Primary health care: now more than ever - World Health Organization

ContentsList of FiguresFigure 1. The PHC reforms necessary to refocus health systemstowards health for allFigure 1.1 Selected best performing countries in reducing underfive mortality by at least 80%, by regions, 1975–2006Figure 1.2 Factors explaining mortality reduction in Portugal,1960–2008Figure 1.3 Variable progress in reducing under-fi ve mortality,1975 and 2006, in selected countries with similar rates in 1975Figure 1.4 GDP per capita and life expectancy at birth in 169countries, 1975 and 2005Figure 1.5 Trends in GDP per capita and life expectancy at birthin 133 countries grouped by the 1975 GDP, 1975−2005Figure 1.6 Countries grouped according to their total healthexpenditure in 2005 (international $)Figure 1.7 Africa’s children are at more risk of dying from traffi caccidents than European children: child road-traffi c deaths per100 000 populationFigure 1.8 The shift towards noncommunicable diseases and 8accidents as causes of deathFigure 1.9 Within-country inequalities in health and health care 10Figure 1.10 How health systems are diverted from PHC core 11valuesFigure 1.11 Percentage of the population citing health as their 15main concern before other issues, such as fi nancial problems,housing or crimeFigure 1.12 The professionalization of birthing care: percentageof births assisted by professional and other carers in selectedareas, 2000 and 2005 with projections to 2015Figure 1.13 The social values that drive PHC and thecorresponding sets of reformsFigure 2.1 Catastrophic expenditure related to out-of-pocket 24payment at the point of serviceFigure 2.2 Three ways of moving towards universal coverage 26Figure 2.3 Impact of abolishing user fees on outpatient27attendance in Kisoro district, Uganda: outpatient attendance1998–2002Figure 2.4 Different patterns of exclusion: massive deprivationin some countries, marginalization of the poor in others. Birthsattended by medically trained personnel (percentage), by incomegroupFigure 2.5 Under-fi ve mortality in rural and urban areas, theIslamic Republic of Iran, 1980–2000Figure 2.6 Improving health-care outputs in the midst ofdisaster: Rutshuru, the Democratic Republic of the Congo,1985–2004xvi23345671718282931Figure 3.1 The effect on uptake of contraception of thereorganization of work schedules of rural health centres in NigerFigure 3.2 Lost opportunities for prevention of mother-to-childtransmission of HIV (MTCT) in Côte d’Ivoire: only a tiny fraction ofthe expected transmissions are actually preventedFigure 3.3 More comprehensive health centres have bettervaccination coverageFigure 3.4 Inappropriate investigations prescribed for simulatedpatients presenting with a minor stomach complaint in ThailandFigure 3.5 Primary care as a hub of coordination: networkingwithin the community served and with outside partnersFigure 4.1 Deaths attributable to unsafe abortion per 100 000live births, by legal grounds for abortionsFigure 4.2 Annual pharmaceutical spending and numberof prescriptions dispensed in New Zealand since thePharmaceutical Management Agency was convened in 1993Figure 4.3 Percentage of births and deaths recorded in countrieswith complete civil registration systems, by WHO region,1975–2004Figure 4.4 Essential public-health functions that 30 nationalpublic-health institutions view as being part of their portfolioFigure 5.1 Percentage of GDP used for health, 2005 82Figure 5.2 Health expenditure in China: withdrawal of the State 84in the 1980s and 1990s and recent re-engagementFigure 5.3 Transforming information systems into instruments 87for PHC reformFigure 5.4 Mutual reinforcement between innovation in the fi eld 89and policy development in the health reform processFigure 5.5 A growing market: technical cooperation as part of 91Offi cial Development Aid for Health. Yearly aid fl ows in 2005,defl ator adjustedFigure 5.6 Re-emerging national leadership in health: the shiftin donor funding towards integrated health systems support, andits impact on the Democratic Republic of the Congo’s 2004 PHCstrategyFigure 6.1 Contribution of general government, private pre-paidand private out-of-pocket expenditure to the yearly growthin total health expenditure per capita, percentage, weightedaveragesFigure 6.2 Projected per capita health expenditure in 2015,rapid-growth health economies (weighted averages)Figure 6.3 Projected per capita health expenditure in 2015, lowexpenditure, low-growth health economies (weighted averages)Figure 6.4 The progressive extension of coverage by communityowned,community–operated health centres in Mali, 1998–200742454953556566747594101103105107v

The World Health Report 2008Primary Health Care – Now More Than EverList of BoxesBox 1 Five common shortcomings of health-care deliveryBox 2 What has been considered primary care in well-resourcedcontexts has been dangerously oversimplifi ed in resourceconstrainedsettingsBox 1.1 Economic development and investment choices in health 3care: the improvement of key health indicators in PortugalBox 1.2 Higher spending on health is associated with better6outcomes, but with large differences between countriesBox 1.3 As information improves, the multiple dimensions of 10growing health inequality are becoming more apparentBox 1.4 Medical equipment and pharmaceutical industries are 12major economic forcesBox 1.5 Health is among the top personal concerns 15Box 2.1 Best practices in moving towards universal coverage 26Box 2.2 Defi ning “essential packages”: what needs to be done to 27go beyond a paper exercise?Box 2.3 Closing the urban-rural gap through progressive29expansion of PHC coverage in rural areas in the Islamic Republicof IranBox 2.4 The robustness of PHC-led health systems: 20 years ofexpanding performance in Rutshuru, the Democratic Republic ofthe CongoBox 2.5 Targeting social protection in Chile 33Box 2.6 Social policy in the city of Ghent, Belgium: how local 35authorities can support intersectoral collaboration betweenhealth and welfare organizationsxivxvii31Box 4.1 Rallying society’s resources for health in Cuba 65Box 4.2 Recommendations of the Commission on Social69Determinants of HealthBox 4.3 How to make unpopular public policy decisions 72Box 4.4 The scandal of invisibility: where births and deaths are 74not countedBox 4.5 European Union impact assessment guidelines 75Box 5.1 From withdrawal to re-engagement in China 84Box 5.2 Steering national directions with the help of policy86dialogue: experience from three countriesBox 5.3 Equity Gauges: stakeholder collaboration to tackle health 88inequalitiesBox 5.4 Limitations of conventional capacity building in low- and 91middle-income countriesBox 5.5 Rebuilding leadership in health in the aftermath of war 94and economic collapseBox 6.1 Norway’s national strategy to reduce social inequalitiesin healthBox 6.2 The virtuous cycle of supply of and demand for primarycareBox 6.3. From product development to fi eld implementation −research makes the link102107109Box 3.1 Towards a science and culture of improvement: evidence 44to promote patient safety and better outcomesBox 3.2 When supplier-induced and consumer-driven demand 44determine medical advice: ambulatory care in IndiaBox 3.3 The health-care response to partner violence against 47womenBox 3.4 Empowering users to contribute to their own health 48Box 3.5 Using information and communication technologies to 51improve access, quality and effi ciency in primary carevi

ContentsList of TablesTable 1 How experience has shifted the focus of the PHCmovementxvTable 3.1 Aspects of care that distinguish conventional healthcare from people-centred primary careTable 3.2 Person-centredness: evidence of its contribution toquality of care and better outcomesTable 3.3 Comprehensiveness: evidence of its contribution toquality of care and better outcomesTable 3.4 Continuity of care: evidence of its contribution toquality of care and better outcomesTable 3.5 Regular entry point: evidence of its contribution toquality of care and better outcomes4347485052Table 4.1 Adverse health effects of changing workcircumstances70Table 5.1 Roles and functions of public-health observatories inEnglandTable 5.2 Signifi cant factors in improving institutional capacityfor health-sector governance in six countries8992vii

The World Health Report 2008Primary Health Care – Now More Than EverDirector-General’sMessageWhen I took office in 2007, I madeclear my commitment to directWHO’s attention towards primaryhealth care. More important thanmy own conviction, this reflectsthe widespread and growingdemand for primary healthcare from Member States. Thisdemand in turn displays agrowing appetite among policymakersfor knowledge related tohow health systems can becomemore equitable, inclusive and fair.It also reflects, more fundamentally, ashift towards the need for more compre-hensive thinking about the performanceof the health system as a whole.This year marks both the 60th birth-dayofWWHO and the 30th anniversary ofthe Declaration of Alma-Ata on PrimaryHealth Care in 1978. While our global health context has changed remarkably over six decades, thevalues that lie at the core of the WHO Constitution and those that informed the Alma-Ata Declarationhave been tested and remain true. Yet, despite enormous progress in health globally, our collective failuresto deliver in line with these values are painfully obvious and deserve our greatest attention.We see a mother suffering complications of labour without access to qualified support, a childmissing out on essential vaccinations, an inner-city slum dweller living in squalor. We see the absenceof protection for pedestrians alongside traffic-laden roads and highways, and the impoverishmentarising from direct payment for care because of a lack of health insurance. These and many othereveryday realities of life personify the unacceptable and avoidable shortfalls in the performance ofour health systems.In moving forward, it is important to learn from the past and, in looking back, it is clear that wecan do better in the future. Thus, this World Health Report revisits the ambitious vision of primaryhealth care as a set of values and principles for guiding the development of health systems. The Reportrepresents an important opportunity to draw on the lessons of the past, consider the challenges thatviii

Director-General’s Messagelie ahead, and identify major avenues for healthsystems to narrow the intolerable gaps betweenaspiration and implementation.These avenues are defined in the Report asfour sets of reforms that reflect a convergencebetween the values of primary health care, theexpectations of citizens and the common healthperformance challenges that cut across all contexts.They include: universal coverage reforms that ensure thathealth systems contribute to health equity,social justice and the end of exclusion, primarilyby moving towards universal accessand social health protection; service delivery reforms that re-organizehealth services around people’s needs andexpectations, so as to make them more sociallyrelevant and more responsive to the changingworld, while producing better outcomes; public policy reforms that secure healthiercommunities, by integrating public healthactions with primary care, by pursuing healthypublic policies across sectors and by strengtheningnational and transnational public healthinterventions; and leadership reforms that replace disproportionatereliance on command and control on onehand, and laissez-faire disengagement of thestate on the other, by the inclusive, participatory,negotiation-based leadership indicatedby the complexity of contemporary healthsystems.While universally applicable, these reformsdo not constitute a blueprint or a manifesto foraction. The details required to give them life ineach country must be driven by specific conditionsand contexts, drawing on the best availableevidence. Nevertheless, there are no reasons whyany country − rich or poor − should wait to beginmoving forward with these reforms. As the lastthree decades have demonstrated, substantialprogress is possible.Doing better in the next 30 years means thatwe need to invest now in our ability to bringactual performance in line with our aspirations,expectations and the rapidly changing realities ofour interdependent health world. United by thecommon challenge of primary health care, thetime is ripe, now more than ever, to foster jointlearning and sharing across nations to chart themost direct course towards health for all.Dr Margaret ChanDirector-GeneralWorld Health Organizationix

Introductionand OverviewWhy a renewal of primary health care (PHC), and whynow, more than ever? The immediate answer is thepalpable demand for it from Member States – not justfrom health professionals, but from theResponding to thepolitical arena as well.challenges of achanging worldGlobalization is putting the socialcohesion of many countries under stress,From the packages ofand health systems, as key constituents the past to thereforms of the futureof the architecture of contemporarysocieties, are clearly not performing asSeizing opportunitieswell as they could and as they should.People are increasingly impatient withthe inability of health services to deliver levels of nationalcoverage that meet stated demands and changing needs,and with their failure to provide services in ways thatcorrespond to their expectations. Few would disagree thathealth systems need to respond better – and faster – to thechallenges of a changing world. PHC can do that.Growing expectationsfor better performanceFour sets of PHC reformsxiixiiixivxvixviiixi

The World Health Report 2008Primary Health Care – Now More Than EverThere is today a recognition that populations areleft behind and a sense of lost opportunities thatare reminiscent of what gave rise, thirty yearsago, to Alma-Ata’s paradigm shift in thinkingabout health. The Alma-Ata Conferencemobilized a “Primary Health Care movement”of professionals and institutions, governmentsand civil society organizations, researchers andgrassroots organizations that undertook to tacklethe “politically, socially and economically unacceptable”1 health inequalities in all countries.The Declaration of Alma-Ata was clear about thevalues pursued: social justice and the right tobetter health for all, participation and solidarity 1 .There was a sense that progress towards thesevalues required fundamental changes in the wayhealth-care systems operated and harnessed thepotential of other sectors.The translation of these values into tangiblereforms has been uneven. Nevertheless, today,health equity enjoys increased prominence inthe discourse of political leaders and ministriesof health 2 , as well as of local government structures,professional organizations and civil societyorganizations.The PHC values to achieve health for allrequire health systems that “Put people at thecentre of health care” 3 . What people considerdesirable ways of living as individuals and whatthey expect for their societies – i.e. what peoplevalue – constitute important parameters forgoverning the health sector. PHC has remainedthe benchmark for most countries’ discourse onhealth precisely because the PHC movement triedto provide rational, evidence-based and anticipatoryresponses to health needs and to thesesocial expectations 4,5,6,7 . Achieving this requirestrade-offs that must start by taking into accountcitizens’ “expectations about health and healthcare” and ensuring “that [their] voice and choicedecisively influence the way in which health servicesare designed and operate” 8 . A recent PHCreview echoes this perspective as the “right tothe highest attainable level of health”, “maximizingequity and solidarity” while being guidedby “responsiveness to people’s needs” 4 . Movingtowards health for all requires that health systemsrespond to the challenges of a changingworld and growing expectations for better performance.This involves substantial reorientationand reform of the ways health systems operatein society today: those reforms constitute theagenda of the renewal of PHC.Responding to the challenges of achanging worldOn the whole, people are healthier, wealthier andlive longer today than 30 years ago. If childrenwere still dying at 1978 rates, there would havebeen 16.2 million deaths globally in 2006. In fact,there were only 9.5 million such deaths 9 . Thisdifference of 6.7 million is equivalent to 18 329children’s lives being saved every day. The oncerevolutionary notion of essential drugs hasbecome commonplace. There have been significantimprovements in access to water, sanitationand antenatal care.This shows that progress is possible. It canalso be accelerated. There have never been moreresources available for health than now. The globalhealth economy is growing faster than grossdomestic product (GDP), having increased itsshare from 8% to 8.6% of the world’s GDP between2000 and 2005. In absolute terms, adjusted forinflation, this represents a 35% growth in theworld’s expenditure on health over a five-yearperiod. Knowledge and understanding of healthare growing rapidly. The accelerated technologicalrevolution is multiplying the potentialfor improving health and transforming healthliteracy in a better-educated and modernizingglobal society. A global stewardship is emerging:from intensified exchanges between countries,often in recognition of shared threats, challengesor opportunities; from growing solidarity; andfrom the global commitment to eliminate povertyexemplified in the Millennium Development Goals(MDGs).However, there are other trends that mustnot be ignored. First, the substantial progressin health over recent decades has been deeplyunequal, with convergence towards improvedhealth in a large part of the world, but at the sametime, with a considerable number of countriesincreasingly lagging behind or losing ground.Furthermore, there is now ample documentation– not available 30 years ago – of considerableand often growing health inequalities withincountries.xii

Introduction and OverviewSecond, the nature of health problems is changingin ways that were only partially anticipated,and at a rate that was wholly unexpected. Ageingand the effects of ill-managed urbanization andglobalization accelerate worldwide transmissionof communicable diseases, and increasethe burden of chronic and noncommunicabledisorders. The growing reality that many individualspresent with complex symptoms andmultiple illnesses challenges service deliveryto develop more integrated and comprehensivecase management. A complex web of interrelatedfactors is at work, involving gradual but longtermincreases in income and population, climatechange, challenges to food security, and socialtensions, all with definite, but largely unpredictable,implications for health in the years ahead.Third, health systems are not insulated fromthe rapid pace of change and transformationthat is an essential part of today’s globalization.Economic and political crises challengestate and institutional roles to ensure access,delivery and financing. Unregulated commercializationis accompanied by a blurring of theboundaries between public and private actors,while the negotiation of entitlement and rightsis increasingly politicized. The information agehas transformed the relations between citizens,professionals and politicians.In many regards, the responses of the healthsector to the changing world have been inadequateand naïve. Inadequate, insofar as theynot only fail to anticipate, but also to respondappropriately: too often with too little, too lateor too much in the wrong place. Naïve insofar asa system’s failure requires a system’s solution –not a temporary remedy. Problems with humanresources for public health and health care,finance, infrastructure or information systemsinvariably extend beyond the narrowly definedhealth sector, beyond a single level of policy purviewand, increasingly, across borders: this raisesthe benchmark in terms of working effectivelyacross government and stakeholders.While the health sector remains massivelyunder-resourced in far too many countries,the resource base for health has been growingconsistently over the last decade. The opportunitiesthis growth offers for inducing structuralchanges and making health systems more effectiveand equitable are often missed. Global and,increasingly, national policy formulation processeshave focused on single issues, with variousconstituencies competing for scarce resources,while scant attention is given to the underlyingconstraints that hold up health systems developmentin national contexts. Rather than improvingtheir response capacity and anticipating newchallenges, health systems seem to be driftingfrom one short-term priority to another, increasinglyfragmented and without a clear sense ofdirection.Today, it is clear that left to their own devices,health systems do not gravitate naturally towardsthe goals of health for all through primary healthcare as articulated in the Declaration of Alma-Ata. Health systems are developing in directionsthat contribute little to equity and social justiceand fail to get the best health outcomes for theirmoney. Three particularly worrisome trends canbe characterized as follows: health systems that focus disproportionately ona narrow offer of specialized curative care; health systems where a command-and-controlapproach to disease control, focused on shorttermresults, is fragmenting service delivery; health systems where a hands-off or laissezfaireapproach to governance has allowedunregulated commercialization of health toflourish.These trends fly in the face of a comprehensiveand balanced response to health needs. In a numberof countries, the resulting inequitable access,impoverishing costs, and erosion of trust in healthcare constitute a threat to social stability.Growing expectations for betterperformanceThe support for a renewal of PHC stems from thegrowing realization among health policy-makersthat it can provide a stronger sense of directionand unity in the current context of fragmentationof health systems, and an alternative to theassorted quick fixes currently touted as curesfor the health sector’s ills. There is also a growingrealization that conventional health-carexiii

The World Health Report 2008Primary Health Care – Now More Than Everdelivery, through different mechanisms and fordifferent reasons, is not only less effective thanit could be, but suffers from a set of ubiquitousshortcomings and contradictions that are summarizedin Box 1.The mismatch between expectations andperformance is a cause of concern for healthauthorities. Given the growing economic weightand social significance of the health sector, itis also an increasing cause for concern amongpoliticians: it is telling that health-care issueswere, on average, mentioned more than 28 timesin each of the recent primary election debates inthe United States 22 . Business as usual for healthsystems is not a viable option. If these shortfallsin performance are to be redressed, the healthBox 1 Five common shortcomings ofhealth-care deliveryInverse care. People with the most means – whose needs forhealth care are often less – consume the most care, whereasthose with the least means and greatest health problems consumethe least 10 . Public spending on health services mostoften benefi ts the rich more than the poor 11 in high- and lowincomecountries alike 12,13 .Impoverishing care. Wherever people lack social protectionand payment for care is largely out-of-pocket at the point ofservice, they can be confronted with catastrophic expenses.Over 100 million people annually fall into poverty because theyhave to pay for health care 14 .Fragmented and fragmenting care. The excessive specializationof health-care providers and the narrow focus of manydisease control programmes discourage a holistic approachto the individuals and the families they deal with and do notappreciate the need for continuity in care 15 . Health servicesfor poor and marginalized groups are often highly fragmentedand severely under-resourced 16 , while development aid oftenadds to the fragmentation 17 .Unsafe care. Poor system design that is unable to ensure safetyand hygiene standards leads to high rates of hospital-acquiredinfections, along with medication errors and other avoidableadverse effects that are an underestimated cause of deathand ill-health 18 .Misdirected care. Resource allocation clusters around curativeservices at great cost, neglecting the potential of primaryprevention and health promotion to prevent up to 70% of thedisease burden 19,20 . At the same time, the health sector lacksthe expertise to mitigate the adverse effects on health fromother sectors and make the most of what these other sectorscan contribute to health 21 .problems of today and tomorrow will requirestronger collective management and accountabilityguided by a clearer sense of overall directionand purpose.Indeed, this is what people expect to happen.As societies modernize, people demand morefrom their health systems, for themselves andtheir families, as well as for the society in whichthey live. Thus, there is increasingly popularsupport for better health equity and an end toexclusion; for health services that are centredon people’s needs and expectations; for healthsecurity for the communities in which they live;and for a say in what affects their health and thatof their communities 23 .These expectations resonate with the valuesthat were at the core of the Declaration of Alma-Ata. They explain the current demand for a betteralignment of health systems with these valuesand provide today’s PHC movement with reinvigoratedsocial and political backing for its attemptsto reform health systems.From the packages of the past tothe reforms of the futureRising expectations and broad support for thevision set forth in Alma-Ata’s values have notalways easily translated into effective transformationof health systems. There have been circumstancesand trends from beyond the healthsector – structural adjustment, for example –over which the PHC movement had little influenceor control. Furthermore, all too often, thePHC movement has oversimplified its message,resulting in one-size-fits-all recipes, ill-adaptedto different contexts and problems 24 . As a result,national and global health authorities have attimes seen PHC not as a set of reforms, as wasintended, but as one health-care delivery programmeamong many, providing poor care forpoor people. Table 1 looks at different dimensionsof early attempts at implementing PHC andcontrasts this with current approaches. Inherentin this evolution is recognition that providing asense of direction to health systems requires aset of specific and context-sensitive reforms thatrespond to the health challenges of today andprepare for those of tomorrow.xiv

Introduction and OverviewThe focus of these reforms goes well beyond“basic” service delivery and cuts across theestablished boundaries of the building blocks ofnational health systems 25 . For example, aligninghealth systems based on the values that drive PHCwill require ambitious human resources policies.However, it would be an illusion to think thatthese can be developed in isolation from financingor service delivery policies, civil service reformand arrangements dealing with the cross-bordermigration of health professionals.At the same time, PHC reforms, and the PHCmovement that promotes them, have to be moreresponsive to social change and rising expectationsthat come with development and modernization.People all over the world are becoming morevocal about health as an integral part of howthey and their families go about their everydaylives, and about the way their society deals withhealth and health care. The dynamics of demandmust find a voice within the policy and decisionmakingprocesses. The necessary reorientation ofhealth systems has to be based on sound scientificevidence and on rational management of uncertainty,but it should also integrate what peopleexpect of health and health care for themselves,their families and their society. This requiresdelicate trade-offs and negotiation with multiplestakeholders that imply a stark departure fromthe linear, top-down models of the past. Thus,PHC reforms today are neither primarily definedby the component elements they address, normerely by the choice of disease control interventionsto be scaled up, but by the social dynamicsthat define the role of health systems in society.Table 1 How experience has shifted the focus of the PHC movementEARLY ATTEMPTS AT IMPLEMENTING PHCExtended access to a basic package of health interventionsand essential drugs for the rural poorConcentration on mother and child healthFocus on a small number of selected diseases, primarilyinfectious and acuteImprovement of hygiene, water, sanitation and healtheducation at village levelSimple technology for volunteer, non-professionalcommunity health workersParticipation as the mobilization of local resourcesand health-centre management through local healthcommitteesGovernment-funded and delivered services with acentralized top-down managementManagement of growing scarcity and downsizingBilateral aid and technical assistancePrimary care as the antithesis of the hospitalPHC is cheap and requires only a modest investmentCURRENT CONCERNS OF PHC REFORMSTransformation and regulation of existing health systems,aiming for universal access and social health protectionDealing with the health of everyone in the communityA comprehensive response to people’s expectations andneeds, spanning the range of risks and illnessesPromotion of healthier lifestyles and mitigation of the healtheffects of social and environmental hazardsTeams of health workers facilitating access to andappropriate use of technology and medicinesInstitutionalized participation of civil society in policydialogue and accountability mechanismsPluralistic health systems operating in a globalized contextGuiding the growth of resources for health towardsuniversal coverageGlobal solidarity and joint learningPrimary care as coordinator of a comprehensive responseat all levelsPHC is not cheap: it requires considerable investment, but itprovides better value for money than its alternativesxv

The World Health Report 2008Primary Health Care – Now More Than EverFour sets of PHC reformsThis report structures the PHC reforms in fourgroups that reflect the convergence betweenthe evidence on what is needed for an effectiveresponse to the health challenges of today’s world,the values of equity, solidarity and social justicethat drive the PHC movement, and the growingexpectations of the population in modernizingsocieties (Figure 1): reforms that ensure that health systems contributeto health equity, social justice and theend of exclusion, primarily by moving towardsuniversal access and social health protection– universal coverage reforms; reforms that reorganize health services asprimary care, i.e. around people’s needs andexpectations, so as to make them more sociallyrelevant and more responsive to the changingworld while producing better outcomes – servicedelivery reforms; reforms that secure healthier communities, byintegrating public health actions with primarycare and by pursuing healthy public policiesacross sectors – public policy reforms; reforms that replace disproportionate relianceon command and control on one hand,and laissez-faire disengagement of the stateon the other, by the inclusive, participatory,negotiation-based leadership required by thecomplexity of contemporary health systems –leadership reforms.The first of these four sets of reforms aims atdiminishing exclusion and social disparities inhealth. Ultimately, the determinants of healthinequality require a societal response, withpolitical and technical choices that affect manydifferent sectors. Health inequalities are alsoshaped by the inequalities in availability, accessand quality of services, by the financial burdenthese impose on people, and even by the linguistic,cultural and gender-based barriers thatare often embedded in the way in which clinicalpractice is conducted 26 .If health systems are to reduce health inequities,a precondition is to make services available toall, i.e. to bridge the gap in the supply of services.Service networks are much more extensive todayFigure 1 The PHC reforms necessary to refocushealth systems towards health for allUNIVERSALCOVERAGEREFORMSto improvehealth equityLEADERSHIPREFORMSto make healthauthorities morereliableSERVICEDELIVERYREFORMSto make health systemspeople-centredPUBLIC POLICYREFORMSto promote andprotect the health ofcommunitiesthan they were 30 years ago, but large populationgroups have been left behind. In some places,war and civil strife have destroyed infrastructure,in others, unregulated commercializationhas made services available, but not necessarilythose that are needed. Supply gaps are still areality in many countries, making extension oftheir service networks a priority concern, as wasthe case 30 years ago.As the overall supply of health services hasimproved, it has become more obvious that barriersto access are important factors of inequity:user fees, in particular, are important sources ofexclusion from needed care. Moreover, when peoplehave to purchase health care at a price that isbeyond their means, a health problem can quicklyprecipitate them into poverty or bankruptcy 14 .That is why extension of the supply of serviceshas to go hand-in-hand with social health protection,through pooling and pre-payment instead ofout-of-pocket payment of user fees. The reformsto bring about universal coverage – i.e. universalaccess combined with social health protection– constitute a necessary condition to improvedhealth equity. As systems that have achieved nearuniversal coverage show, such reforms need tobe complemented with another set of proactivemeasures to reach the unreached: those forwhom service availability and social protectionxvi

Introduction and Overviewdoes too little to offset the health consequencesof social stratification. Many individuals in thisgroup rely on health-care networks that assumethe responsibility for the health of entire communities.This is where a second set of reforms,the service delivery reforms, comes in.These service delivery reforms are meantto transform conventional health-care deliveryinto primary care, optimizing the contribution ofhealth services – local health systems, health-carenetworks, health districts – to health and equitywhile responding to the growing expectations for“putting people at the centre of health care, harmonizingmind and body, people and systems” 3 .These service delivery reforms are but one subsetof PHC reforms, but one with such a high profilethat it has often masked the broader PHC agenda.The resulting confusion has been compoundedby the oversimplification of what primary careentails and of what distinguishes it from conventionalhealth-care delivery (Box 2) 24 .There is a substantial body of evidence on thecomparative advantages, in terms of effectivenessand efficiency, of health care organized as peoplecentredprimary care. Despite variations in thespecific terminology, its characteristic features(person-centredness, comprehensiveness andintegration, continuity of care, and participationof patients, families and communities) arewell identified 15,27 . Care that exhibits these featuresrequires health services that are organizedaccordingly, with close-to-client multidisciplinaryteams that are responsible for a definedpopulation, collaborate with social services andother sectors, and coordinate the contributionsof hospitals, specialists and community organizations.Recent economic growth has broughtadditional resources to health. Combined withthe growing demand for better performance, thiscreates major opportunities to reorient existinghealth services towards primary care – not onlyin well-resourced settings, but also where moneyis tight and needs are high. In the many lowandmiddle-income countries where the supplyof services is in a phase of accelerated expansion,there is an opportunity now to chart a course thatmay avoid repeating some of the mistakes highincomecountries have made in the past.Primary care can do much to improve thehealth of communities, but it is not sufficient torespond to people’s desires to live in conditionsthat protect their health, support health equityBox 2 What has been considered primary care in well-resourced contexts has beendangerously oversimplifi ed in resource-constrained settingsPrimary care has been defi ned, described and studied extensively in well-resourced contexts, often with reference to physicians witha specialization in family medicine or general practice. These descriptions provide a far more ambitious agenda than the unacceptablyrestrictive and off-putting primary-care recipes that have been touted for low-income countries 27,28 : primary care provides a place to which people can bring a wide range of health problems – it is not acceptable that in low-incomecountries primary care would only deal with a few “priority diseases”; primary care is a hub from which patients are guided through the health system – it is not acceptable that, in low-income countries,primary care would be reduced to a stand-alone health post or isolated community-health worker; primary care facilitates ongoing relationships between patients and clinicians, within which patients participate in decision-makingabout their health and health care; it builds bridges between personal health care and patients’ families and communities – it isnot acceptable that, in low-income countries, primary care would be restricted to a one-way delivery channel for priority healthinterventions; primary care opens opportunities for disease prevention and health promotion as well as early detection of disease – it is notacceptable that, in low-income countries, primary care would just be about treating common ailments; primary care requires teams of health professionals: physicians, nurse practitioners, and assistants with specifi c and sophisticatedbiomedical and social skills – it is not acceptable that, in low-income countries, primary care would be synonymous with low-tech,non-professional care for the rural poor who cannot afford any better; primary care requires adequate resources and investment, and can then provide much better value for money than its alternatives– it is not acceptable that, in low-income countries, primary care would have to be fi nanced through out-of-pocket payments onthe erroneous assumption that it is cheap and the poor should be able to afford it.xvii

The World Health Report 2008Primary Health Care – Now More Than Everand enable them to lead the lives that they value.People also expect their governments to put intoplace an array of public policies to deal withhealth challenges, such as those posed by urbanization,climate change, gender discrimination orsocial stratification.These public policies encompass the technicalpolicies and programmes dealing with priorityhealth problems. These programmes can bedesigned to work through, support and give aboost to primary care, or they can neglect to dothis and, however unwillingly, undermine effortsto reform service delivery. Health authoritieshave a major responsibility to make the rightdesign decisions. Programmes to target priorityhealth problems through primary care needto be complemented by public-health interventionsat national or international level. Thesemay offer scale efficiencies; for some problems,they may be the only workable option. The evidenceis overwhelming that action on that scale,for selected interventions, which may rangefrom public hygiene and disease prevention tohealth promotion, can have a major contributionto health. Yet, they are surprisingly neglected,across all countries, regardless of income level.This is particularly visible at moments of crisisand acute threats to the public’s health, whenrapid response capacity is essential not only tosecure health, but also to maintain the publictrust in the health system.Public policy-making, however, is about morethan classical public health. Primary care andsocial protection reforms critically depend onchoosing health-systems policies, such as thoserelated to essential drugs, technology, humanresources and financing, which are supportive ofthe reforms that promote equity and people-centredcare. Furthermore, it is clear that populationhealth can be improved through policies that arecontrolled by sectors other than health. Schoolcurricula, the industry’s policy towards genderequality, the safety of food and consumer goods,or the transport of toxic waste are all issues thatcan profoundly influence or even determine thehealth of entire communities, positively or negatively,depending on what choices are made. Withdeliberate efforts towards intersectoral collaboration,it is possible to give due consideration to“health in all policies” 29 to ensure that, along withthe other sectors’ goals and objectives, healtheffects play a role in public policy decisions.In order to bring about such reforms in theextraordinarily complex environment of thehealth sector, it will be necessary to reinvest inpublic leadership in a way that pursues collaborativemodels of policy dialogue with multiplestakeholders – because this is what people expect,and because this is what works best. Healthauthorities can do a much better job of formulatingand implementing PHC reforms adaptedto specific national contexts and constraintsif the mobilization around PHC is informed bythe lessons of past successes and failures. Thegovernance of health is a major challenge forministries of health and the other institutions,governmental and nongovernmental, that providehealth leadership. They can no longer becontent with mere administration of the system:they have to become learning organizations. Thisrequires inclusive leadership that engages witha variety of stakeholders beyond the boundariesof the public sector, from clinicians to civilsociety, and from communities to researchersand academia. Strategic areas for investment toimprove the capacity of health authorities to leadPHC reforms include making health informationsystems instrumental to reform; harnessing theinnovations in the health sector and the relateddynamics in all societies; and building capacitythrough exchange and exposure to the experienceof others – within and across borders.Seizing opportunitiesThese four sets of PHC reforms are driven byshared values that enjoy large support and challengesthat are common to a globalizing world.Yet, the starkly different realities faced by individualcountries must inform the way they aretaken forward. The operationalization of universalcoverage, service delivery, public policy andleadership reforms cannot be implemented as ablueprint or as a standardized package.In high-expenditure health economies, whichis the case of most high-income countries, there isample financial room to accelerate the shift fromtertiary to primary care, create a healthier policyenvironment and complement a well-establishedxviii

Introduction and Overviewuniversal coverage system with targeted measuresto reduce exclusion. In the large number offast-growing health economies – which is where3 billion people live – that very growth providesopportunities to base health systems on soundprimary care and universal coverage principlesat a stage where it is in full expansion, avoidingthe errors by omission, such as failing to investin healthy public policies, and by commission,such as investing disproportionately in tertiarycare, that have characterized health systems inhigh-income countries in the recent past. Thechallenge is, admittedly, more daunting for the2 billion people living in the low-growth healtheconomies of Africa and South-East Asia, aswell as for the more than 500 million who live infragile states. Yet, even here, there are signs ofgrowth – and evidence of a potential to accelerateit through other means than through the counterproductivereliance on inequitable out-of-pocketpayments at points of delivery – that offer possibilitiesto expand health systems and services.Indeed, more than in other countries, they cannotafford not to opt for PHC and, as elsewhere, theycan start doing so right away.The current international environment isfavourable to a renewal of PHC. Global health isreceiving unprecedented attention, with growinginterest in united action, greater calls for comprehensiveand universal care – be it from peopleliving with HIV and those concerned with providingtreatment and care, ministers of health, orthe Group of Eight (G8) – and a mushrooming ofinnovative global funding mechanisms relatedto global solidarity. There are clear and welcomesigns of a desire to work together in building sustainablesystems for health rather than relying onfragmented and piecemeal approaches 30 .At the same time, there is a perspective ofenhanced domestic investment in re-invigoratingthe health systems around PHC values.The growth in GDP – admittedly vulnerable toeconomic slowdown, food and energy crises andglobal warming – is fuelling health spendingthroughout the world, with the notable exceptionof fragile states. Harnessing this economicgrowth would offer opportunities to effectuatenecessary PHC reforms that were unavailableduring the 1980s and 1990s. Only a fraction ofhealth spending currently goes to correctingcommon distortions in the way health systemsfunction or to overcoming system bottlenecks thatconstrain service delivery, but the potential isthere and is growing fast.Global solidarity – and aid – will remain importantto supplement and suppport countries makingslow progress, but it will become less importantper se than exchange, joint learning andglobal governance. This transition has alreadytaken place in most of the world: most developingcountries are not aid-dependent. Internationalcooperation can accelerate the conversion of theworld’s health systems, including through betterchannelling of aid, but real progress will comefrom better health governance in countries – lowandhigh-income alike.The health authorities and political leadersare ill at ease with current trends in the developmentof health systems and with the obviousneed to adapt to the changing health challenges,demands and rising expectations. This is shapingthe current opportunity to implement PHCreforms. People’s frustration and pressure for different,more equitable health care and for betterhealth protection for society is building up: neverbefore have expectations been so high about whathealth authorities and, specifically, ministries ofhealth should be doing about this.By capitalizing on this momentum, investmentin PHC reforms can accelerate the transformationof health systems so as to yield better and moreequitably distributed health outcomes. The worldhas better technology and better information toallow it to maximize the return on transforming thefunctioning of health systems. Growing civil societyinvolvement in health and scale-efficient collectiveglobal thinking (for example, in essential drugs)further contributes to the chances of success.During the last decade, the global communitystarted to deal with poverty and inequalityacross the world in a much more systematic way– by setting the MDGs and bringing the issue ofinequality to the core of social policy-making.Throughout, health has been a central, closelyinterlinked concern. This offers opportunities formore effective health action. It also creates thenecessary social conditions for the establishmentof close alliances beyond the health sector. Thus,xix

The World Health Report 2008Primary Health Care – Now More Than Everintersectoral action is back on centre stage. Manyamong today’s health authorities no longer seetheir responsibility for health as being limitedto survival and disease control, but as one ofthe key capabilities people and societies value 31 .The legitimacy of health authorities increasinglydepends on how well they assume responsibilityto develop and reform the health sector accordingto what people value – in terms of health andof what is expected of health systems in society.References1. Primary health care: report of the International Conference on Primary HealthCare, Alma-Ata, USSR, 6–12 September, 1978, jointly sponsored by the WorldHealth Organization and the United Nations Children’s Fund. Geneva, World HealthOrganization, 1978 (Health for All Series No. 1).2. Dahlgren G, Whitehead M. Levelling up (part 2): a discussion paper on Europeanstrategies for tackling social inequities in health. Copenhagen, World HealthOrganization Regional Offi ce for Europe, 2006 (Studies on social and economicdeterminants of population health No. 3).3. WHO Regional Offi ce for South-East Asia and WHO Regional Offi ce for the WesternPacifi c. People at the centre of health care: harmonizing mind and body, people andsystems. Geneva, World Health Organization, 2007.4. Renewing primary health care in the Americas: a position paper of the Pan AmericanHealth Organization. Washington DC, Pan American Health Organization, 2007.5. Saltman R, Rico A, Boerma W. Primary health care in the driver’s seat: organizationalreform in European primary care. Maidenhead, England, Open University Press, 2006(European Observatory on Health Systems and Policies Series).6. Report on the review of primary care in the African Region. Brazzaville, World HealthOrganization Regional Offi ce for Africa, 2003.7. International Conference on Primary Health Care, Alma-Ata: twenty-fi fth anniversary.Geneva, World Health Organization, 2003 (Fifty-sixth World Health Assembly,Geneva, 19–28 May 2003, WHA56.6, Agenda Item 14.18).8. The Ljubljana Charter on Reforming Health Care, 1996. Copenhagen, World HealthOrganization Regional Offi ce for Europe, 1996.9. World Health Statistics 2008. Geneva, World Health Organization, 2008.10. Hart T. The inverse care law. Lancet, 1971, 1:405–412.11. World development report 2004: making services work for poor people. WashingtonDC, The World Bank, 2003.12. Filmer D. The incidence of public expenditures on health and education. WashingtonDC, The World Bank, 2003 (background note for World development report 2004 –making services work for poor people).13. Hanratty B, Zhang T, Whitehead M. How close have universal health systems cometo achieving equity in use of curative services? A systematic review. InternationalJournal of Health Services, 2007, 37:89–109.14. Xu K et al. Protecting households from catastrophic health expenditures. HealthAffairs, 2007, 6:972–983.15. Starfi eld B. Policy relevant determinants of health: an international perspective.Health Policy, 2002, 60:201–218.16. Moore G, Showstack J. Primary care medicine in crisis: towards reconstruction andrenewal. Annals of Internal Medicine, 2003, 138:244–247.17. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other healthissues? Health Policy and Planning, 2008, 23:95–100.18. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer healthsystem. Washington DC, National Academy Press, Committee on Quality of Care inAmerica, Institute of Medicine, 1999.19. Fries JF et al. Reducing health care costs by reducing the need and demand formedical services. New England Journal of Medicine, 1993, 329:321–325.20. The World Health Report 2002 – Reducing risks, promoting healthy life. Geneva,World Health Organization, 2002.21. Sindall C. Intersectoral collaboration: the best of times, the worst of times. HealthPromotion International, 1997, 12(1):5–6.22. Stevenson D. Planning for the future – long term care and the 2008 election. NewEngland Journal of Medicine, 2008, 358:19.23. Blendon RJ et al. Inequities in health care: a fi ve-country survey. Health Affairs,2002, 21:182–191.24. Tarimo E, Webster EG. Primary health care concepts and challenges in a changingworld: Alma-Ata revisited. Geneva, World Health Organization, 1997 (Currentconcerns ARA paper No. 7).25. Everybody’s business: strengthening health systems to improve health outcomes:WHO’s framework for action. Geneva, World Health Organization, 2007.26. Dans A et al. Assessing equity in clinical practice guidelines. Journal of ClinicalEpidemiology, 2007, 60:540–546.27. Primary care. America’s health in a new era. Washington DC, National AcademyPress, Institute of Medicine 1996.28. Starfi eld B. Primary care: balancing health needs, services, and technology. NewYork, Oxford University Press, 1998.29. Ståhl T et al, eds. Health in all policies. Prospects and potentials. Oslo, Ministry ofSocial Affairs and Health, 2006.30. The Paris declaration on aid effectiveness: ownership, harmonisation, alignment,results and mutual accountability. Paris, Organisation for Economic Co-operationand Development, 2005.31. Nussbaum MC, Sen A, eds. The quality of life. Oxford, Clarendon Press, 1993.xx

