《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2003_Shaping the Future_Chapter7 Health Systems：principled integrated care

Chapter Seven Health Systems principled integrated care To meet the formidable challenges described earlier, this chap- ter calls for the reinforcement of health systems to be based on the core principles of primary health care as outlined Alma-Ata in 1978: universal access and coverage on the ba sis of need; health equity as part of development oriented to social justice; community participation in defining and imple menting health agendas; and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 25 years. Four important issues that health systems must confront are examined: the global health workforce crisis, in adequate health information, lack of financial resources, and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment

Health Systems: principled integrated care 103 Chapter Seven Health Systems: principled integrated care To meet the formidable challenges described earlier, this chap￾ter calls for the reinforcement of health systems to be based on the core principles of primary health care as outlined at Alma-Ata in 1978: universal access and coverage on the ba￾sis of need; health equity as part of development oriented to social justice; community participation in defining and imple￾menting health agendas; and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 25 years. Four important issues that health systems must confront are examined: the global health workforce crisis, in￾adequate health information, lack of financial resources, and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment

Health Systems principled integrated care Confronting the global health challenges examined in the previous chapters requires health systems to be strengthened. Without this, the health goals described in this report will remain beyond reach. The lessons learnt from past successes, including the skills and strategies developed from the experiences of tackling polio and SARS, must be applied in combating the HIVIAIDS treatment emergency and in working towards the Millennium Development Goals(MDGs). Progress towards these and other objectives will not be sustainable unless specific health targets- including the 3 by 5 target of reaching three million people developing countries with combination antiretroviral therapy for HIviaidS by the end of 2005-support a broad horizontal build-up of the capacities of health systems Despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. Now, however, fresh opportuni ies are emerging. Health stands high on the international development agenda, and new funds are becoming available for health work in poor countries. Extending health-enabling conditions and quality care to all is the major imperative for health systems. This chapter explores how the values and practices of primary health care, adapted to the realities of today's complex health landscape, might provide a basis for the improvement of health systems. It reviews basic ideas about primary health care and clarifies the concept of the development of health systems that are based on primary health care. It then examines four major challenges facing health systems: the global health workforce crisis; the lack of appropriate, timely evidence; the lack of financial resources; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The final section looks at how WHO is working with countries to clarify health systems goals and to strengthen systems in line with primary health care principle The health system comprises all organizations, institutions and resources that produce ac tions whose primary purpose is to improve health(1). The health care system refers to the institutions, people and resources involved in delivering health care to individuals. This chapter is mostly concerned with health care systems. Nevertheless, health care providers are often involved in promoting health-enabling conditions in the community. Indeed, this relation- ship between patient care and public health functions is one of the defining characteristics of the primary health care approach The health systems performance assessment framework developed by WHO in the late 1990s was an attempt to put into effect the primary health care concern for equity and population health outcomes, by providing analytical tools to translate these concerns into relevant

Health Systems: principled integrated care 105 7 Health Systems: principled integrated care Confronting the global health challenges examined in the previous chapters requires health systems to be strengthened. Without this, the health goals described in this report will remain beyond reach. The lessons learnt from past successes, including the skills and strategies developed from the experiences of tackling polio and SARS, must be applied in combating the HIV/AIDS treatment emergency and in working towards the Millennium Development Goals (MDGs). Progress towards these and other objectives will not be sustainable unless specific health targets – including the “3 by 5” target of reaching three million people in developing countries with combination antiretroviral therapy for HIV/AIDS by the end of 2005 – support a broad horizontal build-up of the capacities of health systems. Despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. Now, however, fresh opportuni￾ties are emerging. Health stands high on the international development agenda, and new funds are becoming available for health work in poor countries. Extending health-enabling conditions and quality care to all is the major imperative for health systems. This chapter explores how the values and practices of primary health care, adapted to the realities of today’s complex health landscape, might provide a basis for the improvement of health systems. It reviews basic ideas about primary health care and clarifies the concept of the development of health systems that are based on primary health care. It then examines four major challenges facing health systems: the global health workforce crisis; the lack of appropriate, timely evidence; the lack of financial resources; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The final section looks at how WHO is working with countries to clarify health systems goals and to strengthen systems in line with primary health care principles. The health system comprises all organizations, institutions and resources that produce ac￾tions whose primary purpose is to improve health (1). The health care system refers to the institutions, people and resources involved in delivering health care to individuals. This chapter is mostly concerned with health care systems. Nevertheless, health care providers are often involved in promoting health-enabling conditions in the community. Indeed, this relation￾ship between patient care and public health functions is one of the defining characteristics of the primary health care approach. The health systems performance assessment framework developed by WHO in the late 1990s was an attempt to put into effect the primary health care concern for equity and population health outcomes, by providing analytical tools to translate these concerns into relevant

