

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Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

7

MAURITIAN PRIMARY HEALTHCARE SYSTEM in 2019

Six Health Regions Number of PHC Institutions: 141 (18 AHCs, 116

CHS ,5 Mediclinics, 2 Community Hospitals One PHC Institution for every 8,950 people,

located within a radius of 3 miles of residences No.of attendances at PHC Institutions in 2018: 1.5

million No of attendances at sorted and unsorted

departments of hospitals:1,637,753 3 Mobile NCD caravans 1 Mobile Caravan for HIV screening Public Health Services for Surveillance of

Communicable Diseases integrated with PHC Doctors per 10,000 population: 12.0 Qualified nurses & midwives per 10,000

population: 31.7

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Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

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Health outcome dimensions Implications due to the current state of demand for essential services

Availability of essential services

Level Package of Services

Primary

Diagnosis and Treatment of Common Diseases and Injuries, Immunization, Referralto & Follow up from hospitals, School Health Services, Diabetes Clinics, HealthPromotion and Education ,Antenatal Clinics, Surveillance of CommunicableDiseases, Well Baby Clinics, Environmental & Occupational Health, SpecialistSessions & X-Ray Facilities, Family Planning & Reproductive Health Services, DentalClinics, Post Natal Clinics,, Dispensing of drugsTreatment & Screening of NCDs(Hypertension, Diabetes, Cancer, HIV) , Treatment & Prevention of CommunicableDiseases, Prevention and treatment of substance abuse, Rehabilitative andPalliative care

Coverage of critical health interventions

Implementation of NCD Action Plan NCD Prevention Programme to reduce risk factors Primary Prevention Level: Community Mobilization, Screening Programme and Sustained Awareness

Campaigns Protocols and Guidelines developed for the prevention and management of NCDs Specialized NCD Human Resources Treatment & Screening of NCDs (Hypertension, Diabetes, Cancer, HIV) , Treatment & Prevention of

Communicable Diseases, Prevention and treatment of substance abuse, Rehabilitative and Palliativecare

Treatment of NCDs at both the Primary and Secondary levels Foot care clinics decentralised to Medi Clinics Diabetes Special Clinics in 28 PHCs EPI includes rotavirus, pneumococcal polysaccharide conjugated vaccines, Inactivated Poliomyelitis

Vaccine, Human Papillomavirus vaccine, Liquid Hexavalent Combined Vaccine against diphtheria,Acllular Pertusis+ Haemophillus Influenzae Type 2,<Poliovifus, Hepatitis B

Y. RamfulLead Health Analyst

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

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Demand for essential services attributes Actions Being Undertaken

Individual / HouseholdHealth Awareness

Customer Charter Radio & TV Programmes, including Dedicated Channel on MBCTV Weekly Radio Programme for Addressing Public Grievances Mandatory Vaccination Cards for enrolment in schools Role of Local Health Committees Role of socio-cultural organizations Screening for NCDs and their risk factors ( Mobile Caravans at community

and workplace settings) Special Mobile Caravans for HIV Screening & other STDs

Health Seeking Actions / Behaviors

Health Clubs and Jogging Tracks Legislations & Regulations ( National Action Plans on Tobacco Control,

National Plans of Action on Nutrition, National Action Plans on Physical Activity, National Cancer Control Programme, National Mental Health Strategy)

Smoking Cessation Clinics Mass media campaigns ( Radio & TV) National Drug Observatory set up. Drug Prevention Team set up for drug

prevention in and out of school youth and the community. Methadone dispensing sites at primary care level (9 sites) Taxation Policies (Sin Taxes) for sugary products, alcohol and tobacco Food Control Act

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

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9.7 9.8 9.1 9.5 9.58

8.9

12.9 13.712.1

14.513.6

11.8 12.2

15.9 15.714.5

16 15.5

13.314.3

0.34 0.62 0.66 0.52 0.47 0.46 0.7402468

1012141618

2011 2012 2013 2014 2015 2016 2017

Trends in NMR, IMR, U5MR and MMR per 1000 live births

Neonatal Mortality Rate Infant Mortality rateUnder Five Mortality rate Maternal Mortality