The challengesof a changing worldThis chapter describes the context in whichthe contemporary renewal of primaryhealth care is unfolding. The chapter reviewscurrent challenges to health and health systems anddescribes a set of broadly sharedsocial expectations that set theagenda for health systems changein today’s world.It shows how many countrieshave registered significant healthprogress over recent decades andhow gains have been unevenlyshared. Health gaps betweencountries and among social groups withincountries have widened. Social, demographicand epidemiological transformations fed byglobalization, urbanization and ageing populations,pose challenges of a magnitude that was notanticipated three decades ago.Chapter 1Unequal growth,unequal outcomes2Adapting tonew health challenges7Trends that undermine thehealth systems’ response11Changing values andrising expectations14PHC reforms:driven by demand181

The World Health Report 2008Primary Health Care – Now More Than EverThe chapter argues that, in general, theresponse of the health sector and societies tothese challenges has been slow and inadequate.This reflects both an inability to mobilize therequisite resources and institutions to transformhealth around the values of primary health careas well as a failure to either counter or substantiallymodify forces that pull the health sectorin other directions, namely: a disproportionatefocus on specialist hospital care; fragmentation ofhealth systems; and the proliferation of unregulatedcommercial care. Ironically, these powerfultrends lead health systems away from whatpeople expect from health and health care. Whenthe Declaration of Alma-Ata enshrined the principlesof health equity, people-centred care anda central role for communities in health action,they were considered radical. Social researchsuggests, however, that these values are becomingmainstream in modernizing societies: theycorrespond to the way people look at health andwhat they expect from their health systems.Rising social expectations regarding health andhealth care, therefore, must be seen as a majordriver of PHC reforms.Unequal growth,unequal outcomesLonger lives and better health,but not everywhereIn the late 1970s, the Sultanate of Oman had onlya handful of health professionals. People had totravel up to four days just to reach a hospital,where hundreds of patients would already bewaiting in line to see one of the few (expatriate)doctors. All this changed in less than a generation1 . Oman invested consistently in a nationalhealth service and sustained that investment overtime. There is now a dense network of 180 local,district and regional health facilities staffed byover 5000 health workers providing almost universalaccess to health care for Oman’s 2.2 millioncitizens, with coverage now being extended to foreignresidents 2 . Over 98% of births in Oman arenow attended by trained personnel and over 98%of infants are fully immunized. Life expectancyat birth, which was less than 60 years towardsthe end of the 1970s, now surpasses 74 years.The under-five mortality rate has dropped by astaggering 94% 3 .In each region (except in the African region)there are countries where mortality rates are nowless than one fifth of what they were 30 yearsago. Leading examples are Chile 4 , Malaysia 5 ,Portugal 6 and Thailand 7 (Figure 1.1). Theseresults were associated with improved access toexpanded health-care networks, made possibleby sustained political commitment and by economicgrowth that allowed them to back up theircommitment by maintaining investment in thehealth sector (Box 1.1).Figure 1.1 Selected best performing countries in reducing under-fivemortality by at least 80%, by regions, 1975–2006 a, *Deaths per 1000 children under five150100500Oman Portugal Chile Malaysia ThailandI$ 382) b I$ 2080) b I$ 697) b I$ 500) b I$ 346) b(THE 2006: (THE 2006: (THE 2006: (THE 2006: (THE 2006:a No country in the African region achieved an 80% reduction.b Total health expenditure per capita 2006, international $.* International dollars are derived by dividing local currency units by an estimateof their purchasing power parity compared to the US dollar.Overall, progress in the world has been considerable.If children were still dying at 1978 rates,there would have been 16.2 million deaths globallyin 2006. In fact, there were only 9.5 millionsuch deaths 12 . This difference of 6.7 million isequivalent to 18 329 children’s lives being savedevery day.But these figures mask significant variationsacross countries. Since 1975, the rate of decline inunder-five mortality rates has been much slowerin low-income countries as a whole than in thericher countries 13 . Apart from Eritrea and Mongolia,none of today’s low-income countries hasreduced under-five mortality by as much as 70%.The countries that make up today’s middle-incomecountries have done better, but, as Figure 1.3illustrates, progress has been quite uneven.1975 20062

Chapter 1. The challenges of a changing worldBox 1.1 Economic development and investment choices in health care: the improvement ofkey health indicators in PortugalPortugal recognized the right to health in its 1976 Constitution, following its democratic revolution. Political pressure to reduce largehealth inequalities within the country led to the creation of a national health system, funded by taxation and complemented by publicand private insurance schemes and out-of-pocket payments 8,9 . The system was fully established between 1979 and 1983 andexplicitly organized around PHC principles: a network of health centres staffed by family physicians and nurses progressively coveredthe entire country. Eligibility for benefi ts under the national healthsystem requires patients to register with a family physician in a Figure 1.2 Factors explaning mortality reduction in Portugal, 1960–2008health centre as the fi rst point of contact. Portugal considers this Relative weight of factors (%)network to be its greatest success in terms of improved access Growth in GDP per capita (constant prices)to care and health gains 6 .Development of primary care networks (primaryLife expectancy at birth is now 9.2 years more than it was 30years ago, while the GDP per capita has doubled. Portugal’sperformance in reducing mortality in various age groups hasbeen among the world’s most consistently successful over thelast 30 years, for example halving infant mortality rates everyeight years. This performance has led to a marked convergenceof the health of Portugal’s population with that of other countriesin the region 10 .Multivariate analysis of the time series of the various mortalityindices since 1960 shows that the decision to base Portugal’shealth policy on PHC principles, with the development of anetwork of comprehensive primary care services 11 , has playeda major role in the reduction of maternal and child mortality,whereas the reduction of perinatal mortality was linked to thedevelopment of the hospital network. The relative roles of thedevelopment of primary care, hospital networks and economicgrowth to the improvement of mortality indices since 1960 areshown in Figure 1.2.100care physicians and nurses per inhabitant)Development of hospital networks (hospitalphysicians and nurses per inhabitant)80604020071% reduction ofperinatal mortality86% reduction ofinfant mortality89% reduction inchild mortality96% reduction inmaternal mortalitySome countries have made great improvementsand are on track to achieve the health-relatedMDGs. Others, particularly in the African region,have stagnated or even lost ground 14 . Globally,20 of the 25 countries where under-five mortalityis still two thirds or more of the 1975 level are in sub-Saharan Africa. Slow progress hasbeen associated with disappointing advances inaccess to health care. Despite recent change forthe better, vaccination coverage in sub-SaharanAfrica is still significantly lower than in the restof the world 14 . Current contraceptive prevalenceremains as low as 21%, while in other developingregions increases have been substantial over thepast 30 years and now reach 61% 15,16 . Increasedcontraceptive use has been accompanied bydecreased abortion rates everywhere. In sub-Saharan Africa, however, the absolute numbers ofabortions has increased, and almost all are beingperformed in unsafe conditions 17 . Childbirth carefor mothers and newborns also continues to faceproblems: in 33 countries, less than half of allbirths each year are attended by skilled healthpersonnel, with coverage in one country as low as6% 14 . Sub-Saharan Africa is also the only region3

The World Health Report 2008Primary Health Care – Now More Than Everin the world where access to qualified providersat childbirth is not progressing 18 .Mirroring the overall trends in child survival,global trends in life expectancy pointto a rise throughout the world of almost eightyears between 1950 and 1978, and seven moreyears since: a reflection of the growth in averageincome per capita. As with child survival, wideningincome inequality (income increases fasterin high-income than in low-income countries)is reflected in increasing disparities betweenthe least and most healthy 19 . Between the mid-1970s and 2005, the difference in life expectancybetween high-income countries and countries insub-Saharan Africa, or fragile states, has widenedby 3.8 and 2.1 years, respectively.The unmistakable relation between health andwealth, summarized in the classic Preston curve(Figure 1.4), needs to be qualified 20 .Firstly, the Preston curve continues to shift 12 .An income per capita of I$ 1000 in 1975 wasassociated with a life expectancy of 48.8 years.In 2005, it was almost four years higher for thesame income. This suggests that improvementsin nutrition, education 21 , health technologies 22 ,the institutional capacity to obtain and useinformation, and in society’s ability to translatethis knowledge into effective health and socialaction 23 , allow for greater production of healthfor the same level of wealth.Figure 1.4 GDP per capita and life expectancy at birth in 169 countries a ,1975 and 2005Life expectancy at birth (years)8575655545350NamibiaSwazilandSouth AfricaBotswana5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000a Only outlying countries are named.GDP per capita, constant 2000 international $20051975Secondly, there is considerable variation inachievement across countries with the sameincome, particularly among poorer countries. Forexample, life expectancy in Côte d’Ivoire (GDP I$1465) is nearly 17 years lower than in Nepal (GDPI$ 1379), and between Madagascar and Zambia,the difference is 18 years. The presence of highperformers in each income band shows thatthe actual level of income per capita at a givenmoment is not the absolute rate limiting factorthe average curve seems to imply.Growth and stagnationOver the last 30 years the relation between economicgrowth and life expectancy at birth hasshown three distinct patterns (Figure 1.5).In 1978, about two thirds of the world’s populationlived in countries that went on to experienceincreases in life expectancy at birth and considerableeconomic growth. The most impressive relativegains were in a number of low-income countriesin Asia (including India), Latin America andnorthern Africa, totalling 1.1 billion inhabitants30 years ago and nearly 2 billion today. Thesecountries increased life expectancy at birth by12 years, while GDP per capita was multiplied bya factor of 2.6. High-income countries and countrieswith a GDP between I$ 3000 and I$ 10 000in 1975 also saw substantial economic growthand increased life expectancy.In other parts of the world, GDP growth wasnot accompanied by similar gains in life expectancy.The Russian Federation and Newly IndependentStates increased average GDP per capitasubstantially, but, with the widespread povertythat accompanied the transition from the formerSoviet Union, women’s life expectancy stagnatedfrom the late 1980s and men’s plummeted, particularlyfor those lacking education and jobsecurity 24,25 . After a period of technological andorganizational stagnation, the health system collapsed12 . Public expenditure on health declinedin the 1990s to levels that made running a basicsystem virtually impossible in several countries.Unhealthy lifestyles, combined with the disintegrationof public health programmes, and theunregulated commercialization of clinical servicescombined with the elimination of safetynets has offset any gains from the increase inaverage GDP 26 . China had already increased its4

Chapter 1. The challenges of a changing worldFigure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975–2005*Life expectancy (years)8075706560India cLow-incomecoutries dRussian Federationand NIS gChina hMiddle-incomecountries bHigh-income countries a5550450Fragile states eLow-income African countries f1000 2000 3000 4000 5000 6000 7000 8000 9000 10 000 20 000 25 000 30 000a 27 countries, 766 million (M) inhabitants in 1975, 953 M in 2005.b 43 countries, 587 M inhabitants in 1975, 986 M in 2005 .c India, 621 M inhabitants in 1975, 1 103 M in 2005.d 17 Low-income countries, non-African, fragile states excluded, 471 M inhabitants in 1975, 872 M in 2005.e 20 Fragile states, 169 M inhabitants in 1975, 374 M in 2005.f 13 Low-income African countries, fragile states excluded, 71 M inhabitants in 1975, 872 M in 2005.g Russian Federation and 10 Newly Independent States (NIS), 186 M inhabitants in 1985, 204 M in 2005.h China, 928 M inhabitants in 1975, 1 316 M in 2005.* No data for 1975 for the Newly Independant States. No historical data for the remaining countries.Sources: Life expectancy, 1975, 1985: UN World Population Prospects 2006; 1995, 2005: WHO, 9 November 2008 (draft); China: 3rd, 4th and 5th National Population censuses, 1981, 1990 and 2000. GPD: 2007 37 .life expectancy substantially in the period before1980 to levels far above that of other low-incomecountries in the 1970s, despite the 1961–1963famine and the 1966–1976 Cultural Revolution.The contribution of rural primary care andurban health insurance to this has been welldocumented 27,28 . With the economic reforms ofthe early 1980s, however, average GDP per capitaincreased spectacularly, but access to care andsocial protection deteriorated, particularly inrural areas. This slowed down improvements toa modest rate, suggesting that only the improvedliving conditions associated with the spectaculareconomic growth avoided a regression of averagelife expectancy 29 .Finally, there is a set of low-income countries,representing roughly 10% of the world’spopulation, where both GDP and life expectancystagnated 30 . These are the countries that areconsidered as “fragile states” according to the“low-income countries under stress” (LICUS)criteria for 2003–2006 31 . As much as 66% of thepopulation in these countries is in Africa. Poorgovernance and extended internal conflicts arecommon among these countries, which all facesimilar hurdles: weak security, fractured societalrelations, corruption, breakdown in the ruleof law, and lack of mechanisms for generatinglegitimate power and authority 32 . They have ahuge backlog of investment needs and limitedgovernment resources to meet them. Half ofthem experienced negative GDP growth duringthe period 1995–2004 (all the others remainedbelow the average growth of low-income countries),while their external debt was above average33 . These countries were among those withthe lowest life expectancy at birth in 1975 andhave experienced minimal increases since then.The other low-income African countries sharemany of the characteristics and circumstancesof the fragile states – in fact many of them havesuffered protracted periods of conflict over thelast 30 years that would have classified them asfragile states had the LICUS classification existedat that time. Their economic growth has beenvery limited, as has been their life-expectancygain, not least because of the presence, in thisgroup, of a number of southern African countriesthat are disproportionally confronted by the HIV/AIDS pandemic. On average, the latter have seensome economic growth since 1975, but a markedreversal in terms of life expectancy.What has been strikingly common to fragilestates and sub-Saharan African countries for5

The World Health Report 2008Primary Health Care – Now More Than Evermuch of the last three decades, and differentiatesthem from the others that started out with lessthan I$ 3000 per capita in 1975, is the combinationof stagnating economic growth, political instabilityand lack of progress in life expectancy. Theyaccumulate characteristics that hamper improvementof health. Education, particularly of females,develops more slowly, as does access to moderncommunications and knowledge-intensive workthat broadens people’s intellectual resources elsewhere.People are more exposed and more vulnerableto environmental and other health threatsthat, in today’s globalized world, include lifestylethreats, such as smoking, obesity and urban violence.They lack the material security required toinvest in their own health and their governmentslack the necessary resources and/or commitmentto public investment. They are at much greater riskof war and civil conflict than richer countries 30 .Without growth, peace is considerably more difficultand without peace, growth stagnates: onaverage, a civil war reduces a country’s growthby around 2.3% per year for a typical duration ofseven years, leaving it 15% poorer 34 .The impact of the combination of stagnationand conflicts cannot be overstated. Conflicts are adirect source of considerable excessive suffering,disease and mortality. In the Democratic Republicof the Congo, for example, the 1998–2004 conflictcaused an excess mortality of 450 000 deathsper year 35 . Any strategy to close the health gapsbetween countries – and to correct inequalitieswithin countries – has to give consideration tothe creation of an environment of peace, stabilityand prosperity that allows for investment in thehealth sector.A history of poor economic growth is also ahistory of stagnating resources for health. WhatBox 1.2 Higher spending on health is associated with better outcomes, but with largedifferences between countriesIn many countries, the total amount spent on health is insuffi cientto fi nance access for all to even a very limited package of essentialhealth care 39 . This is bound to make a difference to health andsurvival. Figure 1.6 shows that Kenya has a health-adjusted lifeexpectancy (HALE) of 44.4 years, the median for countries thatcurrently spend less than I$ 100 per capita on health. This is 27years less than Germany, the median for countries that spendmore than I$ 2500 per capita. Every I$ 100per capita spent on heath corresponds to a1.1-year gain in HALE.However, this masks large differences inoutcomes at comparable levels of spending.There are up to fi ve years difference in HALEbetween countries that spend more thanI$ 2500 per capita per year on health. Thespread is wider at lower expenditure levels,even within rather narrow spending bands.Inhabitants of Moldova, for example, enjoy 24more HALE years than those of Haiti, yet theyare both among the 28 countries that spend I$250–500 per capita on health. These gaps caneven be wider if one also considers countriesthat are heavily affected by HIV/AIDS. Lesothospends more on health than Jamaica, yet itspeople have a HALE that is 34 years shorter.In contrast, the differences in HALE betweenthe countries with the best outcomes in eachspending band are comparatively small. Tajikistan, for example,has a HALE that is 4.3 years less than that of Sweden – less thanthe difference between Sweden and the United States. These differencessuggest that how, for what and for whom money is spentmatters considerably. Particularly in countries where the envelopefor health is very small, every dollar that is allocated sub-optimallyseems to make a disproportionate difference.Figure 1.6 Countries grouped according to their total health expenditurein 2005 (international $) 38,40HALE (years)80706050403020TajikistanKenyaTHE < I$ 100(30)Sierra LeoneMoldovaPhillippinesHaitiLesothoTHE I$ 100–250(28)PanamaSaint Vincentand theGrenadinesGabonSwazilandTHE I$ 250–500(30)FinlandColombiaIranBotswanaTHE I$ 500–1000(23)Total health expenditure (no. of countries)Japan SwedenUnited Kingdom / GermanyNew Zealand USAHungaryTHE I$ 1000–2500(16)HighestMedianLowestOutliersTHE > I$ 2500(15)6

Chapter 1. The challenges of a changing worldhappened in sub-Saharan Africa during the yearsfollowing Alma-Ata exemplifies this predicament.After adjusting for inflation, GDP per capita insub-Saharan Africa fell in most years from 1980–1994 36 , leaving little room to expand access tohealth care or transform health systems. By theearly 1980s, for example, the medicines budgetin the Democratic Republic of the Congo, thenZaïre, was reduced to zero and government disbursementsto health districts dropped belowUS$ 0.1 per inhabitant; Zambia’s public sectorhealth budget was cut by two thirds; and fundsavailable for operating expenses and salaries forthe expanding government workforce dropped byup to 70% in countries such as Cameroon, Ghana,Sudan and the United Republic of Tanzania 36 . Forhealth authorities in this part of the world, the1980s and 1990s were a time of managing shrinkinggovernment budgets and disinvestment. Forthe people, this period of fiscal contraction wasa time of crippling out-of-pocket payments forunder-funded and inadequate health services.In much of the world, the health sector is oftenmassively under-funded. In 2005, 45 countries spentless than I$ 100 per capita on health, includingexternal assistance 38 . In contrast, 16 high-incomecountries spent more than I$ 3000 per capita. Lowincomecountries generally allocate a smaller proportionof their GDP to health than high-incomecountries, while their GDP is smaller to start withand they have higher disease burdens.Higher health expenditure is associated withbetter health outcomes, but sensitive to policychoices and context (Box 1.2): where money isscarce, the effects of errors, by omission and bycommission, are amplified. Where expenditureincreases rapidly, however, this offers perspectivesfor transforming and adapting health systemswhich are much more limited in a contextof stagnation.Adapting to new health challengesA globalized, urbanized and ageing worldThe world has changed over the last 30 years:few would have imagined that children in Africawould now be at far more risk of dying from trafficaccidents than in either the high- or the lowandmiddle-income countries of the Europeanregion (Figure 1.7).Many of the changes that affect health werealready under way in 1978, but they have acceleratedand will continue to do so.Thirty years ago, some 38% of the world’spopulation lived in cities; in 2008, it is more than50%, 3.3 billion people. By 2030, almost 5 billionpeople will live in urban areas. Most of thegrowth will be in the smaller cities of developingcountries and metropolises of unprecedented sizeand complexity in southern and eastern Asia 42 .Although on average health indicators incities score better than in rural areas, theenormous social and economic stratificationwithin urban areas results in significant healthinequities 43,44,45,46 . In the high-income area of Nairobi,the under-five mortality rate is below 15per thousand, but in the Emabakasi slum of thesame city the rate is 254 per thousand 47 . Theseand other similar examples lead to the moregeneral observation that within developing countries,the best local governance can help produce75 years or more of life expectancy; with poorurban governance, life expectancy can be as lowas 35 years 48 . One third of the urban populationtoday – over one billion people – lives in slums: inplaces that lack durable housing, sufficient livingarea, access to clean water and sanitation, andsecure tenure 49 . Slums are prone to fire, floodsand landslides; their inhabitants are disproportionatelyexposed to pollution, accidents, workplacehazards and urban violence. Loss of socialFigure 1.7 Africa’s children are at more risk of dying from traffic accidents thanEuropean children: child road-traffic deaths per 100 000 population 4150403020100Africa Europe, low- and middle-income countries Europe, high-income countries0–4 5–9 10–14 15–197

The World Health Report 2008Primary Health Care – Now More Than Evercohesion and globalization of unhealthy lifestylescontribute to an environment that is decidedlyunfavourable for health.These cities are where many of the world’snearly 200 million international migrants arefound 50 . They constitute at least 20% of the populationin 41 countries, 31% of which have lessthan a million inhabitants. Excluding migrantsfrom access to care is the equivalent of denyingall the inhabitants of a country similar to Braziltheir rights to health. Some of the countries thathave made very significant strides towards ensuringaccess to care for their citizens fail to offerthe same rights to other residents. As migrationcontinues to gain momentum, the entitlements ofnon-citizen residents and the ability of the healthcaresystem to deal with growing linguistic andcultural diversity in equitable and effective waysare no longer marginal issues.This mobile and urbanized world is ageing fastand will continue to do so. By 2050, the world willcount 2 billion people over the age of 60, around85% of whom will be living in today’s developingcountries, mostly in urban areas. Contrary totoday’s rich countries, low- and middle-incomecountries are ageing fast before having becomerich, adding to the challenge.Urbanization, ageing and globalized lifestylechanges combine to make chronic and noncommunicablediseases – including depression, diabetes,cardiovascular disease and cancers – andinjuries increasingly important causes of morbidityand mortality (Figure 1.8) 51 . There is a strikingshift in distribution of death and disease fromyounger to older ages and from infectious, perinataland maternal causes to noncommunicablediseases. Traffic accident rates will increase;tobacco-related deaths will overtake HIV/AIDSrelateddeaths. Even in Africa, where the populationremains younger, smoking, elevated bloodpressure and cholesterol are among the top 10 riskfactors in terms of overall disease burden 52 . Inthe last few decades, much of the lack of progressand virtually all reversals in life expectancy wereassociated with adult health crises, such as in theRussian Federation or southern Africa. Improvedhealth in the future will increasingly be a questionof better adult health.Ageing has drawn attention to an issue that isof particular relevance to the organization of servicedelivery: the increasing frequency of multimorbidity.In the industrialized world, as manyas 25% of 65–69 year olds and 50% of 80–84 yearolds are affected by two or more chronic healthconditions simultaneously. In socially deprivedpopulations, children and younger adults arealso likely to be affected 53,54,55 . The frequency ofmulti-morbidity in low-income countries is lesswell described except in the context of the HIV/AIDS epidemic, malnutrition or malaria, but it isprobably greatly underestimated 56,57 . As diseasesof poverty are inter-related, sharing causes thatFigure 1.8 The shift towards noncommunicable diseases and accidents as causes of death*Deaths (millions)3530252015Road-traffic accidentsCerebrovascular diseasesIschaemic heart diseasesCancersPerinatal causesAcute respiratory infectionsDiarrhoeal diseasesMalariaHIV/AIDSTuberculosis10502004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2018 2020 2022 2024 2026 2028 2030* Selected causes.8

Chapter 1. The challenges of a changing worldare multiple and act together to produce greaterdisability and ill health, multi-morbidity isprobably more rather than less frequent in poorcountries. Addressing co-morbidity – includingmental health problems, addictions and violence– emphasizes the importance of dealingwith the person as a whole. This is as importantin developing countries as in the industrializedworld 58 .It is insufficiently appreciated that the shift tochronic diseases or adult health has to come ontop of an unfinished agenda related to communicablediseases, and maternal, newborn and childhealth. Efforts directed at the latter, especiallyin the poorest countries where coverage is stillinsufficient, will have to expand 12 . But all healthsystems, including those in the poorest countries,will also have to deal with the expanding need anddemand for care for chronic and noncommunicablediseases: this is not possible without much moreattention being paid to establishing a continuumof comprehensive care than is the case today. Itis equally impossible without much more attentionbeing paid to addressing the pervasive healthinequalities within each country (Box 1.3).Little anticipation and slow reactionsOver the past few decades, health authorities haveshown little evidence of their ability to anticipatesuch changes, prepare for them or even adapt tothem when they have become an everyday reality.This is worrying because the rate of changeis accelerating. Globalization, urbanization andageing will be compounded by the health effects ofother global phenomena, such as climate change,the impact of which is expected to be greatestamong the most vulnerable communities livingin the poorest countries. Precisely how these willaffect health in the coming years is more difficultto predict, but rapid changes in disease burden,growing health inequalities and disruption ofsocial cohesion and health sector resilience areto be expected. The current food crisis has shownhow unprepared health authorities often are forchanges in the broader environment, even afterother sectors have been sounding the alarm bellfor quite some time. All too often, the acceleratedpace and the global scale of the changes in thechallenges to health is in contrast with the sluggishresponse of national health systems.Even for well-known and documented trends,such as those resulting from the demographic andepidemiologic transitions, the level of responseoften remains inadequate 64 . Data from WHO’sWorld Health Surveys, covering 18 low-incomecountries, show low coverage of the treatment ofasthma, arthritis, angina, diabetes and depression,and of the screening for cervical and breastcancer: less than 15% in the lowest income quintileand less than 25% in the highest 65 . Public-healthinterventions to remove the major risk factors ofdisease are often neglected, even when they areparticularly cost effective: they have the potentialto reduce premature deaths by 47% and increaseglobal healthy life expectancy by 9.3 years 64,66 .For example, premature tobacco-attributabledeaths from ischaemic heart disease, cerebrovasculardisease, chronic obstructive pulmonarydisease and other diseases are projected to risefrom 5.4 million in 2004 to 8.3 million in 2030,almost 10% of all deaths worldwide 67 , with morethan 80% in developing countries 12 . Yet, two outof every three countries are still without, or onlyhave minimal, tobacco control policies 12 .With a few exceptions – the SARS epidemic, forexample – the health sector has often been slowin dealing with new or previously underestimatedhealth challenges. For example, awareness of theemerging health threats posed by climate changeand environmental hazards dates back at least tothe 1990 Earth Summit 68 , but only in recent yearshave these begun to be translated into plans andstrategies 69,70 .Health authorities have also often failed toassess, in a timely way, the significance of changesin their political environment that affect the sector’sresponse capacity. Global and national policyenvironments have often taken health issues intoconsideration, initiating hasty and disruptiveinterventions, such as structural adjustment,decentralization, blueprint poverty reductionstrategies, insensitive trade policies, new taxregimes, fiscal policies and the withdrawal ofthe state. Health authorities have a poor trackrecord in influencing such developments, andhave been ineffective in leveraging the economicweight of the health sector. Many of the criticalsystems issues affecting health require skillsand competencies that are not found within themedical/public health establishment. The failure9

The World Health Report 2008Primary Health Care – Now More Than EverBox 1.3 As information improves, the multiple dimensions of growing health inequality arebecoming more apparentIn recent years, the extent of within-country disparities in vulnerability, access to care and health outcomes has been described in muchgreater detail (Figure 1.9) 59 . Better information shows that health inequalities tend to increase, thereby highlighting how inadequateand uneven health systems have been in responding to people’s health needs. Despite the recent emphasis on poverty reduction,health systems continue to have diffi culty in reaching both the rural and the urban poor, let alone addressing the multiple causes andconsequences of health inequity.Figure 1.9 Within-country inequalities in health and health carePer capita household spending on healthas percentage of total household spending,by income group650Mean time (minutes) taken toreach an ambulatory health facility,by income group54321403020100100Côte d’Ivoire1988Ghana1992Women using malaria prophylaxis (%),by income group0Madagascar1993–4Lowest quintile Quintile 2 Quintile 3 Quintile 4Bosnia and Herzegovina2003–4Highest quintile100Comoros2003–4Full basic immunization coverage (%),by income groupEcuador2003–480806060404020200Guinea2005Malawi2004Niger2006Tanzania2004Lowest quintile Quintile 2 Quintile 3 Quintile 4 Highest quintile0Bangladesh2004Colombia2005Indonesia2002–3Mozambique2003100Neonatal mortality rate,by education of mother100Births attended by health professional (%),by education of mother80806060404020200Bolivia2003Sources: (60, 61, 62, 63).Colombia2005Lesotho2003Nepal2006Philippines2003No education Primary education Secondary or higher education0Benin2001Bolivia2003Botswana1998Cambodia2005Peru200010

Chapter 1. The challenges of a changing worldto recognize the need for expertise from beyondtraditional health disciplines has condemned thehealth sector to unusually high levels of systemsincompetence and inefficiency which society canill afford.Trends that undermine the healthsystems’ responseWithout strong policies and leadership, healthsystems do not spontaneously gravitate towardsPHC values or efficiently respond to evolvinghealth challenges. As most health leaders know,health systems are subject to powerful forces andinfluences that often override rational prioritysetting or policy formation, thereby pulling healthsystems away from their intended directions 71 .Characteristic trends that shape conventionalhealth systems today include (Figure 1.10): a disproportionate focus on specialist, tertiarycare, often referred to as “hospital-centrism”; fragmentation, as a result of the multiplicationof programmes and projects; and the pervasive commercialization of health carein unregulated health systems.With their focus on cost containment andderegulation, many of the health-sector reformsof the 1980s and 1990s have reinforced thesetrends. High-income countries have often beenable to regulate to contain some of the adverseconsequences of these trends. However, incountries where under-funding compoundsFigure 1.10 How health systems are diverted from PHC core valuesHealthsystemsCurrent trendsHospital-centrismCommercializationFragmentationHealth equityUniversal access topeople-centred careHealthy communitiesPHC ReformPHC Reformlimited regulatory capacity, they have had moredamaging effects.Hospital-centrism: health systems built aroundhospitals and specialistsFor much of the 20th century, hospitals, withtheir technology and sub-specialists, have gaineda pivotal role in most health systems throughoutthe world 72,73 . Today, the disproportionate focuson hospitals and sub-specialization has becomea major source of inefficiency and inequality, andone that has proved remarkably resilient. Healthauthorities may voice their concern more insistentlythan they used to, but sub-specializationcontinues to prevail 74 . For example, in Membercountries of the Organisation of Economic Cooperationand Development (OECD), the 35%growth in the number of doctors in the last 15years was driven by rising numbers of specialists(up by nearly 50% between 1990 and 2005– compared with only a 20% increase in generalpractitioners) 75 . In Thailand, less than 20% ofdoctors were specialists 30 years ago; by 2003they represented 70% 76 .The forces driving this growth include professionaltraditions and interests as well as theconsiderable economic weight of the health industry– technology and pharmaceuticals (Box 1.4).Obviously, well functioning specialized tertiarycare responds to a real demand (albeit, at least inpart, induced): it is necessary, at the very least,for the political credibility of the health system.However, the experience of industrialized countrieshas shown that a disproportionate focus onspecialist, tertiary care provides poor value formoney 72 . Hospital-centrism carries a considerablecost in terms of unnecessary medicalization andiatrogenesis 77 , and compromises the human andsocial dimensions of health 73,78 . It also carries anopportunity cost: Lebanon, for example, countsmore cardiac surgery units per inhabitant thanGermany, but lacks programmes aimed at reducingthe risk factors for cardiovascular disease 79 .Inefficient ways of dealing with health problemsare thus crowding out more effective, efficient –and more equitable 80 – ways of organizing healthcare and improving health 81 .Since the 1980s, a majority of OECD countrieshas been trying to decrease reliance on hospitals,11

The World Health Report 2008Primary Health Care – Now More Than EverBox 1.4 Medical equipment andpharmaceutical industries are majoreconomic forcesGlobal expenditure on medical equipment and devices hasgrown from US$ 145 billion in 1998 to US$ 220 billion in 2006:the United States accounts for 39% of the total, the EuropeanUnion for 27%, and Japan for 16% 90 . The industry employsmore than 411 400 workers in the United States alone, occupyingnearly one third of all the country’s bioscience jobs 91 . In2006, the United States, the European Union and Japan spentUS$ 287, US$ 250 and US$ 273 per capita, respectively, onmedical equipment. In the rest of the world, the average ofsuch expenditure is in the order of US$ 6 per capita, andin sub-Saharan Africa – a market with much potential forexpansion – it is US$ 2.5 per capita. The annual growth rateof the equipment market is over 10% a year 92 .The pharmaceutical industry weighs even more heavily in theglobal economy, with global pharmaceutical sales expectedto expand to US$ 735–745 billion in 2008, with a growth rateof 6–7% 93 . Here, too, the United States is the world’s largestmarket, accounting for around 48% of the world total: percapita expenditure on drugs was US$ 1141 in 2005, twicethe level of Canada, Germany or the United Kingdom, and 10times that of Mexico 94 .Specialized and hospital care is vital to these industries, whichdepend on pre-payment and risk pooling for sustainable fundingof their expansion. While this market grows everywhere,there are large differences from country to country. Forexample, Japan and the United States have 5–8 times moremagnetic resonance imaging (MRI) units per million inhabitantsthan Canada and the Netherlands. For computerizedtomography (CT) scanners, the differences are even morepronounced: Japan had 92.6 per million in 2002, the Netherlands5.8 in 2005 95 . These differences show that the marketcan be infl uenced, principally by using appropriate paymentand reimbursement incentives and by careful considerationof the organization of regulatory control 96 .specialists and technologies, and keep costsunder control. They have done this by introducingsupply-side measures including reduction ofhospital beds, substitution of hospitalization byhome care, rationing of medical equipment, anda multitude of financial incentives and disincentivesto promote micro-level efficiency. The resultsof these efforts have been mixed, but the evolvingtechnology is accelerating the shift from specializedhospital to primary care. In many highincomecountries (but not all), the PHC effortsof the 1980s and 1990s have been able to reacha better balance between specialized curativecare, first contact care and health promotion 81 .Over the last 30 years, this has contributed tosignificant improvements in health outcomes 81,82 .More recently, middle-income countries, such asChile with its Atención Primaria de Salud (PrimaryHealth Care) 83 , Brazil with its family healthinitiative and Thailand under its universal coveragescheme 84 have shifted the balance betweenspecialized hospital and primary care in thesame way 85 . The initial results are encouraging:improvement of outcome indicators 86 combinedwith a marked improvement in patient satisfaction87 . In each of these cases, the shift took placeas part of a move towards universal coverage,with expanded citizen’s rights to access and socialprotection. These processes are very similar towhat occurred in Malaysia and Portugal: rightto access, social protection, and a better balancebetween reliance on hospitals and on generalistprimary care, including prevention and healthpromotion 6 .Industrialized countries are, 50 years later,trying to reduce their reliance on hospitals,having realized the opportunity cost of hospitalcentrismin terms of effectiveness and equity.Yet, many low- and middle-income countriesare creating the same distortions. The pressurefrom consumer demand, the medical professionsand the medico-industrial complex 88 is such thatprivate and public health resources flow disproportionatelytowards specialized hospital careat the expense of investment in primary care.National health authorities have often lacked thefinancial and political clout to curb this trend andachieve a better balance. Donors have also usedtheir influence more towards setting up diseasecontrol programmes than towards reforms thatwould make primary care the hub of the healthsystem 89 .Fragmentation: health systems built aroundpriority programmesWhile urban health by and large revolves aroundhospitals, the rural poor are increasingly confrontedwith the progressive fragmentation oftheir health services, as “selective” or “vertical”approaches focus on individual disease controlprogrammes and projects. Originally considered12

Chapter 1. The challenges of a changing worldas an interim strategy to achieve equitable healthoutcomes, they sprang from a concern for theslow expansion of access to health care in a contextof persistent severe excess mortality andmorbidity for which cost-effective interventionsexist 97 . A focus on programmes and projects isparticularly attractive to an international communityconcerned with getting a visible returnon investment. It is well adapted to commandand-controlmanagement: a way of working thatalso appeals to traditional ministries of health.With little tradition of collaboration with otherstakeholders and participation of the public, andwith poor capacity for regulation, programmaticapproaches have been a natural channel for developinggovernmental action in severely resourceconstrainedand donor-dependent countries. Theyhave had the merit of focusing on health care inseverely resource-constrained circumstances,with welcome attention to reaching the poorestand those most deprived of services.Many have hoped that single-disease controlinitiatives would maximize return on investmentand somehow strengthen health systemsas interventions were delivered to large numbersof people, or would be the entry point to startbuilding health systems where none existed.Often the opposite has proved true. The limitedsustainability of a narrow focus on disease control,and the distortions it causes in weak andunder-funded health systems have been criticizedextensively in recent years 98 . Short-termadvances have been short-lived and have fragmentedhealth services to a degree that is now ofmajor concern to health authorities. With parallelchains of command and funding mechanisms,duplicated supervision and training schemes,and multiplied transaction costs, they have led tosituations where programmes compete for scarceresources, staff and donor attention, while thestructural problems of health systems – funding,payment and human resources − are hardlyaddressed. The discrepancy in salaries betweenregular public sector jobs and better-fundedprogrammes and projects has exacerbated thehuman resource crisis in fragile health systems.In Ethiopia, contract staff hired to help implementprogrammes were paid three times morethan regular government employees 99 , while inMalawi, a hospital saw 88 nurses leave for betterpaid nongovernmental organization (NGO) programmesin an 18-month period 100 .Eventually, service delivery ends up dealingonly with the diseases for which a (funded) programmeexists – overlooking people who have themisfortune not to fit in with current programmepriorities. It is difficult to maintain the people’strust if they are considered as mere programmetargets: services then lack social sustainability.This is not just a problem for the population. Itputs health workers in the unenviable position ofhaving to turn down people with “the wrong kindof problem” – something that fits ill with the selfimageof professionalism and caring many cherish.Health authorities may at first be seduced bythe straightforwardness of programme fundingand management, yet once programmes multiplyand fragmentation becomes unmanageable andunsustainable, the merits of more integratedapproaches are much more evident. The re-integrationof programmes once they have been wellestablished is no easy task.Health systems left to drift towardsunregulated commercializationIn many, if not most low- and middle-incomecountries, under-resourcing and fragmentationof health services has accelerated the developmentof commercialized health care, defined hereas the unregulated fee-for-service sale of healthcare, regardless of whether or not it is suppliedby public, private or NGO providers.Commercialization of health care has reachedpreviously unheard of proportions in countriesthat, by choice or due to a lack of capacity, fail toregulate the health sector. Originally limited toan urban phenomenon, small-scale unregulatedfee-for-service health care offered by a multitude ofdifferent independent providers now dominates thehealth-care landscape from sub-Saharan Africa tothe transitional economies in Asia or Europe.Commercialization often cuts across thepublic-private divide 101 . Health-care delivery inmany governmental and even in traditionallynot-for-profit NGO facilities has been de factocommercialized, as informal payment systemsand cost-recovery systems have shifted the costof services to users in an attempt to compensate13

