Primary
Introduction and overview Wby a renewal of primary bealth care(PHC), and oby nore. more than ever? The immediate answer is the palpable demand for it from Member States-not just from bealth professionals, but from the political arena as weell Responding to the changing world Globalization is putting the social Growing expectations cohesion of many countries under stress, for better p mance and bealth systems, as key constituents From the packages of the past to the reforms of the future the arcbitecture of contempora Four sets of phc reforms socleties, are clearly not performing as Seizing opportunities GoelL as y could and as they shou ld People are increasingly impatient with the inability of bealth services to deliver levels of national coverage that meet stated demands and changing needs and with their failure to provide services in eays that correspond to their expectations. Few woould disagree that bealth systems need to respond better -and faster-to the challenges of a changing world. PhC can do that
Introduction and Overview Why a renewal of primary health care (PHC), and why now, more than ever? The immediate answer is the palpable demand for it from Member States – not just from health professionals, but from the political arena as well. Globalization is putting the social cohesion of many countries under stress, and health systems, as key constituents of the architecture of contemporary societies, are clearly not performing as well as they could and as they should. People are increasingly impatient with the inability of health services to deliver levels of national coverage that meet stated demands and changing needs, and with their failure to provide services in ways that correspond to their expectations. Few would disagree that health systems need to respond better – and faster – to the challenges of a changing world. PHC can do that. Responding to the challenges of a changing world xii Growing expectations for better performance xiii From the packages of the past to the reforms of the future xiv Four sets of PHC reforms xvi Seizing opportunities xviii xi
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever There is today a recognition that populations are I and reform of the ways health systems operate left behind and a sense of lost opportunities that in society today: those reforms constitute the are reminiscent of what gave rise, thirty years agenda of the renewal of PHC ago, to Alma-Ata's paradigm shift in think- ing about health. The Alma-Ata Conference Responding to the challenges of a mobilized a"Primary Health Care movement of professionals and institutions, governments/ changing world and civil society organizations, researchers and On the whole, people are healthier, wealthier and grassroots organizations that undertook to tackle live longer today than 30 years ago. If children the"politically, socially and economically unac- were still dying at 1978 rates, there would have ceptable"health inequalities in all countries. been 16.2 million deaths globally in 2006. In fact, The Declaration of Alma-Ata was clear about the there were only 9.5 million such deaths. This values pursued: social justice and the right to difference of 6.7 million is equivalent to 18329 better health for all, participation and solidarity. children's lives being saved every day. The once There was a sense that progress towards these revolutionary notion of essential drugs has values required fundamental changes in the way become commonplace. There have been signifi- health-care systems operated and harnessed the cant improvements in access to water, sanitation potential of other sectors and antenatal care This shows that progress is possible. It can reforms has been uneven. Nevertheless, today, also be accelerated. There have never been more health equity enjoys increased prominence in resources available for health than now.The glo- the discourse of political leaders and ministri bal health economy is growing faster than gross of health, as well as of local government struc- domestic product (GDP), having increased its share from 8%to 8. 6% of the world's gDP between tures,professional organizations and civil society 2000 and 2005.In absolute terms,adjusted for organizations The PHC values to achieve health for all inflation, this represents a 35% growth in the require health systems that "Put people at the I worlds expenditure on health over a five-year centre of health care".What people consider period. Knowledge and understanding of health desirable ways of living as individuals and what are growing rapidly. The accelerated techno- they expect for their societies -i.e. what peo. logical revolution is multiplying the potential ple value-constitute important parameters for for improving health and transforming health governing the health sector. PHC has remained literacy in a better-educated and modernizing the benchmark for most countries' discourse on global society. A global stewardship is emerging health precisely because the PHC movement tried from intensified exchanges between countries to provide rational, evidence-based and antici- often in recognition of shared threats, challenges patory responses to health needs and to these or opportunities: from growing solidarity; and social expectations*..6. 7. Achieving this requires from the global commitment to eliminate poverty trade-offs that must start by taking into account xemplified in the Millennium Development Goals citizens'"expectations about health and health(MDGs care"and ensuring " that their/ voice and choice However there are other trends that must decisively infuence the way in which health serv. not be ignored. First, the substantial progress ices are designed and operate".A recent PHC in health over recent decades has been deeply review echoes this perspective as the"right to unequal, with convergence towards improved the highest attainable levelof health", "maximiz. health in a large part of the world, but at the same ing equity and solidarity "while being guided ne. with a considerable number of countries by responsiveness to people's needs".Moving increasingly lagging behind or losing ground towards health for all requires that health sys- Furthermore, there is now ample documenta tems respond to the challenges of a changing tion-not available 30 years ago -of consider world and growing expectations for better per- able and often growing health inequalities within formance. This involves substantialreorientation countries