• Life Expectancy at birth (bothsexes):74.8 years

• Life Expectancy for Male:71.3 years• Life Expectancy for Female:77.7 years• Inc. Rate per 100,000 population,• Tuberculosis: 9

Malaria(Imported):2HIV/AIDS : 29

• IMR per thousand live births:14.0• MMR per thousand live births:0.3• Universal Health Coverage Index: 64• Immunization Coverage:100%• Prevalence of smoking decreased from

21% in 2009 to 19% in2015• World No Tobacco Day Award2019 by

WHO• Import of Tobacco sticks decreased from

1,306,406,000 in 2009 to 1,003,931,000in 2018

• Prevalence of HIV and AIDS: 0.88%

Y. RamfulLead Health Analyst 19 June 2019

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

11-Jul-19 11

Prevalence of modifiable risk factors for NCDs

Lipids (abnormal cholesterol other blood fats) Prevalence of elevatedtotal cholesterol (≥ 5.2 mmol/l): 44.1%

Harmful use of alcohol: Total alcohol per capita consumption, adultsaged 15+ (Lts of pure alcohol): 4

Physical inactivity: adults aged 18+ not undertaking sufficient physicalactivity(%): 29

Salt/Sodium intake: Mean population salt intake, adults aged 20+(g/day) :14

Tobacco use : Current tobacco smoking,adults aged 15+ (%): 21

Raised blood pressure: adults aged 18+ (%)27

Diabetes : Raised blood glucose, adultsaged 18+ (%): 14

Obesity: adults aged 18+ (%) :12 ;adolescents aged 10-19 (%): 4

Population not eating fruits and vegetablesdaily: 30%

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

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Primary Health Care (PHC) Assessment Findings and Policy Recommendations, April2019

(with the Technical Support of WHO)

Objective of Assessment

To conduct a comprehensive PHC assessment; identifying strengths,weaknesses, and a set of evidence-informed policy options to improve PHC inMauritius. Special attention was paid to exploring policy options for familymedicine training and shifting attendances from hospital emergency andunsorted outpatients to PHC facilities.

Methodology

Interview questions based on the WHO EURO NCD HSS approach. Theperformance initiative (PHCPI) framework was used in tandem with the 2010WHO Health System Framework to analyse the critical components of thecurrent primary care system. Findings were presented using the PHCPI indicatorheadings. Desk review of policy documents, peer-reviewed studies, and greyliterature supplemented in-person site visits and interviews with patients,practitioners, and policymakers.

Y RAMFULLEAD HEALTH ANALYST

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

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Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

11/7/2019 14

Note: Top right (green) quadrant contains ‘easy wins’. Bottom left (red) contains policies that are not worth pursuing.Top left (orange) contains high priority policies that are technically or politically difficult to introduce. Bottom right(orange) contains policies that are easier to introduce but are unlikely to make a big impact.

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

11-Jul-19 15

Short term (months) Medium term (<3 years) Long term (>3 years)

High priority • Select family medicine training partner organization(s)

• Introduce e-health system • Expedite facility upgrade processes

• Start training family physicians• Long term doctor postings for CHCs and AHCs• Develop guidelines for common conditions• National standards for PHC and facilities• Strengthen clinical appraisal systems• Data analysis at local level

• Train and empower PHC doctors to manage local facility staff, budgets, and services

Medium priority • Widely disseminate existing clinical guidelines

• Customer services improvements

• Mass media/sensitization• Inter-sectoral action on social determinants of

health • Deepen community engagement with PHC local

service planning• Better access to investigations and results• Mandatory patient registration (empanelment)

• Train and empower PHC doctors to manage local facility staff, budgets, and services

Low priority • Increase community exposure to PHC facilities

• Consider demand for more specialties holding clinics in PHC

• Consider if any of the disincentives for using the unsorted hospital OPD are appropriate

• Consider extended hours if demand has increased for PHC

Priority and recommended timing for the introduction of each policy option

Y. RamfulLead Health Analyst

Primary Health Care ConferenceMahe, Seychelles

11-13 July, 2019

11-Jul-19 16

Thank you.