The World Health Rep evidence. The framework drew the attention of policy-makers to issues such as the cata strophic health expenditure in a number of countries. Although this report does not directly apply the framework, it assumes that policy-makers will use this and other relevant tools to measure the success of an approach to health systems scale-up based on primary health care Valuable knowledge has been gained in recent years about how health systems work and why they fail. Initiatives such as the European Observatory on Health Care Systems are producing important insights(see Box 7.1), though fundamental questions remain unresolved. This report does not propose a complete model of the development of health systems based on primary health care, which would be impossible given the current state of evidence. The aim is to open lines of enquiry that will be of use to countries and international health partners as they weigh options and take action to strengthen systems, making them responsive to the needs and demands of all, especially the poor. The core principles of primary health care Primary health care became a core policy for WHO in 1978, with the adoption of the Decla ration of Alma-Ata and the strategy of"Health for all by the year 2000". Twenty-five years later, international support for the values of primary health care remains strong. Preliminary results of a major review suggest that many in the global health community consider a pri- mary health care orientation to be crucial for equitable progress in health(2) No uniform, universally applicable definition of primary health care exists. Ambiguities were present in the Alma-Ata document, in which the concept was discussed as both a level of care and an overall approach to health policy and service provision. In high-income and middle- income countries, primary health care is mainly understood to be the first level of care. In low-income countries where significant challenges in access to health care persist, it is seen more as a system-wide strategy. Box 7.1 The European Observatory on Health Care Systems Countries in the European Region-diverse in terms of language, his- set of questions and uses clear definitions to create a baseline of infor tory and wealth -have an array of approaches to the organization of mation, drawing attention to what is distinct about a particular country health systems. The European Observatory on Health Care Systems and The Observatory covers the whole European Region and some addi olicies seeks to disseminate information on more than a decade of tional OECD countries, to allow systematic comparisons and the review change, analysing the reforms and generating evidence on what works of reforms over time. in different contexts and why. It ensures that Europe's national policy Analysis. The Observatory produces comprehensive studies on key makers can set their own experiences in the European context and make health system and policy areas, including hospitals, funding, regulation, comparisons across borders, draw on thematic and comparative analy- European enlargement, social health insurance, purchasing, primary care, sis of the key challenges they face, and have access to clear, practical pharmaceuticals, mental health, human resources, and targets. It uses evidence secondary or meta-analytical research, bringing together experts from The Observatory is a partnership that brings together the WHo across Europe to synthesize existing findings, to work country experi- Regional Office for Europe, governments(Greece, Norway and Spain), ences into a conceptual framework and to draw out practical lessons international and nongovernmental agencies (the European Investment and options Bank, the Open Society Institute, and the World Bank) and academia Dissemination. Engaging with policy-makers and their advisers (the London School of Economics and Political Science and the London helps ensure they can use the information and analyses generated. The School of Hygiene and Tropical Medicine). All the Observatorys materi- Observatory runs seminars and workshops for small groups of high level ls are available on its web site I policy-makers, often in partnership with agencies supporting health Information and monitoring. The Health System in Transition tem and policy reform, on matters such as funding options, the implica- series of 70 country profiles provides analytical answers to a standard tions of EU accession for new Member States, or equity Iwww.observatory.dk