Primary Health Care – Now More Than Ever xii The World Health Report 2008 There is today a recognition that populations are left behind and a sense of lost opportunities that are reminiscent of what gave rise, thirty years ago, to Alma-Ata’s paradigm shift in thinking about health. The Alma-Ata Conference mobilized a “Primary Health Care movement” of professionals and institutions, governments and civil society organizations, researchers and grassroots organizations that undertook to tackle the “politically, socially and economically unacceptable”1 health inequalities in all countries. The Declaration of Alma-Ata was clear about the values pursued: social justice and the right to better health for all, participation and solidarity1 . There was a sense that progress towards these values required fundamental changes in the way health-care systems operated and harnessed the potential of other sectors. The translation of these values into tangible reforms has been uneven. Nevertheless, today, health equity enjoys increased prominence in the discourse of political leaders and ministries of health2 , as well as of local government structures, professional organizations and civil society organizations. The PHC values to achieve health for all require health systems that “Put people at the centre of health care”3 . What people consider desirable ways of living as individuals and what they expect for their societies – i.e. what people value – constitute important parameters for governing the health sector. PHC has remained the benchmark for most countries’ discourse on health precisely because the PHC movement tried to provide rational, evidence-based and anticipatory responses to health needs and to these social expectations4,5,6,7. Achieving this requires trade-offs that must start by taking into account citizens’ “expectations about health and health care” and ensuring “that [their] voice and choice decisively infl uence the way in which health services are designed and operate”8 . A recent PHC review echoes this perspective as the “right to the highest attainable level of health”, “maximizing equity and solidarity” while being guided by “responsiveness to people’s needs”4 . Moving towards health for all requires that health systems respond to the challenges of a changing world and growing expectations for better performance. This involves substantial reorientation and reform of the ways health systems operate in society today: those reforms constitute the agenda of the renewal of PHC. Responding to the challenges of a changing world On the whole, people are healthier, wealthier and live longer today than 30 years ago. If children were still dying at 1978 rates, there would have been 16.2 million deaths globally in 2006. In fact, there were only 9.5 million such deaths9 . This difference of 6.7 million is equivalent to 18 329 children’s lives being saved every day. The once revolutionary notion of essential drugs has become commonplace. There have been signifi - cant improvements in access to water, sanitation and antenatal care. This shows that progress is possible. It can also be accelerated. There have never been more resources available for health than now. The global health economy is growing faster than gross domestic product (GDP), having increased its share from 8% to 8.6% of the world’s GDP between 2000 and 2005. In absolute terms, adjusted for infl ation, this represents a 35% growth in the world’s expenditure on health over a fi ve-year period. Knowledge and understanding of health are growing rapidly. The accelerated technological revolution is multiplying the potential for improving health and transforming health literacy in a better-educated and modernizing global society. A global stewardship is emerging: from intensifi ed exchanges between countries, often in recognition of shared threats, challenges or opportunities; from growing solidarity; and from the global commitment to eliminate poverty exemplifi ed in the Millennium Development Goals (MDGs). However, there are other trends that must not be ignored. First, the substantial progress in health over recent decades has been deeply unequal, with convergence towards improved health in a large part of the world, but at the same time, with a considerable number of countries increasingly lagging behind or losing ground. Furthermore, there is now ample documentation – not available 30 years ago – of considerable and often growing health inequalities within countries