The World Health Report 2008Primary Health Care – Now More Than Everfor the chronic under-funding of the publichealth sector and the fiscal stringency of structuraladjustment 102,103 . In these same countries,moonlighting civil servants make up a considerablepart of the unregulated commercial sector104 , while others resort to under-the-counterpayments 105,106,107 . The public-private debate of thelast decades has, thus, largely missed the point:for the people, the real issue is not whether theirhealth-care provider is a public employee or aprivate entrepreneur, nor whether health facilitiesare publicly or privately owned. Rather, it iswhether or not health services are reduced to acommodity that can be bought and sold on a feefor-servicebasis without regulation or consumerprotection 108 .Commercialization has consequences for qualityas well as for access to care. The reasons arestraightforward: the provider has the knowledge;the patient has little or none. The provider hasan interest in selling what is most profitable,but not necessarily what is best for the patient.Without effective systems of checks and balances,the results can be read in consumer organizationreports or newspaper articles that expressoutrage at the breach of the implicit contract oftrust between caregiver and client 109 . Those whocannot afford care are excluded; those who canmay not get the care they need, often get care theydo not need, and invariably pay too much.Unregulated commercialized health systemsare highly inefficient and costly 110 : they exacerbateinequality 111 , and they provide poor qualityand, at times, dangerous care that is bad forhealth (in the Democratic Republic of the Congo,for example, “la chirurgie safari” (safari surgery)refers to a common practice of health workersmoonlighting by performing appendectomiesor other surgical interventions at the patients’homes, often for crippling fees).Thus, commercialization of health care is animportant contributor to the erosion of trustin health services and in the ability of healthauthorities to protect the public 111 . This is whatmakes it a matter of concern for politicians and,much more than was the case 30 years ago, oneof the main reasons for increasing support forreforms that would bring health systems morein line not only with current health challenges,but also with people’s expectations.Changing valuesand rising expectationsThe reason why health systems are organizedaround hospitals or are commercialized is largelybecause they are supply-driven and also correspondto demand: genuine as well as supplyinduced.Health systems are also a reflectionof a globalizing consumer culture. Yet, at thesame time, there are indications that people areaware that such health systems do not providean adequate response to need and demand, andthat they are driven by interests and goals thatare disconnected from people’s expectations. Associeties modernize and become more affluentand knowledgeable, what people consider to bedesirable ways of living as individuals and asmembers of societies, i.e. what people value,changes 112 . People tend to regard health servicesmore as a commodity today, but they also haveother, rising expectations regarding health andhealth care. People care more about health asan integral part of how they and their familiesgo about their everyday lives than is commonlythought (Box 1.5) 113 . They expect their familiesand communities to be protected from risks anddangers to health. They want health care thatdeals with people as individuals with rights andnot as mere targets for programmes or beneficiariesof charity. They are willing to respect healthprofessionals but want to be respected in turn,in a climate of mutual trust 114 .People also have expectations about the waytheir society deals with health and health care.They aspire to greater health equity and solidarityand are increasingly intolerant of social exclusion– even if individually they may be reluctant toact on these values 115 . They expect health authorities– whether in government or other bodies –to do more to protect their right to health. Thesocial values surveys that have been conductedsince the 1980s show increasing convergencein this regard between the values of developingcountries and of more affluent societies, whereprotection of health and access to care is oftentaken for granted 112,115,116 . Increasing prosperity,access to knowledge and social connectivity areassociated with rising expectations. People wantto have more say about what happens in theirworkplace, in the communities in which they liveand also in important government decisions that14

Chapter 1. The challenges of a changing worldBox 1.5 Health is among the toppersonal concernsWhen people are asked to name the most important problemsthat they and their families are currently facing, fi nancial worriesoften come out on top, with health a close second 118 . Inone country out of two, personal illness, health-care costs,poor quality care or other health issues are the top personalconcerns of over one third of the population surveyed(Figure 1.11). It is, therefore, not surprising that a breakdownof the health-care system – or even the hint of a breakdown– can lead to popular discontent that threatens the ambitionsof the politicians seen to be responsible 119 .Figure 1.11 Percentage of the population citing health as their main concernbefore other issues, such as financial problems, housing or crime 118PolandUkraineRussian FederationBulgariaGermanyItalySwedenIsraelTurkeySpainCzech RepublicFranceSlovakiaUnited KingdomMexicoChileCanadaPeruArgentinaBrazilUnited StatesVenezuelaBoliviaRepublic of KoreaChinaJapanMalaysiaBangladeshIndiaIndonesiaMoroccoPakistanEgyptLebanonKuwaitJordanOccupied Palestinian TerritoryUgandaMaliUnited Republic of TanzaniaCôte d’IvoireSenegalNigeriaGhanaSouth AfricaKenyaEthiopia0 10 20 30 40 50 60 70affect their lives 117 . The desire for better care andprotection of health, for less health inequity andfor participation in decisions that affect healthis more widespread and more intense now thanit was 30 years ago. Therefore, much more isexpected of health authorities today.Health equityEquity, whether in health, wealth or power israrely, if ever, fully achieved. Some societies aremore egalitarian than others, but on the wholethe world is “unequal”. Value surveys, however,clearly demonstrate that people care about theseinequalities – considering a substantial proportionto be unfair “inequities” that can and shouldbe avoided. Data going back to the early 1980sshow that people increasingly disagree with theway in which income is distributed and believethat a “just society” should work to correctthese imbalances 120,121,122,123 . This gives policymakersless leeway to ignore the social dimensionsof their policies than they might have hadpreviously 120,124 .People are often unaware of the full scope ofhealth inequalities. Most Swedish citizens, forexample, were probably unaware that the differencein life expectancy between 20-year-oldmen from the highest and lowest socioeconomicgroups was 3.97 years in 1997: a gap that hadwidened by 88% compared to 1980 125 . However,while people’s knowledge on these topics may bepartial, research shows that people regard socialgradients in health as profoundly unjust 126 . Intoleranceto inequality in health and to the exclusionof population groups from health benefits andsocial protection mirrors or exceeds intoleranceto inequality in income. In most societies, there iswide consensus that everybody should be able totake care of their health and to receive treatmentwhen ill or injured – without being bankruptedand pushed into poverty 127 .As societies become wealthier, popular supportfor equitable access to health care and socialprotection to meet basic health and social needsgains stronger ground. Social surveys show that,in the European region, 93% of the populationssupport comprehensive health coverage 117 . In theUnited States, long reputed for its reluctance toadopt a national health insurance system, morethan 80% of the population is in favour of it 115 ,while basic care for all continues to be a widelydistributed, intensely held, social goal 128 . Theattitudes in lower income countries are less wellknown, but extrapolating from their views onincome inequality, it is reasonable to assumethat increasing prosperity is coupled with risingconcern for health equity – even if consensusabout how this should be achieved may be ascontentious as in richer countries.15

The World Health Report 2008Primary Health Care – Now More Than EverCare that puts people firstPeople obviously want effective health carewhen they are sick or injured. They want it tocome from providers with the integrity to actin their best interests, equi tably and honestly,with knowledge and compe tence. The demandfor competence is not trivial: it fuels the healtheconomy with steadily increased demand forprofessional care (doctors, nurses and othernon-physician clinicians who play an increasingrole in both industrialized and developingcountries) 129 . For example, throughout the world,women are switching from the use of traditionalbirth attendants to midwives, doctors and obstetricians(Figure 1.12) 130 .The PHC movement has underestimated thespeed with which the transition in demand fromtraditional caregivers to professional care wouldbypass initial attempts to rapidly expand accessto health care by relying on non-professional“community health workers”, with their addedvalue of cultural competence. Where strategiesfor extending PHC coverage proposed lay workersas an alternative rather than as a complement toprofessionals, the care provided has often beenperceived to be poor 131 . This has pushed peopletowards commercial care, which they, rightly orwrongly, perceived to be more competent, whileattention was diverted from the challenge of moreeffectively incorporating professionals under theumbrella of PHC.Proponents of PHC were right about the importanceof cultural and relational competence,which was to be the key comparative advantage ofcommunity health workers. Citizens in the developingworld, like those in rich countries, are notlooking for technical competence alone: they alsowant health-care providers to be understanding,respectful and trustworthy 132 . They want healthcare to be organized around their needs, respectfulof their beliefs and sensitive to their particularsituation in life. They do not want to be takenadvantage of by unscrupulous providers, nor dothey want to be considered mere targets for diseasecontrol programmes (they may never haveliked that, but they are now certainly becomingmore vocal about it). In poor and rich countries,people want more from health care than interventions.Increasingly, there is recognition that theresolution of health problems should take intoaccount the socio-cultural context of the familiesand communities where they occur 133 .Much public and private health care today isorganized around what providers consider to beeffective and convenient, often with little attentionto or understanding of what is importantfor their clients 134 . Things do not have to be thatway. As experience – particularly from industrializedcountries – has shown, health servicescan be made more people-centred. This makesthem more effective and also provides a morerewarding working environment 135 . Regrettably,developing countries have often put less emphasison making services more people-centred, as ifthis were less relevant in resource-constrainedcircumstances. However, neglecting people’sneeds and expectations is a recipe for disconnectinghealth services from the communities theyserve. People-centredness is not a luxury, it is anecessity, also for services catering to the poor.Only people-centred services will minimize socialexclusion and avoid leaving people at the mercy ofunregulated commercialized health care, wherethe illusion of a more responsive environmentcarries a hefty price in terms of financial expenseand iatrogenesis.Securing the health of communitiesPeople do not think about health only in terms ofsickness or injury, but also in terms of what theyperceive as endangering their health and that oftheir community 118 . Whereas cultural and politicalexplanations for health hazards vary widely,there is a general and growing tendency to holdthe authorities responsible for offering protectionagainst, or rapidly responding to such dangers 136 .This is an essential part of the social contractthat gives legitimacy to the state. Politicians inrich as well as poor countries increasingly ignoretheir duty to protect people from health hazardsat their peril: witness the political fall-out of thepoor management of the hurricane Katrina disasterin the United States in 2005, or of the 2008garbage disposal crisis in Naples, Italy.Access to information about health hazards inour globalizing world is increasing. Knowledgeis spreading beyond the community of healthprofessionals and scientific experts. Concernsabout health hazards are no longer limited tothe traditional public health agenda of improving16

Chapter 1. The challenges of a changing worldFigure 1.12 The professionalization of birthing care: percentage of births assistedby professional and other carers in selected areas, 2000 and 2005with projections to 2015 aPercentage of births10080Lay personTraditional birthattendantOther healthprofessionalDoctor60402002000 2005 2015Sub-SaharanAfrica2000 2005 2015South and South-EastAsia2000 2005 2015Middle East, North Africaand Central Asia2000 2005 2015Latin America andthe Caribbeana Source: Pooled data from 88 DHS surveys 1995–2006, linear projection to 2015.the quality of drinking water and sanitation toprevent and control infectious diseases. In thewake of the 1986 Ottawa Charter for HealthPromotion 137 , a much wider array of issues constitutethe health promotion agenda, includingfood safety and environmental hazards as well ascollective lifestyles, and the social environmentthat affects health and quality of life 138 . In recentyears, it has been complemented by growing concernsfor a health hazard that used to enjoy littlevisibility, but is increasingly the object of mediacoverage: the risks to the safety of patients 139 .Reliable, responsive health authoritiesDuring the 20th century, health has progressivelybeen incorporated as a public good guaranteedby government entitlement. There may be disagreementas to how broadly to define the welfarestate and the collective goods that go with it 140,141 ,but, in modernizing states, the social and politicalresponsibility entrusted to health authorities– not just ministries of health, but also localgovernmental structures, professional organizationsand civil society organizations with a quasigovernmentalrole – is expanding.Circumstances or short-term political expediencymay at times tempt governments to withdrawfrom their social responsibilities for financingand regulating the health sector, or from servicedelivery and essential public health functions.Predictably, this creates more problems than itsolves. Whether by choice or because of externalpressure, the withdrawal of the state thatoccurred in the 1980s and 1990s in China and theformer Soviet Union, as well as in a considerablenumber of low-income countries, has had visibleand worrisome consequences for health and forthe functioning of health services. Significantly,it has created social tensions that affected thelegitimacy of political leadership 119 .In many parts of the world, there is considerableskepticism about the way and the extent towhich health authorities assume their responsibilitiesfor health. Surveys show a trend ofdiminishing trust in public institutions as guarantorsof the equity, honesty and integrity of thehealth sector 123,142,143 . Nevertheless, on the whole,people expect their health authorities to workfor the common good, to do this well and withforesight 144 . There is a multiplication of scoring17

The World Health Report 2008Primary Health Care – Now More Than Evercards, rankings and other league tables of publicaction used either at the national or global level 141 ,while consumer organizations are addressinghealth sector problems 111 , and national andglobal civil society watchdog organizations areemerging 146,147,148,149 . These recent trends attest toprevailing doubts about how well health authoritiesare able to provide stewardship for the healthsystem, as well as to the rising expectations forthem to do even better.ParticipationAt the same time, however, surveys show that, associeties modernize, people increasingly want to“have a say” in “important decisions that affecttheir lives” 123,112 , which would include issues suchas resource allocation and the organization andregulation of care. Experience from countries asdiverse as Chile, Sweden and Thailand shows,however, that people are more concerned withhaving guarantees for fair and transparent processesthan with the actual technicalities of prioritysetting 150,151 . In other words, an optimumresponse to aspirations for a bigger say in healthpolicy matters would be evidence of a structuredand functional system of checks and balances.This would include relevant stakeholders andwould guarantee that the policy agenda couldnot be hijacked by particular interest groups 152 .PHC reforms:driven by demandThe core values articulated by the PHC movementthree decades ago are, thus, more powerfullypresent in many settings now than at the timeof Alma-Ata. They are not just there in the formof moral convictions espoused by an intellectualvanguard. Increasingly, they exist as concretesocial expectations felt and asserted by broadgroups of ordinary citizens within modernizingsocieties. Thirty years ago, the values of equity,people-centredness, community participation andself-determination embraced by the PHC movementwere considered radical by many. Today,these values have become widely shared socialexpectations for health that increasingly pervademany of the world’s societies – though the languagepeople use to express these expectationsmay differ from that of Alma-Ata.This evolution from formal ethical principlesto generalized social expectations fundamentallyalters the political dynamics around health systemschange. It opens fresh opportunities for generatingsocial and political momentum to movehealth systems in the directions people want themto go, and that are summarized in Figure 1.13.It moves the debate from a purely technical discussionon the relative efficiency of various waysof “treating” health problems to include politicalconsiderations on the social goals that definethe direction in which to steer health systems.The subsequent chapters outline a set of reformsaimed at aligning specialist-based, fragmentedand commercialized health systems with theserising social expectations. These PHC reformsaim to channel society’s resources towards moreequity and an end to exclusion; towards healthservices that revolve around people’s needs andexpectations; and towards public policies thatsecure the health of communities. Across thesereforms is the imperative of engaging citizens andother stakeholders: recognizing that vested intereststhat tend to pull health systems in differentdirections raises the premium on leadership andvision and on sustained learning to do better.Figure 1.13 The social values that drive PHCand the corresponding sets of reformsHealth equitySolidaritySocial inclusionUniversal coverage reformsChapter 2Health authorities thatcan be relied onLeadership reformsChapter 5People-centred careService delivery reformsChapter 3Communities wherehealth is promotedand protectedPublic policy reformsChapter 418

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Advancing and sustaininguniversal coveragePeople expect their health systems to beequitable. The roots of health inequitieslie in social conditions outside the health system’sdirect control. These root causes have to be tackledthrough intersectoral and cross-government action.At the same time, the health sector can takesignificant actions to advancehealth equity internally. The basisfor this is the set of reforms thataim at moving towards universalcoverage, i.e. towards universalaccess to health services withsocial health protection.Chapter 2The central place ofhealth equity in PHC24Moving towardsuniversal coverage25Challenges in movingtowards universal coverage27Targeted interventionsto complement universalcoverage mechanisms32Mobilizing for health equity 3423

Chapter 2. Advancing and sustaining universal coverageadequate pay, using labour intensive growthstrategies, promoting equal opportunities forwomen and making free education available,etc.;reduction of vulnerabilities, e.g. by providingsocial security for the unemployed or disabled,developing social networks at community level,introducing social inclusion policies and policiesthat protect mothers while working orstudying, offering cash benefits or transfers,providing free healthy lunches at school,etc.;protection, particularly of the disadvantaged,against exposure to health hazards, e.g. byintroducing safety regulations for the physicaland social environment, providing safe waterand sanitation, promoting healthy lifestyles,establishing healthy housing policies, etc.);mitigation of the consequences of unequalhealth outcomes that contribute to furthersocial stratification, e.g. by protecting the sickfrom unfair dismissal from their jobs.The need for such multiple strategies coulddiscourage some health leaders who might feelthat health inequality is a societal problem overwhich they have little influence. Yet, they dohave a responsibility to address health inequality.The policy choices they make for the healthsector define the extent to which health systemsexacerbate or mitigate health inequalities andtheir capacity to mobilize around the equityagenda within government and civil society.These choices also play a key part in society’sresponse to citizens’ aspirations for more equityand solidarity. The question, therefore, is notif, but how health leaders can more effectivelypursue strategies that will build greater equityin the provision of health services.Moving towards universal coverageThe fundamental step a country can take to promotehealth equity is to move towards universalcoverage: universal access to the full range ofpersonal and non-personal health services theyneed, with social health protection. Whether thearrangements for universal coverage are taxbasedor are organized through social healthinsurance, or a mix of both, the principles arethe same: pooling pre-paid contributions collectedon the basis of ability to pay, and usingthese funds to ensure that services are available,accessible and produce quality care for those whoneed them, without exposing them to the risk ofcatastrophic expenditures 14,15,16 . Universal coverageis not, by itself, sufficient to ensure healthfor all and health equity – inequalities persist incountries with universal or near-universal coverage– but it provides the necessary foundation 9 .While universal coverage is fundamental tobuilding health equity, it has rarely been the objectof an easy social consensus. Indeed, in countrieswhere universal coverage has been achieved orembraced as a political goal, the idea has oftenmet with strong initial resistance, for example,from associations of medical professionals concernedabout the impact of government-managedhealth insurance schemes on their incomes andworking conditions, or from financial expertsdetermined to rein in public spending. As withother entitlements that are now taken for grantedin almost all high-income countries, universalhealth coverage has generally been struggled forand won by social movements, not spontaneouslybestowed by political leaders. There is now widespreadconsensus that providing such coverage issimply part of the package of core obligations thatany legitimate government must fulfil vis-à-vis itscitizens. In itself, this is a political achievementthat shapes the modernization of society.Industrialized countries, particularly inEurope, began to put social health protectionschemes in place in the late 19th century, movingtowards universalism in the second half ofthe 20th century. The opportunity now exists forlow- and middle-income countries to implementcomparable approaches. Costa Rica, Mexico,the Rebublic of Korea, Thailand and Turkey areamong the countries that have already introducedambitious universal coverage schemes, movingsignificantly faster than industrialized countriesdid in the past. Other countries are weighing similaroptions 14 . The technical challenge of movingtowards universal coverage is to expand coveragein three ways (Figure 2.2).The breadth of coverage – the proportion ofthe population that enjoys social health protection– must expand progressively to encompass25

The World Health Report 2008Primary Health Care – Now More Than EverFigure 2.2 Three ways of moving towards universal coverage 17Extend touninsuredBreadth: who is insured?Total health expenditureReducecost sharingPublic expenditureon healthIncludeotherservicesDepth:which benefitsare covered?Height:whatproportionof the costsis covered?the uninsured, i.e. the population groups thatlack access to services and/or social protectionagainst the financial consequences of taking uphealth care. Expanding the breadth of coverageis a complex process of progressive expansionand merging of coverage models (Box 2.1). Duringthis process, care must be taken to ensuresafety nets for the poorest and most vulnerableuntil they also are covered. It may take years tocover the entire population but, as recent experiencefrom a number of middle-income countriesshows, it is possible to move much faster thanwas the case for industrialized countries duringthe 20th century.Meanwhile, the depth of coverage must alsogrow, expanding the range of essential servicesthat are necessary to address people’s healthneeds effectively, taking into account demand andexpectations, and the resources society is willingand able to allocate to health. The determinationof the corresponding “essential package” of benefitscan play a key role here, provided the processis conducted appropriately (Box 2.2).The third dimension, the height of coverage,i.e. the portion of health-care costs coveredthrough pooling and pre-payment mechanismsmust also rise, diminishing reliance on out-ofpocketco-payments at the point of service delivery.In the 1980s and 1990s, many countriesintroduced user fees in an effort to infuse newresources into struggling services, often in acontext of disengagement of the state and dwindlingpublic resources for health. Most undertookthese measures without anticipating the extentof the damage they would do. In many settings,dramatic declines in service use ensued, particularlyamong vulnerable groups 20 , while thefrequency of catastrophic expenditure increased.Some countries have since reconsidered theirposition and have started phasing out user feesand replacing the lost income from pooled funds(government subsidies or contracts, insuranceBox 2.1 Best practices in moving towards universal coverageEmphasize pre-payment from the start. It may take many years before access to health services and fi nancial protection against thecosts involved in their use are available for all: it took Japan and the United Kingdom 36 years 14 . The road may seem discouragingly long,particularly for the poorest countries, where health-care networks are sparsely developed, fi nancial protection schemes embryonic andthe health sector highly dependent on external funds. Particularly in these countries, however, it is crucial to move towards pre-paymentsystems from a very early stage and to resist the temptation to rely on user fees. Setting up and maintaining appropriate mechanismsfor pre-payment builds the institutional capacity to manage the fi nancing of the system along with the extension of service supply thatis usually lacking in such contexts.Coordinate funding sources. In order to organize universal coverage, it is necessary to consider all sources of funding in a country:public, private, external and domestic. In low-income countries, it is particularly important that international funding be channelledthrough nascent pre-payment and pooling schemes and institutions rather than through project or programme funding. Routing funds inthis way has two purposes. It makes external funding more stable and predictable and helps build the institutional capacity to developand extend supply, access and fi nancial protection in a balanced way.Combine schemes to build towards full coverage. Many countries with limited resources and administrative capacity have experimentedwith a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes, as away to foster pre-payment and pooling in preparation for the move towards more comprehensive national systems 18 . Such schemes areno substitute for universal coverage although they can become building blocks of the universal system 18 . Realizing universal coveragemeans coordinating or combining these schemes progressively into a coherent whole that ensures coverage to all population groups 15and builds bridges with broader social protection programmes 19 .26

Chapter 2. Advancing and sustaining universal coverageBox 2.2 Defi ning “essential packages”:what needs to be done to go beyond a paper exercise?In recent years, many low- and midde-income countries (55 out of a sample of 69 reviewed in 2007) have gone through exercises todefi ne the package of benefi ts they feel should be available to all their citizens. This has been one of the key strategies in improving theeffectiveness of health systems and the equitable distribution of resources. It is supposed to make priority setting, rationing of care,and trade-offs between breadth and depth of coverage explicit.On the whole, attempts to rationalize service delivery by defi ning packages have not been particularly successful 24 . In most cases, theirscope has been limited to maternal and child health care, and to health problems considered as global health priorities. The lack ofattention, for example, to chronic and noncommunicable diseases confi rms the under-valuation of the demographic and epidemiologicaltransitions and the lack of consideration for perceived needs and demand. The packages rarely give guidance on the division of tasksand responsibilities, or on the defi ning features of primary care, such as comprehensiveness, continuity or person-centredness.A more sophisticated approach is required to make the defi nition of benefi t packages more relevant. The way Chile has provided adetailed specifi cation of the health rights of its citizens 25 suggests a number of principles of good practice. The exercise should not be limited to a set of predefi ned priorities: it should look at demand as well as at the full range of healthneeds. It should specify what should be provided at primary and secondary levels. The implementation of the package should be costed so that political decision-makers are aware of what will not be included ifhealth care remains under-funded. There have to be institutionalized mechanisms for evidence-based review of the package of benefi ts. People need to be informed about the benefi ts they can claim, with mechanisms of mediation when claims are being denied. Chilewent to great lengths to ensure that the package of benefi ts corresponds to people’s expectations, with studies, surveys and systemsto capture the complaints and misgivings of users 26 .or pre-payment schemes) 21 . This has resultedin substantial increases in the use of services,especially by the poor 20 . In Uganda, for example,service use increased suddenly and dramaticallyand the increase was sustained after the eliminationof user fees (Figure 2.3) 22,23 .Pre-payment and pooling institutionalizessolidarity between the rich and the less well-off,and between the healthy and the sick. It lifts barriersto the uptake of services and reduces theFigure 2.3 Impact of abolishing user fees on outpatient attendance inKisoro district, Uganda: outpatient attendance 1998–2002 23Outpatients per month30 00020 00010 00001998User fees abolished1999 2000 2001 2002risk that people will incur catastrophic expenseswhen they are sick. Finally, it provides the meansto re-invest in the availability, range and qualityof services.Challenges in movingtowards universal coverageAll universal coverage reforms have to find compromisesbetween the speed with which theyincrease coverage and the breadth, depth andheight of coverage. However, the way countriesdevise their strategies and focus their reformsvery much depends on their specific nationalcontexts.In some countries, a very large part of the populationlives in extremely deprived areas, withan absent or dysfunctional health-care infrastructure.These are countries of mass exclusiontypically brought to mind when one talksabout “scaling up”: the poor and remote ruralareas where health-care networks have not beendeployed yet or where, after years of neglect, thehealth infrastructure continues to exist in nameonly. Such patterns occur in low-income countries27

The World Health Report 2008Primary Health Care – Now More Than Eversuch as Bangladesh, Chad and Niger (Figure 2.4),and are common in conflict and post-conflictareas where health workers have departed andthe health infrastructure has been destroyed andneeds to be rebuilt from scratch.In other parts of the world, the challenge isin providing health support to widely dispersedpopulations, for example, in small island states,remote desert or mountainous regions, andamong nomadic and some indigenous populations.Ensuring access to quality care in thesesettings entails grappling with the diseconomiesof scale connected with small, scattered populations;logistical constraints on referral; difficultieslinked to limited infrastructure and communicationscapacities; and, in some cases, more specifictechnical complications, such as maintainingpatient records for nomadic groups.A different challenge is extending coverage insettings where inequalities do not result from thelack of available health infrastructure, but fromthe way health care is organized, regulated and,above all, paid for by official or under-the-counteruser charges. These are situations where underutilizationof available services is concentratedamong the poor, whereas users are exposed tothe risks of catastrophic expenditure. Such patternsof exclusion occur in countries such asColombia, Nicaragua and Turkey (Figure 2.4). Itis particularly striking in the many urban areasof low- and middle-income countries where aFigure 2.4 Different patterns of exclusion: massive deprivation in somecountries, marginalization of the poor in others. Births attended by medicallytrained personnel (percentage), by income group 27100Nigaragua (2001)806040200Colombia (2005)Turkey (1998)Quintille 1(lowest)Niger (1998)Chad (2004)Bangladesh (2004)Quintille 2 Quintille 3 Quintille 4 Quintille 5(highest)plethora of assorted, unregulated, commercialhealth-care providers charge users prohibitivefees while providing inadequate services.Ways of tackling the situations described inthis section are elaborated below.Rolling out primary-care networks tofill the availability gapIn areas where no health services are availablefor large population groups, or where such servicesare grossly inadequate or fragmented, thebasic health-care infrastructure needs to be builtor rebuilt, often from the ground up. These areasare always severely resource-constrained andfrequently affected by conflicts or complex emergencies,while the scale of under-servicing, alsoin other sectors, engenders logistical difficultiesand problems in deploying health professionals.Health planners in these settings face a fundamentalstrategic dilemma: whether to prioritize amassive scale-up of a limited set of interventionsto the entire population or a progressive roll-outof more comprehensive primary-care systems ona district-by-district basis.Some would advocate, in the name of speedand equity, an approach in which a restrictednumber of priority programmes is rolled outsimultaneously to all the inhabitants in thedeprived areas. This allows for task shifting tolow-skilled personnel, lay workers and volunteersand, consequently, rapid extension of coverage.It is still central to what the global communityoften prescribes for the rural areas of the poorestcountries 28 , and quite a number of countrieshave chosen this option over the last 30 years.Ethiopia, for example, is currently deploying30 000 health extension workers to provide massivenumbers of people with a limited packageof priority preventive interventions. The poorskills base is often well recognized as a limitingfactor 29 , but Ethiopia’s extension workers areno longer as low skilled as they once were, andcurrently benefit from a year of post-Grade 10training. Nevertheless, skill limitations reinforcethe focus on a limited number of effective butsimple interventions.Scaling up a limited number of interventionshas the advantage of rapidly covering the entirepopulation and focusing resources on what isknown to be cost effective. The downside is that28

Chapter 2. Advancing and sustaining universal coveragewhen people experience health problems, theywant them to be dealt with, whether or not theyfit nicely within the programmatic priorities thatare being proposed. Ignoring this dimension ofdemand too much opens the door to “drug peddlers”,“injectors” and other types of providers,who can capitalize on commercial opportunitiesarising from unmet health needs. They offerpatients an appealing alternative, but one that isoften exploitative and harmful. Compared witha situation of utter lack of health action, thereis an indisputable benefit in scaling up even avery limited package of interventions and thepossibility of relying on low-skilled staff makesit an attractive option. However, upgrading oftenproves more difficult than initially envisaged 30and, in the meantime, valuable time, resourcesand credibility are lost which might have allowedfor investment in a more ambitious, but alsomore sustainable and effective primary-careinfrastructure.The alternative is a progressive roll-out ofprimary care, district-by-district, of a networkof health centres with the necessary hospitalsupport. Such a response obviously includes thepriority interventions, but integrated in a comprehensiveprimary-care package. The extensionplatform is the primary-care centre: a professionalizedinfrastructure where the interface with thecommunity is organized, with a problem solvingcapacity and modular expansion of the range ofactivities. The Islamic Republic of Iran’s progressiveroll-out of rural coverage is an impressiveexample of this model. As one of the fathers ofthe country’s PHC strategy put it: “Since it wasimpossible to launch the project in all provincesat the same time, we decided to focus on a singleprovince each year” (Box 2.3).The limiting factors for a progressive roll-outof primary-care networks are the lack of a stablecadre of mid-level staff with the leadershipqualities to organize health districts and with theability to maintain, over the years, the constanteffort required to build sustainable results for theentire population. Where the roll-out has beenconducted as an administrative exercise, it hasled to disappointment: many health districts existin name only. But where impatience and pressurefor short-term visibility has been managedBox 2.3 Closing the urban-rural gap throughprogressive expansion of PHC coverage in ruralareas in the Islamic Republic of Iran 31In the 1970s, the Iranian Government’s policies emphasized preventionas a long-term investment, allocation of resources to rural andunder-privileged areas, and prioritizing ambulatory care over hospitalization.A network of district teams to manage and oversee almost 2500village-based rural health centres was established. These centres arestaffed by a team that includes a general practitioner, midwife, nurse andseveral health technicians. Each of the rural health centres oversees 1–5smaller points of care known as “health houses”. With 17 000 of thesehealth houses, over 90% of the rural population has access to healthcare. In remote rural areas, these health houses are staffed by Behvarz(multi-purpose health workers) who are selected by the community,receive between 12 and 18 months training and are then recruited bythe Government. The district teams provide training based on problemsolving,as well as ongoing supervision and support.The Government deployed this strategy progressively, extending coverageto one province at a time. Over the years, the PHC network has grownand is now able to provide services to over 24 million people in ruralvillages and small cities by bringing the points of care closer to wherepeople live and work, as well as by training the necessary auxiliary healthstaff to provide family planning, preventive care services, and essentialcurative care for the majority of health problems. Rural health serviceutilization rates are now the same as in urban areas. The progressiveroll-out of this system has helped to reduce the urban-rural gap in childmortality (Figure 2.5).Figure 2.5 Under-five mortality in rural and urban areas, the Islamic Republicof Iran, 1980–2000 32Mortality per 1000 children under five8060402001980RuralUrban1985 1990 1995 2000adequately, a blend of response to need anddemand, and participation of the population andkey actors has made it possible to build robustprimary-care networks, even in very difficult andresource-constrained settings of conflict, andpost-conflict environments (Box 2.4).29

The World Health Report 2008Primary Health Care – Now More Than EverThe distinction between rapid deployment ofpriority interventions and progressive roll-out ofprimary-care networks is, in practice, often notas straightforward as described above. However,for all the convergence, trying to balance speedand sustainability is a real political dilemma 30 .Mali, among others, has shown that, given thechoice, people willingly opt for progressive rollout,making community health centres – whoseinfrastructure is owned and personnel employedby the local community – the basis of functionalhealth districts.Crucially, concern for equity should not betranslated into a “lowest common denominator”approach: equal access for all to a set of largelyunsatisfactory services. Quality and sustainabilityare important, particularly since nowadaysthe multitude of varied and dynamic governmental,not-for-profit and for-profit private providersof various kinds are in dire need of alignment.Progressive roll-out of health services providesthe opportunity to establish welcome leadershipcoherence in health-care provision at district level.Typical large-scale examples of this approachin developing countries are the contracting outof district health services in Cambodia, or theincorporation of missionary “designated districthospitals” in East Africa. Nevertheless, there isno getting away from the need for massive andsustained investment to expand and maintainhealth districts in the long term and from thefact that this represents a considerable challengein a context of sluggish economic growth andstagnating health expenditure.Extending health-care networks to underservedareas depends on public initiative andincentives. One way to accelerate the extensionof coverage is to adjust budget allocation formulae(or contract specifications) to reflect theextra efforts required to contact hard-to-reachpopulations. Several countries have taken steps inthis direction. In January 2004, for example, theUnited Republic of Tanzania adopted a revisedformula for the allocation of basket funds to districtsthat includes population size and underfivemortality as a proxy for disease burden andpoverty level, while adjusting for the differentialcosts of providing health services in rural andlow-density areas. Similarly, allocations to districtsunder Uganda’s PHC budget factor in thedistricts’ Human Development Index and levelsof external health funding, in addition to populationsize. Supplements are paid to districts withdifficult security situations or lacking a districthospital 20 . In Chile, budgets are allocated on acapitation basis but, as part of the PHC reforms,these were adjusted using municipal humandevelopment indices and a factor to reflect theisolation of underserved areas.Overcoming the isolation ofdispersed populationsAlthough providing access to services for dispersedpopulations is often a daunting logisticalchallenge, some countries have dealt withit by developing creative approaches. Devisingmechanisms to share innovative experiences andresults has clearly been a key step, for example,through the “Healthy Islands” initiative, launchedat the meeting of Ministers and Heads of Healthin Yanuca, Fiji, in 1995 34 . The initiative bringstogether health policy-makers and practitionersto address challenges to islanders’ health andwell-being from an explicitly multi-sectoral perspective,with a focus on expanding coverage ofcurative health-care services, but also reinforcingpromotive strategies and cross-sectoral action onthe determinants of health and health equity.Through the Healthy Islands initiative andrelated experiences, a number of principles haveemerged as crucial to the advancement of universalcoverage in these settings. The first concernscollaboration in organizing infrastructure thatmaximizes scales of efficiency. An isolated communitymay be unable to afford key inputs toexpand coverage, which includes infrastructure,technologies and human resources (particularlythe training of personnel). However, when communitiesjoin forces, they can secure such inputsat manageable costs 35 . A second strategic focus ison “mobile resources” or those that can overcomedistance and geographical obstacles efficientlyand affordably. Depending on the setting, thisstrategic focus may include transportation, radiocommunications, and other information and communicationstechnologies. Telecommunications30

Chapter 2. Advancing and sustaining universal coverageBox 2.4 The robustness of PHC-led health systems: 20 years of expanding performance inRutshuru, the Democratic Republic of the CongoRutshuru is a health district in the east of the country. It has anetwork of health centres, a referral hospital and a district managementteam where community participation has been fosteredfor years through local committees. Rutshuru has experiencedsevere stress over the years, testing the robustness of the districthealth system.Over the last 30 years, the economy of the country has goneinto a sharp decline. GDP dropped from US$ 300 per capita inthe 1980s to below US$ 100 at the end of the 1990s. Massiveimpoverishment was made worse as the State retreated from thehealth sector. This was compounded by an interruption of overseasdevelopment aid in the early 1990s. In that context, Rutshurusuffered inter-ethnic strife, a massive infl ux of refugees and twosuccessive wars. This complex of disasters severely affected theworking conditions of health professionals and access to healthservices for the 200 000 people living in the district.Nevertheless, instead ofcollapsing, PHC servicescontinued their expansionover the years. Thenumber of health centresand their output increased(Figure 2.6), and qualityof care improved foracute cases (case-fatalityrate after caesarean sectiondropped from 7% toless than 3%) as well asfor chronic patients (atleast 60% of tuberculosispatients were treatedsuccessfully). With nomore than 70 nurses andthree medical doctors ata time, and in the midstof war and havoc, theFigure 2.6 Improving health-care outputs in the midst of disaster:Rutshuru, the Democratic Republic of the Congo, 1985–2004 33Coverage DPT3 vaccination (%)Birth attended by medicallytrained personnel (%)New cases curative careper 100 inhabitants per year100External aid90interrupted807060504030201001985health centres and the district hospital took care of more than1 500 000 disease episodes in 20 years, immunized more than100 000 infants, provided midwifery care to 70 000 women andcarried out 8 000 surgical procedures. This shows that, even indisastrous circumstances, a robust district health system canimprove health-care outputs.These results were achieved with modest means. Out-of-pocketpayments amounted to US$ 0.5 per capita per year. Nongovernmentalorganizations subsidized the district with an average of US$1.5 per capita per year. The Government’s contribution was virtuallynil during most of these 20 years. The continuity of the workunder extremely diffi cult circumstances can be explained by teamwork and collegial decision-making, unrelenting efforts to build upand maintain a critical mass of dedicated human resources, andlimited but constant nongovernmental support, which provided aminimum of resources for health facilities and gave the districtmanagement team the opportunity to maintain contact with theoutside world.RefugeecrisisFirstWarSecondWar1990 1995 2000Three lessons can be learntfrom this experience. Inthe long run, PHC-ledhealth districts are anorganizational model thathas the robustness toresist extremely adverseconditions. Maintainingminimal fi nancial supportand supervision to suchdistricts can yield verysignificant results, whileempowering and retainingnational health professionals.Local health serviceshave a considerablepotential for coping withcrises 33 .can enable less skilled frontline health-centrestaff to be advised and guided by experts at adistance in real time 36 . Finally, the financingof health care for dispersed populations posesspecific challenges, which often require largerper capita expenditure compared to more clusteredpopulations. In countries whose territoriesinclude both high-density and low-density populations,it is expected that dispersed populationswill receive some subsidy of care. After all, equitydoes not come without solidarity.Providing alternatives tounregulated commercial servicesIn urban and periurban contexts, health servicesare physically within reach of the poor and othervulnerable populations. The presence of multiplehealth-care providers does not mean, however,that these groups are protected from diseases,nor that they can get quality care when they needit: the more privileged tend to get better access tothe best services, public and private, easily comingout on top in a de facto competition for scarce31

The World Health Report 2008Primary Health Care – Now More Than Everresources. In the urban and increasingly in therural areas of many low- and middle-incomecountries – from India and Viet Nam to sub-Saharan Africa – much health care for the pooris provided by small-scale, largely unregulatedand often unlicenced providers, both commercialand not-for-profit. Often, they work alongsidedysfunctional public services and capturean overwhelmingly large part of the health-caremarket, while the health promotion and preventionagenda is totally ignored. Vested interestsmake the promotion of universal coverage paradoxicallymore difficult in these circumstancesthan in areas where the challenge is to buildhealth-care delivery networks from scratch.These contexts often combine problems of financialexploitation, bad quality and unsafe care, andexclusion from needed services 37,38,39,40,41,42,43,44,45.46 .The Pan American Health Organization (PAHO)has estimated that 47% of Latin America’s populationis excluded from needed services 47 . Thismay be for broader reasons of poverty, ethnicityor gender, or because the resources of thehealth system are not correctly targeted. It maybe because there are no adequate systems to protectpeople against catastrophic expenditure orfrom financial exploitation by unscrupulous orinsensitive providers. It may have to do with theway people, rightly or wrongly, perceive healthservices: lack of trust, the expectation of ill-treatmentor discrimination, uncertainty about thecost-of-care, or the anticipation that the cost willbe unaffordable or catastrophic. Services mayalso be untimely, ineffective, unresponsive orplain discriminatory, providing poorer patientswith inferior treatment 48,49,21 . As a result, healthoutcomes vary considerably by social class, evenin well-regulated and well-funded health-caresystems.In addressing these patterns of exclusionwithin the health-care sector, the starting pointis to create or strengthen networks of accessiblequality primary-care services that rely on pooledpre-payment or public resources for their funding.Whether these networks are expanded bycontracting commercial or not-for-profit providers,or by revitalizing dysfunctional public facilitiesis not the critical issue. The point is to ensurethat they offer care of an acceptable standard. Acritical mass of primary-care centres that providean essential package of quality services free-ofcharge,provides an important alternative to substandard,exploitative commercial care. Furthermore,peer pressure and consumer demand canhelp to create an environment in which regulationof the commercial sector becomes possible.More active involvement of municipal authoritiesin pre-payment and pooling schemes to improvethe supply of quality care is probably one of theavenues to follow, particularly where ministriesof health with budgetary constraints also have toextend services to underserved rural areas.Targeted interventions tocomplement universal coveragemechanismsRising average national income, a growing supplyof health-care providers and accelerated progresstowards universal coverage are, unfortunately, notsufficient to eliminate health inequities. Sociallydetermined health differences among populationgroups persist in high-income countries withrobust, universal health-care and social-servicesystems, such as Finland and France 11,50 . Healthinequalities do not just exist between the poor andthe non-poor, but across the entire socioeconomicgradient. There are circumstances where otherforms of exclusion are of prime concern, includingthe exclusion of adolescents, ethnic groups,drug users and those affected by stigmatizingdiseases 51 . In Australia, Canada and New Zealand,among others, health equity gaps betweenAboriginal and non-Aboriginal populations haveemerged as national political issues 52,53,54 . In othersettings, inequalities in women’s access to healthcare merit attention 55 . In the United States, forexample, declines in female life expectancy of upto five years in over 1000 counties point to differentialexposure and clustering of risks to healtheven as the country’s economy and health sectorcontinues to grow 56 . For a variety of reasons,some groups within these societies are either notreached or insufficiently reached by opportunitiesfor health or services and continue to experiencehealth outcomes systematically inferior to thoseof more advantaged groups.32