106 The World Health Report 2003 evidence. The framework drew the attention of policy-makers to issues such as the cata￾strophic health expenditure in a number of countries. Although this report does not directly apply the framework, it assumes that policy-makers will use this and other relevant tools to measure the success of an approach to health systems scale-up based on primary health care. Valuable knowledge has been gained in recent years about how health systems work and why they fail. Initiatives such as the European Observatory on Health Care Systems are producing important insights (see Box 7.1), though fundamental questions remain unresolved. This report does not propose a complete model of the development of health systems based on primary health care, which would be impossible given the current state of evidence. The aim is to open lines of enquiry that will be of use to countries and international health partners as they weigh options and take action to strengthen systems, making them responsive to the needs and demands of all, especially the poor. The core principles of primary health care Primary health care became a core policy for WHO in 1978, with the adoption of the Decla￾ration of Alma-Ata and the strategy of “Health for all by the year 2000”. Twenty-five years later, international support for the values of primary health care remains strong. Preliminary results of a major review suggest that many in the global health community consider a pri￾mary health care orientation to be crucial for equitable progress in health (2). No uniform, universally applicable definition of primary health care exists. Ambiguities were present in the Alma-Ata document, in which the concept was discussed as both a level of care and an overall approach to health policy and service provision. In high-income and middle￾income countries, primary health care is mainly understood to be the first level of care. In low-income countries where significant challenges in access to health care persist, it is seen more as a system-wide strategy. Box 7.1 The European Observatory on Health Care Systems Countries in the European Region – diverse in terms of language, his￾tory and wealth – have an array of approaches to the organization of health systems. The European Observatory on Health Care Systems and policies seeks to disseminate information on more than a decade of change, analysing the reforms and generating evidence on what works in different contexts and why. It ensures that Europe’s national policy￾makers can set their own experiences in the European context and make comparisons across borders, draw on thematic and comparative analy￾sis of the key challenges they face, and have access to clear, practical evidence. The Observatory is a partnership that brings together the WHO Regional Office for Europe, governments (Greece, Norway and Spain), international and nongovernmental agencies (the European Investment Bank, the Open Society Institute, and the World Bank) and academia (the London School of Economics and Political Science and the London School of Hygiene and Tropical Medicine). All the Observatory’s materi￾als are available on its web site.1 Information and monitoring. The Health System in Transition series of 70 country profiles provides analytical answers to a standard set of questions and uses clear definitions to create a baseline of infor￾mation, drawing attention to what is distinct about a particular country. The Observatory covers the whole European Region and some addi￾tional OECD countries, to allow systematic comparisons and the review of reforms over time. Analysis. The Observatory produces comprehensive studies on key health system and policy areas, including hospitals, funding, regulation, European enlargement, social health insurance, purchasing, primary care, pharmaceuticals, mental health, human resources, and targets. It uses secondary or meta-analytical research, bringing together experts from across Europe to synthesize existing findings, to work country experi￾ences into a conceptual framework and to draw out practical lessons and options. Dissemination. Engaging with policy-makers and their advisers helps ensure they can use the information and analyses generated. The Observatory runs seminars and workshops for small groups of high level policy-makers, often in partnership with agencies supporting health sys￾tem and policy reform, on matters such as funding options, the implica￾tions of EU accession for new Member States, or equity. 1 www.observatory.dk

Health Systems: principled integrated care It is useful to understand primary health care as involving both core principles and a variable set of basic activities. For the purposes of this discussion, it is the principles that are most significant(3), including: universal access to care and coverage on the basis of need; commitment to health equity as part of development oriented to social justice; community participation in defining and implementing health agendas intersectoral approaches to health Enduring principles in a changing environment The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries(see the example in Box 7. 2). Advances in health technology have transformed many aspects of medi cal practice and raised expectations concerning the types of functions and services that health systems should provide The institutional context of health policy-making and health care delivery has also changed Government responsibilities and objectives in the health sector have been redefined, with in health care provision. The r profit and not-for-profit, playing an increasingly visible role reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentralize tion and health sector reform have had mixed effects on health care system performance (4) The ideas and activities associated with primary health care have themselves undergone changes In the 1980s, the approach termed "selective primary health care"gained favour By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged"" programme structures. These programmes produced Box 7. 2 Primary care in a changing environment: the"health houses"of the Islamic Republic of Iran The Government of the Islamic Republic of Iran has invested strongly in tion is increasing, with an associated change in lifestyle. The private training health care providers. Primary health care facilities, popularly health sector is increasing. Clinical case management is often not as known as"health houses, provide an active network staffed by com- evidence-based as it could be. A recent study on health financing dem- munity health workers, or behvarzes, who are trained and regularly su- onstrated that the financing system is not as equitable as had been ervised by staff from district health centres. The behvarzes provide basic thought: out-of-pocket payments are high, and the poor are less well are and advice on many aspects of maternal and child health and com- protected from catastrophic health expenditures than they were previously mon communicable diseases. They also record local health information The government is moving to respond to these new challenges. It through the"vital horoscope" data system, which includes information is already beginning to reorient the primary health care activities deliv- ollected during annual household visits. This system provides valuable ered in health houses. Technical guidelines for interventions and train- information for planning services both locally and nationally. There are ing for different cadres of health worker are being reviewed as part of high levels of community involvement in the delivery of community-based an effort to improve quality of care. There are discussions about a com- health care: 90% of the population belongs to a health insurance scheme, mon benefit package, what it should include and by whom it should be and some schemes are explicitly designed to protect the poor provided; specifically, how to involve private providers more effectively Today, the Islamic Republic of Iran faces several challenges to main. in the delivery of critical interventions, both preventive and curative, for taining these achievements in a changing environment. The country's example through contracting. The different insurance schemes are epidemiological profile has changed, partly as a consequence of the being reviewed within a broader analysis of overall health system success of the strategy led by primary care. The major burden of disease financing, and there are debates about what sort of organizational is attributable to noncommunicable diseases and injuries, though there arrangements within the public sector would enhance the quality and are some differences between richer and poorer provinces. Urbaniza. efficiency of public providers