Introduction and overview Second, the nature of health problems is chang-I changes and making health systems more effec ng in ways that were only partially anticipated,I tive and equitable are often missed. Global and nd at a rate that was wholly unexpected. Ageing increasingly, national policy formulation proc and the effects of ill-managed urbanization and esses have focused on single issues, with various globalization accelerate worldwide transmis- constituencies competing for scarce resources, sion of communicable diseases, and increase while scant attention is given to the underlying the burden of chronic and noncommunicable constraints that hold up health systems develop disorders. The growing reality that many indi- ment in national contexts Rather than improv viduals present with complex symptoms and ing their response capacity and anticipating new multiple illnesses challenges service delivery challenges, health systems seem to be drifting to develop more integrated and comprehensive from one short-term priority to another, increas- se management. A complex web of interrelated ingly fragmented and without a clear sense of factors is at work, involving gradual but long-direction term increases in income and population, climate Today, it is clear that left to their own devices, change,challenges to food security, and social health systems do not gravitate naturally towards tensions, all with definite, but largely unpredict- the goals of health for all through primary health ble, implications for health in the years ahead. care as articulated in the Declaration of Alma- Third, health systems are not insulated from Ata. Health systems are developing in directions the rapid pace of change and transformation that contribute little to equity and social justice that is an essential part of today's globaliza- and fail to get the best health outcomes for their tion. Economic and political crises challenge money. Three particularly worrisome trends can state and institutional roles to ensure access, be characterized as follows delivery and financing Unregulated commer- a health systems that focus disproportionately on cialization is accompanied by a blurring of the a narrow offer of specialized curative care: boundaries between public and private actors, health systems where a command-and-control while the negotiation of entitlement and rights approach to disease control, focused on short- s increasingly politicized. The information age term results, is fragmenting service delivery has transformed the relations between citizens, a health systems where a hands-off or laissez- professionals and politicians faire approach to governance has allowed In many regards, the responses of the health unregulated commercialization of health to sector to the changing world have been inad flourish equate and naive. Inadequate, insofar as they not only fail to anticipate, but also to respond These trends fly in the face of a comprehensive appropriately: too often with too little, too late and balanced response to health needs. In a num- or too much in the wrong place. Naive insofar as ber of countries, the resulting inequitable access, a systems failure requires a systems solution- impoverishing costs, and erosion of trust in health not a temporary remedy. Problems with human care constitute a threat to social stability resources for public health and health care, finance, infrastructure or information systems Growing expectations for better invariably extend beyond the narrowly defined health sector, beyond a single level of policy pur The support for a renewal of PHC stems from the view and, increasingly, across borders: this raises the benchmark in terms of working effectively growing realization among health policy-makers across government and stakeholders that it can provide a stronger sense of direction While the health sector remains massively and unity in the current context of fragmenta under-resourced in far too many countries,I tion of health systems, and an alternative to the the resource base for health has been growing assorted quick fixes currently touted as cures consistently over the last decade. The opportu for the health sectors ills. There is also a grow nities this growth offers for inducing structural ing realization that conventional health-care XI
xiii Introduction and Overview Second, the nature of health problems is changing in ways that were only partially anticipated, and at a rate that was wholly unexpected. Ageing and the effects of ill-managed urbanization and globalization accelerate worldwide transmission of communicable diseases, and increase the burden of chronic and noncommunicable disorders. The growing reality that many individuals present with complex symptoms and multiple illnesses challenges service delivery to develop more integrated and comprehensive case management. A complex web of interrelated factors is at work, involving gradual but longterm increases in income and population, climate change, challenges to food security, and social tensions, all with defi nite, but largely unpredictable, implications for health in the years ahead. Third, health systems are not insulated from the rapid pace of change and transformation that is an essential part of today’s globalization. Economic and political crises challenge state and institutional roles to ensure access, delivery and fi nancing. Unregulated commercialization is accompanied by a blurring of the boundaries between public and private actors, while the negotiation of entitlement and rights is increasingly politicized. The information age has transformed the relations between citizens, professionals and politicians. In many regards, the responses of the health sector to the changing world have been inadequate and naïve. Inadequate, insofar as they not only fail to anticipate, but also to respond appropriately: too often with too little, too late or too much in the wrong place. Naïve insofar as a system’s failure requires a system’s solution – not a temporary remedy. Problems with human resources for public health and health care, fi nance, infrastructure or information systems invariably extend beyond the narrowly defi ned health sector, beyond