The World Health Report 2008Primary Health Care – Now More Than EverMobilizing for health equityHealth systems are invariably inequitable. Moreand higher quality services gravitate to thewell-off who need them less than the poor andmarginalized 8 . The universal coverage reformsrequired to move towards greater equity demandthe enduring commitment of the highest politicallevels of society. Two levers may be especiallyimportant in accelerating action on health equityand maintaining momentum over time. The firstis raising the visibility of health inequities in publicawareness and policy debates: the history ofprogress in the health of populations is intimatelylinked to the measurement of health inequalities.It was the observation of excess mortality amongthe working class that informed the “Great SanitaryAwakening” reforms of the Poor Laws Commissionin the United Kingdom in the 1830s 68 . Thesecond is the creation of space for civil societyparticipation in shaping the PHC reforms that areto advance health equity: the history of progressin universal coverage is intimately linked to thatof social movements.Increasing the visibility ofhealth inequitiesWith the economic optimism of the 1960s and1970s (and the expansion of social insurance inindustrialized countries), poverty ceased beinga priority issue for many policy-makers. It tookAlma-Ata to put equity back on the politicalagenda. The lack of systematic measurement andmonitoring to translate this agenda into concretechallenges has long been a major constraint inadvancing the PHC agenda. In recent years,income-related and other health inequalities havebeen studied in greater depth. The introduction ofcomposite asset indices has made it possible to reanalyzedemographic and health surveys from anequity viewpoint 69 . This has generated a wealthof documentary evidence on socioeconomic differentialsin health outcomes and access to care.It took this acceleration of the measurement ofpoverty and inequalities, particularly since themid-1990s, to bring first poverty and then, moregenerally, the challenge of persisting inequalitiesto the centre of the health policy debate.Measurement of health inequities is paramountwhen confronting the common misperceptionsthat strongly influence health policydebates 70,71 . Simple population averages are sufficient toassess progress – they are not. Health systems designed for universal accessare equitable – they are a necessary, but nota sufficient condition. In poor countries, everybody is equally poorand equally unhealthy – all societies arestratified. The main concern is between countries’ differences– inequalities within countries mattermost to people. Well-intended reforms to improve efficiencywill ultimately benefit everybody – they oftenhave unintended inequitable consequences.Measurement matters for a variety ofreasons 2 . It is important to know the extent and understandthe nature of health inequalities andexclusion in a given society, so as to be ableto share that information and translate it intoobjectives for change. It is equally important, for the same reasons,to identify and understand the determinantsof health inequality not only in general terms,but also within each specific national context.Health authorities must be informed of theextent to which current or planned healthpolicies contribute to inequalities, so as to beable to correct them. Progress with reforms designed to reducehealth inequalities, i.e. progress in movingtowards universal coverage, needs to be monitored,so as to steer and correct these reformsas they unfold.Despite policy-makers’ long-held commitment tothe value of equity in health, its definition andmeasurement represent a more recent publichealth science. Unless health information systemscollect data using standardized social stratifiers,such as socioeconomic status, gender, ethnicityand geographical area, it is difficult to identifyand locate inequalities and, unless their magnitudeand nature are uncovered, it is unlikelythat they will be adequately addressed 72 . Thenow widely available analyses of Demographicand Health Survey (DHS) data by asset quintiles34

Chapter 2. Advancing and sustaining universal coveragehave made a major difference in the awarenessof policy-makers about health equity problemsin their countries. There are also examples ofhow domestic capacities and capabilities can bestrengthened to better understand and manageequity problems. For example, Chile has recentlyembarked on integrating health sector informationsystems in order to have more comprehensiveinformation on determinants and to improvethe ability to disaggregate information accordingto socioeconomic groups. Indonesia has addedhealth modules to household expenditure anddemographic surveys. Building in capabilities,across administrative database systems, to linkhealth and socioeconomic data through uniqueidentifiers (national insurance numbers or censusgeo-codes) is key to socioeconomic stratificationand provides information that is usually inaccessible.However, this is more than a technicalchallenge. Measuring health systems’ progresstowards equity requires an explicit deliberativeprocess to identify what constitutes a fair distributionof health against shortfalls and gaps thatcan be measured 73 . It relies on the developmentof institutional collaboration between multiplestakeholders to ensure that measurement andmonitoring translates into concrete political proposalsfor better equity and solidarity.Creating space for civil societyparticipation and empowermentKnowledge about health inequalities can onlybe translated into political proposals if there isorganized social demand. Demand from the communitiesthat bear the burden of existing inequitiesand other concerned groups in civil societyare among the most powerful motors drivinguniversal coverage reforms and efforts to reachthe unreached and the excluded.The amount of grassroots advocacy to improvethe health and welfare of populations in need hasgrown enormously in the last 30 years, mostlywithin countries, but also globally. There arenow thousands of groups around the world, largeand small, local and global, calling for action toimprove the health of particularly deprived socialgroups or those suffering from specific healthconditions. These groups, which were virtuallynon-existent in the days of the Alma-Ata,constitute a powerful voice of collective action.Box 2.6 Social policy in the city ofGhent, Belgium: how local authoritiescan support intersectoral collaborationbetween health and welfareorganizations 76In 2004, a regional government decree in Flanders, Belgium,institutionalized the direct participation of local stakeholdersand citizens in intersectoral collaboration on social rights. Thisnow applies at the level of cities and villages in the region. Inone of these cities, Ghent, some 450 local actors of the healthand welfare sector have been clustered in 11 thematic forums:legal help; support and security of minors; services for youngpeople and adolescents; child care; ethnic cultural minorities;people with a handicap; the elderly; housing; work and employment;people living on a “critical income”; and health.The local authorities facilitate and support the collaborationof the various organizations and sectors, for example, throughthe collection and monitoring of data, information and communication,access to services, and efforts to make servicesmore pro-active. They are also responsible for networkingbetween all the sectors with a view to improving coordination.They pick up the signals, bottlenecks, proposals and plans,and are responsible for channelling them, if appropriate, tothe province, region, federal state or the European Union fortranslation into relevant political decisions and legislation.A steering committee reports directly to the city council andintegrates the work of the 11 forums. The support of the administrationand a permanent working party is critical for thesustainability and quality of the work in the different groups.Participation of all stakeholders is particularly prominent inthe health forum: it includes local hospitals, family physicians,primary-care services, pharmacists, mental health facilities,self-help groups, home care, health promotion agencies,academia sector, psychiatric home care, and communityhealth centres.This complex web of collaboration is showing results. Intersectoralcoordination contributes to a more effi cient local socialpolicy. For the period 2008–2013, four priority themes havebeen identifi ed in a bottom-up process: sustainable housing,access to health care, reduced thresholds to social rights, andoptimization of growth and development. The yearly action planoperationalizes the policy through improvement projects inareas that include fi nancial access to health care, educationalsupport, care for the homeless, and affordable and fl exiblechild care. Among the concrete realizations is the creationof Ghent’s “social house”, a network of service entry pointssituated in the different neighbourhoods of the city, wheredelivery of primary care is organized with special attentionto the most vulnerable groups of people. The participatingorganizations report that the creation of the sectoral forums,in conjunction with the organization of intersectoral cooperation,has signifi cantly improved the way social determinantsof health are tackled in the city.35

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London, Department for InternationalDevelopment (DFID) Health Resource Systems Resource Centre, 2004 (http:www.dfi dhealthrc.org/publications/health_sector_fi nancing/04hut01.pdf, accessed 19July 2008).24. Tarimo E. Essential health service packages: uses, abuse and future directions.Current concerns. Geneva, World Health Organization, 1997 (ARA Paper No. 15;WHO/ARA/CC/97.7).25. Republica de Chile. Ley 19.966. Projecto de ley: título I del régimen general degarantías en salud. Santiago, Ministerio de Salud, 2008 (http://webhosting.redsalud.gov.cl/minsal/archivos/guiasges/leyauge.pdf accessed 19 July 2008).26. Moccero D. Delivering cost-effi cient public services in health care, education andhousing in Chile. Paris, Organisation for Economic Co-operation and Development,2008 (Economics Department Working Papers No. 606).27. Gwatkin DR et al. Socio-economic differences in health, nutrition, and populationwithin developing countries. An overview. Washington DC, The World Bank, HumanDevelopment Network, Health, Population and Nutrition, and Population Family,2007 (POPLINE Document Number: 324740).28. Conway MD, Gupta S, Khajavi K. Addressing Africa’s health workforce crisis. TheMckinsey Quarterly, November 2007.29. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige asconstraints to referral by isolated nurses in rural Niger. Human Resources for Health,2004, 2:1.30. Maiga Z, Traoré Nafo F, El Abassi A. La Réforme du secteur santé au Mali, 1989-1996. Studies in Health Services Organisation & Policy, 1999, 12:1–132.31. Abolhassani F. Primary health care in the Islamic Republic of Iran. Teheran, TeheranUniversity of Medical Sciences, Health Network Development Centre (unpublished).32. Naghavi M. Demographic and health surveys in Iran, 2008 (personal communication).33. Porignon D et al. How robust are district health systems? Coping with crisis anddisasters in Rutshuru, Democratic Republic of Congo. Tropical Medicine andInternational Health, 1998, 3:559–565.34. Gauden GI, Powis B, Tamplin SA. Healthy Islands in the Western Pacifi c –international settings development. Health Promotion International, 2000,15:169–178.35. The World Health Report 2006: Working together for health. Geneva, World HealthOrganization, 2006.36. Bossyns P et al. Unaffordable or cost-effective? Introducing an emergency referralsystem in rural Niger. Tropical Medicine & International Health, 2005, 10:879–887.37. Tibandebage P, Mackintosh M. The market shaping of charges, trust and abuse:health care transactions in Tanzania. Social Science and Medicine, 2005,61:1385–1395.38. Segall, M et al. Health care seeking by the poor in transitional economies: the caseof Vietnam. Brighton, Institute of Development Studies, 2000 (IDS Research ReportsNo. 43).39. Baru RV. Private health care in India: social characteristics and trends. New Delhi,Sage Publications, 1998.40. Tu NTH, Huong NTL, Diep NB. Globalisation and its effects on health care andoccupational health in Viet Nam. Geneva, United Nations Research Institute for SocialDevelopment, 2003 (http://www.unrisd.org, accessed 19 July 2008).41. Narayana K. The role of the state in the privatisation and corporatisation of medicalcare in Andhra Pradesh, India. In: Sen K, ed. Restructuring health services: changingcontexts and comparative perspectives. London and New Jersey, Zed Books, 2003.42. Bennett S, McPake B, Mills A. The public/private mix debate in health care. In:Bennett S, McPake B, Mills A, eds. Private health providers in developing countries.Serving the public interest? London and New Jersey, Zed Books, 1997.43. Ogunbekun I, Ogunbekun A, Orobaton N. Private health care in Nigeria: walking thetightrope. Health Policy and Planning, 1999, 14:174–181.44. Mills A, Bennett S, Russell S. The challenge of health sector reform: what mustgovernments do? Basingstoke, Palgrave Macmillan, 2001.45. The unbearable cost of illness: poverty, ill health and access to healthcare - evidencefrom Lindi Rural District, Tanzania, London, Save the Children, 2001.46. Ferrinho P, Bugalho AM, Van Lerberghe W. Is there a case for privatisingreproductive health? Patchy evidence and much wishful thinking. Studies in HealthServices Organisation & Policy, 2001, 17:343–370.47. Pan American Health Organization and Swedish International Development Agency.Exclusion in health in Latin America and the Caribbean. Washington DC, PanAmerican Health Organization, 2003 (Extension of Social Protection in Health SeriesNo. 1).37

Primary carePutting people firstThis chapter describes how primary care bringspromotion and prevention, cure and care together ina safe, effective and socially productive way at the interfacebetween the population and the healthsystem. In short, what needs to be done toachieve this is “to put people first”: to givebalanced consideration to health and wellbeingas well as to the values and capacitiesof the population and the health workers .1The chapter starts by describing features ofhealth care that, along with effectiveness and safety, are essentialin ensuring improved health and social outcomes.Chapter 3Good care is about people 42The distinctive features ofprimary care43Organizingprimary-care networks52Monitoring progress 5641

The World Health Report 2008Primary Health Care – Now More Than EverThese features are person-centredness, comprehensivenessand integration, and continuity ofcare, with a regular point of entry into the healthsystem, so that it becomes possible to build anenduring relationship of trust between peopleand their health-care providers. The chapterthen defines what this implies for the organizationof health-care delivery: the necessaryswitch from specialized to generalist ambulatorycare, with responsibility for a defined populationand the ability to coordinate support fromhospitals, specialized services and civil societyorganizations.Good care is about peopleBiomedical science is, and should be, at the heartof modern medicine. Yet, as William Osler, one ofits founders, pointed out, “it is much more importantto know what sort of patient has a diseasethan what sort of disease a patient has” 2 . Insufficientrecognition of the human dimension inhealth and of the need to tailor the health service’sresponse to the specificity of each community andindividual situation represent major shortcomingsin contemporary health care, resulting notonly in inequity and poor social outcomes, butalso diminishing the health outcome returns onthe investment in health services.Putting people first, the focus of service deliveryreforms is not a trivial principle. It can requiresignificant – even if often simple – departuresfrom business as usual. The reorganization ofa medical centre in Alaska in the United States,accommodating 45 000 patient contacts per year,illustrates how far-reaching the effects can be.The centre functioned to no great satisfaction ofeither staff or clients until it decided to establisha direct relationship between each individualand family in the community and a specific staffmember 3 . The staff were then in a position toknow “their” patients’ medical history and understandtheir personal and family situation. Peoplewere in a position to get to know and trust theirhealth-care provider: they no longer had to dealwith an institution but with their personal caregiver.Complaints about compartmentalized andfragmented services abated 4 . Emergency roomvisits were reduced by approximately 50% andreferrals to specialty care by 30%; waiting timesshortened significantly. With fewer “rebound”visits for unresolved health problems, the workloadactually decreased and staff job satisfactionimproved. Most importantly, people felt thatthey were being listened to and respected – a keyaspect of what people value about health care 5,6 . Aslow bureaucratic system was thus transformedinto one that is customer-responsive, customerownedand customer-driven 4 .In a very different setting, the health centresof Ouallam, a rural district in Niger, implementedan equally straightforward reorganization oftheir way of working in order to put people first.Rather than the traditional morning curative careconsultation and specialized afternoon clinics(growth monitoring, family planning, etc.), thefull range of services was offered at all times,while the nurses were instructed to engage in anactive dialogue with their patients. For example,they no longer waited for women to ask for contraceptives,but informed them, at every contact,about the range of services available. Within a fewmonths, the very low uptake of family planning,previously attributed to cultural constraints, wasa thing of the past (Figure 3.1) 7 .People’s experiences of care provided by thehealth system are determined first and foremostby the way they are treated when they experiencea problem and look for help: by the responsivenessof the health-worker interface between populationFigure 3.1 The effect on uptake of contraception of the reorganizationof work schedules of rural health centres in NigerWomen attending the health centre (%)100Informed Interested Contraception started806040200Source: 7Year before reorganizationYear after reorganization42

Chapter 3. Primary care: putting people firstand health services. People value some freedomin choosing a health provider because they wantone they can trust and who will attend to thempromptly and in an adequate environment, withrespect and confidentiality 8 .Health-care delivery can be made more effectiveby making it more considerate and convenient,as in Ouallam district. However, primarycare is about more than shortening waitingtimes, adapting opening hours or getting staffto be more polite. Health workers have to carefor people throughout the course of their lives,as individuals and as members of a family and acommunity whose health must be protected andenhanced 9 , and not merely as body parts withsymptoms or disorders that require treating 10 .The service delivery reforms advocated by thePHC movement aim to put people at the centre ofhealth care, so as to make services more effective,efficient and equitable. Health services thatdo this start from a close and direct relationshipbetween individuals and communities and theircaregivers. This, then, provides the basis for person-centredness,continuity, comprehensivenessand integration, which constitute the distinctivefeatures of primary care. Table 3.1 summarizesthe differences between primary care and careprovided in conventional settings, such as inclinics or hospital outpatient departments, orthrough the disease control programmes thatshape many health services in resource-limitedsettings. The section that follows reviews thesedefining features of primary care, and describeshow they contribute to better health and socialoutcomes.The distinctive features ofprimary careEffectiveness and safety are not justtechnical mattersHealth care should be effective and safe. Professionalsas well as the general public oftenover-rate the performance of their health services.The emergence of evidence-based medicinein the 1980s has helped to bring the powerand discipline of scientific evidence to healthcaredecision-making 11 , while still taking intoconsideration patient values and preferences 12 .Over the last decade, several hundred reviews ofTable 3.1 Aspects of care that distinguish conventional health care from people-centred primary careConventional ambulatorymedical care in clinics oroutpatient departments Disease control programmes People-centred primary careFocus on illness and cure Focus on priority diseases Focus on health needsRelationship limited to the moment ofconsultationRelationship limited to programmeimplementationEnduring personal relationshipEpisodic curative careProgramme-defi ned disease controlinterventionsComprehensive, continuous and personcentredcareResponsibility limited to effectiveand safe advice to the patient at themoment of consultationUsers are consumers of the care theypurchaseResponsibility for disease-controltargets among the target populationPopulation groups are targets ofdisease-control interventionsResponsibility for the health of all inthe community along the life cycle;responsibility for tackling determinantsof ill-healthPeople are partners in managing theirown health and that of their community43

The World Health Report 2008Primary Health Care – Now More Than Evereffectiveness have been conducted 13 , which haveled to better information on the choices availableto health practitioners when caring for theirpatients.Evidence-based medicine, however, cannotin itself ensure that health care is effective andsafe. Growing awareness of the multiple ways inwhich care may be compromised is contributingto a gradual rise in standards of quality andsafety (Box 3.1). Thus far, however, such effortshave concentrated disproportionately on hospitaland specialist care, mainly in high- and middleincomecountries. The effectiveness and safety ofgeneralist ambulatory care, where most interactionsbetween people and health services takeplace, has been given much less attention 14 . Thisis a particularly important issue in the unregulatedcommercial settings of many developingBox 3.1 Towards a science and cultureof improvement: evidence to promotepatient safety and better outcomesThe outcome of health care results from the balance betweenthe added value of treatment or intervention, and the harm itcauses to the patient 16 . Until recently, the extent of such harmhas been underestimated. In industrialized countries, approximately1 in 10 patients suffers harm caused by avoidableadverse events while receiving care 17 : up to 98 000 deaths peryear are caused by such events in the United States alone 18 .Multiple factors contribute to this situation 19 , ranging fromsystemic faults to problems of competence, social pressure onpatients to undergo risky procedures, to incorrect technologyusage 20 . For example, almost 40% of the 16 billion injectionsadministered worldwide each year are given with syringesand needles that are reused without sterilization 14 . Each year,unsafe injections thus cause 1.3 million deaths and almost 26million years of life lost, mainly because of transmission ofhepatitis B and C, and HIV 21 .Especially disquieting is the paucity of information on theextent and determinants of unsafe care in low- and middleincomecountries. With unregulated commercialization of care,weaker quality control and health resource limitations, healthcareusers in low-income countries may well be even moreexposed to the risk of unintended patient harm than patients inhigh-income countries. The World Alliance for Patient Safety 22 ,among others, advocates making patients safer through systemicinterventions and a change in organizational culturerather than through the denunciation of individual health-carepractitioners or administrators 23 .countries where people often get poor value formoney (Box 3.2) 15 .Technical and safety parameters are not theonly determinants of the outcomes of health care.The disappointingly low success rate in preventingmother-to-child transmission (MTCT) of HIVin a study in the Côte d’Ivoire (Figure 3.2) illustratesthat other features of the organization ofhealth care are equally critical – good drugs areBox 3.2 When supplier-induced andconsumer-driven demand determinemedical advice: ambulatory care in India“Ms. S is a typical patient who lives in urban Delhi. Thereare over 70 private-sector medical care providers within a15-minute walk from her house (and virtually any householdin her city). She chooses the private clinic run by Dr. SM andhis wife. Above the clinic a prominent sign says “Ms. MM,Gold Medalist, MBBS”, suggesting that the clinic is staffed bya highly profi cient doctor (an MBBS is the basic degree for amedical doctor as in the British 2 system). As it turns out, Ms.MM is rarely at the clinic. We were told that she sometimescomes at 4 a.m. to avoid the long lines that form if people knowshe is there. We later discover that she has “franchised” hername to a number of different clinics. Therefore, Ms. S seesDr. SM and his wife, both of whom were trained in traditionalAyurvedic medicine through a six-month long-distance course.The doctor and his wife sit at a small table surrounded, on oneside, by a large number of bottles full of pills, and on the other,a bench with patients on them, which extends into the street.Ms. S sits at the end of this bench. Dr. SM and his wife are themost popular medical care providers in the neighbourhood,with more than 200 patients every day. The doctor spends anaverage of 3.5 minutes with each patient, asks 3.2 questions,and performs an average of 2.5 examinations. Following thediagnosis, the doctor takes two or three different pills, crushesthem using a mortar and pestle, and makes small paper packetsfrom the resulting powder which he gives to Ms. S andasks her to take for two or three days. These medicines usuallyinclude one antibiotic and one analgesic and anti-infl ammatorydrug. Dr. SM tells us that he constantly faces unrealistic patientexpectations, both because of the high volume of patients andtheir demands for treatments that even Dr. SM knows areinappropriate. Dr. SM and his wife seem highly motivated toprovide care to their patients and even with a very crowdedconsultation room they spend more time with their patientsthan a public sector doctor would. However, they are not boundby their knowledge […] and instead deliver health care likethe crushed pills in a paper packet, which will result in morepatients willing to pay more for their services” 24 .44

Chapter 3. Primary care: putting people firstnot enough. How services deal with people is alsovitally important. Surveys in Australia, Canada,Germany, New Zealand, the United Kingdom andthe United States show that a high number ofpatients report safety risks, poor care coordinationand deficiencies in care for chronic conditions25 . Communication is often inadequate andlacking in information on treatment schedules.Nearly one in every two patients feels that doctorsonly rarely or never asked their opinion abouttreatment. Patients may consult different providersfor related or even for the same conditionswhich, given the lack of coordination among theseproviders, results in duplication and contradictions25 . This situation is similar to that reportedin other countries, such as Ethiopia 26 , Pakistan 27and Zimbabwe 28 .There has, however, been progress in recentyears. In high-income countries, confrontationwith chronic disease, mental health problems,multi-morbidity and the social dimension of diseasehas focused attention on the need for morecomprehensive and person-centred approachesand continuity of care. This resulted not onlyfrom client pressure, but also from professionalswho realized the critical importance of suchFigure 3.2 Lost opportunities for prevention of mother-to-child transmission of HIV (MTCT) inCôte d’Ivoire 29 : only a tiny fraction of the expected transmissions areactually prevented462 mother-to-childtransmissions of HIV(expected among 11 582pregnant women)MotherattendsantenatalcareHIV testingofferedCounsellingrecommendstreatmentConsentobtainedTreatmentofferedTreatmenttakenTreatmenteffective12 mother-to-childtransmissionssuccessfullypreventedDid not attendantenatal careDid notaccepttestWere notcounselledDid notagree tobe treatedDid not getthe treatmentTreatmentineffectiveLack ofcoverage:77 lostBadcommunication:107 lostLack offollow-up:153 lostBadcommunication:50 lostAccess todrugs:40 lost23 lost450 failures to prevent transmission45

The World Health Report 2008Primary Health Care – Now More Than Everfeatures of care in achieving better outcomes fortheir patients. Many health professionals havebegun to appreciate the limitations of narrowclinical approaches, for example, to cardiovasculardisease. As a result there has been a welcomeblurring of the traditional boundaries betweencurative care, preventive medicine and healthpromotion.In low-income countries, this evolution is alsovisible. In recent years, many of the programmestargeting infectious disease priorities have givencareful consideration to comprehensiveness,continuity and patient-centredness. Maternaland child health services have often been at theforefront of these attempts, organizing a continuumof care and a comprehensive approach.This process has been consolidated through thejoint UNICEF/WHO Integrated Management ofChildhood Illness initiatives 30 . Their experiencewith programmes such as the WHO’s ExtendedProgramme for Immunization has put health professionalsin many developing countries a stepahead compared to their high-income countrycolleagues, as they more readily see themselvesresponsible not just for patients, but also forpopulation coverage. More recently, HIV/AIDSprogrammes have drawn the attention of providersand policy-makers to the importance ofcounselling, continuity of care, the complementarityof prevention, treatment and palliation andcritically, to the value of empathy and listeningto patients.Understanding people:person-centred careWhen people are sick they are a great deal lessconcerned about managerial considerations ofproductivity, health targets, cost-effectivenessand rational organization than about their ownpredicament. Each individual has his or her ownway of experiencing and coping with health problemswithin their specific life circumstances 31 .Health workers have to be able to handle thatdiversity. For health workers at the interfacebetween the population and the health services,the challenge is much more complicated than fora specialized referral service: managing a welldefineddisease is a relatively straightforwardtechnical challenge. Dealing with health problems,however, is complicated as people need tobe understood holistically: their physical, emotionaland social concerns, their past and theirfuture, and the realities of the world in which theylive. Failure to deal with the whole person in theirspecific familial and community contexts missesout on important aspects of health that do notimmediately fit into disease categories. Partnerviolence against women (Box 3.3), for example,can be detected, prevented or mitigated by healthservices that are sufficiently close to the communitiesthey serve and by health workers whoknow the people in their community.People want to know that their health workerunderstands them, their suffering and the constraintsthey face. Unfortunately, many providersneglect this aspect of the therapeutic relation,particularly when they are dealing withdisadvantaged groups. In many health services,responsiveness and person-centredness aretreated as luxury goods to be handed out onlyto a selected few.Over the last 30 years, a considerable bodyof research evidence has shown that personcentrednessis not only important to relievethe patient’s anxiety but also to improve theprovider’s job satisfaction 50 . The response toa health problem is more likely to be effectiveif the provider understands its various dimensions51 . For a start, simply asking patients howthey feel about their illness, how it affects theirlives, rather than focusing only on the disease,results in measurably increased trust and compliance52 that allows patient and provider tofind a common ground on clinical management,and facilitates the integration of prevention andhealth promotion in the therapeutic response 50,51 .Thus, person-centredness becomes the “clinicalmethod of participatory democracy” 53 , measurablyimproving the quality of care, the success oftreatment and the quality of life of those benefitingfrom such care (Table 3.2).In practice, clinicians rarely address theirpatients’ concerns, beliefs and understandingof illness, and seldom share problem managementoptions with them 58 . They limit themselvesto simple technical prescriptions, ignoring thecomplex human dimensions that are critical tothe appropriateness and effectiveness of the carethey provide 59 .46

Chapter 3. Primary care: putting people firstBox 3.3 The health-care response to partner violence against womenIntimate partner violence has numerous well-documented consequences for women’s health (and for the health of their children), includinginjuries, chronic pain syndromes, unintended and unwanted pregnancies, pregnancy complications, sexually transmitted infections anda wide range of mental health problems 32,33,34,35,36,37 . Women suffering from violence are frequent health-care users 38,39 .Health workers are, therefore, well placed to identify and provide care to the victims of violence, including referral for psychosocial,legal and other support. Their interventions can reduce the impact of violence on a woman’s health and well-being, and that of herchildren, and can also help prevent further violence.Research has shown that most women think health-care providers should ask about violence 40 . While they do not expect them to solvetheir problem, they would like to be listened to and treated in a non-judgemental way and get the support they need to take control overtheir decisions. Health-care providers often fi nd it diffi cult to ask women about violence. They lack the time and the training and skillsto do it properly, and are reluctant to be involved in judicial proceedings.The most effective approach for health providers to use when responding to violence is still a matter of debate 41 . They are generallyadvised to ask all women about intimate partner abuse as a routine part of any health assessment, usually referred to as “screening”or routine enquiry 42 . Several reviews found that this technique increased the rate of identifi cation of women experiencing violence inantenatal and primary-care clinics, but there was little evidence that this was sustained 40 , or was effective in terms of health outcomes 43 .Among women who have stayed in shelters, there is evidence that those who received a specifi c counselling and advocacy servicereported a lower rate of re-abuse and an improved quality of life 44 . Similarly, among women experiencing violence during pregnancy,those who received “empowerment counselling” reported improved functioning and less psychological and non-severe physical abuse,and had lower postnatal depression scores 45 .While there is still no consensus on the most effective strategy, there is growing agreement that health services should aim to identifyand support women experiencing violence 46 , and that health-care providers should be well educated about these issues, as they areessential in building capacity and skills. Health-care providers should, as a minimum, be informed about violence against women, itsprevalence and impact on health, when to suspect it and how to best respond. Clearly, there are technical dimensions to this. For example,in the case of sexual assault, providers need to be able to provide the necessary treatment and care, including provision of emergencycontraception and prophylaxis for sexually transmitted infections, including HIV where relevant, as well as psychosocial support. Thereare other dimensions too: health workers need to be able to document any injuries as completely and carefully as possible 47,48,49 andthey need to know how to work with communities – in particular with men and boys – on changing attitudes and practices related togender inequality and violence.Table 3.2 Person-centredness: evidence of itscontribution to quality of care and better outcomesImproved treatment intensity and quality of life − Ferrer(2005) 54Better understanding of the psychological aspects of apatient's problems − Gulbrandsen (1997) 55Improved satisfaction with communication −Jaturapatporn (2007) 56Improved patient confi dence regarding sensitiveproblems − Kovess-Masféty (2007) 57Increased trust and treatment compliance − Fiscella(2004) 52Better integration of preventive and promotive care −Mead (1982) 50Thus, technical advice on lifestyle, treatmentschedule or referral all too often neglectsnot only the constraints of the environment inwhich people live, but also their potential for selfhelpin dealing with a host of health problemsranging from diarrhoeal disease 60 to diabetesmanagement 61 . Yet, neither the nurse in Niger’srural health centre nor the general practitionerin Belgium can, for example, refer a patient tohospital without negotiating 62,63 : along with medicalcriteria, they have to take into account thepatient’s values, the family’s values, and theirlifestyle and life perspective 64 .Few health providers have been trained forperson-centred care. Lack of proper preparationis compounded by cross-cultural conflicts, socialstratification, discrimination and stigma 63 . As aconsequence, the considerable potential of peopleto contribute to their own health through lifestyle,behaviour and self-care, and by adapting47

The World Health Report 2008Primary Health Care – Now More Than EverBox 3.4 Empowering users to contribute to their own healthFamilies can be empowered to make choices that are relevant to their health. Birth and emergency plans 66 , for example, are based ona joint examination between the expectant mother and health staff − well before the birth − of her expectations regarding childbirth.Issues discussed include where the birth will take place, and how support for care of the home and any other children will be organizedwhile the woman is giving birth. The discussion can cover planning for expenses, arrangements for transport and medical supplies, aswell as identifi cation of a compatible blood donor in case of haemorrhage. Such birth plans are being implemented in countries as diverseas Egypt, Guatemala, Indonesia, the Netherlands and the United Republic of Tanzania. They constitute one example of how people canparticipate in decisions relating to their health in a way that empowers them 67 . Empowerment strategies can improve health and socialoutcomes through several pathways; the condition for success is that they are embedded in local contexts and based on a strong anddirect relationship between people and their health workers 68 . The strategies can relate to a variety of areas, as shown below: developing household capacities to stay healthy, make healthy decisions and respond to emergencies − France’s self-help organizationof diabetics 69 , South Africa’s family empowerment and parent training programmes 70 , the United Republic of Tanzania’s negotiatedtreatment plans for safe motherhood 71 , and Mexico’s active ageing programme 72 ; increasing citizens’ awareness of their rights, needs and potential problems − Chile’s information on entitlements73 and Thailand’sDeclaration of Patients’ Rights 74 ; strengthening linkages for social support within communities and with the health system − support and advice to family caregiversdealing with dementia in developing country settings 75 , Bangladesh’s rural credit programmes and their impact on care-seekingbehaviour 76 , and Lebanon’s neighbourhood environment initiatives 77 .professional advice optimally to their life circumstancesis underutilized. There are numerous,albeit often missed, opportunities to empowerpeople to participate in decisions that affecttheir own health and that of their families (Box3.4). They require health-care providers whocan relate to people and assist them in makinginformed choices. The current payment systemsand incentives in community health-care deliveryoften work against establishing this type ofdialogue 65 . Conflicts of interest between providerand patient, particularly in unregulated commercialsettings, are a major disincentive to personcentredcare. Commercial providers may be morecourteous and client-friendly than in the averagehealth centre, but this is no substitute for personcentredness.Comprehensive and integrated responsesThe diversity of health needs and challenges thatpeople face does not fit neatly into the discretediagnostic categories of textbook promotive, preventive,curative or rehabilitative care 78,79 . Theycall for the mobilization of a comprehensive rangeof resources that may include health promotionand prevention interventions as well as diagnosisand treatment or referral, chronic or long-termhome care, and, in some models, social services 80 .It is at the entry point of the system, where peoplefirst present their problem, that the need for acomprehensive and integrated offer of care ismost critical.Comprehensiveness makes managerial andoperational sense and adds value (Table 3.3).People take up services more readily if they knowa comprehensive spectrum of care is on offer.Moreover, it maximizes opportunities for preventivecare and health promotion while reducingunnecessary reliance on specialized or hospitalcare 81 . Specialization has its comforts, but thefragmentation it induces is often visibly counterproductiveand inefficient: it makes no sense tomonitor the growth of children and neglect thehealth of their mothers (and vice versa), or to treatsomeone’s tuberculosis without considering theirHIV status or whether they smoke.Table 3.3 Comprehensiveness: evidence of itscontribution to quality of care and better outcomesBetter health outcomes − Forrest (1996) 82 , Chande(1996) 83 , Starfi eld (1998) 84Increased uptake of disease-focused preventive care(e.g. blood pressure screen, mammograms, pap smears)− Bindman (1996) 85Fewer patients admitted for preventable complications ofchronic conditions − Shea (1992) 8648

Chapter 3. Primary care: putting people firstThat does not mean that entry-point healthworkers should solve all the health problemsthat are presented there, nor that all health programmesalways need to be delivered througha single integrated service-delivery point. Nevertheless,the primary-care team has to be ableto respond to the bulk of health problems in thecommunity. When it cannot do so, it has to beable to mobilize other resources, by referring orby calling for support from specialists, hospitals,specialized diagnostic and treatment centres,public-health programmes, long-term care services,home-care or social services, or self-helpand other community organizations. This cannotmean giving up responsibility: the primary-careteam remains responsible for helping people tonavigate this complex environment.Comprehensive and integrated care for thebulk of the assorted health problems in the communityis more efficient than relying on separateservices for selected problems, partly because itleads to a better knowledge of the population andbuilds greater trust. One activity reinforces theother. Health services that offer a comprehensiverange of services increase the uptake and coverageof, for example, preventive programmes, suchas cancer screening or vaccination (Figure 3.3).They prevent complications and improve healthoutcomes.Comprehesive services also facilitate earlydetection and prevention of problems, even in theabsence of explicit demand. There are individualsand groups who could benefit from care even ifthey express no explicit spontaneous demand, asin the case of women attending the health centresin Ouallam district, Niger, or people with undiagnosedhigh blood pressure or depression. Earlydetection of disease, preventive care to reducethe incidence of poor health, health promotionto reduce risky behaviour, and addressing socialand other determinants of health all require thehealth service to take the initiative. For manyproblems, local health workers are the only oneswho are in a position to effectively address problemsin the community: they are the only ones,for example, in a position to assist parents withcare in early childhood development, itself animportant determinant of later health, well-beingand productivity 87 . Such interventions requireproactive health teams offering a comprehensiverange of services. They depend on a close andtrusting relationship between the health servicesand the communities they serve, and, thus, onhealth workers who know the people in theircommunity 88 .Continuity of careUnderstanding people and the context in whichthey live is not only important in order to providea comprehensive, person-centred response,it also conditions continuity of care. Providersoften behave as if their responsibility starts whena patient walks in and ends when they leave thepremises. Care should not, however, be limited tothe moment a patient consults nor be confined tothe four walls of the consultation room. Concernfor outcomes mandates a consistent and coherentapproach to the management of the patient’s problem,until the problem is resolved or the risk thatjustified follow-up has disappeared. Continuityof care is an important determinant of effectiveness,whether for chronic disease management,reproductive health, mental health or for makingsure children grow up healthily (Table 3.4).Figure 3.3 More comprehensive health centres have bettervaccination coverage a,bDPT3 vaccination coverage (%)Democratic Republic of the Congo(380 health centres, 2004)Madagascar (534 health centres, 2006)Weighted average of coveragein each country quintileRwanda (313 health centres, 1999)12010080604020020% health centreswith lowest overallperformanceQuintile 2 Quintile 3 Quintile 4 20% health centreswith highest overallperformanceFacility performance scorea Total 1227 health centres, covering a population of 16 million people.b Vaccination coverage was not included in the assessment of overall health-centreperformance across a range of services.c Includes vaccination of children not belonging to target population.c49

The World Health Report 2008Primary Health Care – Now More Than EverTable 3.4 Continuity of care: evidence of itscontribution to quality of care and better outcomesLower all-cause mortality − Shi (2003) 90 , Franks(1998) 91 , Villalbi (1999) 92 , PAHO (2005) 93Better access to care − Weinick (2000) 94 , Forrest(1998) 95Less re-hospitalization − Weinberger (1996) 96Fewer consultations with specialists − Woodward(2004) 97Less use of emergency services − Gill (2000) 98Better detection of adverse effects of medicalinterventions − Rothwell (2005) 99 , Kravitz (2004) 100Continuity of care depends on ensuring continuityof information as people get older, whenthey move from one residence to another, or whendifferent professionals interact with one particularindividual or household. Access to medicalrecords and discharge summaries, electronic,conventional or client-held, improves the choiceof the course of treatment and of coordinationof care. In Canada, for example, one in sevenpeople attending an emergency department hadmedical information missing that was very likelyto result in patient harm 101 . Missing informationis a common cause of delayed care and uptakeof unnecessary services 102 . In the United States,it is associated with 15.6% of all reported errorsin ambulatory care 103 . Today’s information andcommunication technologies, albeit underutilized,gives unprecedented possibilities toimprove the circulation of medical informationat an affordable cost 104 , thus enhancing continuity,safety and learning (Box 3.5). Moreover, it isno longer the exclusive privilege of high-resourceenvironments, as the Open Medical Record Systemdemonstrates: electronic health recordsdeveloped through communities of practice andopen-source software are facilitating continuityand quality of care for patients with HIV/AIDS inmany low-income countries 105 .Better patient records are necessary but notsufficient. Health services need to make activeefforts to minimize the numerous obstacles tocontinuity of care. Compared to payment bycapitation or by fee-for-episode, out-of-pocketfee-for-service payment is a common deterrent,not only to access, but also to continuity of care 107 .In Singapore, for example, patients were formerlynot allowed to use their health savings account(Medisave) for outpatient treatment, resultingin patient delays and lack of treatment compliancefor the chronically ill. This had become soproblematic that regulations were changed. Hospitalsare now encouraged to transfer patientswith diabetes, high blood pressure, lipid disorderand stroke to registered general practitioners,with Medisave accounts covering ambulatorycare 108 .Other barriers to continuity include treatmentschedules requiring frequent clinic attendancethat carry a heavy cost in time, travel expensesor lost wages. They may be ill-understood andpatient motivation may be lacking. Patients mayget lost in the complicated institutional environmentof referral hospitals or social services. Suchproblems need to be anticipated and recognizedat an early stage. The effort required from healthworkers is not negligible: negotiating the modalitiesof the treatment schedule with the patientsso as to maximize the chances that it can becompleted; keeping registries of clients withchronic conditions; and creating communicationchannels through home visits, liaison with communityworkers, telephonic reminders and textmessages to re-establish interrupted continuity.These mundane tasks often make the differencebetween a successful outcome and a treatmentfailure, but are rarely rewarded. They are mucheasier to implement when patient and caregiverhave clearly identified how and by whom followupwill be organized.A regular and trusted provider asentry pointComprehensiveness, continuity and person-centrednessare critical to better health outcomes.They all depend on a stable, long-term, personalrelationship (a feature also called“longitudinality” 84 ) between the population andthe professionals who are their entry point to thehealth system.Most ambulatory care in conventional settingsis not organized to build such relationships. The50