Health Systems: principled integrated care 107 It is useful to understand primary health care as involving both core principles and a variable set of basic activities. For the purposes of this discussion, it is the principles that are most significant (3), including: – universal access to care and coverage on the basis of need; – commitment to health equity as part of development oriented to social justice; – community participation in defining and implementing health agendas; – intersectoral approaches to health. Enduring principles in a changing environment The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries (see the example in Box 7.2). Advances in health technology have transformed many aspects of medi￾cal practice and raised expectations concerning the types of functions and services that health systems should provide. The institutional context of health policy-making and health care delivery has also changed. Government responsibilities and objectives in the health sector have been redefined, with private sector entities, both for-profit and not-for-profit, playing an increasingly visible role in health care provision. The reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentraliza￾tion and health sector reform have had mixed effects on health care system performance (4). The ideas and activities associated with primary health care have themselves undergone changes. In the 1980s, the approach termed “selective primary health care” gained favour. By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged “vertical” programme structures. These programmes produced Box 7.2 Primary care in a changing environment: the “health houses” of the Islamic Republic of Iran The Government of the Islamic Republic of Iran has invested strongly in training health care providers. Primary health care facilities, popularly known as “health houses”, provide an active network staffed by com￾munity health workers, or behvarzes, who are trained and regularly su￾pervised by staff from district health centres. The behvarzes provide basic care and advice on many aspects of maternal and child health and com￾mon communicable diseases. They also record local health information through the “vital horoscope” data system, which includes information collected during annual household visits. This system provides valuable information for planning services both locally and nationally. There are high levels of community involvement in the delivery of community-based health care; 90% of the population belongs to a health insurance scheme, and some schemes are explicitly designed to protect the poor. Today, the Islamic Republic of Iran faces several challenges to main￾taining these achievements in a changing environment. The country’s epidemiological profile has changed, partly as a consequence of the success of the strategy led by primary care. The major burden of disease is attributable to noncommunicable diseases and injuries, though there are some differences between richer and poorer provinces. Urbaniza￾tion is increasing, with an associated change in lifestyle. The private health sector is increasing. Clinical case management is often not as evidence-based as it could be. A recent study on health financing dem￾onstrated that the financing system is not as equitable as had been thought: out-of-pocket payments are high, and the poor are less well protected from catastrophic health expenditures than they were previously. The government is moving to respond to these new challenges. It is already beginning to reorient the primary health care activities deliv￾ered in health houses. Technical guidelines for interventions and train￾ing for different cadres of health worker are being reviewed as part of an effort to improve quality of care. There are discussions about a com￾mon benefit package, what it should include and by whom it should be provided; specifically, how to involve private providers more effectively in the delivery of critical interventions, both preventive and curative, for example through contracting. The different insurance schemes are being reviewed within a broader analysis of overall health system financing, and there are debates about what sort of organizational arrangements within the public sector would enhance the quality and efficiency of public providers