a single level of policy purview and, increasingly, across borders: this raises the benchmark in terms of working effectively across government and stakeholders. While the health sector remains massively under-resourced in far too many countries, the resource base for health has been growing consistently over the last decade. The opportunities this growth offers for inducing structural changes and making health systems more effective and equitable are often missed. Global and, increasingly, national policy formulation processes have focused on single issues, with various constituencies competing for scarce resources, while scant attention is given to the underlying constraints that hold up health systems development in national contexts. Rather than improving their response capacity and anticipating new challenges, health systems seem to be drifting from one short-term priority to another, increasingly fragmented and without a clear sense of direction. Today, it is clear that left to their own devices, health systems do not gravitate naturally towards the goals of health for all through primary health care as articulated in the Declaration of AlmaAta. Health systems are developing in directions that contribute little to equity and social justice and fail to get the best health outcomes for their money. Three particularly worrisome trends can be characterized as follows: Q health systems that focus disproportionately on a narrow offer of specialized curative care; Q health systems where a command-and-control approach to disease control, focused on shortterm results, is fragmenting service delivery; Q health systems where a hands-off or laissezfaire approach to governance has allowed unregulated commercialization of health to fl ourish. These trends fl y in the face of a comprehensive and balanced response to health needs. In a number of countries, the resulting inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability. Growing expectations for better performance The support for a renewal of PHC stems from the growing realization among health policy-makers that it can provide a stronger sense of direction and unity in the current context of fragmentation of health systems, and an alternative to the assorted quick fi xes currently touted as cures for the health sector’s ills. There is also a growing realization that conventional health-care
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever delivery, through different mechanisms and for problems of today and tomorrow will require different reasons, is not only less effective than stronger collective management and accountabil- it could be, but suffers from a set of ubiquitous ity guided by a clearer sense of overall direction shortcomings and contradictions that are sum- and purpose marized in box 1 Indeed, this is what people expect to happen The mismatch between expectations and As societies modernize, people demand more erformance is a cause of concern for health from their health systems, for themselves and authorities. Given the growing economic weight their families, as well as for the society in which and social significance of the health sector, it they live. Thus, there is increasingly popular is also an increasing cause for concern among support for better health equity and an end to politicians: it is telling that health-care issues exclusion; for health services that are centred vere,on average, mentioned more than 28 times on people's needs and expectations; for health in each of the recent primary election debates in security for the communities in which they live; the United States. Business as usual for health and for a say in what affects their health and that systems is not a viable option. If these shortfalls of their communities23, in performance are to be redressed, the health These expectations resonate with the values that were at the core of the declaration of alma Ata. They explain the current demand for a better Box 1 Five common shortcomings of alignment of health systems with these values health-care delivery and provide todays PHC movement with reinvigo rated social and political backing for its attempts to reform health systems. Inverse care. People with the most means-whose needs for ealth care are often less -consume the most care. whereas those with the least means and greatest health problems con- From the packages of the past to me the least. Public spending on health services most the reforms of the future often benefits the rich more than the poor in high-and low- income countries alike Rising expectations and broad support for the Impoverishing care. Wherever people lack social vision set forth in Alma-Ata's values have not and payment for care is largely out-of-pocket at the point of lways easily translated into effective transfor service, they can be confronted with catastrophic expenses. mation of health systems. There have been cir Over 100 million people annually fall into poverty because they cumstances and trends from beyond the health have to pay for health care. sector-structural adjustment, for example frag of health-care providers and the narrow focus of many ed and fragmenting care. The excessive specializa- over which the phc movement had little influ- disease control programmes discourage a holistic approach ence or control. Furthermore, all too often, the to the individuals and the families they deal with and do no PHC movement has oversimplified its message, ppreciate the need for continuity in care. Health services resulting in one-size-fits-all recipes, ill-adapted poor and marginalized groups are often highly fragmented to different contexts and problems.As a result and severely under-resourced, while development aid often