Chapter 3. Primary care: putting people firstbusy, anonymous and technical environment ofhospital outpatient departments, with their manyspecialists and sub-specialists, produce mechanicalinteractions between nameless individualsand an institution – not people-centred care.Smaller clinics are less anonymous, but the carethey provide is often more akin to a commercialor administrative transaction that starts andends with the consultation than to a responsiveproblem-solving exercise. In this regard, privateclinics do not perform differently than publichealth centres 64 . In the rural areas of low-incomecountries, governmental health centres are usuallydesigned to work in close relationship withthe community they serve. The reality is oftendifferent. Earmarking of resources and staff forselected programmes is increasingly leading tofragmentation 109 , while the lack of funds, thepauperization of the health staff and rampantcommercialization makes building such relationshipsdifficult 110 . There are many examples to thecontrary, but the relationship between providersand their clients, particularly the poorer ones, isoften not conducive to building relationships ofunderstanding, empathy and trust 62 .Building enduring relationships requires time.Studies indicate that it takes two to five yearsbefore its full potential is achieved 84 but, as theAlaska health centre mentioned at the beginningof this chapter shows, it drastically changes theway care is being provided. Access to the sameteam of health-care providers over time fostersthe development of a relationship of trustbetween the individual and their health-care provider97,111,112 . Health professionals are more likelyto respect and understand patients they knowBox 3.5 Using information and communication technologies to improve access, quality andeffi ciency in primary careInformation and communication technologies enable people in remote and underserved areas to have access to services and expertiseotherwise unavailable to them, especially in countries with uneven distribution or chronic shortages of physicians, nurses and healthtechnicians or where access to facilities and expert advice requires travel over long distances. In such contexts, the goal of improvedaccess to health care has stimulated the adoption of technology for remote diagnosis, monitoring and consultation. Experience in Chileof immediate transmission of electrocardiograms in cases of suspected myocardial infarction is a noteworthy example: examinationis carried out in an ambulatory setting and the data are sent to a national centre where specialists confi rm the diagnosis via fax ore-mail. This technology-facilitated consultation with experts allows rapid response and appropriate treatment where previously itwas unavailable. The Internet is a key factor in its success, as is the telephone connectivity that has been made available to all healthfacilities in the country.A further benefi t of using information and communication technologies in primary-care services is the improved quality of care. Healthcareproviders are not only striving to deliver more effective care, they are also striving to deliver safer care. Tools, such as electronichealth records, computerized prescribing systems and clinical decision aids, support practitioners in providing safer care in a rangeof settings. For example, in a village in western Kenya, electronic health records integrated with laboratory, drug procurement andreporting systems have drastically reduced clerical labour and errors, and have improved follow-up care.As the costs of delivering health care continue to rise, information and communication technologies provide new avenues for personalized,citizen-centred and home-centred care. Towards this end, there has been signifi cant investment in research and development ofconsumer-friendly applications. In Cape Town, South Africa, an “on cue compliance service” takes the names and mobile telephonenumbers of patients with tuberculosis (supplied by a clinic) and enters them into a database. Every half an hour, the on cue serverreads the database and sends personalized SMS messages to the patients, reminding them to take their medication. The technologyis low-cost and robust. Cure and completion rates are similar to those of patients receiving clinic-based DOTS, but at lower cost toboth clinic and patient, and in a way that interferes much less with everyday life than the visits to the clinic 106 . In the same concept ofsupporting lifestyles linked to primary care, network devices have become a key element of an innovative community programme inthe Netherlands, where monitoring and communication devices are built into smart apartments for senior citizens. This system reducesclinic visits and facilitates living independently with chronic diseases that require frequent checks and adjustment of medications.Many clinicians who want to promote health and prevent illness are placing high hopes in the Internet as the place to go for health adviceto complement or replace the need to seek the advice of a health professional. New applications, services and access to informationhave permanently altered the relationships between consumers and health professionals, putting knowledge directly into people’sown hands.51

The World Health Report 2008Primary Health Care – Now More Than EverTable 3.5 Regular entry point: evidence of itscontribution to quality of care and better outcomesIncreased satisfaction with services − Weiss (1996) 116 ,Rosenblatt (1998) 117 , Freeman (1997) 124 , Miller (2000) 125Better compliance and lower hospitalization rate − Weiss(1996) 116 , Rosenblatt (1998) 117 , Freeman (1997) 124 ,Mainous (1998) 126Less use of specialists and emergency services −Starfi eld (1998) 82 , Parchman (1994) 127 , Hurley (1989) 128 ,Martin (1989) 129 , Gadomski (1998) 130Fewer consultations with specialists − Hurley (1989) 128 ,Martin (1989) 129More effi cient use of resources − Forrest (1996) 82 ,Forrest (1998) 95 , Hjortdahl (1991) 131 , Roos (1998) 132Better understanding of the psychological aspects of apatient's problem − Gulbrandsen (1997) 55Better uptake of preventive care by adolescents − Ryan(2001) 133Protection against over-treatment − Schoen (2007) 134well, which creates more positive interaction andbetter communication 113 . They can more readilyunderstand and anticipate obstacles to continuityof care, follow up on the progress and assess howthe experience of illness or disability is affectingthe individual’s daily life. More mindful ofthe circumstances in which people live, they cantailor care to the specific needs of the person andrecognize health problems at earlier stages.This is not merely a question of building trustand patient satisfaction, however important thesemay be 114,115 . It is worthwhile because it leads tobetter quality and better outcomes (Table 3.5).People who use the same source of care for mostof their health-care needs tend to comply betterwith advice given, rely less on emergency services,require less hospitalization and are moresatisfied with care 98 116,117,118 . Providers save consultationtime, reduce the use of laboratory testsand costs 95,119,120 , and increase uptake of preventivecare 121 . Motivation improves through thesocial recognition built up by such relationships.Still, even dedicated health professionals will notseize all these opportunities spontaneously 122,123 .The interface between the population and theirhealth services needs to be designed in a way thatnot only makes this possible, but also the mostlikely course of action.Organizing primary-care networksA health service that provides entry point ambulatorycare for health- and health-related problemsshould, thus, offer a comprehensive rangeof integrated diagnostic, curative, rehabilitativeand palliative services. In contrast to most conventionalhealth-care delivery models, the offerof services should include prevention and promotionas well as efforts to tackle determinants ofill-health locally. A direct and enduring relationshipbetween the provider and the people in thecommunity served is essential to be able to takeinto account the personal and social context ofpatients and their families, ensuring continuityof care over time as well as across services.In order for conventional health services tobe transformed into primary care, i.e. to ensurethat these distinctive features get due prominence,they must reorganized. A preconditionis to ensure that they become directly and permanentlyaccessible, without undue reliance onout-of-pocket payments and with social protectionoffered by universal coverage schemes. Butanother set of arrangements is critical for thetransformation of conventional care – ambulatory-and institution-based, generalist andspecialist – into local networks of primary-carecentres 135,136,137,138,139,140 : bringing care closer to people, in settings inclose proximity and direct relationship withthe community, relocating the entry point tothe health system from hospitals and specialiststo close-to-client generalist primary-carecentres; giving primary-care providers the responsibilityfor the health of a defined population, in itsentirety: the sick and the healthy, those whochoose to consult the services and those whochoose not to do so; strengthening primary-care providers’ role ascoordinators of the inputs of other levels ofcare by giving them administrative authorityand purchasing power.52

Chapter 3. Primary care: putting people firstBringing care closer to the peopleA first step is to relocate the entry point to thehealth system from specialized clinics, hospitaloutpatient departments and emergency services,to generalist ambulatory care in close-to-clientsettings. Evidence has been accumulating thatthis transfer carries measurable benefits in termsof relief from suffering, prevention of illness anddeath, and improved health equity. These findingshold true in both national and cross-nationalstudies, even if all of the distinguishing featuresof primary care are not fully realized 31 .Generalist ambulatory care is more likely oras likely to identify common life-threateningconditions as specialist care 141,142 . Generalistsadhere to clinical practice guidelines to the sameextent as specialists 143 , although they are slowerto adopt them 144,145 . They prescribe fewer invasiveinterventions 146,147,148,149 , fewer and shorterhospitalizations 127,133,149 and have a greater focuson preventive care 133,150 . This results in loweroverall health-care costs 82 for similar healthoutcomes 146,151,152,153,154,155 and greater patientsatisfaction 125,150,156 . Evidence from comparisonsbetween high-income countries shows that higherproportions of generalist professionals workingin ambulatory settings are associated withlower overall costs and higher quality rankings 157 .Conversely, countries that increase reliance onspecialists have stagnating or declining healthoutcomes when measured at the populationFigure 3.4 Inappropriate investigations prescribed for simulated patientspresenting with a minor stomach complaint, Thailand a,b,162Patients for whom inappropriate investigations were prescribed (%)604020BiopsyX-rayGastroscopyGastroscopy + X-ray0Public health centre, Private clinic,general practitioner general practitioner(US $ 5.7) b (US $ 11.1) bPrivate clinic,specialist(US $ 16.4) bPublic hospital,outpatient departmentPrivate hospital,outpatient(US $15.2) b department (US $ 43.7) ba Observation made in 2000, before introduction of Thailand’s universal coverage scheme.b Cost to the patient, including doctor’s fees, drugs, laboratory and technical investigations.level, while fragmentation of care exacerbatesuser dissatisfaction and contributes to a growingdivide between health and social services 157,158,159 .Information on low- and middle-income countriesis harder to obtain 160 , but there are indicationsthat patterns are similar. Some studies estimatethat in Latin America and the Caribbean morereliance on generalist care could avoid one out oftwo hospital admissions 161 . In Thailand, generalistambulatory care outside a hospital contexthas been shown to be more patient-centred andresponsive as well as cheaper and less inclinedto over-medicalization 162 (Figure 3.4).The relocation of the entry point into the systemfrom specialist hospital to generalist ambulatorycare creates the conditions for more comprehensiveness,continuity and person-centredness.This amplifies the benefits of the relocation. Itis particularly the case when services are organizedas a dense network of small, close-to-clientservice delivery points. This makes it easier tohave teams that are small enough to know theircommunities and be known by them, and stableenough to establish an enduring relationship.These teams require relational and organizationalcapacities as much as the technical competenciesto solve the bulk of health problemslocally.Responsibility for a well-identifiedpopulationIn conventional ambulatory care, the providerassumes responsibility for the person attendingthe consultation for the duration of the consultationand, in the best of circumstances, thatresponsibility extends to ensuring continuity ofcare. This passive, response-to-demand approachfails to help a considerable number of people whocould benefit from care. There are people who,for various reasons, are, or feel, excluded fromaccess to services and do not take up care evenwhen they are in need. There are people who sufferillness but delay seeking care. Others presentrisk factors and could benefit from screening orprevention programmes (e.g. for cervical canceror for childhood obesity), but are left out becausethey do not consult: preventive services that arelimited to service users often leave out thosemost in need 163 . A passive, response-to-demand53

The World Health Report 2008Primary Health Care – Now More Than Everapproach has a second untoward consequence: itlacks the ambition to deal with local determinantsof ill-health – whether social, environmental orwork-related. All this represents lost opportunitiesfor generating health: providers that onlyassume responsibility for their customers concentrateon repairing rather than on maintainingand promoting health.The alternative is to entrust each primary-careteam with the explicit responsibility for a welldefinedcommunity or population. They can thenbe held accountable, through administrative measuresor contractual arrangements, for providingcomprehensive, continuous and person-centredcare to that population, and for mobilizing acomprehensive range of support services – frompromotive through to palliative. The simplestway of assigning responsibility is to identify thecommunity served on the basis of geographicalcriteria – the classic approach in rural areas. Thesimplicity of geographical assignment, however,is deceptive. It follows an administrative, publicsector logic that often has problems adapting tothe emergence of a multitude of other providers.Furthermore, administrative geography may notcoincide with sociological reality, especially inurban areas. People move around and may workin a different area than where they live, makingthe health unit closest to home actually an inconvenientsource of care. More importantly, peoplevalue choice and may resent an administrativeassignment to a particular health unit. Somecountries find geographical criteria of proximitythe most appropriate to define who fits in thepopulation of responsibility, others rely on activeregistration or patient lists. The important pointis not how but whether the population is wellidentified and mechanisms exist to ensure thatnobody is left out.Once such explicit comprehensive responsibilitiesfor the health of a well-identified and definedpopulation are assigned, with the related financialand administrative accountability mechanisms,the rules change. The primary-care team has to broaden theportfolio of care it offers, developing activitiesand programmes that can improve outcomes,but which they might otherwise neglect 164 . Thissets the stage for investment in prevention andpromotion activities, and for venturing intoareas that are often overlooked, such as healthin schools and in the workplace. It forces theprimary-care team to reach out to and workwith organizations and individuals within thecommunity: volunteers and community healthworkers who act as the liaison with patients oranimate grassroots community groups, socialworkers, self-help groups, etc.It forces the team to move out of the four wallsof their consultation room and reach out tothe people in the community. This can bringsignificant health benefits. For example, largescaleprogrammes, based on home-visits andcommunity animation, have been shown to beeffective in reducing risk factors for neonatalmortality and actual mortality rates. In theUnited States, such programmes have reducedneonatal mortality by 60% in some settings 165 .Part of the benefit is due to better uptake ofeffective care by people who would otherwiseremain deprived. In Nepal, for example, thecommunity dynamics of women’s groups ledto the better uptake of care, with neonatal andmaternal mortality lower than in control communitiesby 29% and 80%, respectively 166 .It forces the team to take targeted initiatives,in collaboration with other sectors, to reachthe excluded and the unreached and tacklebroader determinants of ill-health. As Chapter2 has shown, this is a necessary complement toestablishing universal coverage and one wherelocal health services play a vital role. The 2003heatwave in western Europe, for example,highlighted the importance of reaching out tothe isolated elderly and the dramatic consequencesof failing to do so: an excess mortalityof more than 50 000 people 167 .For people and communities, formal links withan identifiable source of care enhance the likelihoodthat long-term relationships will develop;that services are encouraged to pay more attentionto the defining features of primary care; andthat lines of communication are more intelligible.At the same time, coordination linkages can beformalized with other levels of care – specialists,hospitals or other technical services – and withsocial services.54

Chapter 3. Primary care: putting people firstThe primary-care team as a hubof coordinationPrimary-care teams cannot ensure comprehensiveresponsibility for their population withoutsupport from specialized services, organizationsand institutions that are based outside the communityserved. In resource-constrained circumstances,these sources of support will typicallybe concentrated in a “first referral level districthospital”. Indeed, the classic image of a healthcaresystem based on PHC is that of a pyramidwith the district hospital at the top and a set of(public) health centres that refer to the higherauthority.In conventional settings, ambulatory care professionalshave little say in how hospitals andspecialized services contribute – or fail to contribute– to the health of their patients, and feellittle inclination to reach out to other institutionsand stakeholders that are relevant to the healthof the local community. This changes if they areentrusted with responsibility for a defined populationand are recognized as the regular point ofentry for that population. As health-care networksexpand, the health-care landscape becomes farmore crowded and pluralistic. More resourcesallow for diversification: the range of specializedservices that comes within reach may includeemergency services, specialists, diagnosticinfrastructure, dialysis centres, cancer screening,environmental technicians, long-term careinstitutions, pharmacies, etc. This representsnew opportunities, provided the primary-careteams can assist their community in making thebest use of that potential, which is particularlycritical to public health, mental health and longtermcare 168 .The coordination (or gatekeeping) role thisentails effectively transforms the primary-carepyramid into a network, where the relationsbetween the primary-care team and the otherinstitutions and services are no longer based onlyon top-down hierarchy and bottom-up referral,but on cooperation and coordination (Figure 3.5).The primary-care team then becomes the mediatorbetween the community and the other levelsFigure 3.5 Primary care as a hub of coordination: networking within the community servedand with outside partners 173,174Specialized careDiabetes clinicTBcontrolcentreCommunitymentalhealth unitReferral formulti-drug resistanceReferral forcomplicationsConsultantsupportEmergencydepartmentTrafficaccidentPlacentapraeviaHospitalMaternityHerniaSurgeryDiagnostic servicesCTScanCytologylabDiagnostic supportPap smearsSelf-helpgroupLiaisoncommunityhealth workerPrimary-care team:continuous,comprehensive,person-centred careOtherOtherSocialservicesTrainingsupportTraining centreEnvironmentalhealth labSpecializedprevention servicesWaste disposalinspectionMammographyCancerscreeningcentreCommunityGenderviolenceWomen’sshelterAlcoholismAlcoholicsanonymousNGOs55

The World Health Report 2008Primary Health Care – Now More Than Everof the health system, helping people navigate themaze of health services and mobilizing the supportof other facilities by referring patients orcalling on the support of specialized services.This coordination and mediation role alsoextends to collaboration with other types oforganizations, often nongovernmental. Thesecan provide significant support to local primarycare. They can help ensure that people know whatthey are entitled to and have the information toavoid substandard providers 169,170 . Independentombudsman structures or consumer organizationscan help users handle complaints. Mostimportantly, there is a wealth of self-help andmutual support associations for diabet ics, peopleliving with handicaps and chronic diseases thatcan help people to help themselves 171 . In theUnited States alone, more than five million peoplebelong to mutual help groups while, in recentyears, civil society organizations dealing withhealth and health-related issues, from self-helpto patient’s rights, have been mushrooming inmany low- and middle-income countries. Thesegroups do much more than just inform patients.They help people take charge of their own situation,improve their health, cope better with illhealth,increase self-confidence and diminishover-medicalization 172 . Primary-care teams canonly be strengthened by reinforcing their linkageswith such groups.Where primary-care teams are in a positionto take on this coordinator role, their workbecomes more rewarding and attractive, whilethe overall effects on health are positive. Relianceon specialists and hospitalization is reduced byfiltering out unnecessary uptake, whereas patientdelay is reduced for those who do need referralcare, the duration of their hospitalization isshortened, and post-hospitalization follow-up isimproved 83,128,129 .The coordination function provides the institutionalframework for mobilizing across sectors tosecure the health of local communities. It is not anoptional extra but an essential part of the remit ofprimary-care teams. This has policy implications:coordination will remain wishful thinking unlessthe primary-care team has some form of eitheradministrative or financial leverage. Coordinationalso depends on the different institutions’recognition of the key role of the primary-careteams. Current professional education systems,career structure and remuneration mechanismsmost often give signals to the contrary. Reversingthese well-entrenched disincentives to primarycare requires strong leadership.Monitoring progressThe switch from conventional to primary care isa complex process that cannot be captured in asingle, universal metric. Only in recent years hasit been possible to start disentangling the effectsof the various features that define primary care.In part, this is because the identification of thefeatures that make the difference between primarycare and conventional health-care deliveryhas taken years of trial and error, and the instrumentsto measure them have not been generalized.This is because these features are never allput into place as a single package of reforms, butare the result of a gradual shaping and transformationof the health system. Yet, for all thiscomplexity, it is possible to measure progress, asa complement to the follow-up required for measuringprogress towards universal coverage.The first dimension to consider is the extentto which the organizational measures requiredto switch to primary care are being put intoplace. Is the predominant type of first-contact providerbeing shifted from specialists and hospitalsto generalist primary-care teams in closeproximity to where the people live? Are primary-care providers being maderesponsible for the health of all the members ofa well-identified population: those who attendhealth services and those who do not? Are primary-care providers being empoweredto coordinate the various inputs of specialized,hospital and social services, by strengtheningtheir administrative authority and purchasingpower?The second dimension to consider is the extentto which the distinctive features of primary careare gaining prominence. Person-centredness: is there evidence ofimprovement, as shown by direct observationand user surveys?56

Chapter 3. Primary care: putting people first Comprehensiveness: is the portfolio of primary-careservices expanding and becomingmore comprehensive, reaching the full essentialbenefits package, from promotion throughto palliation, for all age groups? Continuity: is information for individuals beingrecorded over the life-course, and transferredbetween levels of care in cases of referral andto a primary-care unit elsewhere when peoplerelocate? Regular entry point: are measures taken toensure that providers know their clients andvice versa?This should provide the guidance to policy-makersas to the progress they are making with the transformationof health-care delivery. However, theydo not immediately make it possible to attributehealth and social outcomes to specific aspects ofthe reform efforts. In order to do so, the monitoringof the reform effort needs to be complementedwith a much more vigorous research agenda. It isrevealing that the Cochrane Review on strategiesfor integrating primary-health services in lowandmiddle-income countries could identify onlyone valid study that took the user’s perspectiveinto account 160 . There has been a welcome surgeof research on primary care in high-income countriesand, more recently, in the middle-incomecountries that have launched major PHC reforms.Nevertheless, it is remarkable that an industrythat currently mobilizes 8.6% of the world’s GDPinvests so little in research on two of its mosteffective and cost-effective strategies: primarycare and the public policies that underpin andcomplement it.References1. People at the centre of health care: harmonizing mind and body, people and systems.New Delhi, World Health Organization Regional Offi ce for South-East Asia, Manila,World Health Organization Regional Offi ce for the Western Pacifi c, 2007.2. Osler W. Aequanimitas. Philadelphia PA, Blakiston, 1904.3. Eby D. 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Public policiesfor the public’s healthPublic policies in the health sector, together withthose in other sectors, have a huge potential tosecure the health of communities. They represent an importantcomplement to universal coverage andservice delivery reforms. Unfortunately,in most societies, this potential is largelyuntapped and failures to effectivelyengage other sectors are widespread.Looking ahead at the diverse range ofchallenges associated with the growingimportance of ageing, urbanization andthe social determinants of health, thereis, without question, a need for a greatercapacity to seize this potential. That is why a drive for betterpublic policies – the theme of this chapter – forms a thirdpillar supporting the move towards PHC, along with universalcoverage and primary care.Chapter 4The importance of effectivepublic policies for health64System policies that arealigned with PHC goals66Public-health policies 67Towards healthin all policies69Understanding theunder-investment71Opportunities forbetter public policies7363

The World Health Report 2008Primary Health Care – Now More Than EverThe chapter reviews the policies that must be inplace. These are: systems policies – the arrangements that areneeded across health systems’ building blocksto support universal coverage and effectiveservice delivery; public-health policies – the specific actionsneeded to address priority health problemsthrough cross-cutting prevention and healthpromotion; and policies in other sectors – contributions tohealth that can be made through intersectoralcollaboration.The chapter explains how these different publicpolicies can be strengthened and aligned withthe goals pursued by PHC.The importance of effective publicpolicies for healthPeople want to live in communities and environmentswhich secure and promote their health 1 .Primary care, with universal access and socialprotection represent key responses to theseexpectations. People also expect their governmentsto put into place an array of public policiesthat span local through to supra-national levelarrangements, without which primary care anduniversal coverage lose much of their impact andmeaning. These include the policies required tomake health systems function properly; to organizepublic-health actions of major benefit to all;and, beyond the health sector, the policies thatcan contribute to health and a sense of security,while ensuring that issues, such as urbanization,climate change, gender discrimination or socialstratification are properly addressed.A first group of critical public policies arethe health systems policies (related to essentialdrugs, technology, quality control, humanresources, accreditation, etc.) on which primarycare and universal coverage reforms depend.Without functional supply and logistics systems,for example, a primary-care network cannotfunction properly: in Kenya, for example, childrenare now much better protected against malariaas a result of local services providing them withinsecticide-treated bednets 2 . This has only beenpossible because the work of primary care wassupported by a national initiative with strongpolitical commitment, social marketing andnational support for supply and logistics.Effective public-health policies that addresspriority health problems are a second group withoutwhich primary care and universal coveragereforms would be hindered. These encompass thetechnical policies and programmes that provideguidance to primary-care teams on how to dealwith priority health problems. They also encompassthe classical public-health interventions,from public hygiene and disease prevention tohealth promotion. Some interventions, such asthe fortification of salt with iodine, are only feasibleat the regional, national or, increasingly atsupra-national level. This may be because it isonly at those levels that there is the necessaryauthority to decide upon such policies, or becauseit is more efficient to develop and implementsuch policies on a scale that is beyond the localdimensions of primary-care action. Finally, publicpolicies encompass the rapid response capacity,in command-and-control mode, to deal withacute threats to the public’s health, particularlyepidemics and catastrophes. The latter is of theutmost political importance, because failuresprofoundly affect the public’s trust in its healthauthorities. The lack of preparedness and uncoordinatedresponses of both the Canadian andthe Chinese health systems to the outbreak ofSARS in 2003, led to public outcries and eventuallyto the establishment of a national publichealth agency in Canada. In China, a similar lackof preparedness and transparency led to a crisisin confidence – a lesson learned in time for subsequentevents 3,4 .The third set of policies that is of critical concernis known as “health in all policies”, which isbased on the recognition that population healthcan be improved through policies that are mainlycontrolled by sectors other than health 5 . Thehealth content of school curricula, industry’spolicy towards gender equality, or the safetyof food and consumer goods are all issues thatcan profoundly influence or even determine thehealth of entire communities, and that can cutacross national boundaries. It is not possible toaddress such issues without intensive intersectoralcollaboration that gives due weight to healthin all policies.64

Chapter 4. Public policies for the public’s healthBetter public policies can make a differencein very different ways. They can mobilize thewhole of society around health issues, as in Cuba(Box 4.1). They can provide a legal and social environmentthat is more or less favourable to healthoutcomes. The degree of legal access to abortion,for example, co-determines the frequencyand related mortality of unsafe abortion 6 . InSouth Africa, a change in legislation increasedwomen’s access to a broad range of options forthe prevention and treatment of unwanted pregnancy,resulting in a 91% drop in abortion-relateddeaths 7 . Public policies can anticipate futureproblems. In Bangladesh, for example, the deathtoll due to high intensity cyclones and floodingwas 240 000 people in 1970. With emergency preparednessand multisectoral risk reduction programmes,the death toll of comparable or moresevere storms was reduced to 138 000 people in1991 and 4500 people in 2007 8,9,10 .In the 23 developing countries that comprise80% of the global chronic disease burden, 8.5million lives could be saved in a decade by a 15%dietary salt reduction through manufacturersvoluntarily reducing salt content in processedfoods and a sustained mass-media campaignencouraging dietary change. Implementation offour measures from the Framework Conventionon Tobacco Control (increased tobacco taxes;Figure 4.1 Deaths attributable to unsafe abortion per 100 000 live births,by legal grounds for abortion a,12,13> 200200150100500To savethewomen’slife only,or no groundsAlso topreservehealthAlso incasesof rapeorincestAlso in Also forcases economicof fetal orimpairmentsocialreasonsAlso on requestsmoke-free workplaces; convention-compliantpackaging, labelling and awareness campaignsabout health risks; and a comprehensive advertising,promotion, and sponsorship ban) couldsave a further 5.5 million lives in a decade 11 . As isoften the case when considering social, economicand political determinants of ill-health, improvementsare dependent on a fruitful collaborationbetween the health sector and a variety of othersectors.Box 4.1 Rallying society’s resources forhealth in Cuba 14,15,16In Cuba, average life expectancy at birth is the second highestin the Americas: in 2006, it was 78 years, and only 7.1 per1000 children died before the age of fi ve. Educational indicatorsfor young children are among the best in Latin America.Cuba has achieved these results despite signifi cant economicdiffi culties – even today, GDP per capita is only I$ 4500. Cuba’ssuccess in ensuring child welfare refl ects its commitment tonational public-health action and intersectoral action.The development of human resources for health has been anational priority. Cuba has a higher proportion of doctors inthe population than any other country. Training for primarycare gives specifi c attention to the social determinants ofhealth. They work in multidisciplinary teams in comprehensiveprimary-care facilities, where they are accountable for thehealth of a geographically defi ned population providing bothcurative and preventive services. They work in close contactwith their communities, social services and schools, reviewingthe health of all children twice a year with the teachers.They also work with organizations such as the Federation ofCuban Women (FMC) and political structures. These contactsprovide them with the means to act on the social determinantsof health within their communities.Cuban national policy has also prioritized investing in earlychild development. There are three non-compulsory preschooleducation programmes, which together are taken upby almost 100% of children under six years of age. In theseprogrammes, screening for developmental disorders facilitatesearly intervention. Children who are identifi ed with specialneeds, and their families, receive individual attention throughmultidisciplinary teams that contain both health and educationalspecialists. National policy in Cuba has not succumbedto a false choice between investing in the medical workforceand acting on the social determinants of health. Instead, it haspromoted intersectoral cooperation to improve health througha strong preventive approach. In support of this policy, a largeworkforce has been trained to be competent in clinical care,working as an active part of the community it serves.aEvery dot represents one country.65

The World Health Report 2008Primary Health Care – Now More Than EverSystem policies that arealigned with PHC goalsThere is growing awareness that when parts ofthe health system malfunction, or are misaligned,the overall performance suffers. Referred to variouslyas “core functions” 17 or “building blocks” 18 ,the components of health systems include infrastructure,human resources, information, technologiesand financing – all with consequencesfor the provision of services. These componentsare not aligned naturally or simply with theintended direction of PHC reforms that promoteprimary care and universal coverage: to obtainthat alignment requires deliberate and comprehensivepolicy arrangements.Experience in promoting essential medicineshas shed light on both the opportunities andobstacles to effective systems policies for PHC.Since the WHO List of Essential Medicines wasestablished in 1977, it has become a primarystimulus to the development of national medicinespolicies. Over 75% of the 193 WHO MemberStates now claim to have a national list of essentialmedicines, and over 100 countries have developeda national medicine policy. Surveys revealthat these policies have been effective in makinglower cost and safer medicines available andmore rationally used 19,20 . This particular policyhas been successfully designed to support PHC,and it offers lessons on how to handle cross-cuttingchallenges of scale efficiencies and systemsco-dependence. Without such arrangements,the health costs are enormous: nearly 30 000children die every day from diseases that couldeasily have been treated if they had had accessto essential medicines 21 .Medicines policies are indicative of how efficienciesin the scale of organization can be tapped.Safety, efficacy and quality of care have universalproperties that make them amenable to globallyagreed international standards. Adoption andadaptation of these global standards by nationalauthorities is much more efficient than eachcountry inventing its own standards. Nationaldecision-making and purchasing mechanismscan then guide rational, cost-effectiveness-basedselection of medicines and reduce costs throughbulk purchase. For example, Figure 4.2 showshow centralized oversight of drug purchasingand subsidization in New Zealand significantlyimproved access to essential medicines whilelowering the average prescription price. On alarger scale, transnational mechanisms, such asUNICEF’s international procurement of vaccines,PAHO’s Revolving Fund and the Global DrugFacility for tuberculosis treatment, afford considerablesavings as well as quality assurancesthat countries on their own would be unlikely tonegotiate 22,23,24,25 .A second key lesson of experience with essentialdrugs policies is that a policy cannot existas an island and expect to be effectively implemented.Its formulation must identify those othersystems elements, be they financing, information,infrastructure or human resources, upon whichits implementation is dependent. Procurementmechanisms for pharmaceuticals, for example,raise important considerations for systems financingpolicies: they are interdependent. Likewise,human resources issues related to the educationof consumers as well as the training and workingconditions of providers are likely to be keydeterminants of the rational use of drugs.Systems policies for human resources havelong been a neglected area and one of the mainconstraints to health systems development 27 . Therealization that the health MDGs are contingenton bridging the massive health-worker shortfallin low-income countries has brought long overdueattention to a previously neglected area. Furthermore,the evidence of increasing dependence onmigrant health workers to address shortages inOECD countries underlines the fact that one country’spolicies may have a significant impact onanother’s. The choices countries make – or fail toFigure 4.2 Annual pharmaceutical spending and number of prescriptionsdispensed in New Zealand since the Pharmaceutical ManagementAgency was convened in 1993 26Net expenditure (NZ$, millions)700600500400300200100Average costper prescription:NZ$ 24.3Prescriptions (millions)35Average costper prescription:NZ$ 19.0001993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20073025201510566

Chapter 4. Public policies for the public’s healthmake – can have major long-term consequences.Human resources for health are the indispensableinput to effective implementation of primarycare and universal coverage reforms, and theyare also the personification of the values thatdefine PHC. Yet, in the absence of a deliberatechoice to guide the health workforce policy by thePHC goals, market forces within the health-caresystem will drive health workers towards greatersub-specialization in tertiary care institutions,if not towards migration to large cities or othercountries. PHC-based policy choices, on the otherhand, focus on making staff available for theextension of coverage to underserved areas anddisadvantaged population groups, as with Malaysia’sscaling up of 11 priority cadres of workers,Ethiopia’s training of 30 000 Health ExtensionWorkers, Zambia’s incentives to health workersto serve in rural areas, the 80 000 Lady HealthWorkers in Pakistan, or the task shifting for thecare of HIV patients. These policies direct investmentstowards the establishment of the primarycareteams that are to be the hub of the PHCbasedhealth system: the 80 000 health workersfor Brazil’s 30 000 Family Health Teams or theretraining of over 10 000 nurses and physiciansin Turkey. Furthermore, these policies requireboth financial and non-financial incentives tocompete effectively for scarce human resources,as in the United Kingdom, where measures havebeen taken to make a career in primary carefinancially competitive with specialization.The core business of ministries of healthand other public authorities is to put into place,across the various building blocks of the healthsystem, the set of arrangements and mechanismsrequired to meet their health goals. When acountry chooses to base its health systems onPHC – when it starts putting into place primarycare and universal coverage reforms – its wholearsenal of system policies needs to be alignedbehind these reforms: not just those pertainingto service delivery models or financing. It is possibleto develop system policies that do not takeaccount of the PHC agenda. It is also possible tochoose to align them to PHC. If a country optsfor PHC, effective implementation allows no halfmeasures; no health systems building block willbe left untouched.Public-health policiesAligning priority health programmeswith PHCMuch action in the health sector is marshalledaround specific high-burden diseases, such asHIV/AIDS, or stages of the life course such aschildren – so-called priority health conditions.The health programmes that are designed aroundthese priorities are often comprehensive insofaras they set norms, ensure visibility and qualityassurance, and entail a full range of entrypoints to address them locally or at the level ofcountries or regions. Responses to these priorityhealth conditions can be developed in ways thateither strengthen or undercut PHC 28 .In 1999 for example, the Primary Care Departmentof the Brazilian Paediatrics Society (SBP)prepared a plan to train its members in the IntegratedManagement of Childhood Illness (IMCI)and to adapt this strategy to regional epidemiologicalcharacteristics 29 . Despite conducting aninitial training course, the SBP then warnedpaediatricians that IMCI was not a substitute fortraditional paediatric care and risked breachingthe basic rights of children and adolescents. In anext step, it objected to the delegation of tasks tothe nurses, who are part of the multidisciplinaryfamily health teams, the backbone of Brazil’s PHCpolicy. Eventually, the SBP attempted to reclaimchild and adolescent care as the exclusive domainof paediatricians with the argument that thisensured the best quality of care.Experience with priority health programmesshows that the way they are designed makes thedifference: trying to construct an entire set ofPHC reforms around the unique requirementsof a single disease leads to considerable inefficiencies.Yet, the reverse is equally true. WhileAIDS has been referred to as a metaphor for allthat ails health systems and the wider society 30 ,the global response to the HIV pandemic can, inmany respects, also be viewed as a pathfinder forPHC. From the start, it has had a strong rightsbasedand social justice foundation 31 . Its links tooften marginalized and disadvantaged high-riskconstituencies, and concerns about stigma, haveled to concerted efforts to secure their rights andentitlements to employment, social services and67

The World Health Report 2008Primary Health Care – Now More Than Everhealth care. Efforts to scale-up services to conformto the goals of universal access have helpedto expose the critical constraints deriving fromthe workforce crisis. The challenge of providinglife-long treatment in resource-constrainedsettings has inspired innovations, such as moreeffective deployment of scarce human resourcesvia “task shifting”, the use of “patient advocates” 32 ,and the unexpected implementation of electronichealth records. Most importantly, the adoptionof a continuum of care approaches for HIV/AIDSfrom prevention to treatment to palliation hashelped to revive and reinforce core features ofprimary care, such as comprehensiveness, continuityand person-centredness 32 .Countrywide public-health initiativesWhile it is essential that primary-care teamsseek to improve the health of populations at locallevel, this may be of limited value if national- andglobal-level policy-makers fail to take initiativesfor broader, public policy measures, which areimportant in changing nutrition patterns andinfluencing the social determinants of health.These can rarely be implemented only in thecontext of local policies. Classical areas in whichbeyond-local-scale public-health interventionsmay be beneficial include: altering individualbehaviours and lifestyles; controlling and preventingdisease; tackling hygiene and the broaderdeterminants of health; and secondary prevention,including screening for disease 33 . Thisincludes measures such as the fortification ofbread with folate, taxation of alcohol and tobacco,and ensuring the safety of food, consumer goodsand toxic substances. Such national- and transnational-scalepublic-health interventions have thepotential to save millions of lives. The successfulremoval of the major risk factors of disease,which is technically possible, would reduce prematuredeaths by an estimated 47% and increaseglobal healthy life expectancy by an estimated 9.3years 34 . However, as is the case for the priorityprogrammes discussed above, the correspondingpublic-health policies must be designed so as toreinforce the PHC reforms.Not all such public-health interventions willimprove, for example, equity. Health promotionefforts that target individual risk behaviours,such as health education campaigns aimed atsmoking, poor nutrition and sedentary lifestyles,have often inadvertently exacerbated inequities.Socioeconomic differences in the uptake of onesize-fits-allpublic-health interventions have, attimes, not only resulted in increased health inequities,but also in victim-blaming to explain thephenomenon 35 . Well-designed public-health policiescan, however, reduce inequities when theyprovide health benefits to entire populations orwhen they explicitly prioritize groups with poorhealth 36 . The evidence base for privileging publicpolicies that reduce inequities is increasing, mostnotably through the work of the Commission onSocial Determinants of Health (Box 4.2) 37 .Rapid response capacityWhile PHC reforms emphasize the importanceof participatory and deliberative engagement ofdiverse stakeholders, humanitarian disastersor disease outbreaks demand a rapid responsecapacity that is crucial in dealing effectively withthe problem at hand and is an absolute imperativein maintaining the trust of the populationin their health system. Invoking quarantines ortravel bans, rapidly sequencing the genome ofa new pathogen to inform vaccine or therapeuticdesign, and mobilizing health workers andinstitutions without delay can be vital. While theadvent of an “emergency” often provides the necessarygood will and flexibility of these diverseactors to respond, an effective response is morelikely if there have been significant investmentsin preparedness 38 .Global efforts related to the threat of pandemicavian influenza (H5N1) provide a number ofinteresting insights into how policies that informpreparedness and response could be guided bythe values of PHC related to equity, universalcoverage and primary-care reforms. In dealingwith seasonal and pandemic influenza, 116national influenza laboratories, and five internationalcollaborating centre laboratories shareinfluenza viruses in a system that was started byWHO over 50 years ago. The system was implementedto identify new pandemic virus threatsand inform the optimal annual preparation of aseasonal influenza vaccine that is used primarilyby industrialized countries. With the primarily68

Chapter 4. Public policies for the public’s healthBox 4.2 Recommendations of theCommission on Social Determinants ofHealth 37The Commission on Social Determinants of Health (CSDH)was a three-year effort begun in 2005 to provide evidencebasedrecommendations for action on social determinants toreduce health inequities. The Commission accumulated anunprecedented collection of material to guide this process,drawing from theme-based knowledge networks, civil societyexperiences, country partners and departments within WHO.The fi nal report of the CSDH contains a detailed series ofrecommendations for action, organized around the followingthree overarching recommendations.1. Improve daily living conditionsKey improvements required in the well-being of girls andwomen; the circumstances in which their children are born,early child development and education for girls and boys; livingand working conditions; social protection policy; and conditionsfor a fl ourishing older life.2. Tackle the inequitable distribution of power, money andresourcesTo address health inequities it is necessary to address inequitiesin the way society is organized. This requires a strongpublic sector that is committed, capable and adequatelyfi nanced. This in turn requires strengthened governanceincluding stronger civil society and an accountable privatesector. Governance dedicated to pursuing equity is requiredat all levels.3. Measure and understand the problem and assess the impactof actionIt is essential to acknowledge the problem of health inequityand ensure that it is measured – both within countries andglobally. National and global health equity surveillance systemsfor routine monitoring of health inequity and the social determinantsof health are required that also evaluate the healthequity impact of policy and action. Other requirements are thetraining of policy-makers and health practitioners, increasedpublic understanding of social determinants of health, and astronger social determinants focus in research.developing country focus of human zoonoticinfections and the spectre of a global pandemicassociated with H5N1 strains of influenza, theinterest in influenza now extends to developingcountries, and the long-standing public-privateapproach to influenza vaccine production andvirus sharing has come under intense scrutiny.The expectation of developing countries for equitableaccess to protection, including affordableaccess to anti-virals and vaccines in the event of apandemic, is resulting in changes to national andglobal capacity strengthening: from surveillanceand laboratories to capacity transfer for vaccineformulation and production, and capacity forstock-piling. Thus, the most equitable responseis the most effective response, and the most effectiverapid response capacity can only emergefrom the engagement of multiple stakeholders inthis global process of negotiation.Towards health in all policiesThe health of populations is not merely a productof health sector activities – be they primary-careaction or countrywide public-health action. It isto a large extent determined by societal and economicfactors, and hence by policies and actionsthat are not within the remit of the health sector.Changes in the workplace, for example, can havea range of consequences for health (Table 4.1).Confronted with these phenomena, the healthauthorities may perceive the sector as powerlessto do more than try to mitigate the consequences.It cannot, of itself, redefine labour relations orunemployment arrangements. Neither can itincrease taxes on alcohol, impose technicalnorms on motor vehicles or regulate rural migrationand the development of slums – although allthese measures can yield health benefits. Goodurban governance, for example, can lead to 75years or more of life expectancy, against as fewas 35 years with poor governance 39 . Thus, it isimportant for the health sector to engage withother sectors, not just in order to obtain collaborationon tackling pre-identified priority healthproblems, as is the case for well-designed publichealthinterventions, but to ensure that health isrecognized as one of the socially valued outcomesof all policies.Such intersectoral action was a fundamentalprinciple of the Alma-Ata Declaration. However,ministries of health in many countries have struggledto coordinate with other sectors or wieldinfluence beyond the health system for whichthey are formally responsible. A major obstacleto reaping the rewards of intersectoral action hasbeen the tendency, within the health sector, to seesuch collaboration as “mostly symbolic in tryingto get other sectors to help [health] services” 40 .Intersectoral action has often not concentrated69