The World Health Report 2003 ortant gains, for example in immunization coverage and child mortality reduction, but were at odds with the comprehensive vision of primary health care developed at Alma-Ata, notably its emphasis on tackling the socioeconomic determinants of ill-health. In the 1990s, the World Bank recommended a set of core public health interventions and a package of essential clinical services influenced by primary health care models, though critics questioned whether these strategies responded adequately to the messages of equity and community tion delivered at Alm Originally, primary health care and the health-for-all movement represented an effort to change practices and structures in the health sector based on population health criteria. Subsequent health sector reform efforts have often been steered by criteria largely extrinsic to health(for xample, broad commitments to decentralization or civil service reform, or the need to re- duce government spending). Reaffirmation of primary health care principles by global health stakeholders signals a recognition of the need to return to population health criteria as the basis for decisions affecting how health care services are organized, paid for and delivered. Principles in a systems perspective This report reinforces an important conceptual shift towards the model of health systems based on primary health care. In a systems perspective, the potential conflict between pri- mary health care as a discrete level of care and as an overall approach to responsive, equitable health service provision can be reconciled. This shift emphasizes that primary health care is integrated into a larger whole, and its principles will inform and guide the functioning of the em A health system based on primary health care will build on the Alma-Ata principles of equity, universal access, community participation, nd intersectoral approaches take account of broader population health issues, reflecting and reinforcing public health functions: create the conditions for effective provision of services to poor and excluded groups organize integrated and seamless care, linking prevention, acute care and chronic care across all components of the health system continuously evaluate and strive to improve performance. Intervention across the disease continuum is needed to achieve the comprehensive care en visaged by such a system. To deal with the increasing burden of chronic diseases, both noncommunicable and communicable, requires upstream health promotion and disease pre- vention in the community as well as downstream disease management within health care services. Two integrated health care models, the chronic care model and its extension-WHO innovative care for chronic conditions framework- promote primary health care concepts intersectoral partnerships, community participation and seamless population-based care Evidence supports the use of these integrated models as a means of implementing primary health care principles, with demonstrated reduction in health care costs, lower use of health care services, and improved health status(6-9) ded Hiviaids treatment and health challenge. No blueprint exists, but valuable examples are emerging. Since May 2001, Medecins Sans Frontieres has provided antiretroviral therapy for HIVIAIDS through primary health care centres in the township of Khayelitsha, South Africa(10). The delivery of HIV/AIDS treatment in a primary health care setting underscores the potential for integration of differ ent types of care and begins to show how scaling up treatment could fit into-and help drive

108 The World Health Report 2003 important gains, for example in immunization coverage and child mortality reduction, but were at odds with the comprehensive vision of primary health care developed at Alma-Ata, notably its emphasis on tackling the socioeconomic determinants of ill-health. In the 1990s, the World Bank recommended a set of core public health interventions and a package of essential clinical services influenced by primary health care models, though critics questioned whether these strategies responded adequately to the messages of equity and community participation delivered at Alma-Ata (5). Originally, primary health care and the health-for-all movement represented an effort to change practices and structures in the health sector based on population health criteria. Subsequent health sector reform efforts have often been steered by criteria largely extrinsic to health (for example, broad commitments to decentralization or civil service reform, or the need to re￾duce government spending). Reaffirmation of primary health care principles by global health stakeholders signals a recognition of the need to return to population health criteria as the basis for decisions affecting how health care services are organized, paid for and delivered. Principles in a systems perspective This report reinforces an important conceptual shift towards the model of health systems based on primary health care. In a systems perspective, the potential conflict between pri￾mary health care as a discrete level of care and as an overall approach to responsive, equitable health service provision can be reconciled. This shift emphasizes that primary health care is integrated into a larger whole, and its principles will inform and guide the functioning of the overall system. A health system based on primary health care will: – build on the Alma-Ata principles of equity, universal access, community participation, and intersectoral approaches; – take account of broader population health issues, reflecting and reinforcing public health functions; – create the conditions for effective provision of services to poor and excluded groups; – organize integrated and seamless care, linking prevention, acute care and chronic care across all components of the health system; – continuously evaluate and strive to improve performance. Intervention across the disease continuum is needed to achieve the comprehensive care en￾visaged by such a system. To deal with the increasing burden of chronic diseases, both noncommunicable and communicable, requires upstream health promotion and disease pre￾vention in the community as well as downstream disease management within health care services. Two integrated health care models, the chronic care model and its extension – WHO’s innovative care for chronic conditions framework – promote primary health care concepts: intersectoral partnerships, community participation and seamless population-based care. Evidence supports the use of these integrated models as a means of implementing primary health care principles, with demonstrated reduction in health care costs, lower use of health care services, and improved health status (6–9). Linking expanded HIV/AIDS treatment and health care systems development is a crucial challenge. No blueprint exists, but valuable examples are emerging. Since May 2001, Médecins Sans Frontières has provided antiretroviral therapy for HIV/AIDS through primary health care centres in the township of Khayelitsha, South Africa (10). The delivery of HIV/AIDS treatment in a primary health care setting underscores the potential for integration of differ￾ent types of care and begins to show how scaling up treatment could fit into – and help drive