national and global health authorities have at ids to the fragmentation times seen PHC not as a set of reforms. as was Unsafe care. Poor system design that is unable to ensure safety intended, but as one health-care delivery pro- nfections, along with medication errors and other avoidable gramme among many, providing poor care for adverse effects that are an underestimated cause of death poor people. Table 1 looks at different dimen sions of early attempts at implementing PHC and Misdirected care Resource allocation clusters around cura- contrasts this with current approaches. Inherent tive services at great cost, neglecting the potential of primary in this evolution is recognition that providing a prevention and health promotion to prevent up to 70% of the disease burden,20. At the same time, the health sectorlacks sense of direction to health systems requires the expertise to mitigate the adverse effects on health from set of specific and context-sensitive reforms that ther sectors and make the most of what these other sectors respond to the health challenges of today and an contribute to health21 prepare for those of tomorrow
Primary Health Care – Now More Than Ever xiv The World Health Report 2008 delivery, through different mechanisms and for different reasons, is not only less effective than it could be, but suffers from a set of ubiquitous shortcomings and contradictions that are summarized in Box 1. The mismatch between expectations and performance is a cause of concern for health authorities. Given the growing economic weight and social signifi cance of the health sector, it is also an increasing cause for concern among politicians: it is telling that health-care issues were, on average, mentioned more than 28 times in each of the recent primary election debates in the United States22. Business as usual for health systems is not a viable option. If these shortfalls in performance are to be redressed, the health problems of today and tomorrow will require stronger collective management and accountability guided by a clearer sense of overall direction and purpose. Indeed, this is what people expect to happen. As societies modernize, people demand more from their health systems, for themselves and their families, as well as for the society in which they live. Thus, there is increasingly popular support for better health equity and an end to exclusion; for health services that are centred on people’s needs and expectations; for health security for the communities in which they live; and for a say in what affects their health and that of their communities23. These expectations resonate with the values that were at the core of the Declaration of AlmaAta. They explain the current demand for a better alignment of health systems with these values and provide today’s PHC movement with reinvigorated social and political backing for its attempts to reform health systems. From the packages of the past to the reforms of the future Rising expectations and broad support for the vision set forth in Alma-Ata’s values have not always easily translated into effective transformation of health systems. There have been circumstances and trends from beyond the health sector – structural adjustment, for example – over which the PHC movement had little infl uence or control. Furthermore, all too often, the PHC movement has oversimplifi ed its message, resulting in one-size-fi ts-all recipes, ill-adapted to different contexts and problems24. As a result, national and global health authorities have at times seen PHC not as a set of reforms, as was intended, but as one health-care delivery programme among many, providing poor care for poor people. Table 1 looks at different dimensions of early attempts at implementing PHC and contrasts this with current approaches. Inherent in this evolution is recognition that providing a sense of direction to health systems requires a set of specifi c and context-sensitive reforms that respond to the health challenges of today and prepare for those of tomorrow. Box 1 Five common shortcomings of health-care delivery Inverse care. People with the most means – whose needs for health care are often less – consume the most care, whereas those with the least means and greatest health problems consume the least10. Public spending on health services most often benefi ts the rich more than the poor11 in high- and lowincome countries alike12,13. Impoverishing care. Wherever people lack social protection and payment for care is largely out-of-pocket at the point of service, they can be confronted with catastrophic expenses. Over 100 million people annually fall into poverty because they have to pay for health care14. Fragmented and fragmenting care. The excessive specialization of health-care providers and the narrow focus of many disease control programmes discourage a holistic approach to the individuals and the families they deal with and do not appreciate the need for continuity in care15. Health services for poor and marginalized groups are often highly fragmented and severely under-resourced16, while development aid often adds to the fragmentation17. Unsafe care. Poor system design that is unable to ensure safety and hygiene standards leads to high rates of hospital-acquired infections, along with medication errors and other avoidable adverse effects that are an underestimated cause of death and ill-health18. Misdirected care. Resource allocation clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion to prevent up to 70% of the disease burden19,20. At the same time, the health sector lacks the expertise to mitigate the adverse effects on health from other sectors and make the most of what these other sectors can contribute to health21