The World Health Report 2008Primary Health Care – Now More Than EverTable 4.1 Adverse health effects of changing work circumstances 5Adverse health effectsof unemploymentElevated blood pressureIncreased depression andanxietyIncreased visits to generalpractitionersIncreased symptoms ofcoronary diseaseWorse mental health andgreater stressIncreased psychologicalmorbidity and increasedmedical visitsDecreased self-reportedhealth status and anincrease in the number ofhealth problemsIncrease in familyproblems, particularlyfi nancial hardshipsAdverse health effects ofrestructuringReduced job satisfaction, reducedorganizational commitment andgreater stressFeelings of unfairness indownsizing processSurvivors face new technologies,work processes, new physicaland psychological exposures(reduced autonomy, increasedwork intensity, changes inthe characteristics of socialrelationships, shifts in theemployment contracts andchanges in personal behaviour)Changes in the psychologicalcontract and lost sense of trustProlonged stress withphysiological and psychologicalsignsAdverse health effects of non-standardwork arrangementsHigher rates of occupational injury and disease thanworkers with full-time stable employmentHigh level of stress, low job satisfaction and othernegative health and well-being factorsMore common in distributive and personal servicesub-sectors where people in general have lowereducational attainment and low skill levelsLow entitlement to workers’ compensation and lowlevel of claims by those who are coveredIncreased occupational health hazards due to workintensifi cation motivated by economic pressuresInadequate training and poor communication causedby institutional disorganization and inadequateregulatory controlInability of workers to organize their own protectionCumulative trauma claims are diffi cult to show dueto mobility of workersReduced ability to improve life conditions due toinability to obtain credit, fi nd housing, make pensionarrangements, and possibility for trainingFewer concerns for environmental issues and healthand safety at workon improving the policies of other sectors, buton instrumentalizing their resources: mobilizingteachers to contribute to the distributionof bednets, police officers to trace tuberculosistreatment defaulters, or using the transport ofthe department of agriculture for the emergencyevacuation of sick patients.A “whole-of-government approach”, aiming for“health in all policies” follows a different logic 41,42 .It does not start from a specific health problemand look at how other sectors can contribute tosolving them – as would be the case, for example,for tobacco-related disease. It starts by lookingat the effects of agricultural, educational, environmental,fiscal, housing, transport and otherpolicies on health. It then seeks to work withthese other sectors to ensure that, while contributingto well-being and wealth, these policiesalso contribute to health 5 .Other sector’s public policies, as well as privatesector policies, can be important to healthin two ways. Some may lead to adverse consequences forhealth (Table 4.1). Often such adverse consequencesare identified retrospectively, as in thecase of the negative health effects of air pollutionor industrial contamination. Yet, it is alsooften possible to foresee them or detect themat an early stage. Decision-makers in othersectors may be unaware of the consequences70

Chapter 4. Public policies for the public’s healthof the choices they are making, in which caseengagement, with due consideration for theother sectors’ goals and objectives, may thenbe the first step in minimizing the adversehealth effects.Public policies developed by other sectors –education, gender equality and social inclusion– may positively contribute to health in waysthat these other sectors are equally unawareof. They may be further enhanced by morepurposefully pursuing these positive healthoutcomes, as an integral part of the policy. Forexample, a gender equality policy, developedin its own right, may produce health benefits,often to a degree that the proponents of thepolicy underestimate. By collaborating to givemore formal recognition to these outcomes, thegender equality policy itself is reinforced, andthe synergies enhance the health outcomes.In that case, the objective of intersectoral collaborationis to reinforce the synergies.Failing to collaborate with other sectors is notwithout its consequences. It affects the performanceof health systems and, particularly, primarycare. For example, Morocco’s trachomaprogramme relied both on high levels of communitymobilization and on effective collaborationwith the ministries of education, interior andlocal affairs. That collaboration has been the keyto the successful elimination of trachoma 43 . Incontrast, the same country’s tuberculosis controlprogramme failed to link up with urban developmentand poverty reduction efforts and, as aresult, its performance has been disappointing 44 .Both were administered by the same Ministry ofHealth, by staff with similar capacities workingunder similar resource constraints, but with differentstrategies.Failing to collaborate with other sectors hasanother consequence, which is that avoidable illhealthis not avoided. In the NGagne Diaw quarterof Thiaroye-sur-Mer, Dakar, Senegal, peoplemake a living from the informal recycling of leadbatteries. This was of little concern to the authoritiesuntil an unexplained cluster of child deathsprompted an investigation. The area was found tobe contaminated with lead, and the siblings andmothers of the dead children were found to haveextremely high concentrations of lead in theirblood. Now, major investments are required todeal with the health and social consequencesand to decontaminate the affected area, includingpeople’s homes. Before the cluster of deathsoccurred, the health sector had, unfortunately,not considered it a priority to work with othersectors to help to avoid this situation 45 .Where intersectoral collaboration is successful,the health benefits can be considerable, althoughdeaths avoided are less readily noticed than liveslost. For example, pressure from civil society andprofessionals led to the development, in France, ofa multi-pronged, high-profile strategy to improveroad safety as a social and political issue that hadto be confronted (and not primarily as a healthsector issue). Various sectors worked together in asustained effort, with high-level political endorsement,to reduce road-traffic accidents, withhighly publicized monitoring of progress and areduction in fatalities of up to 21% per year 46 .The health and health equity benefits of workingtowards health in all policies have become apparentin programmes such as “Healthy Cities andMunicipalities”, “Sustainable Cities”, and “CitiesWithout Slums”, with integrated approaches thatrange from engagement in budget hearings andsocial accountability mechanisms to data gatheringand environmental intervention 47 .In contemporary societies, health tends tobecome fragmented into various sub-institutionsdealing with particular aspects of healthor health systems, while the capacity to assemblethe various aspects of public policy that jointlydetermine health is underdeveloped. Even in thewell-resourced context of, for example, the EuropeanUnion, the institutional basis for doing thisremains poorly developed 48 . Ministries of healthhave a vital role to play in creating such a basis,which is among the key strategies for makingheadway in tackling the socioeconomic determinantsof ill-health 49 .Understanding the under-investmentDespite the benefits and low relative cost of betterpublic policies, their potential remains largelyunderutilized across the world. One high-profileexample is that only 5% of the world’s populationlive in countries with comprehensive tobacco71

The World Health Report 2008Primary Health Care – Now More Than Everadvertising, promotion and sponsorship bans,despite their proven efficacy in reducing healththreats, which are projected to claim one billionlives this century 50 .The health sector’s approach to improving publicpolicies has been singularly unsystematic andguided by patchy evidence and muddled decisionmaking– not least because the health communityhas put so little effort into collating andcommunicating these facts. For all the progressthat has been made in recent years, informationon the effectiveness of interventions to redress,for example, health inequities is still hard to comeby and, when it is available, it is confined to aprivileged circle of concerned experts. A lackof information and evidence is, thus, one of theexplanations for under-investment.Box 4.3 How to make unpopular public policy decisions 51The Seventh Futures Forum of senior health executives organized by the World Health Organization’s Regional Offi ce for Europe in2004 discussed the diffi culties decision-makers can have in tackling unpopular policy decisions. A popular decision is usually one thatresults from broad public demand; an unpopular decision does not often respond to clearly expressed public expectations, but is madebecause the minister or the chief medical offi cer knows it is the right action to bring health gains and improve quality. Thus, a potentiallyunpopular decision should not seek popularity but, rather, efforts must be made to render it understandable and, therefore, acceptable.Making decisions more popular is not an academic exercise but one that deals with actual endorsement. When a decision is likely to beunpopular, participants in the Forum agreed that it is advisable for health executives to apply some of the following approaches.Talk about health and quality improvement. Health is the core area of expertise and competence, and the explanations of how thedecision will improve the quality of health and health services should therefore come fi rst. Avoiding non-health arguments that arediffi cult to promote may be useful – for instance, in the case of hospital closures, it is much better to talk about improving quality ofcare than about containing costs.Offer compensation. Explain what people will receive to balance what they will have to give up. Offer some gains in other sectors or inother services; work to make a win-win interpretation of the coming decision by balancing good and bad news.Be strong on implementation. If health authorities are not ready to implement the decision, they should refrain from introducing it untilthey are ready to do so.Be transparent. Explain who is taking the decision and the stakes of those involved and those who are affected. Enumerate all thestakeholders and whether they [are] involved negatively.Avoid one-shot decisions. Design and propose the decisions as part of an overall plan or strategy.Ensure good timing. Before making a decision, it is essential to take enough time to prepare and develop a good plan. When the planis ready, the best choice may be to act quickly for implementation.Involve all groups. Bring into the discussion both the disadvantaged groups and the ones who will benefi t from the decision. Diversifythe approach.Do not expect mass-media support solely because the decision is the right one from the viewpoint of health gains. The mass mediacannot be expected to be always neutral or positive; they may often be brought into the debate by the opponents of the decision. Beprepared to face problems with the press.Be modest. Acceptability of the decision is more likely when decision-makers acknowledge in public that there is some uncertaintyabout the result and they commit openly to monitoring and evaluating the outcomes. This leaves the door open for adjustments duringthe process of implementation.Be ready for quick changes. Sometimes the feelings of the public change quickly and what was perceived as opposition can turn intoacceptance.Be ready for crisis and unexpected side-effects. Certain groups of populations can be especially affected by a decision (such as generalpractitioners in the case of hospital closures). Public-health decision-makers have to cope with reactions that were not planned.Stick to good evidence. Public acceptance may be low without being based on any objective grounds. Having good facts is a good wayto shape the debate and avoid resistance.Use examples from other countries. Decision-makers may look at what is being done elsewhere and explain why other countries dealwith a problem differently; they can use such arguments to make decisions more acceptable in their own country.Involve health professionals and, above all, be courageous.72

Chapter 4. Public policies for the public’s healthThe fact is, however, that even for wellinformedpolitical decision-makers, many publicpolicy issues have a huge potential for unpopularity:whether it is reducing the number of hospitalbeds, imposing seatbelts, culling poultry ortaxing alcohol, resistance is to be expected andcontroversy an everyday occurrence. Other decisionshave so little visibility, e.g. measures thatensure a safe food production chain, that theyoffer little political mileage. Consensus on sternmeasures may be easy to obtain at a momentof crisis, but public opinion has a notoriouslyshort attention span. Politicians often pay moreattention to policies that produce benefits withinelectoral cycles of two to four years and, therefore,undervalue efforts where benefits, such asthose of environmental protection or early childdevelopment, accrue over a time span of 20 to 40years. If unpopularity is one intractable disincentiveto political commitment, active oppositionfrom well-resourced lobbies is another. An obviousexample is the tobacco industry’s efforts tolimit tobacco control. Similar opposition is seento the regulation of industrial waste and to themarketing of food to children. These obstaclesto steering public policy are real and need to bedealt with in a systematic way (Box 4.3).Compounding these disincentives to politicalcommitment is the difficulty of coordinatingoperations across multiple institutions and sectors.Many countries have limited institutionalcapacity to do so and, very often, do not haveenough capable professionals to cope with thework involved. Crisis management, short-termplanning horizons, lack of understandableevidence, unclear intersectoral arrangements,vested interests and inadequate modes of governingthe health sector reinforce the need for comprehensivepolicy reforms to realize the potentialof public-health action. Fortunately, there arepromising opportunities to build upon.Opportunities for better publicpoliciesBetter information and evidenceAlthough there are strong indications that thepotential gains from better public policies areenormous, the evidence base on their outcomesand on their cost-effectiveness is surprisinglyweak 52 . We know much about the relationshipbetween certain behaviours – smoking, diet,exercise, etc. – and health outcomes, but muchless about how to effect behavioural change in asystematic and sustainable way at population levels.Even in well-resourced contexts, the obstaclesare many: the time-scale in achieving outcomes;the complexity of multifactorial disease causationand intervention effects; the lack of data; themethodological problems, including the difficultiesin applying the well-accepted criteria usedin the evaluation of clinical methods; and thedifferent perspectives of the multiple stakeholdersinvolved. Infectious disease surveillance isimproving, but information on chronic diseasesand their determinants or on health inequities ispatchy and often lacks systematic focus. Even theelementary foundations for work on populationhealth and the collection of statistics on birthsand deaths or diseases are deficient in manycountries (Box 4.4) 53 .Over the last 30 years, however, there has beena quantum leap in the production of evidence forclinical medicine through collaborative effortssuch as the Cochrane Collaboration and the InternationalClinical Epidemiology Network 56,57 . Asimilar advance is possible in the production ofevidence on public policies, although such effortsare still too tentative compared to the enormousresources available for research in other areasof health, e.g. diagnostic and therapeutic medicaltechnologies. There are, however, signs of progressin the increasing use of systematic reviewsby policy-makers 58,59 .Two tracks offer potential for significantlystrengthening the knowledge base. Speeding up the organization of systematicreviews of critical interventions and theireconomic evaluation. One way of doing thisis by expanding the remit of existing healthtechnology assessment agencies to includethe assessment of public-health interventionsand delivery modes, since this would make useof existing institutional capacities with ringfencedresources. The emerging collaborativenetworks, such as the Campbell Collaboration60 , can play a catalyzing role, exploiting73

The World Health Report 2008Primary Health Care – Now More Than EverBox 4.4 The scandal of invisibility: where births and deaths are not countedCivil registration is both a product of economic and social development,and a condition for modernization. There has been littleimprovement in coverage of vital registration (offi cial recordingof births and deaths) over recent decades (see Figure 4.3).Almost 40% (48 million) of 128 million global births each yeargo uncounted because ofthe lack of civil 53 registrationsystems. The situationis even worse for deathsregistration. Globally, twothirds (38 million) of 57 millionannual deaths are notregistered. WHO receivesreliable cause-of-deathstatistics from only 31 ofits 193 Member States.International efforts toimprove vital statisticsinfrastructure in developingcountries have beentoo limited in size andscope 54 . Neither, the globalhealth community nor thecountries have given thedevelopment of health statisticsand civil registrationsystems the same priorityas health interventions. Within the UN system, civil registrationdevelopment has no identifi able home. There are no coordinationmechanisms to tackle the problem and respond to requestsfor technical support for mobilizing the necessary fi nancial andtechnical resources. Establishing the infrastructure of civil registrationsystems to ensureFigure 4.3 Percentage of births and deaths recorded in countries withcomplete civil registration systems, by WHO region, 1975–2004 aPercentage of birthsand deaths registered1975–84 1985–94 1995–2004100BirthsDeaths806040200a Source: adapted from 54 .AfricaAmericasEastern MediterraneanEuropeSouth-East AsiaWestern PacificAfricaAmericasEastern MediterraneanEuropeSouth-East AsiaWestern Pacificall births and deaths arecounted requires collaborationbetween differentpartners in different sectors.It needs sustainedadvocacy, the nurturingof public trust, supportivelegal frameworks,incentives, fi nancial support,human resourcesand modernized datamanagement systems 55 .Where it functions well,vital statistics providebasic information for prioritysetting. The lack ofprogress in the registrationof births and deathsis a major concern for thedesign and implementationof PHC reforms.the comparative advantage of scale efficiencyand international comparisons.Accelerating the documentation and assessmentof whole-of-government approachesusing techniques that build on the initialexperience with “health impact assessment”or “health equity impact assessment”tools 61,62,63 . Although these tools are still indevelopment, there is growing demand fromlocal to supra-national policy-makers for suchanalyses (Box 4.5). Evidence of their utility ininfluencing public policies is building up 64,65,66 ,and they constitute a strategic way of organizingmore thoughtful cross-sector discussions.That in itself is an inroad into one of the moreintractable aspects of the use of the availableevidence base: the clear need for moresystematic communication on the potentialhealth gains to be derived from better publicpolicies. Decision-makers, particularly inother sectors, are insufficiently aware of thehealth consequences of their policies, and ofthe potential benefits that could be derivedfrom them. Communication beyond the realmof the specialist is as important as the productionof evidence and requires far more effectiveapproaches to the dissemination of evidenceamong policy-makers 67 . Framing populationhealth evidence in terms of the health impactof policies, rather than in the classical modesof communication among health specialists,has the potential to change radically the typeand quality of policy dialogue.A changing institutional landscapeAlong with lack of evidence, the area where newopportunities are appearing is in the institutionalcapacity for developing public policies that arealigned with PHC goals. Despite the reluctance,including from donors, to commit substantialfunds to National Institutes of Public Health(NIPHs) 69 , policy-makers rely heavily on them or74

Chapter 4. Public policies for the public’s healthBox 4.5 European Union impact assessment guidelines 68European Union guidelines suggest that the answers to the following questions can form the basis of an assessment of the impact ofproposed public-health interventions.Public health and safetyDoes the proposed option: affect the health and safety of individuals or populations, including life expectancy, mortality and morbidity through impacts on thesocioeconomic environment, e.g. working environment, income, education, occupation or nutrition? increase or decrease the likelihood of bioterrorism? increase or decrease the likelihood of health risks attributable to substances that are harmful to the natural environment? affect health because of changes in the amount of noise or air, water or soil quality in populated areas? affect health because of changes in energy use or waste disposal? affect lifestyle-related determinants of health such as the consumption of tobacco or alcohol, or physical activity? produce specifi c effects on particular risk groups (determined by age, sex, disability, social group, mobility, region, etc.)?Access to and effects on social protection, health and educational systemsDoes the proposed option: have an impact on services in terms of their quality and access to them? have an effect on the education and mobility of workers (health, education, etc.)? affect the access of individuals to public or private education or vocational and continuing training? affect the cross-border provision of services, referrals across borders and cooperation in border regions? affect the fi nancing and organization of and access to social, health and education systems (including vocational training)? affect universities and academic freedom or self-governance?on their functional equivalents. In many countries,NIPHs have been the primary repositories ofindependent technical expertise for public health,but also, more broadly, for public policies. Somehave a prestigious track record: the Fiocruz inBrazil, the Instituto de Medicina Tropical “PedroKouri” in Cuba, Kansanterveyslaitos in Finland,the Centers for Disease Control and Preventionin the United States, or the National Institute ofHygiene and Epidemiology in Viet Nam. Theytestify to the importance that countries accordto being able to rely on such capacity 69 . Increasingly,however, this capacity is unable to copewith the multiple new demands for public policiesto protect or promote health. This is leavingtraditional national and global institutes of publichealth with an oversized, under-funded mandate,which poses problems of dispersion and difficultiesin assembling the critical mass of diversifiedand specialized expertise (Figure 4.4).In the meantime, the institutional landscapeis changing as the capacity for public policy supportis being spread over a multitude of nationaland supra-national institutions. The number ofloci of expertise, often specialized in some aspectof public policy, has increased considerably,spanning a broad range of institutional formsincluding: research centres, foundations, academicunits, independent consortia and thinktanks, projects, technical agencies and assortedinitiatives. Malaysia’s Health Promotion FoundationBoard, New Zealand’s Alcohol AdvisoryFigure 4.4 Essential public-health functions that 30 national public-healthinstitutions view as being part of their portfolio 69Surveillance, problem investigation,control of risks and threats to public healthPublic health researchEvaluation and analysis of health statusHealth promotion and prevention programmesPlanning and managementReduction of the impactof disasters on healthHuman resource development and trainingSocial participationand citizen empowermentRegulation and enforcementQuality assurance in personal andpopulation-based health servicesEvaluation and promotion of coverageand access to health services0 20 40 60 80Proportion of institutions surveyed (%)1075

The World Health Report 2008Primary Health Care – Now More Than EverCouncil and Estonia’s Health Promotion Commissionshow that funding channels have diversifiedand may include research grants and contracts,government subsidies, endowments, or hypothecatedtaxes on tobacco and alcohol sales. Thisresults in a more complex and diffuse, but alsomuch richer, network of expertise.There are important scale efficiencies to beobtained from cross-border collaboration ona variety of public policy issues. For example,the International Association of National PublicHealth Institutes (IANPHI) helps countries to setup strategies for institutional capacity development70 . In this context, institution building willhave to establish careful strategies for specializationand complementarity, paying attention to thechallenge of leadership and coordination.At the same time, this offers perspectives fortransforming the production of the highly diverseand specialized workforce that better public policiesrequire. Schools of public health, communitymedicine and community nursing have traditionallybeen the primary institutional reservoirs forgenerating that workforce. However, they producetoo few professionals who are too often focusedon disease control and classical epidemiology,and are usually ill-prepared for a career of flexibility,continuous learning and coordinatedleadership.The multi-centric institutional developmentprovides opportunities for a fundamental rethinkof curricula and of the institutional settingsof pre-service education, with on-the-job trainingin close contact with the institutions wherethe expertise is located and developed 71 . Thereare promising signs of renewal in this regardin the WHO South-East Asian Region (SEARO)that should be drawn upon to stimulate similarthinking and action elsewhere 27 . The increasingcross-border exchange of experience and expertise,combined with a global interest in improvingpublic policy-making capacity, is creating newopportunities – not just in order to prepare professionalsin more adequate numbers but, aboveall, professionals with a broader outlook and whoare better prepared to address complex publicheath challenges of the future.Equitable and efficient globalhealth actionIn many countries, responsibilities for health andsocial services are being delegated to local levels. Atthe same time, financial, trade, industrial and agriculturalpolicies are shifting to international level:health outcomes have to be obtained locally, whilehealth determinants are being influenced at internationallevel. Countries increasingly align theirpublic policies with those of a globalized world.This presents both opportunities and risks.In adjusting to globalization, fragmentedpolicy competencies in national governance systemsare finding convergence. Various ministries,including health, agriculture, finance, trade andforeign affairs are now exploring together howthey can best inform pre-negotiation trade positions,provide input during negotiations, andweigh the costs and benefits of alternative policyoptions on health, the economy and the future oftheir people. This growing global health “interdependence”is accompanied by a mushroomingof activities expressed at the global level. Thechallenge is, therefore, to ensure that emergingnetworks of governance are adequately inclusiveof all actors and sectors, responsive to local needsand demands, accountable, and oriented towardssocial justice 72 . The recent emergence of a globalfood crisis provides further legitimacy to an inputfrom the health sector into the evolving globalresponse. Gradually, a space is opening for theconsideration of health in the trade agreementsnegotiated through the World Trade Organization(WTO). Although implementation has provedproblematic, the flexibilities agreed at Doha forprovision in the Agreement on Trade-RelatedAspects of Intellectual Property Rights (TRIPS) 73of compulsory licencing of pharmaceuticals areexamples of emerging global policies to protecthealth.There is a growing demand for global normsand standards as health threats are being shiftedfrom areas where safety measures are being tightenedto places where they barely exist. Assemblingthe required expertise and processes is complexand expensive. Increasingly, countries are relyingon global mechanisms and collaboration 74 . Thistrend started over 40 years ago with the creationof the Codex Alimentarius Commission in 196376

Chapter 4. Public policies for the public’s healthby the Food and Agriculture Organization (FAO)and the WHO to coordinate international foodstandards and consumer protection. Anotherlong-standing example is the International Programmeon Chemical Safety, established in 1980as a joint programme of the WHO, the InternationalLabour Organization (ILO) and the UnitedNations Environment Programme (UNEP). In theEuropean Union, the construction of health protectionstandards is shared between agencies andapplied across Europe. Given the expense andcomplexity of drug safety monitoring, many countriesadapt and use the standards of the UnitedStates Food and Drug Administration (FDA). WHOsets global standards for tolerable levels of manycontaminants. In the meantime, countries musteither undertake these processes themselves orensure access to standards from other countriesor international agencies, adapted to their owncontext.The imperative for global public-health action,thus, places further demands on the capacity andstrength of health leadership to respond to theneed to protect the health of their communities.Local action needs to be accompanied by thecoordination of different stakeholders and sectorswithin countries. It also needs to manage globalhealth challenges through global collaborationand negotiation. As the next chapter shows, thisis a key responsibility of the state.References1. Sen A. Development as freedom. Oxford, Oxford University Press, 1999.2. Fegan GW et al. Effect of expanded insecticide-treated bednet coverage on childsurvival in rural Kenya: a longitudinal study. Lancet, 2007, 370:1035–1039.3. Liu Y. China’s public health-care system: facing the challenges. 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The World Health Report 2008Primary Health Care – Now More Than Ever37. Commission on Social Determinants of Health. Closing the gap in a generation:health equity through action on the social determinants of health. Final report.Geneva, World Health Organization, 2008.38. The World Health Report 2007 – A safer future: global public health security in the21st century. Geneva, World Health Organization, 200739. Satterthwaite D. In pursuit of a healthy urban environment. In: Marcotullkio PJ,McGranahan G, eds. Scaling urban environmental challenges: from local to globaland back. London, Earthscan, 2007.40. Taylor CE, Taylor HG. Scaling up community-based primary health care. In: RohdeJ, Wyon J, eds. Community-based health care: lessons from Bangladesh to Boston.Boston, Management Sciences for Health, 2002.41. WHO/Public Health Agency Canada Collaborative Project. Improving health equitythrough intersectoral action. Geneva, World Health Organization, 2008 (in press).42. Puska P. 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Sweet M, Moynihan R. Improving population health: the uses of systematic reviews.New York NY, Milbank Memorial Fund, 2007.60. Davies P, Boruch R. The Campbell Collaboration does for public policy whatCochrane does for health. BMJ, 2001, 323:294–295.61. An idea whose time has come: New opportunities for HIA in New Zealand publicpolicy and planning. Wellington, Public Health Advisory Committee, 2007.62. Harris P et al. Health impact assessment: a practical guide. Sydney, University ofNew South Wales, 2007.63. Wismar M et al. Implementing and institutionalizing health impact assessment inEurope. In: Ståhl T et al, eds. Health in all policies: prospects and potentials. Helsinki,Ministry of Social Affairs and Health, 2006.64. Blau J et al. The use of health impact assessment across Europe. In: Ståhl T etal, eds. Health in all policies: prospects and potentials. Helsinki, Ministry of SocialAffairs and Health, 2006.65. Dannenberg AL et al. Use of health impact assessment in the US: 27 case studies,1999–2007. American Journal of Preventive Medicine, 2008, 34:241–256.66. Wismar M et al, eds. The effectiveness of health impact assessment: scopeand limitations of supporting decision-making in Europe. Geneva, World HealthOrganization, 2007.67. Jewell CJ, Bero LA. Developing good taste in evidence: facilitators of andhindrances to evidence-informed health policymaking in state government. TheMilbank Quarterly, 2008, 86:177–208.68. Communication from the Commission on Better Regulation for Growth and Jobs in theEuropean Union. Brussels, European Commission, 2005 (COM (2005) 97 fi nal).69. Binder S et al. National public health institutes: contributing to the public good.Journal of Public Health Policy, 2008, 29:3–21.70. Framework for the creation and development of national public health institutes.Helsinki, International Association of National Public Health Institutes, 2007.71. Khaleghian P, Das Gupta M. Public management and the essential public healthfunctions. Washington DC, The World Bank, 2004 (World Bank Policy ResearchWorking Paper 3220).72. Kickbusch I. A new agenda for health. Perspectives in Health, 2004, 9:8–13.73. World Trade Organization Declaration on the TRIPS Agreement and Public Health.Ministerial Conference, 4th Session, Doha, 9–14 November 2001. 2001 (WT/MIN(01)/DEC/2).74. Wilk EA van der et al. Learning from our neighbours – cross-national inspirationfor Dutch public health polices: smoking, alcohol, overweight, depression, healthinequalities, youth screening. Bilthoven, National Institute for Public Health and theEnvironment, 2008 (RIVM Rapport 270626001; http://www.rivm.nl/bibliotheek/rapporten/270626001.pdf, accessed 30 July 2008).78

Leadership andeffective governmentThe preceding chapters have described how healthsystems can be transformed to deliver better healthin ways that people value: equitably, people-centred, and withthe knowledge that health authorities administer public-healthfunctions to secure the well-being of allcommunities. These PHC reforms demandnew forms of leadership for health. Thischapter begins by clarifying why thepublic sector needs to have a strong role Managing the politicalprocess: from launchingin leading and steering public health care reform to implementing itreforms, and emphasizes the fact that thisfunction should be exercised through collaborative models ofpolicy dialogue with multiple stakeholders, because this iswhat people expect and because it is the most effective. It thenconsiders strategies to improve the effectiveness of reformefforts and the management of the political processes thatcondition them.Chapter 5Governments as brokers forPHC reform82Effective policy dialogue 869281

The World Health Report 2008Primary Health Care – Now More Than EverGovernments as brokers forPHC reformMediating the social contractfor healthThe ultimate responsibility for shaping nationalhealth systems lies with governments. Shapingdoes not suggest that governments should − oreven could – reform the entire health sector ontheir own. Many different groups have a role toplay: national politicians and local governments,the health professions, the scientific community,the private sector and civil society organizations,as well as the global health community. Nevertheless,the responsibility for health that is entrustedto government agencies is unique and is rootedin principled politics as well as in widely heldexpectations 1 .Politically, the legitimacy of governments andtheir popular support depends on their ability toprotect their citizens and play a redistributiverole. The governance of health is among the corepublic policy instruments for institutionalizedprotection and redistribution. In modern states,governments are expected to protect health, toguarantee access to health care and to safeguardpeople from the impoverishment that illness canbring. These responsibilities were progressivelyextended, incorporating the correction of marketfailures that characterize the health sector 2 .Since the beginning of the 20th century, healthprotection and health care have progressivelybeen incorporated as goods that are guaranteedby governments and are central to the socialcontract between the state and its citizens. Theimportance of health systems as a key elementof the social contract in modernizing societies ismost acutely evident during reconstruction afterperiods of war or disaster: rebuilding health servicescounts among the first tangible signs thatsociety is returning to normal 3 .The legitimacy of state intervention is notonly based on social and political considerations.There are also key economic actors – themedical equipment industry, the pharmaceuticalindustry and the professions – with an interest ingovernments taking responsibility for health toensure a viable health market: a costly modernhealth economy cannot be sustained without risksharing and pooling of resources. Indeed, thosecountries that spend the most on health are alsothose countries with the largest public financingof the health sector (Figure 5.1).Figure 5.1 Percentage of GDP used for health, 2005 4Percentage GDP1614External resourcesOut-of-pocket expenditure12Other private expenditureGeneral government expenditure1086420Low-incomecountries,without IndiaIndia Lowermiddle-incomecountries,without ChinaChinaUpper Brazilmiddle-incomecountries,without BrazilHigh-incomecountries,without USAEven in the United States, its exceptionalismstems not from lower public expenditure – at 6.9%of GDP it is no lower than the high-income countriesaverage of 6.7% – but from its singularly highadditional private expenditure. The persistentunder-performance of the United States healthsector across domains of health outcomes, quality,access, efficiency and equity 5 , explains opinionpolls that show increasing consensus of thenotion of government intervention to secure moreequitable access to essential health care 6,7 .A more effective public sector stewardship ofthe health sector is, thus, justified on the groundsof greater efficiency and equity. This crucial stewardshiprole is often misinterpreted as a mandatefor centralized planning and complete administrativecontrol of the health sector. While sometypes of health challenges, e.g. public-healthemergencies or disease eradication, may requireauthoritative command-and-control management,effective stewardship increasingly relieson “mediation” to address current and futurecomplex health challenges. The interests of publicauthorities, the health sector and the publicare closely intertwined. Over the years, this hasmade all the institutions of medical care, suchas training, accreditation, payment, hospitals,USA82

Chapter 5. Leadership and effective governmententitlements, etc., the object of intensive bargainingon how broadly to define the welfare state andthe collective goods that go with it 8,9 . This meansthat public and quasi-public institutions have tomediate the social contract between institutionsof medicine, health and society 10 . In high-incomecountries today, the health-care system and thestate appear indissolubly bound together. Inlow- and middle-income countries, the state hasoften had a more visible role, but paradoxically,one that was less effective in steering the healthsector, particularly when, during the 1980s and1990s, some countries of them became severelytested by conflicts and economic recession. Thisresulted in their health systems being drawn indirections quite different from the goals and valuespursued by the PHC movement.Disengagement and its consequencesIn many socialist and post-socialist countriesundergoing economic restructuring, the statehas withdrawn abruptly from its previously predominantrole in health. China’s deregulation ofthe health sector in the 1980s, and the subsequentsteep increases in reliance on out-of-pocketspending, is a case in point and a warning to therest of the world 11 . A spectacular deterioration ofhealth-care provision and social protection, particularlyin rural areas, led to a marked slowdownin the increase in life expectancy 11,12 . This causedChina to re-examine its policies and reassert theGovernment’s leadership role − a re-examinationthat is far from over (Box 5.1) 13 .A similar scenario of disengagement wasobserved in many of the countries of centraland eastern Europe and the Commonwealth ofIndependent States (CEE-CIS). In the early 1990s,public expenditure on health declined to levelsthat made administering a basic system virtuallyimpossible. This contributed to a major declinein life expectancy 17 . Catastrophic health spendingbecame a major cause of poverty 18 . More recently,funding levels have stabilized or even increased,but significant improvements in health outcomeshave not followed and socioeconomic inequalitiesin health and health-care access are rising.Evidence and trends related to these rises, as wellas increases in informal payment mechanismsfor health care, indicate that re-engagement isstill insufficient.Elsewhere, but most spectacularly in lowincomecountries and fragile states, the absenceor withdrawal of the state from its responsibilitiesfor health reflects broader conditions ofeconomic stagnation, political and social crisisand poor governance 19 . In such conditions, publicleadership has often become dysfunctional andde-institutionalized 20 , a weakness that is compoundedby a lack of financial leverage to steerthe health sector. Global development policieshave often added to the difficulties governmentsface in assuming their responsibilities, for atleast two reasons. The global development agenda of the 1980sand 1990s was dominated by concern for theproblems created by too much state involvement21 . The structural adjustment and downsizingrecipes of these decades still constrainthe reconstruction of leadership capacitytoday. Public financing in the poorest countriesbecame unpredictable, making medium-termcommitments to the growth of the health sectordifficult or impossible. Health planningbased on needs became the exception ratherthan the rule, since key fiscal decisions weretaken with little understanding of the potentialconsequences for the health sector and healthministries were unable to make an effectivecase for prioritizing budget increases 22 . For decades, the international community’shealth agenda – including that of WHO – hasbeen structured around diseases and interventionsrather than around the broader challengesbeing faced by health systems. Whilethis agenda has certainly contributed to abetter appreciation of the burden of diseaseaffecting poor countries, it has also profoundlyinfluenced the structure of governmental andquasi-governmental institutions in low- andmiddle-income countries. The resulting fragmentationof the governance of the healthsector has diverted attention from importantissues, such as the organization of primarycare, the control of the commercialization ofthe health sector and human resources forhealth crises.83

The World Health Report 2008Primary Health Care – Now More Than EverThe untoward consequences of this trend aremost marked in aid-dependent countries becauseit has shaped the way funds are channelled 23 .The disproportionate investment in a limitednumber of disease programmes considered asglobal priorities in countries that are dependenton external support has diverted the limitedenergies of ministries of health away from theirprimary role as mediator in the comprehensiveplanning of primary care and the public’s health.Box 5.1 From withdrawal to re-engagement in ChinaDuring the 1980s and 1990s, reduced Government engagement in the health sector exposed increasing numbers of Chinese householdsto catastrophic expenditures for health care. As a result, millions of families in both rural and urban areas found themselves unableto meet the costs and were effectively excluded from health care. In cities, the Government Insurance Scheme (GIS) and LabourInsurance Scheme (LIS) had previously covered more than half of the population with either full or partial health insurance. However,the structural weaknesses of these schemes reached critical levels under the impact of accelerating economic change in the 1990s.The percentage of China’s urban population not covered by any health insurance or health plan rose from 27.3% in 1993 to 44.1% in1998 14 . By the end of the century, out-of-pocket payments made up more than 60% of health expenditure. This crisis spurred effortsto invert the trend: pooling and pre-payment schemes were bolstered in 1998 with the introduction of Basic Medical Insurance (BMI)for urban employees.Financed through compulsory contributions from workers and employers, the BMI aims to replace the old GIS and LIS systems. TheBMI has aimed for breadth of coverage with a relatively modest depth of benefi ts, linked to fl exibility that can enable the developmentof different types of packages according to local needs in the participating municipalities. Structurally, the BMI fund is divided into twoparts: individual savings accounts and social pooling funds. Generally speaking, the fi nancial contribution from an employee’s salary orwages goes to his or her individual savings account, while the employer’s contribution is split between the individual savings accountsand the social pooling fund, applying different percentages according to the age group of employees.Financial resources under the new BMI are pooled at municipal or city level, instead of by individual enterprises, which signifi cantlystrengthens the capacity for risk sharing. Each municipal government has developed its own regulations on the use of the resourcesof individual savings accounts and social pooling funds (the two structural parts of the system). The individual savings accounts coveroutpatient services, while the social pooling fund is meant to cover inpatient expenditures 14 .Signifi cant diffi culties with the BMI model remain to be ironed out, in particular as regards equity. For example, studies indicate that, inurban areas, better-off populations have been quicker to benefi t from the provisions of the BMI than households with very low incomes,while informal sector workers remain on the margins of the scheme. Nonetheless, the BMI has made progress in expanding healthinsurance coverage and access to services among China’s urban population, and is instrumental in reversing the deleterious trends ofthe 1980s and 1990s and, at the same time, assigning a new, intermediary role to government institutions.Figure 5.2 Health expenditure in China: withdrawal of the State in the 1980s and 1990sand recent re-engagementPercentage of total health expenditure100806040Out-of-pocketexpenditurePre-paid privateexpenditureSocial securityexpenditureOther generalgovernmentexpenditure20019651970197519781979198119821980198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006Sources: 1965 to 1975 15 ; 1978 to 1994 16 ; 1995 to 2006 4 .84

Chapter 5. Leadership and effective governmentAs a result, multiple, fragmented funding streamsand segmented service delivery are leading toduplication, inefficiencies and counterproductivecompetition for resources between differentprogrammes. Consequently, the massive mobilizationof global solidarity has not been able tooffset a growing estrangement between countryneeds and global support, and between people’sexpectations for decent care and the priorities setby their health-sector managers. Moreover, thegrowth in aid-flow mechanisms and new implementinginstitutions has further heightened thedegree of complexity faced by weak governmentbureaucracies in donor-dependent countries,increasing transaction costs for those countriesthat can least afford them 24 . So much effort isrequired to respond to international partners’short-term agendas that little energy is left to dealwith the multiple domestic stakeholders – professions,civil society organizations, politicians,and others – where, in the long run, leadershipmatters most. As advocates have rightly arguedin recent years, better inter-donor coordinationis not going to solve this problem on its own:there is also an urgent need for reinvestment ingovernance capacity.Participation and negotiationThe necessary reinvestment in governmental orquasi-governmental institutions cannot meana return to command-and-control health governance.Health systems are too complex: thedomains of the modern state and civil society areinterconnected, with constantly shifting boundaries25 . Professions play a major role in how healthis governed 26 , while, as mentioned in Chapter2, social movements and quasi-governmentalautonomous institutions have become complexand influential political actors 27 . Patients, professions,commercial interests and other groups areorganizing themselves in order to improve theirnegotiating position and to protect their interests.Ministries of health are, also, far from homogenous:individuals and programmes compete forinfluence and resources, adding to the complexityof promoting change. Effective mediation inhealth must replace overly simplistic managementmodels of the past and embrace new mechanismsfor multi-stakeholder policy dialogue to work outthe strategic orientations for PHC reforms 28 .At the core of policy dialogue is the participationof the key stakeholders. As countries modernize,their citizens attribute more value to socialaccountability and participation. Throughout theworld, increasing prosperity, intellectual skillsand social connectivity are associated with people’srising aspiration to have more say 29 in whathappens at their workplaces and in their communities− hence the importance of people-centrednessand community participation − and inimportant government decisions that affect theirlives − hence the importance of involving civilsociety in the social debate on health policies 30 .Another reason that policy dialogue is soimportant is that PHC reforms require a broadpolicy dialogue to put the expectations of variousstakeholders in perspective, to weigh up need,demand and future challenges, and to resolve theinevitable confrontations such reforms imply 31 .Health authorities and ministries of health, whichhave a primary role, have to bring together thedecision-making power of the political authorities,the rationality of the scientific community, thecommitment of the professionals, and the valuesand resources of civil society 32 . This is a processthat requires time and effort (Box 5.2). It wouldbe an illusion to expect PHC policy formationto be wholly consensual, as there are too manyconflicting interests. However, experience showsthat the legitimacy of policy choices depends lesson total consensus than on procedural fairnessand transparency 33,34,35 .Without a structured, participatory policydialogue, policy choices are vulnerable to appropriationby interest groups, changes in politicalpersonnel or donor fickleness. Without a socialconsensus, it is also much more difficult to engageeffectively with stakeholders whose interestsdiverge from the options taken by PHC reforms,including other sectors that compete for society’sresources; for the “medico-industrial complex” 36 ,for whom PHC reform may imply a realignment oftheir industrial strategy and for vested interests,such as those of the tobacco or alcohol industries,where effective PHC reform constitutes a directthreat.85

The World Health Report 2008Primary Health Care – Now More Than EverBox 5.2 Steering national directions with the help of policy dialogue:experience from three countriesIn Canada, a Commission examining the future of health care drew on inputs from focus group discussions and public hearings. Diversestakeholders and groups of the public made clear the value placed by Canadians on equitable access to high-quality care, based onneed and regardless of ability to pay. At the same time, the Commission had to ensure that this debate would be fed by evidence fromtop policy experts on the realities of the country’s health system. Of critical importance was the evidence that public fi nancing ofhealth care not only achieves goals of equity, but also those of effi ciency, in view of the higher administrative costs associated withprivate fi nancing. The discussion on values and the relevant evidence were then brought together in a policy report in 2002 that setout the direction for a responsive, sustainable and publicly funded PHC system, considered to be “the highest expression of Canadianscaring for one another” 37 . The strong uptake by policy-makers of the Commission’s recommendations refl ects the robustness of theevidence-informed analysis and public engagement.In Brazil, the fi rst seven Conferências Nacionais de Saúde, the platform for national policy dialogue in the health sector between 1941and 1977, had a distinctly top-down and public-sector-only fl avour, with a classic progression from national plans to programmes andextension of the network of basic health services. The watershed came with the 8th conference in 1980: the number of participantsincreased from a few hundred to 4000, from a wide range of constituencies. This and subsequent conferências pursued agendas thatwere driven far more than before by values of health democracy, access, quality, humanization of care and social control. The 12thnational conference, in 2003, ushered in a third consolidation phase: 3000 delegates, 80% of them elected, and a focus on health asa right for all and a duty of the State 38 .Thailand went through similar phases. The extension of basic health care coverage by a proactive Ministry of Health, encouraged bythe lobby of the Rural Doctors Association, resulted in the 1992 launch of the Decade of Health Centre Development. After the 1994economic crisis, ministry offi cials started mobilizing civil society and academia around the universal coverage agenda, convening afew thousand delegates to the First Health Care Reform Forum in 1997. Liaison with the political world soon followed, with a bold movetowards universal access and social protection known as the “30 Baht policy” 39 . With the National Health Act of 2007, stakeholderparticipation has been institutionalized through a National Health Commission that includes health professionals, civil society membersand politicians.Effective policy dialogueThe institutional capacities to enable a productivepolicy dialogue are not a given. They are typicallyweak in countries where, by choice or bydefault, laissez-faire dominates the approach topolicy formation in health. Even in countries withmature and well-resourced health systems thereis scope, and need, for more systematic and institutionalizedapproaches: negotiation betweenhealth authorities and professional institutionsis often well established, but is much less so withother stakeholders and usually limited to discussionson resource allocation for service delivery.Policy dialogue must be built. How to do thatdepends very much on context and background.Experience from countries that have been able toaccelerate PHC reforms suggests three commonelements of effective policy dialogue: the importance of making information systemsinstrumental to PHC reform; systematically harnessing innovations; and sharing lessons on what works.Information systems tostrengthen policy dialoguePolicy dialogue on PHC reforms needs to beinformed, not just by better data, but also byinformation obtained through a departure fromtraditional views on the clients, the scope andthe architecture of national health informationsystems (Figure 5.3).Many national health information systems thatare used to inform policy can be characterized asclosed administrative structures through whichthere is a limited flow of data on resource use,services and health status. They are often onlyused to a limited extent by officials at nationaland global level when formulating policy reforms,while little use is made of critical information thatcould be extracted from other tools and sources(census data, household expenditure or opinionsurveys, academic institutions, NGOs, healthinsurance agencies, etc.), many of which arelocated outside the public system or even outsidethe health sector.86

Chapter 5. Leadership and effective governmentRoutine data from traditional health informationsystems fails to respond to the rising demandfor health-related information from a multitudeof constituencies. Citizens need easier access totheir own health records, which should informthem about the progress being made in theirtreatment plans and allow them to participatein decisions related to their own health and thatof their families and communities. Communitiesand civil society organizations need better informationto protect their members’ health, reduceexclusion and promote equity. Health professionalsneed better information to improve the qualityof their work, and to improve coordination andintegration of services. Politicians need informationon how well the health system is meetingsociety’s goals and on how public money is beingused.Information that can be used to steer changeat the policy level is quite different from thedata that most conventional health informationsystems currently produce. There is a need tomonitor what the reforms are achieving acrossthe range of social values and the associated outcomesthat are central to PHC: equity, people-centredness,protection of the health of communitiesand participation. That means asking questionssuch as: is care comprehensive, integrated, continuousand effective? is access guaranteed and are people aware ofwhat they are entitled to? are people protected against the economicconsequences of ill-health?Figure 5.3 Transforming information systems into instruments for PHC reformFromMinistry of healthMonitor routine data on: morbidity resource usage service productionInformation flowing upwardswithin the public sectorhierarchyClientsScopeArchitectureToMultiple users, producers andstakeholders are authorities effective in ensuring protectionagainst exclusion from care? are they effective in ensuring protection againstexploitation by commercial providers?Such questions go well beyond what can beanswered by tracking health outcome indicators,resource use and service output, which is whatconventional health information systems focus on.The paradigm shift required to make informationsystems instrumental to PHC reform is to refocuson what is holding up progress in reorientingthe health system. Better identification of priorityhealth problems and trends is important (andvital to anticipate future challenges) but, froma policy point of view, the crucial information isthat which allows identification of the operationaland systemic constraints. In low-income countriesin particular, where planning has long beenstructured along epidemiological considerations,this can provide a new and dynamic basis fororienting systems development 40 . The report bythe Bangladesh Health Watch on the state of thecountry’s health workforce, for example, identifiedsuch systemic constraints and correspondingrecommendations for the consideration of healthauthorities 41 .The multiplication of information needs andusers implies that the way health information isgenerated, shared and used also has to evolve.This critically depends on accessibility and transparency,for example, by making all health-relatedinformation readily accessible via the Internet –as in Chile, where effective communication wasconsidered both an outcome Produce intelligence tounderstand challenges Monitor performance towardssocial objectives Identify system constraintsOpen knowledge networkswith multiple collaboratinginstitutions; transparencyessentialand a motor of their “Regimeof Explicit Health Guarantees”.PHC reform calls for open andcollaborative models to ensurethat all the best sources of dataare tapped and informationflows quickly to those who cantranslate it into appropriateaction.Open and collaborativestructures, such as the “Observatories”or “Equity Gauges”offer specific models of complementingroutine information87

The World Health Report 2008Primary Health Care – Now More Than Eversystems, by directly linking the production anddissemination of intelligence on health and socialcare to policy-making and to the sharing of bestpractices 42 . They reflect the increasing valuegiven to cross-agency work, health inequalitiesand evidence-based policy-making. Theybring together various constituencies, such asacademia, NGOs, professional associations, corporateproviders, unions, user representatives,governmental institutions and others, arounda shared agenda of monitoring trends, studies,information sharing, policy development andpolicy dialogue (Box 5.3).Paradoxically, these open and flexible configurationsprovide continuity in settings whereadministrative and policy continuity may beaffected by a rapid turnover of decision-makers.In the Americas, there are observatories that specificallyfocus on human resource issues in 22countries. In Brazil, for example, the observatoryis a network of more than a dozen participatinginstitutions (referred to as “workstations”): universityinstitutes, research centres and a federaloffice, coordinated through a secretariat basedat the Ministry of Health and the Brasilia officeof PAHO 44 . These networks played a key role insetting up Brazil’s current PHC initiatives. Suchnational and sub-national structures also existin various European countries, including France,Italy and Portugal 45 . Comparatively autonomous,such state/non-state multi-stakeholder networkscan cover a wide range of issues and be sensitiveto local agendas. In the United Kingdom, eachregional observatory takes the lead on specificBox 5.3 Equity Gauges: stakeholderholder collaboration to tackle health inequalities 43Equity Gauges are partnerships of multiple stakeholders that organize active monitoring and remedial action around inequity in healthand health care. So far, they have been established in 12 countries on three continents. Some operate at a countrywide level, somemonitor a subset of districts or provinces in a country, a few operate at a regional level and others focus specifi cally on equity within acity or municipality; nine have a national focus and three work at the municipal level (in Cape Town (South Africa), El Tambo (Ecuador)and Nairobi (Kenya). The Equity Gauges bring together stakeholders representing a diversity of local contexts, including parliamentariansand councillors, the media, ministries and departments of health, academic institutions, churches, traditional leaders, women’sassociations, community-based and nongovernmental organizations, local authority organizations and civic groups. Such a diversity ofstakeholders not only encourages wide social and political investment, but also supports capacity development within countries.Equity Gauges develop an active approach to monitoring and dealing with inequity in health and health care. They move beyond amere description or passive monitoring of equity indicators to a set of specifi c actions designed to effect real and sustained change inreducing unfair disparities in health and health care. This work entails an ongoing set of strategically planned and coordinated actionsthat involves a range of different actors who cut across a number of different disciplines and sectors.The Equity Gauge strategy is explicitly based on three “pillars of action”. Each one is considered to be equally important and essentialto a successful outcome and all three are developed in parallel: research and monitoring to measure and describe inequities; advocacy and public participation to promote the use of information to effect change, involving a broad range of stakeholders fromcivil society working together in a movement for equity; community involvement to involve poor and marginalized people as active participants in decision-making rather than passiverecipients of measures designed for their benefi t.The Equity Gauge strategy consists, therefore, of a set of interconnected and overlapping actions – it is not, as the name might suggest,just a set of measurements. For example, the selection of equity indicators for measurement and monitoring should take account ofthe views of community groups and consider what would be useful from an advocacy perspective. In turn, the advocacy pillar relies onreliable indicators developed by the measurement pillar and may involve community members or public fi gures.Equity Gauges choose indicators according to the particular needs of the country as well as of the stakeholders. Emphasis is placed,however, on generating trend data within all Gauges to enable understanding of progress over time. Indicators are measured across avariety of dimensions of health, including health status; health-care fi nancing and resource allocation; access to health care; and qualityof health care (such as maternal and child health, communicable diseases and trauma). All indicators are disaggregated according to the“PROGRESS” acronym that describes a broad range of socioeconomic factors often associated with inequities in health determinants:Place of residence, Religion, Occupation, Gender, Race/ethnicity, Education, Socioeconomic status and Social networks/capital.88

Chapter 5. Leadership and effective governmentissues, such as inequalities, primary care, violenceand health, or the health of older people 46 .All cover a wide range of issues of regionalrelevance (Table 5.1): they thus institutionalizethe linkages between local developments andcountrywide policy-making.Strengthening policy dialogue withinnovations from the fieldThese links between local reality and policy-makingconditions the design and implementation ofPHC reforms. The build up to the introduction ofThailand’s “30 Baht” universal coverage schemeprovides an example of a deliberate attempt toinfuse policy deliberations with learning fromthe field. Leaders of Thailand’s reform processorganized a mutually reinforcing interplaybetween policy development at the central leveland “field model development” in the country’sprovinces. Health workers on the periphery andcivil society organizations were given the spaceto develop and test innovative approaches to caredelivery, to see how well they met both professionalstandards and community expectations(Figure 5.4). Field model development activities,which were supported by the Ministry of Health,were organized and managed at provincial level,and extensively discussed and negotiated withprovincial contracts. Each province developed itsown strategies to deal with its specific problems.The large amount of flexibility given to the provincesin deciding their own work programmeshad the advantage of promoting ownership,fostering creativity and allowing original ideasto come forward. It also built local capacities.The downside to the high level of autonomy ofthe provinces was a tendency to multiply initiatives,making it difficult to evaluate the results tobe fed into the policy work in a systematic way.Figure 5.4 Mutual reinforcement between innovation in the fi eld andpolicy development in the health reform processDemonstration,diffusion andpressure for changePolicymobilizationand developmentField modeldevelopmentIdentify opportunitiesand alliancesTable 5.1 Roles and functions of public-healthobservatories in England 42RolesMonitoring health anddisease trends andhighlighting areas foractionIdentifying gaps inhealth informationAdvising on methodsfor health and healthinequality impactassessmentDrawing togetherinformation fromdifferent sources innew ways to improvehealthCarrying out projectsto highlight particularhealth issuesEvaluating progressby local agencies inimproving health andeliminating inequalityLooking ahead to giveearly warning of futurepublic health problemsFunctions aStudy on the inequalities existingin coronary heart disease, togetherwith recommendations for action 47Study of current information sourcesand gaps on perinatal and infanthealth 48Overview of health impactassessment 49Health profi le using housing andemployment data alongside healthdata 50A study of the dental health of fi veyear-oldsin the Region 51Baselines and trend dataForum for partners to address likelyfuture public health issues such asthe ageing population and geneticsaExample: Northern and Yorkshire Public Health Observatory.On balance, however, the difficulties due to thelocally-driven approach were compensated forby the positive effects related to reform dynamicsand capacity building. By 2001, nearly halfof Thailand’s 76 provinces were experimentingwith organizational innovation, most of it aroundissues of equitable access, local health-care systemsand community health 52 .Thailand’s “30 Baht” universal coveragereform was a bold political initiative to improvehealth equity. Its transformation into a concretereality was made possible through the accumulatedexperience from the field and through thealliances the fieldwork had built between healthworkers, civil society organizations and the public.When the scheme was launched in 2001, theseprovinces were ready to pilot and implement the89

The World Health Report 2008Primary Health Care – Now More Than Everscheme. Furthermore, the organizational modelsthey had developed informed the translation ofpolitical commitment to universal coverage intoconcrete measures and regulations 53 .This mutually reinforcing process of linkingpolicy development with learning from the fieldis important for several reasons: it taps the wealth of latent knowledge and innovationwithin the health sector; bold experiments in the field give front-lineworkers, system leaders and the public aninspiring glimpse of what the future might looklike in a health system shaped by PHC values.This overcomes one of the greatest obstacles tobold change in systems − people’s inability toimagine that things could actually be differentand be an opportunity rather than a threat; the linking of policy development with frontlineaction fosters alliances and support fromwithin the sector, without which far-reachingreform is not sustainable; such processes engage society both locally andat national level, generating the demand forchange that is essential in building politicalcommitment and maintaining the momentumfor reform.Building a critical mass ofcapacity for changeThe stimulation of open, collaborative structuresthat supply reforms with strategic intelligenceand harness innovation throughout the healthsystem requires a critical mass of committed andexperienced people and institutions. They mustnot only carry out technical and organizationaltasks, but they must also be able to balance flexibilityand coherence, adapt to new ways of working,and build credibility and legitimacy 54 .However, that critical mass of people andinstitutions is often not available 31 . Institutionsin low-income countries that have sufferedfrom decades of neglect and disinvestment areof particular concern. They are often short oncredibility and starved of resources, while keystaff may have found more rewarding workingenvironments with partner agencies. Poor governancecomplicates matters, and is compoundedby international pressure for state minimalismand the disproportionate influence of the donorcommunity. The conventional responses to leadershipcapacity shortfalls in such settings, whichare characterized by a heavy reliance on externaltechnical assistance, toolkits and training, havebeen disappointing (Box 5.4). They need to bereplaced by more systematic and sustainableapproaches in order to institutionalize competenciesthat learn from and share experience 55 .Documented evidence of how individual andinstitutional policy dialogue and leadershipcapacities build up over time is hard to find, buta set of extensive interviews of health sector leadersin six countries shows that personal careertrajectories are shaped by a combination of threedecisive experiences 56 . At some point in their careers, all had beenpart of a major sectoral programme or project,particularly in the area of basic health services.Many of them refer to this as a formativeexperience: it is where they learned aboutPHC, but also where they forged a commitmentand started building critical alliancesand partnerships. Many became involved in national planningexercises, which strengthened their capacity togenerate and use information and, again, theircapacity to build alliances and partnerships.Few had participated personally in major studiesor surveys, but those who had, found it anopportunity to hone their skills in generatingand analyzing information. All indicated the importance of cooptation andcoaching by their elders: “You have to start outas a public health doctor and be noticed in oneof the networks that influence decision makingin MOH. After that your personal qualities andlearning by doing [determine whether you’ll getto be in a position of leadership].” 56These personal histories of individual capacitystrengthening are corroborated by more in-depthanalysis of the factors that contributed to theinstitutional capacities for steering the healthsector in these same countries. Table 5.2 showsthat opportunities to learn from large-scalehealth-systems development programmes havecontributed most, confirming the importance ofhands-on engagement with the problems of thehealth sector in a collaborative environment.90

Chapter 5. Leadership and effective governmentBox 5.4 Limitations of conventional capacity building in low- and middle-income countries 55The development community has always tended to respond to theconsequences of institutional disinvestment in low- and middleincomecountries through its traditional arsenal of technical assistanceand expert support, toolkits and training (Figure 5.5). Fromthe 1980s onwards, however, it became clear that such “technicalassistance” was no longer relevant 58 and the response re-inventeditself as “project management units” concentrating on planning,fi nancial management and monitoring.The stronger health systems were able to benefit from theresources and innovation that came with projects but, in others,the picture was much more mixed. As a recurrent irritant to nationalauthorities, accountability to funding agencies often provedstronger than commitment to national development: demonstratingproject results took precedence over capacity building andlong-term development 59 , giving disproportionate weight to projectmanagers at the expense of policy coherence and country leadership.In more recent years, the wish to reinforce country ownership– and changes in the way donors purchase technical assistanceservices – paved the way for a shift from project management tothe supply of short-term expertise through external consultants.In the 1980s and early 1990s, the expertise was essentially providedby academic institutions and the in-house experts of bilateralcooperation and United Nations agencies. The increased volume offunding for technical supportcontributed to shiftingthe expertise marketto freelance consultantsand consultancy fi rms, sothat expertise has becomeincreasingly provided on aone-time basis, by technicalexperts whose understandingof the systemicand local political contextis necessarily limited 60 .In 2006, technical cooperationconstituted 41%of total overseas developmentaid for health.Adjusted for infl ation, itsvolume tripled between1999 and 2006, particularlythrough expansion oftechnical cooperation onFigure 5.5 A growing market: technical cooperation as part of OfficialDevelopment Aid for Health. Yearly aid flows in 2005,deflator adjusted 61Millions I$ 200514 00012 00010 0008000600040002000HIV/AIDS. Adapting to the complexities of the aid architecture,experts and consultants now also increasingly act as intermediariesbetween countries and the donor community: harmonizationhas become a growth business, lack of country capacity fuellingfurther disempowerment.0Other health aidTechnical cooperation HIV/AIDSTechnical cooperation health200211%36%The second mainstay response to the capacity problem has been themultiplication of planning, management and programme toolkits.These toolkits promise to solve technical problems encounteredby countries while aiming for self-reliance. For all their potential,rigour and evidence base, the usefulness of toolkits in the fi eld hasoften not lived up to expectations for four main reasons. They often underestimate the complexity of the problems theyare supposed to deal with 62 . They often rely on international expertise for their implementation,thereby defeating one of their main purposes, which isto equip countries with the ways and means to deal with theirproblems themselves. Some have not delivered the promised technical results63 orled to unexpected untoward side-effects 64 . The introduction of toolkits is largely supply driven and linked toinstitutional interests, which makes it diffi cult for countries tochoose among the multitude of competing tools that are proposed.The capacity-building prescription that completes the spectrum istraining. Sometimes, this is part of a coherent strategy: Morocco’sMinistry of Health, for example, has applied a saturation trainingapproach similar to that of Indonesia’s Ministry of Finance 65 , sendingout large numbers of young professionals for training in orderto build up a recruitment2003 2004 2005 200620%21%base of qualifi ed staff and,eventually, a critical massof leaders. Such deliberateapproaches, however, arerare. Much more common areshort “hotel” training coursesthat mix technical objectivesand exchange with implicitaims to top-up salaries andbuy political goodwill. Theprevailing scepticism aboutthe usefulness of such programmes(systematic evaluationis uncommon) contrastssharply with the resourcesthey mobilize, at a considerableopportunity cost.In the meantime, new marketsin education, trainingand virtual learning aredeveloping, while actors inlow- and middle-income countries can access Internet sites onmost health systems issues and establish electronic communitiesof practice. With contemporary information technology andglobalization, traditional recipes for capacity development in poorcountries are quickly becoming obsolete 54 .91

The World Health Report 2008Primary Health Care – Now More Than EverTable 5.2 Signifi cant factors in improving institutionalcapacity for health-sector governance in six countries a,56Factors bSector programmes/large-scale projectsEstablishment ofinstitutionsNational policydebate eventsResearch, studiesand situationanalysisNew planning andmanagement toolsNo. of countrieswhere factor was animportant contributorAverage scorefor strength ofcontribution4 7.253 6.73 5.64 5.11 5a Burkina Faso, the Democratic Republic of the Congo, Haiti, Mali, Morocco and Tunisia.b Identifi ed through document analysis and interviews with 136 key informants.Especially noteworthy is the fact that the introductionof tools was rarely identified as a criticalinput, and respondents did not highlight inputsfrom experts and training.The implication is that the key investmentfor capacity building for PHC reforms should beto create opportunities for learning by linkingindividuals and institutions to ongoing reformprocesses. A further consideration is the importanceof doing so in an environment whereexchange, within and between countries, isfacilitated. Unlike the conventional approachesto capacity building, exchange and exposure tothe experience of others enhances self-reliance.This is not just a recipe for under-resourcedand poorly performing countries. Portugal, forexample, has organized a broad societal debateon its 2004−2010 National Health Plan involvinga pyramid of participation platforms from localand regional to national level, and 108 substantialcontributions to the plan from sources rangingfrom civil society and professional organizationsto local governments and academia. At three criticalmoments in the process, international panelsof experts were also invited from other countriesto act as sounding boards for their policy debate:a collaboration that was a learning exercise forall parties 57 .Managing the political process: fromlaunching reform to implementing itPHC reforms change the balance of power withinthe health sector and the relationship betweenhealth and society. Success depends not only ona credible technical vision, but also on the abilityto obtain the high-level political endorsementand the wider commitment that is necessary tomobilize governmental, financial and other institutionalmachineries.As a technical sector, health rarely has prominencein the hierarchy of the political arena.Ministries of health have often had enough todeal with simply trying to resolve the technicalchallenges internal to the sector. They aretraditionally ill at ease, short of leverage and illequipped to make their case in the wider politicalarena, particularly in low- and low-middleincomecountries.The general lack of political influence limitsthe ability of health authorities, and of otherstakeholders in the PHC movement, to advancethe PHC agenda, especially when it challengesthe interests of other constituencies. It explainsthe frequently absent or overly cautious reactionsagainst the health effects of working conditionsand environmental damage, or the slow implementationof regulations that may interfere withthe commercial interests of the food and tobaccoindustry. Similarly, ambitious reform efforts areoften diluted or watered down under the influenceof the donor community, the pharmaceuticaland the health technology industries, or theprofessional lobbies 26,66 .Lack of political influence also has consequenceswithin governmental spheres. Ministriesof health are in a particularly weak position inlow- and low-middle-income countries, as isevidenced by the fact that they can claim only4.5% and 1.7%, respectively, of total governmentexpenditure (against 10% and 17.7%, respectively,in upper-middle and high-income countries) 67 .The lack of prominence of health priorities inwider development strategies, such as the PovertyReduction Strategy Papers (PRSPs), is anotherillustration of that weakness 68 . Equally, ministriesof health are often absent in discussionsabout caps on social (and health) spending, which92

Chapter 5. Leadership and effective governmentare dominated by debates on macroeconomicstability, inflation targets or sustainable debt. Itis telling that, in highly indebted countries, thehealth sector’s efforts to obtain a share of the debtrelief funds have been generally slow, less thanforceful and unconvincing compared to education,foregoing possibilities for rapid expansionof their resource base 69 .Despite these challenges, there is a growingindication that the political will for ambitiousreforms based on PHC is taking place. India’shealth missions − “rural” and subsequently“urban” − are accompanied by a doubling of publicexpenditure on health. China is preparing anextremely ambitious rural PHC reform that alsoincludes a major commitment of public resources.The size and comprehensiveness of PHC-orientedreforms in Brazil, Chile, Ethiopia, the IslamicRepublic of Iran, New Zealand, Thailand andmany other countries, reflect very clearly that itis not unrealistic to mobilize political will. Evenin extremely unfavourable circumstances, it hasproven possible to gain credibility and politicalclout through pragmatic engagement with politicaland economic forces (Box 5.5).Experience across these countries shows thatpolitical endorsement of PHC reforms criticallydepends on a reform programme that is formulatedin terms that show its potential politicaldividends. To do that it has to: respond explicitly to rising demand as wellas to the health challenges and health systemconstraints the country faces, showing that itis not merely a technical programme, but onerooted in concerns relevant to society; specify the expected health, social and politicalreturns, as well as the relevant costs, inorder to demonstrate the expected politicalmileage as well as its affordability; be visibly based on the key constituencies’consensus to tackle the obstacles to PHC, providingreassurance of the reforms’ politicalfeasibility.Creating the political alignment and commitmentto reform, however, is only a first step.Insufficient preparation of its implementation isoften the weak point. Of particular importanceis an understanding of resistance to change,particularly from health workers 70,71,72,73 . Whilethe intuition of leadership has its merits, it is alsopossible to organize more systematic exercises toanticipate and respond to the potential reactionsof stakeholders and the public: political mappingexercises, as in Lebanon 34 ; marketing studies andopinion polls, as in the United States 74 ; publichearings, as in Canada; or sector-wide meetingsof stakeholders, as in the Etats Généraux de laSanté in French-speaking Africa. Delivering onPHC reforms requires a sustained managementcapacity across levels of the system, embeddedin institutions that are fit for the purpose. InChile, for example, administrative structures andcompetencies across the whole of the Ministryof Health are being redefined in line with thePHC reforms. Such structural changes are notsufficient. They need to be instigated in conjunctionwith changes in the organizational culture,from one of issuing decrees for change to a moreinclusive collaboration with a variety of stakeholdersacross the levels of the health system.That in turn requires the institutionalization ofpolicy-dialogue mechanisms drawing practicebasedknowledge up from the ground level toinform overall systems governance, while reinforcingsocial linkages and collaborative actionamong constituencies at community level 75 . Thismanagement capacity should not be assumed, itrequires active investment.Even with effective political dialogue to gainconsensus on specific PHC reforms and the requisitemanagement for implementation acrosslevels of the system, many such reforms do nothave their intended impact. The best-planned andexecuted policy reforms often run into unanticipatedchallenges or rapidly changing contexts.Broad experience in dealing with complex systemsbehaviour suggests that significant shortfallsor shifts away from articulated goals are tobe expected. An important component to buildinto the reform processes is mechanisms thatcan pick up significant unintended consequencesor deviations from expected performance benchmarks,which allow for course corrections duringimplementation.Widespread evidence on inequities in healthand health care in virtually all countries is ahumbling reminder of the difficulties confronting93

The World Health Report 2008Primary Health Care – Now More Than EverBox 5.5 Rebuilding leadership in health in the aftermath of war and economic collapseRecent developments in the Democratic Republic of the Congoshow how renewed leadership can emerge even under extremelychallenging conditions. The beginnings of the reconstruction ofthe country’s health system, devastated by economic collapseand state failure culminating in a brutal war is, above all, a storyof skilful political management.The Democratic Republic of the Congo had seen a number of successfulexperiences in PHC development at the district level duringthe 1970s and early 1980s. The economic and political turmoilfrom the mid-1980s onwards saw central government authorityin health disintegrate, with an extreme pauperization of the healthsystem and the workers within it. Health workers developed amultiplicity of survival strategies, charging patients and capitalizingon the many aid-funded projects, with little regard for theconsequences for the health system. Donors and internationalpartners lost confi dence in the district model of integrated servicedelivery in the country and instead chose to back stand-alone diseasecontrol and humanitarian aid programmes. While, between1999 and 2002, the Ministry of Health commanded less than 0.5%of total government expenditure, its central administration and itsDepartment of Planning and Studies – 15 staff in total – faced theoverwhelming task of providing guidance to some 25 bilateral andmultilateral agencies, more than 60 international and 200 nationalNGOs, 53 disease control programmes (with 13 government donorcoordination committees)and 13 provincial ministriesof health – not forgettinghealth-care structures organizedby private companies anduniversities.As the intensity of civil strifeabated, a number of keyMinistry of Health staff took itupon themselves to revitalizeand update the district modelof primary health care. Awareof the marginal position of theMinistry in the health sector,they co-opted the “internaldiaspora” (former civil servantsnow working for themany international developmentagencies present in thecountry) in an open structure around the Ministry. This steeringgroup drafted a national health systems strengthening strategy.It included (i) a progressive roll-out of integrated services, districtby district, coordinated through regional plans and backed by afundamental shift in funding from programme-specifi c fl ows tosystem funding; (ii) a set of protective “damage-control” measuresto halt institutional infl ation and prevent further distortion of thesystem; and (iii) an explicit plan to tackle the problem of donorfragmentation, which had reached critical proportions. In designingthe strategy, the steering group made deliberate efforts to set upnetworks within the health sector itself and alliances with othergovernment actors and social constituencies.The formal endorsement of the national plan by donors and civilsociety sent a strong political signal of the success of this newmode of working. The national health systems strengthening strategybecame the health component of the national poverty reductionstrategy. Donors and international partners aligned existingprojects, albeit to a variable degree, while others reshaped newinitiatives to fi t the national strategy.Figure 5.6 Re-emerging national leadership in health: the shift in donor fundingtowards integrated health systems support, and its impact on theDemocratic Republic of the Congo’s 2004 PHC strategyUS$ millions300Humanitarian aidVertical programmes250Support to health districts20015010050020032004 2005 2006 2007Perhaps the most powerful testimony to the effective managementof this process is the change in the composition of donorfunding for health (Figure 5.6). The proportion of funds dedicatedto general systems strengthening under provincial and districtplans has increased appreciablyin relation to the levelof funding earmarked fordisease control and humanitarianrelief programmes.The advances remain fragile,in a context where much ofthe health sector – includingits governance – needs to bereconstructed.Nevertheless, the nationalstrategy has strong roots infi eldwork and, in a remarkableturnaround against highodds, the Ministry of Healthhas gained credibility withother stakeholders and hasimproved its position in renegotiatingthe fi nances of thehealth sector.94

Chapter 5. Leadership and effective governmentPHC reforms. This chapter has emphasized thatleadership for greater equity in health must bean effort undertaken by the whole of society andengage all relevant stakeholders. Mediating multistakeholderdialogues around ambitious reformsbe they for universal coverage or primary careplaces a high premium on effective government.This requires re-orienting information systemsthe better to inform and evaluate reforms, buildingfield-based innovations into the design andredesign of reforms, and drawing on experiencedand committed individuals to manage thedirection and implementation of reforms. Whilenot a recipe, these elements of leadership andeffective government constitute in and of themselvesa major focus of reform for PHC. 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Réfl exionsà partir de la réforme de l’administration publique en République Démocratique duCongo. BTC Seminar on Implementing the Paris Declaration on Aid Effectiveness,Brussels, 2006.61. OECD. StatExtracts [online database]. Paris, Organisation for EconomicCo-operation and Development, 2008 (http://stats.oecd.org/WBOS/Index.aspxaccessed June 2008).62. Irwin A. Beyond the toolkits: bringing engagement into practice. In: Engagingscience: thoughts, deeds, analysis and action. London, Wellcome Trust, 2007:50–55.63. Rowe AK et al. How can we achieve and maintain high-quality performance of healthworkers in low-resource settings? Lancet, 2005, 366:1026–1035.64. Blaise P, Kegels G. A realistic approach to the evaluation of the quality managementmovement in health care systems: a comparison between European and Africancontexts based on Mintzberg’s organizational models. International Journal of HealthPlanning and Management, 2004, 19:337–364.65. Lippingcott DF. 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The wayforwardThe starkly different social, economic and healthrealities faced by countries must inform the wayforward for primary health care. This chapter discussesthe implications for the way universalcoverage, primary care, public policy andleadership reforms are operationalized.Adapting reforms tocountry contextIt shows how expanding health systemsHigh-expenditurehealth economiesoffer opportunities for PHC reform inRapid-growthvirtually every country. Despite the need health economiesfor contextual specificity, there are crosscuttingelements in the reforms, common Mobilizing thedrivers of reformto all countries, which provide a basis forglobally shared learning and understanding about how PHCreforms can be advanced more systematically everywhere.Chapter 6Low-expenditure, lowgrowthhealth economies10010110310510899

The World Health Report 2008Primary Health Care – Now More Than EverAdapting reforms to country contextAlthough insufficiently acknowledged, the PHCmovement has been a critical success in that ithas contributed to the recognition of the socialvalue of health systems, which has now takenhold in most countries in the world. This changeof mindset has created a radically differenthealth-policy landscape.Present-day health systems are a patchwork ofcomponents, many of which may be far removedfrom the goals set out 30 years ago. These samehealth systems are converging. Driven by thedemographic, financial and social pressures ofmodernization, they increasingly share the aimsof improved health equity, people-centred care,and a better protection of the health of theirpopulations.However, that does not mean that health systemsacross the world will change overnight.Reorienting a health system is a long-termprocess, if only because of the long time lag torestructure the workforce 1 and because of theenormous inertia stemming from misalignedfinancial incentives and inadequate paymentsystems 2 . Given the countervailing forces andvested interests that drive health systems awayfrom PHC values, reform requires a clear visionfor the future. Many countries have understoodthis and are developing their strategic vision ofpublic policies for health with a perspective of10 to 20 years.These visions are often couched in technicalterms and are highly vulnerable to electoralcycles. Nevertheless, they are also increasinglydriven by what people expect their healthauthorities to do: secure their health and improveaccess to care, protect them against catastrophicexpenditure and financial exploitation, and guaranteean equitable distribution of resources 3,4 .As shown throughout this Report, the pressurethat stems from these value-based expectations,if used resolutely, can ensure that the vision isnot deflected and safeguard it from capture byshort-term vested interests or changes in politicalleadership.The protection this offers is greatly reinforcedby early implementation. The possibilities to starteffecting change as of now exist in virtually allcountries: the growth of the health sector providesfinancial leverage to do so, and globalizationis offering some unprecedented opportunitiesto make use of that leverage.This does not in any way diminish the need torecognize the widely divergent contexts in whichcountries find themselves today: the nature of thehealth challenges they face and their wider socioeconomicreality; and the degree of adaptation tochallenges, the level of development and speed atwhich their health systems expand.Opportunity for change is largely related tothe flow of new resources into the health sector.Across the world, expenditure on health is growing:between 1995 and 2005, it almost doubledfrom I$ 2.6 to I$ 5.1 trillion. The rate of growthis accelerating: between 2000 and 2005, the totalamount spent on health in the world increased byI$ 330 billion on average each year, against anaverage of I$ 197 billion in each of the five previousyears. Health expenditure is growing fasterthan GDP and faster than population growth. Thenet result is that, with some exceptions, healthspending per capita grows at a rate of more than5% per year throughout the world.This common trend in the growth in healthexpenditure masks a greater than 300-fold variationacross countries in per capita expenditure,which ranges from less than I$ 20 per capitato well over I$ 6 000. These disparities stratifycountries into three categories: high-expenditurehealth economies, rapid-growth health economies,and low-expenditure, low-growth healtheconomies.The high-expenditure health economies, notsurprisingly, are those of the nearly 1 billionpeople living in high-income countries. In 2005,these countries spent on average I$ 3752 percapita on health, I$ 1563 per capita more thanin 1995: a growth rate of 5.5% per year.At the other extreme is a group of low-expenditure,low-growth health economies: low-incomecountries in Africa and South- and South-EastAsia, as well as fragile states. They total 2.6 billioninhabitants who spent a mere I$ 103 percapita on health in 2005, against I$ 58 in 1995.In relative terms, these countries have seen theirhealth expenditure per capita grow at roughly the100

Chapter 6. The way forwardsame rate as high-expenditure countries: 5.8%each year since 1995, but, in absolute terms, thegrowth has been disappointingly low.In between those two groups are the otherlow- and middle-income countries, those withrapid-growth health economies. The 2.9 billioninhabitants in these countries spent an averageof I$ 413 per capita in 2005, more that double theI$ 189 per capita that they spent in 1995. Healthexpenditure in these countries has been growingat a rate of 8.1% per year.These groups differ not only in the rate andsize of their growth in health expenditure. Abreakdown according to the source of growthreveals strikingly different patterns (Figure 6.1).In the low-expenditure, low-growth healtheconomies, out-of-pocket payments account forthe largest share of the growth, while in rapidgrowthand high-expenditure health economies,increased government expenditure and prepaymentmechanisms dominate. Where growthin health expenditure is through pre-paymentmechanisms, there is greater opportunity to supportPHC reforms: collectively pooled monies aremore readily re-allocated towards interventionsFigure 6.1 Contribution of general government, private pre-paid and privateout-of-pocket expenditure to the yearly growth in total healthexpenditure per capita, percentage, weighted averages 5Yearly growth in per capita health expenditure (percentage)100806040200Out-of-pocket health expenditurePrivate pre-paid health expenditureGovernment health expenditureLow-expenditure,low-growthhealth economiesRapid-growthhealth economiesHigh-expenditurehealth economiesthat provide a larger health return on investmentthan out-of-pocket payments. Conversely, countrieswhere growth is primarily through out-ofpocketexpenditures have less leverage to supportPHC reforms. Alarmingly, it is in countries whereexpenditure is the lowest and the burden of diseasehighest that there is a real lack of opportunitiesfor harnessing the growth of their healthsector for PHC reforms.The following sections outline broad categoriesof contexts that can shape responses for PHCreforms.High-expenditure health economiesThis group of countries funds almost 90% of itsgrowth in health expenditure – an extra I$ 200per capita per year in recent years − throughincreased government and private pre-paymentfunds. Expanding or changing the offer of servicesin these countries is less constrained by financesthan by the relative lack of human resources tomeet rising and changing demand. Their healthsystems are built around a strong and prestigioustertiary care sector that is important to the heavyweightsof the pharmaceutical and medical supplyindustries 2 . Out-of-pocket payments, though stillsignificant at 15% of total expenditure, have beendwarfed by more progressive collective means offinancing. The third-party payment institutionshave, thus, become central actors while the longstandingautonomy of the health professionals iswaning. Efforts to control costs, improve qualityand access to disadvantaged groups have givenrise to a widening public debate on which usersand special interest groups have increasing influence.Nevertheless, the state carries more weightin the health sector of these countries than everbefore, with increasingly sophisticated regulatorytools and institutions.Despite worries over their long-term sustainability,the solidarity mechanisms that financethese health systems enjoy considerable socialconsensus. The secular trend towards extensionof coverage to all citizens, and, often reluctantly,to non-citizen residents as well, continues. In thestate of Massachusetts, the United States, forexample, the 2006 health insurance bill aimsat 99% coverage by 2010. At the same time, itis becoming increasingly clear that universal101

The World Health Report 2008Primary Health Care – Now More Than Evercoverage schemes need to be complemented byefforts: (i) to identify those who are excluded andset up specifically tailored programmes to includethem; and (ii) to tackle the social determinants ofhealth inequalities through policy initiatives thatcut across a large number of sectors (Box 6.1), soas to translate the political commitment to healthequity into concrete advances.In many of these countries, the shift in point ofgravity from tertiary and specialized care to primarycare is well under way. Better informationBox 6.1 Norway’s national strategy toreduce social inequalities in health 6Norway’s strategy to reduce health inequalities illustrates thatthere is no single solution to this complex problem. Norwayhas identifi ed a large number of determinants that infl uencethe health of individuals: income, social support, education,employment, early childhood development, healthy environmentsand access to health services. These complex and interrelateddeterminants of health are not equally distributed insociety, and it is, therefore, not surprising that this leads toinequities in health as well.The Norwegian strategy attempts to address the root causesof poor health and health inequity by infl uencing the underlyingdeterminants of health, and making the distribution of thesedeterminants more equitable from the outset. The Norwegianstrategy focuses on: reducing social inequities; reducing inequities in health behaviours and access tohealth services; targeted initiatives to improve social inclusion; and cross-sectoral tools to promote a whole-of-governmentapproach to health.This brings together a number of interventions that are effectivein tackling inequities, and that can be applied both withinhealth systems, as well as through cooperation with othersectors. For instance, health systems are able to establishprogrammes for early childhood development as well as policiesthat reduce fi nancial, geographical and social barriers tohealth services for those who need care the most. Workingwith other sectors, such as labour and fi nance, can createjob opportunities and taxation systems that encourage moreequitable distribution and redistribution of wealth, which canhave a large impact on population health. In addition to universalapproaches, social inclusion interventions targeted atproviding better living conditions for the most disadvantagedare also critical in reducing the gaps between the most well-offand the least well-off members of society.and technological developments are creatingnew opportunities – and a market – for movingmuch of the traditionally hospital-based care intolocal services staffed by primary-care teams oreven into the hands of patients themselves. Thisis fuelling a change in perception of how healthservices should operate. It provides support forprimary care, including self-care and home care.Movement in this direction, however, is held up byinertial forces stemming from the threat of downsizingand dismantling massive tertiary-carefacilities and from demand induced by the illusionthat the extension of life through technologyis unlimited 7 . Technological innovation is indeeda driver of improvement and current trends showthat it is expanding the range of services offeredby primary-care teams. Technological innovationcan, however, also be a driver of exclusion andinefficiency. The marked inter-country differencesin the diffusion of medical technology area reflection, not of rational evaluation, but of theincentives to providers to adopt these technologies,and the capacity to control that adoption 2 .There are two reasons why the environmentin which this is taking place is changing. Public contestation of the management of technologyhas continued to increase for reasons oftrust, price, exclusion or unmet need. Regulation increasingly depends on supranationalinstitutions. The European Union’sregulatory system, for example, plays anincreasing role in the harmonization of thetechnical requirements for registering newmedicines or of product licencing, offering possibilities,among others, for more effective supportto legal provisions encouraging genericsubstitution for pharmaceuticals in the privatesector 8 . Such mechanisms offer opportunitiesto increase safety and access, and thus createan environment in which national primarycare reforms are encouraged.This comes at a time when the supply of professionalswilling and able to engage in primarycare is under stress. In Europe, for example, thepopulation of general practitioners is ageing rapidly,and new recruits are more likely than beforeto opt for part-time or low-intensity careers 1 .There is pressure to give a more pivotal role to102

Chapter 6. The way forwardfamily physicians in primary care 9 . In the longrun, however, a more pluralistic approach willbe required with teams that include a varietyof professionals with the instruments to providecoordination and continuity of care. That willrequire a different, more varied and more flexiblecadre of health workers. The sustainabilityof primary-care reforms in the category of highspendingcountries is questionable without: (i) achange in paradigm of the training of health personnel;and (ii) the necessary career, social andfinancial incentives to move health professionalsto what in the past have been less prestigious andrewarding career options.Spurred by the growing awareness of globalhealth threats and of the stratification of healthoutcomes along social fault lines, there is amajor renaissance in public health. The connectionsbetween health and other sectors arebetter understood and are bringing health to theattention of all sectors. Research and informationsystems, demand for public health training andnew discourses on public health are occupyingthe centre stage of public concerns. This situationneeds to be translated into multi-pronged crosssectorstrategies to address the social determinantsof health and their influence on priorityhealth challenges (Box 6.1).Over the last decades, most countries in thiscategory are leading reforms through a steerand-negotiaterather than a command-and-controlapproach. This reflects the growing publicvisibility of the health-policy agenda and the needto find a balance between the different and oftenirreconcilable demands of diverse constituencies.As a result, reform efforts are usually multi-levelled,with multiple actors. They progress incrementally:a protracted messy process of muddlingthrough and hard bargaining. In England andWales, for example, a major primary-care reformincluded an extensive public consultation throughquestionnaires addressed to more than 42 000people, while over 1 000 individuals were invitedto voice their interests and concerns in publichearings. This involvement facilitated consensuson a number of contentious parts of the reform,including shifts of resources to primary careand to underserved areas, while responsibilitieswere redistributed to improve cooperation andcoordination 10 . Time and effort for systematicbut principled negotiation is the price to pay forobtaining the social consensus that can overcomeentrenched resistance to reform.Rapid-growth health economiesIn rapid-growth health economies, the challengeof engaging PHC reforms presents itself quitedifferently. The growing demand that comeswith increased purchasing power is fuelling anexpansion of services at unprecedented speed.Assuming current growth rates continue throughto 2015, per capita health expenditure will growby 60% in the fast-growing health economies ofthe Americas compared to 2005 levels. In thesame time period, that expenditure will doublein Europe and the Middle-East and triple in EastAsia (Figure 6.2).Figure 6.2 Projected per capita health expenditure in 2015, rapid-growthhealth economies (weighted averages) aProjected total health expenditure per capita, I$, 2015140012001000800600400200Projected growth in out-of-pocket expenditureProjected growth in private pre-paid expenditureProjected growth in government expenditureLevel of total health expenditure in 20050Low- and Low- andmiddleincomincomemiddle-countries*, countries*,Eastern East Asia,Mediterranean Westernregion Pacific regionLow- andmiddleincome*,AmericasLow- andmiddleincomecountries*,EuropeanregionAll rapidgrowthhealtheconomies* Without fragile states.aAssuming the yearly growth rates for government-, private pre-paid-, and out-of-pocketexpenditure estimated from 1995−2005 data 5 persist to 2015.While the rate of growth in expenditure representsan opportunity to engage in PHC reforms,it also fuels patterns of health-sector developmentthat run counter to the vision and values103

The World Health Report 2008Primary Health Care – Now More Than Everof PHC. Beginnings count: policy choices that aremade for political or technical expediency, suchas to refrain from regulating commercial healthcare, may make it more difficult to redirect healthsystems towards PHC values at a later stage, aspowerful vested interests emerge and patternsof supply-induced demand become entrenched 11 .Biases towards highly sophisticated and specializedinfrastructures that cater to the expectationsof a wealthy minority are being further fuelledby a new growth market in medical tourismwhereby patients from high-expenditure healtheconomies with high-fixed costs are out-sourcedto these comparatively low-cost environments.This drains the supply of professionals for primarycare, encouraging unprecedented rates ofspecialization within the workforce 12 . In contrastwith these developments, ministries of healthin many of these countries are still organizedaround specific disease control efforts, and areill-equipped to use the leverage of expandingresources to regulate health-care delivery. Theresult is all too often a two-tiered system, withhighly sophisticated and specialized health infrastructurethat caters to expectations of a wealthyminority, in the presence of huge gaps in serviceavailability for a large part of the populationReforms that emphasize universal access topeople-centred primary care can help to correctsuch distortions. These reforms can take advantageof technological innovations that facilitaterapid, simple, reliable and low-cost access to servicesthat were previously inaccessible becausethey were too expensive or required complexsupportive infrastructure. Such innovationsinclude rapid diagnostic tests for HIV and gastriculcers, better drugs that facilitate the shift frominstitution-based to primary care-based mentalhealth 13 , and advances in surgery that eithereliminate or dramatically reduce the need forhospitalization. Combined with the multiplicationof evidence-based guidelines, such innovationshave considerably enlarged the problem solvingcapacity of primary-care teams, broadening therole of non-physician clinicians 14 and the potentialof self-care. Rapid expansion of people-centredcare is thus possible in a context where the technologicalgap between close-to-client ambulatorycare and tertiary institutions is less strikingthan it was 30 years ago. Chile, for example, hasdoubled the uptake of primary-care servicesin a period of five years, along with a massiveinvestment in personnel and equipment rangingfrom emergency dental care and laboratories tohome-based management of chronic pain. Theimpact of this transformation can be amplifiedby targeting and empowering the large numbersof poor and excluded in these countries and byreforming public policies accordingly.In the rapid-growth health economies of theAmericas and the European region less that onethird of the expected growth on current trends isthrough increased out-of-pocket expenditure onhealth. Two thirds are through increased governmentexpenditure, in combination, in the Americas,with expanded private pre-paid expenditure(Figure 6.2). The latter also plays a growing rolein the Far East, where, as in the Middle East,around 40% of the growth, on current trends,will be in out-of-pocket expenditure. Leverageof PHC reforms will depend in part on the possibilityto regulate and influence private pre-paidexpenditure, and, particularly in Asia, to curb thereliance on out-of-pocket expenditure.In most of these countries, the level of expenditurecompared to GDP or to total governmentexpenditure remains low, offering financial roomto further accelerate PHC reforms and underpinthem through parallel, and equally important,moves towards universal coverage and reducedreliance on out-of-pocket payments. In many ofthese countries, public resources are allocatedon a capitation basis as are, at least, part ofpooled private pre-payment funds. This providesopportunities to include criteria, such asrelative deprivation or unmet health needs in thecapitation formulas. This effectively transformsresource allocation into an instrument for promotinghealth equity and for introducing incentivesfavouring conversion towards primary careand healthier public policies.Some of the largest countries in the world –Brazil, for example – are now seizing these kindsof opportunities on a massive scale, expandingtheir primary-care networks while diminishingtheir reliance on out-of-pocket payments 15 . Suchreforms, however, rarely come about withoutpressure from the user’s side. Chile’s health policy104

Chapter 6. The way forwardhas defined a detailed benefit package, well publicizedamong the population as an enforceableright. People are being informed about the kindof services, including access to specialized care,which they can claim from their primary-careteams. In combination with sustained investment,such unambiguous entitlements create apowerful dynamic for the development of primarycare. Managed well, they have the potential toaccelerate convergence while avoiding at leastpart of the distortions and inefficiencies that haveplagued high-income countries in earlier years.Low-expenditure,low-growth health economiesWith 2.6 billion people and less than 5% of theworld’s health expenditure, countries in thisgroup suffer from an absolute under-funding oftheir health sector, along with a disproportionallyhigh disease burden. The persistence of highlevels of maternal mortality in these countries− they claim close to 90% of all maternal deaths− is perhaps the clearest indication of the consequencesof the under-funding of health on theperformance of their health systems.Worryingly, growth in health expenditure inthese countries is low and highly vulnerable totheir political and economic contexts. In fragilestates, particularly in those located in Africa,health expenditure is not only low but barelygrowing at all, and 28% of this little amountof growth in recent years is accounted for byexternal aid. Health expenditure in the othercountries of this group is growing at a strongeraverage rate of 6% to 7% per year. On currenttrends, by 2015, per capita health expenditurewill have more than doubled in India comparedto 2005, and increased by half elsewhere, exceptin fragile states (Figure 6.3). In many countries,this represents significant leverage to engagePHC reforms, particularly where the growth isthrough increased government expenditure or, asin Southern Africa, through other forms of prepayment.In India, however, more than 80% of thegrowth will, on current trends, be in out-of pocketexpenditure, offering much less leverage.Countries in these regions accumulate a set ofproblems that in all their diversity share manycharacteristics. Whole population groups areexcluded from access to quality care: becauseno services are available; because they are tooexpensive, or under-funded, under-staffed andunder-equipped; or because they are fragmentedand limited to a few priority programmes. Effortsto establish sound public policies that promotehealth and deal with determinants of ill-health arelimited at best. Unregulated commercializationof both private- and public-health care is quicklybecoming the norm for urban and, increasingly,for rural populations − a much bigger and moreunderestimated challenge to PHC’s values thanthe verticalism that so worries the internationalhealth community.In most of these countries, the state has had,in the past, the ambition to run the health sectoron an authoritarian basis. In today’s pluralisticcontext, with a multitude of different providers,formal and informal, public and private, onlyfew have succeeded in switching to more appropriatesteer-and-negotiate approaches. Instead,as public resources stagnated and bureaucraticmechanisms failed, laissez-faire has become thedefault approach to management of the healthsector.Figure 6.3 Projected per capita health expenditure in 2015, low-expenditure,low-growth health economies (weighted averages) aProjected health expenditure per capita, I$, 2015300250200150100500Projected growth in out-of-pocket expenditureProjected growth in private pre-paid expenditureProjected growth in government expenditureLevel of total health expenditure in 2005FragilestatesSouth- andSouth-East Asia*IndiaSub-saharanAfrica*All lowexpenditure,low-growthhealtheconomies* Without fragile states.aAssuming the yearly growth rates for government-, private pre-paid-, and out-of-pocketexpenditure estimated from 1995−2005 data 5 persist to 2015.105

The World Health Report 2008Primary Health Care – Now More Than EverThis has resulted in few or feeble attempts toregulate commercial health-care provision – notonly by the private, but also within the publicsector, which has, in many instances, adoptedthe commercial practices of unregulated privatecare. In such settings, government capacity oftenlimits the extent to which new resources can beleveraged for improved performance. Healthauthorities are, thus, left with an unfunded mandatefor steering the health sector.Therefore, growing the resource base is a priority:to refinance resource-starved health systems;to provide them with new life through PHCreforms; and to re-invest in public leadership. Prepaymentsystems must be nurtured now, discouragingdirect levies on the sick and encouragingpooling of resources. This will make it possible toallocate limited resources more intelligently andexplicitly than when health services are paid forout-of-pocket. While there is no single prescriptionfor the type of pooling mechanism, thereare greater efficiencies in larger pools: gradualmerging or federation of pre-payment schemescan accelerate the build-up of regulatory capacityand accountability mechanisms 16 .In a significant number of these low-expenditure,low-growth health economies, particularlyin sub-Saharan Africa and fragile states,the steep increase in external funds directedtowards health through bilateral channels orthrough the new generation of global financinginstruments has boosted the vitality of thehealth sector. These external funds need to beprogressively re-channelled in ways that helpbuild institutional capacity towards a longer-termgoal of self-sustaining, universal coverage. In thepast, the bulk of donor assistance has targetedshort-term projects and programmes resulting inunnecessary delays, or even detracting from theemergence of the financing institutions requiredto manage universal coverage schemes. Therenewed interest among donors in supportingnational planning processes as part of the harmonizationand alignment agenda, and the consensusthat calls for universal access, representimportant opportunities for scaling up investmentsin the institutional apparatus necessary foruniversal coverage. While reduced catastrophicexpenditure on health care and universal accessare sufficiently strong rationales for such changein donor behaviour, the build-up of sustainablenational financing capacities also offers an eventualexit strategy from donor dependence.Governments can do more to support the healthsector in these settings. Low-expenditure, lowgrowthhealth economies allocate only a smallfraction of their government revenue to health.Even in sub-Saharan African countries, whichhave made progress and allocated an average of8.8% of their government expenditure to healthin 2005, the Abuja Declaration target of 15% isstill a long way off 5 . Reaching that target wouldincrease total health expenditure in the regionby 34%. Experience of the last decade shows thatit is possible to increase government revenuesallocated to health rapidly. For example, followingrising pressure from a broad range of civilsociety and political movements, India’s generalgovernment expenditure on health – with a specificfocus on primary health care – is expectedto triple within the next five years 17 . In a differentcontext, the Ministry of Health in Burundiquadrupled its budget between 2005 and 2007 bysuccessfully applying for funds that became availablethrough debt reduction under the EnhancedHeavily Indebted Poor Countries (HIPC) initiative.On average, in the 23 countries at completionpoint for the HIPC and Multilateral Debt ReliefInitiative (MDRI), the annual savings from HIPCdebt relief during the 10 years following qualificationare equivalent to 70% of public spendingon health at 2005 levels 18 . While only part of thatmoney is to be directed to health, even that canmake a considerable difference to the financialclout of public-health authorities.Opportunities arise not only from increasedresources. The preponderance of pilot projectsis gradually being replaced by more systematicefforts to achieve universal access, albeit oftenfor a single intervention or disease programme.These high visibility programmes, developed inrelation to the MDGs, have revitalized a numberof concepts that are key to people-centredcare. Among them are the imperative of universalaccess to high quality and safe care withoutfinancial penalty, and the importance of continuityof care, and the need to understand thesocial, cultural and economic context in which all106

Chapter 6. The way forwardBox 6.2 The virtuous cycle of supply of and demand for primary careIn Mali, the primary care network is made up of communityowned,community-operated primary-care centres, backed upby government-run district teams and referral units. There is acoverage plan, negotiated with the communities, which, if theyso wish, can take the initiative to create a primary-care centreaccording to a set of criteria. The commitment is important, sincethe health centre will be owned and run by the community: forexample, the staff of the health centre, a three to four personteam led by a nurse or a family doctor, has to be employed (andfi nanced) by the local community health association. The communitycan make an agreement with the Ministry of Health toobtain technical and fi nancial support from the district-healthteams, for the launch of the health centre and the supervisionand back up of its subsequent operation.The model has proved quite popular, despite the huge effort communitieshave had to put into the mobilization and organizationof these facilities: by 2007, 826 such centres were in operation(up from 360 10 years before), set up at an average cost ofUS$ 17 000. The system has proved resilient and has signifi cantlyincreased the production of health care: the number of curativecare episodes managed by the health centres has been multipliedby 2.1. The number of women followed up in antenatal care hasbeen multiplied by 2.7 and births attended by a health professionalby 2.5, with coverage levels as measured through DemographicHealth Surveys in 2006 standing at 70% and 49%, respectively;DTP3 vaccination coverage in 2006 was 68%.People obviously consider the investment worthwhile. Twiceduring the last 10 years, between 2000 and 2001 and 2004and 2005, demand and local initiative for the creation of newcentres was rising so fast that Mali’s health authorities had totake measures to slow down the expansion of the network in orderto be able to guarantee quality standards (Figure 6.4). This suggeststhat the virtuous cycle of increased demand and improvedFigure 6.4 The progressive extension of coverage by community-owned,community–operated health centres in Mali, 1998–2007Population (millions)Not yet coveredCovered, but living more than 5 km from health careCovered, living within 5 km of health care12108642019981999 2000 2001 2002 2003 2004 2005 2006 2007Demand-drivenacceleration ofcommunityinitiativesSlowdownto safeguardqualityDemand-drivenacceleration ofcommunityinitiativesSlowdownto safeguardqualitySource: Système national d’information sanitaire (SNIS), Cellule de Planification et deStatistiques Ministère de la Santé Mali [National health information system (SNIS), Planningand Statistics Unit, Ministry of Health, Mali].supply is functioning. Health authorities are expanding the rangeof services offered and improving the quality – by encouraging therecruitment of doctors in the rural primary-care centres − whilecontinuing their support to the extension of the network.men, women and families of a given communitylive. Integration is becoming a reality throughapproaches, such as the Integrated Managementof Adolescent and Adult Illness (IMAI) and thecommunity-based interventions emerging fromthe Onchocerciasis Control Programme (OCP) 19 .Global initiatives are loosening their grip ondisease-control mandates and are beginningto appreciate the importance of strengtheningthe system more generally, such as throughGAVI Alliance’s Health System Strengtheningwindow, paving the way for better alignment ofpreviously fragmented initiatives. Driven largelyby demand, information technologies to supportprimary care, such as electronic medical records,are spreading much faster than anticipated.Efforts to scale up HIV treatment have helped toexpose the shortfalls in key systems inputs, suchas the supply chain management of diagnosticsand drugs, and build bridges to other sectors,such as agriculture, given the imperative of foodsecurity. Emerging awareness of the magnitudeof the workforce crisis is leading to ambitiouspolicies and programmes, including task shifting,distance learning and the innovative deploymentof financial and non-financial incentives.In this context, the challenge is no longer to domore with less, but to harness the growth in the107

The World Health Report 2008Primary Health Care – Now More Than Everhealth sector to do more with more. The unmetneed in these countries is vast and making servicesavailable is still a major issue. It requires aprogressive roll-out of health districts – whetherthrough government services or by contractingNGOs, or a combination of both. Yet the complexitiesof contemporary health systems, particularly,but not only in urban areas, call for flexible andinnovative interpretations of these organizationalstrategies. In many of Africa’s capitals, for example,public facilities of primary, and even secondary,level have almost or completely disappeared,and have been replaced by unregulated commercialproviders 20 . Creative solutions will have tobuild on alliances with local authorities, civilsociety and consumer organizations to use growingfunds – pooled private pre-payment, socialsecurity contributions, funds from municipalauthorities and tax-sourced funding – to createa primary-care offer that acts as a public safetynet, as an alternative to unregulated commercialcare, and as a signal of what trustworthy, peoplecentredhealth care can look like.What eventually matters is the experience ofpatients accessing services. Trust will grow if theyare welcomed and not turned away; rememberedand not forgotten; seen by someone who knowsthem well; respected in terms of their privacyand dignity; responded to with appropriate care;informed about tests; and provided with drugsand not charged a fee at the point of service.Growing trust can induce a virtuous cycle ofincreased demand and improved supply (Box 6.2).The gain in credibility that comes from instatingsuch a virtuous cycle is key to gaining social andpolitical consensus on investment in healthierpublic policies across sectors. Effective foodsecurity, education and rural-urban policies arecritical for health and health equity: the healthsector’s influence on these policies depends toa large extent on its performance in providingquality primary care.Mobilizing the drivers of reformAcross all of the diverse national contexts in whichPHC reforms must find their specific expression,globalization plays a major role. It is altering thebalance between international organizations,national governments, non-state actors, local andregional authorities and individual citizens.The global health landscape is not immune tothese wider changes. Over the last 30 years, thetraditional nation state and multilateral architecturehave been transformed. Civil society organizationshave mushroomed, along with the emergenceof public-private partnerships and globaladvocacy communities identified with specifichealth problems. Governmental agencies workwith research consortia and consulting firmsas well as with non-state transnational institutions,foundations and NGOs that operate on aglobal scale. National diasporas have appearedthat command substantial resources and influencewith remittances – about US$ 150 billionin 2005 – that dwarf overseas development aid.Illicit global networks make a business out ofcounterfeit drugs or toxic waste disposal, andnow have the resources that allow them to captureand subvert the capacity of public agencies.Power is gravitating from national governmentsto international organizations and, at the sametime, to sub-national entities, including a rangeof local and regional governments and non-governmentalinstitutions 21 .This new and often chaotic complexity is challenging,particularly to health authorities thathesitate between ineffective and often counterproductivecommand and control and deleteriouslaissez-faire approaches to governance. However,it also offers new, common opportunitiesfor investing in the capacity to lead and mediatethe politics of reform, by mobilizing knowledge,the workforce and people.Mobilizing the production of knowledgePHC reforms can be spurred and kept on trackby institutionalizing PHC policy reviews thatmobilize organizational imagination, intelligenceand ingenuity. The know-how to conduct policyreviews exists 22 , but requires more explicit articulations.They need to refocus on monitoring suchprogress with each of the four interlocking sets ofPHC reforms; on identifying, as they unfold, thetechnical and political obstacles to their advancement;and on providing the elements for coursecorrections, where necessary.108

Chapter 6. The way forwardIn a globalizing world, PHC policy reviewscan take advantage of the emerging within- andacross-country collaborative networks to buildup the critical mass that can lead and implementthe necessary reforms. Indeed, for manycountries, it is not realistic to find, within theirown institutions, all the technical expertise, contextualknowledge and necessary capacity fordispassionate analysis that PHC policy reviewsrequire. Open, inclusive and collaborative structures,such as the Latin American observatorymodels 23 , can go a long way in harnessing thediversity of national resources. Such models alsomake it possible to derive further benefits frominternational collaboration and to overcome thescarcities within a single nation’s capacities. Policy-makerstoday are more open to lessons fromabroad than they may have been in the past, andare using them to feed national policy dialoguewith innovative approaches and better evidenceof what works and what does not 22 . Embeddingnational institutions in regional networks thatcollaborate around PHC policy reviews makes itpossible to pool technical competencies as well asinformation. Importantly, it can create regionalmechanisms to get more effective representationin important but labour-intensive global bodies,with less strain on scarce national resources.More structured and intensive inter-countrycollaboration around PHC policy reviews wouldyield better international comparative data onvariations in the development of health systemsbased on PHC, on models of good practice and onthe determinants of successful PHC reforms. Suchinformation is currently often either absent, hardto compare or outdated. By building on networksof experts and institutions from different regions,it is possible to produce consensus-based andvalidated benchmarks for assessing progressand easier access to (inter)national sources ofinformation relevant to monitoring primary care.This could make a big difference in steering PHCreforms. Various initiatives in this direction, suchas the Primary Health Care Activity Monitor forEurope (PHAMEU) 24 , a network of institutes andorganizations from 10 European Union MemberStates, or the Regional Network on Equity inHealth (EQUINET) 25 , a network of professionals,civil society members, policy-makers, and stateofficials in Southern Africa, are promising stepsin that direction.There is a huge research agenda with enormouspotential to accelerate PHC reforms thatrequires more concerted attention (see Box 6.3).Yet, currently, the share of health expensesdevoted to determining what works best – tohealth services research – is less that 0.1% ofhealth expenditure in the United States, the countrythat spends the highest proportion (5.6%) ofBox 6.3. From product development tofi eld implementation – research makesthe link 27The WHO-based Special Programme for Research and Trainingin Tropical Diseases (TDR) has been a pioneer in research toinform policy and practice. TDR-sponsored studies were thefi rst to broadly document the effi cacy of insecticide-treatedbednets for malaria prevention in the mid-1990s, in multicountry,multi-centre controlled trials. Following introductionof the drug Ivermectin for onchocerciasis, or “river blindness”,control in the late 1980s, TDR, together with the African Programmefor Onchocerciasis Control, initiated research on howbest to get Ivermectin into mass distribution in the fi eld. Whatevolved was a tested and fi ne-tuned region-wide system for“community-directed treatment” of river blindness, describedas “one of the most triumphant public health campaigns everwaged in the developing world.” 28Now, as the global health community moves away from verticaldisease control, operational research is facilitating the shift.Recent TDR-supported large-scale, controlled studies involving2.5 million people in 35 health districts in three countries havedemonstrated that the community-directed treatment methodsdeveloped to combat river blindness can be utilized as aplatform for integrated delivery of multiple primary health-careinterventions, including, bednets, malaria treatment and otherbasic health-care interventions, with signifi cant increases incoverage. For example, more than twice as many children withfever received appropriate antimalarial treatment, exceeding60% coverage on average. Critical to both the funding andexecution of such research are the partnerships fostered withcountries in the region, as well as other public, civil society andprivate institutions. The vision now is to make implementationand operations research an even more important element ofglobal research agendas, so that new products may fi nallybegin to yield their hoped-for health impact through sounderprimary health-care system implementation. Thus, the longstandingburden of deadly diseases, such as malaria, may bemore effectively addressed – through global, regional andlocal knowledge-sharing and cooperation.109

The World Health Report 2008Primary Health Care – Now More Than Everits health expenditure on biomedical research 26 .As another striking example, only US$ 2 millionout of US$ 390 million in 32 GAVI HealthSystem Strengthening grants were allocated toresearch, despite encouragement to countries todo so. No other I$ 5 trillion economic sector wouldbe happy with so little investment in researchrelated to its core agenda: the reduction of healthinequalities; the organization of people-centredcare; and the development of better, more effectivepublic policies. No other industry of that sizewould be satisfied with so little investment in abetter understanding of what their clients expectand how they perceive performance. No otherindustry of that size would pay so little attentionto intelligence on the political context in whichit operates – the positions and strategies of keystakeholders and partners. It is time for healthleaders to understand the value of investmentin this area.Mobilizing the commitment ofthe workforceEach of the sets of PHC reforms emphasizes thepremium placed on human resources in health.The expected skills and competencies constitutean ambitious workforce programme thatrequires a rethink and review of existing pedagogicapproaches. The science of health equityand primary care has yet to find its central placein schools of public health. Pre-service educationfor the health professions is already beginningto build in shared curricular activities thatemphasize problem-solving in multi-disciplinaryteams, but they need to go further in preparingfor the skills and attitudes that PHC requires.This includes creating opportunities for on-thejoblearning across sectors through mentoring,coaching and continuing education. These andother changes to the wide array of curricula andon-the-job learning require a deliberate effort tomobilize the responsible institutional actors bothwithin and across countries.However, as we have learned in recent years,the content of what is learned or taught, althoughextremely important, is but one part of a complexof systems that governs the performance of thehealth workforce 1 . A set of systems issues relatedto the health workforce need to be guided to agreater degree by PHC reforms. For example,health equity targets for underserved populationgroups will remain elusive if they do not considerhow health workers can be effectively recruitedand retained to work among them. Likewise,grand visions of care coordinated around theperson or patient are unlikely to be translatedinto practice if credible career options for workingin primary-care teams are not put in place.Similarly, incentives are critical complements inensuring that individuals and institutions exercisetheir competencies when engaging healthin all policies.The health workforce is critical to PHC reforms.Significant investment is needed to empowerhealth staff – from nurses to policy-makers –with the wherewithal to learn, adapt, be teamplayers, and to combine biomedical and socialperspectives, equity sensitivity and patient centredness.Without investing in their mobilization,they can be an enormous source of resistance tochange, anchored to past models that are convenient,reassuring, profitable and intellectuallycomfortable. If, however, they can be made tosee and experience that primary health careproduces stimulating and gratifying work, whichis socially and economically rewarding, healthworkers may not only come on board but alsobecome a militant vanguard. Here again, takingadvantage of the opportunities afforded by theexchange and sharing of experience offered bya globalizing world can speed up the necessarytransformations.Mobilizing the participation of peopleThe history of the politics of PHC reforms in thecountries that have made major strides is largelyunwritten. It is clear, however, that where thesereforms have been successful, the endorsementof PHC by the health sector and by the politicalworld has invariably followed on rising demandand pressure expressed by civil society. Thereare many examples of such demand. In Thailand,the initial efforts to mobilize civil society andpoliticians around an agenda of universal coveragecame from within the Ministry of Health 29,30 .However, it was only when Thai reformers joineda surge in civil society pressure to improve accessto care, did it become possible to take advantage110

Chapter 6. The way forwardof a political opportunity and launch the reform 31 .In just a few years, coverage was extended andmost of the population was covered with a publiclyfunded primary-care system that benefitincidenceanalysis shows to be pro-poor 32,33 . InMali, the revitalization of PHC in the 1990s startedwith an alliance between part of the Ministry ofHealth and part of the donor community, whichmade it possible to overcome initial resistanceand scepticism 34 . However, sustained extensionof coverage only came about when hundreds oflocal “community health associations” federatedin a powerful pressure group to spur the Ministryof Health and sustain political commitment 35 . Inwestern Europe, consumer organizations havea prominent place in the discussions on healthcare and public policies relating to health, as havemany other civil society organizations. Elsewhere,such as in Chile, the initiative has come from thepolitical arena as part of an agenda of democratization.In India, the National Rural HealthMission came about as a result of strong pressurefrom civil society and the political world, while, inBangladesh, much of the pressure for PHC comesfrom quasi-public NGOs 36 .There is an important lesson there: powerfulallies for PHC reform are to be found within civilsociety. They can make the difference betweena well-intentioned but short-lived attempt, andsuccessful and sustained reform; and betweena purely technical initiative, and one that isendorsed by the political world and enjoys socialconsensus. This is not to say that public policyshould be purely demand-driven. Health authoritieshave to ensure that popular expectationsand demand are balanced with need, technicalpriorities and anticipated future challenges.Health authorities committed to PHC will haveto harness the dynamics of civil society pressurefor change in a policy debate that is supportedwith evidence and information, and informed byexchange of experience with others, within andacross national boundaries.Today, it is possible to make a stronger casefor health than in previous times. This is not onlybecause of intrinsic values, such as health equity,or for the sector’s contribution to economic growth− however valid they may be, these argumentsare not always the most effective – but on politicalgrounds. Health constitutes an economic sectorof growing importance in itself and a feature ofdevelopment and social cohesion. Reliable protectionagainst health threats and equitable accessto quality health care when needed are amongthe most central demands people make on theirgovernments in advancing societies. Health hasbecome a tangible measure of how well societiesare developing and, thus, how well governmentsare performing their role. This constitutes a reservoirof potential strength for the sector, and isa basis for obtaining a level of commitment fromsociety and political leadership that is commensuratewith the challenges.Economic development and the rise of a knowledgesociety make it likely, though not inevitable,that expectations regarding health and healthsystems will continue to rise – some realistic,some not, some self-serving, others balancedwith concern for what is good for society at large.The increasing weight of some of the key valuesunderlying these expectations − equity, solidarity,the centrality of people and their wish to havea say in what affects them and their health − is along-term trend. Health systems do not naturallygravitate towards these values, hence the need foreach country to make a deliberate choice whendeciding the future of their health systems. Itis possible not to choose PHC. In the long run,however, that option carries a huge penalty: inforfeited health benefits, impoverishing costs, inloss of trust in the health system as a whole and,ultimately, in loss of political legitimacy. Countriesneed to demonstrate their ability to transformtheir health systems in line with changingchallenges as well as to rising popular expectations.That is why we need to mobilize for PHC,now more than ever.111

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IndexAAboriginal populations, health inequities 32abortion, legal access vs unsafe abortion 65Africalow-income countries under stress (LICUS) criteria 5PHC replaced by unregulated commercial providers 108see also North Africa; South Africa; sub-Saharan Africaageing populations 8Agreement on Trade-Related Aspects of Intellectual PropertyRights (TRIPS) 76Alma-Ata see Declaration of Alma-Ata on Primary Health Careambulatory caregeneralist vs specialist 53professionals, conventional health care 55avian infl uenza (H5N1) 68Ayurvedic medicine training 44BBangladeshinequalities in health/health care 10neglect of health infrastructure 2–8patterns of exclusion 28quasi-public NGOs 111resource-constrained settings 87rural credit programmes 48Belgium, local authorities, support of intersectoralcollaboration 35benefi t packages, defi ning 27Benin, inequalities in health/health care 10birthing careempowering users to contribute to their own health 48professionalization 17, 28births and deaths, unrecorded/uncounted 74Bolivia, inequalities in health/health care 10Bosnia and Herzegovina, inequalities in health/health care 10Botswana, inequalities in health/health care 10BrazilFamily Health Teams 67human resource issues (PAHO) 88Integrated Management of Childhood Illness (IMCI) 67policy dialogue 86Burkina Faso, institutional capacity for health-sectorgovernance 92Burundi, Enhanced Heavily Indebted Poor Countries (HIPC)initiative 106CCambodiainequalities in health/health care 10progressive roll-out of rural coverage 30Campbell Collaboration 74Canadapolicy dialogue 86SARS leading to establishment of a national public healthagency 64cancer screening 9capacity for changecritical mass 90limitations of conventional capacity building in low- andmiddle-income countries 91Caribbean, professionalization of birthing care 17Central Asia, professionalization of birthing care 17Central and Eastern Europe and the Commonwealth ofIndependent States (CEE-CIS), disengagement from healthprovision 83cerebrovascular disease, tobacco-related 9Chadneglect of health infrastructure 27–8patterns of exclusion 28Chileadministrative structures redefi ned 93benefi t package as an enforceable right 104–5integrating health sector information systems 35outreach to families in long-term poverty 33Regime of Explicit Health Guarantees 87targeting social protection 33under-fi ve mortality 1975–2006 2Chinaambitious rural PHC reform 93deregulation of health sector (1980s) 83–4health expenditure 84outbreak of SARS in 2003 64re-engagement of health care 84chronic disease, prevention in developing countries 65chronic obstructive pulmonary disease, tobacco-related 9civil registration 74Cochrane Collaboration 73Codex Alimentarius Commission (1963) 76Columbiainequalities in health/health care 10patterns of exclusion 28113

The World Health Report 2008Primary Health Care – Now More Than Evercommercialization of health carealternatives to unregulated commercial services 31consequences for quality and access to care 14unregulated, drift to 13–14in unregulated health systems 11, 14, 106Commission on Social Determinants of Health (CSDH),recommendations 69community health workers, bypassing 16Comoros, inequalities in health/health care 10comprehensivenessbetter vaccination coverage 49evidence of its contribution to quality of care and betteroutcomes 48conditional cash transfers 33continuity of care 53, 57contraceptive prevalence, sub-Saharan Africa 3conventional health careambulatory care professionals 55switch to PHC 56vs people-centredness 43coordination (gatekeeping) role of ambulatory careprofessionals 55Costa Ricabias-free framework of health systems 36local reorganization, template for national effort 36universal coverage scheme 25Cote d’IvoireGDP 4inequalities in health/health care 10mother-to-child transmission (MTCT) of HIV 44–5Cuba, maximizing society’s resources 65DDeclaration of Alma-Ata on Primary Health Care (1978) ix, xiii,34, 69Democratic Republic of the Congohealth budget cuts 7institutional capacity for health-sector governance 92rebuilding leadership in health, post-war and economicdecline 94robustness of PHC-led health systems 31safari surgery 14Demographic and Health Survey (DHS) data 34–5developing countries, chronic disease burden 65diasporas 108dietary salt reduction 65disease control programmes 16return on investment 13vs challenges of health systems 83vs people-centred PHC 43disengagement from health provision, CEE-CIS 83documentation and assessment 74domestic investment, re-invigorating health systems xxdrugscounterfeit drugs 108global expenditure 12national medicine policies 66product licencing 102transnational mechanisms of access 66WHO List of Essential Medicines 66EEcuadorEquity Gauges 88inequalities in health/health care 10electronic health records 50entry point to PHC 50–2, 53, 57EQUINET (Regional Network on Equity in Health) 109Equity Gauges, stakeholder collaboration to tackle healthinequalities 88essential packages, defi ning 27Ethiopiacontract staff pay 13Health Extension Workers 67priority preventive interventions 28Europe2003 heatwave 54Primary Health Care Activity Monitor for Europe (PHAMEU)109Regional Network on Equity in Health (EQUINET) 109European Unionimpact assessment guidelines 75technical requirements, registering new medicines orproduct licencing 102evidence-based medicine 43–4FFiji, isolated/dispersed populations 30–1Finland, health inequities 32fooddietary salt reduction 65marketing to children 73“fragile states”increase in external funds 106low-income countries under stress (LICUS) criteria 5per capita health expenditure 105fragmentation of health care 11, 12–13causes 51fragmented funding streams and service delivery 85Francehealth inequities 32reduction in traffi c fatalities 71self-help organization of diabetics 48funding see total health expenditure114

IndexGGDPgrowth in GDP xviiilife expectancy at birth, 169 countries 4percentage of GDP used for health (2005) 82trends per capita and life expectancy at birth, 133countries 5generalist ambulatory care 53global expendituremedical equipment and devices 12percentage of GDP used for health (2005) 82pharmaceutical industry 12global trendscity dwelling 7life expectancy 4that undermine health systems’ response 11–12globalization xiii–xivadjusting to 76global health interdependence 76governmentsas brokers for PHC reform 82–6or quasi-governmental institutions, participation andnegotiation 85grassroots advocacy 35–6growth, and peace 6growth market in medical tourism 104Guinea, inequalities in health/health care 10HHaiti, institutional capacity for health-sector governance 92health, feature of development and social cohesion 111Health Action Zones, United Kingdom 36health equity 34–5central place of 15, 24–5common misperceptions 34–5“health in all policies” concept 64health expenditure see total health expenditurehealth hazards, political fall-out from 16health inequities 15, 24, 32Aboriginal and non-Aboriginal populations 32catastrophic expenditure related to out-of-pocket payment24Equity Gauges 88increasing the visibility 34political proposals, organized social demand 35see also fragmentation of health carehealth systemschanging values and rising expectations 14–15components and provision of services 66consistent inequity 24dangerous oversimplifi cation in resource-constrainedsettings xviiidefi ning essential packages 27diversion from primary health care core values 11expectations for better performance xivfailure to assess political environment 9–10inequalities in health/health care 10, 15, 24, 32, 34–5little anticipation and slow reactions to change 9–10making more people-centred 16Medisave accounts 50mismatch between expectations and performance xvmitigating effects of social inequities 36moving towards universal coverage 25–7PHC reforms necessary (4 groups) xviishift of focus of primary health care movement xvithree bad trends xivuniversal coverage 25see also primary health care (PHC) reforms; public policymakinghealth-adjusted life expectancy (HALE) 6health-care deliveryfi ve common shortcomings xvreorganization of work schedules of rural health centres42–3health-sector governance, institutional capacity 92“Healthy Islands” initiative 30heatwave, western Europe (2003) 54Heavily Indebted Poor Countries (HIPC) initiative 106high spending on health, better outcomes 5high-expenditure health economies 100, 101–3HIV infection, mother-to-child transmission (MTCT) 44HIV/AIDS, continuum of care approaches 68hospital-centrism 11opportunity cost 12Iimpact assessment, European Union guidelines 75IndiaNational Rural Health Mission 111per capita health expenditure 105private sector medical-care providers 44public expenditure on health 93under-fi ve mortality 1975 and 2006 3Indonesia, inequalities in health/health care 10infl uenza, avian (H5N1) 68information and communication technologies 51information systemsdemand for health-related information 87instrumental to PHC reform 87strengthening policy dialogue 86–7transforming into instruments for PHC reform 87injections, patient safety 44institutions (national)capacity for health-sector governance 92critical mass for capacity for change 90generation of workforce 76115

The World Health Report 2008Primary Health Care – Now More Than Everleadership capacity shortfalls 90multi-centric development 76productive policy dialogue 86instruments for PHC reform, information systems 87Integrated Management of Adolescent and Adult Illness (IMAI)107International Clinical Epidemiology Network 73international environment, favourable to a renewal of PHC xxinternational migration 8interventions, scaling up 28–9investigations, inappropriate investigations prescribed 53invisibility, births and deaths unrecorded/uncounted 74ischaemic heart disease, tobacco-related 9Islamic Republic of Iran, progressive roll-out of rural coverage28isolated/dispersed populations 30–1fi nancing of health care 31JJapan, magnetic resonance imaging (MRI) units per capita 12KKenyaEquity Gauges 88malaria prevention 64knowledge, production of 108Korea, universal coverage scheme 25LLatin Americaexclusion of 47from needed services 32Pan American Health Organization (PAHO) 32, 66, 88professionalization of birthing care 17targeting social protection 33lead poisoning, avoidable 71leadership capacity, shortfalls 90leadership and effective government 81–94“learning from the fi eld”, policy development 89–90Lebanonhospital-centrism vs risk reduction 11neighbourhood environment initiatives 48Lesotho, inequalities in health/health care 10life expectancy at birthin 169 countries 4global trends 4local action, starting point for broader structural changes 36low- and middle-income countries 101low-expenditure low-growth health economies 100–1, 105–8per capita health expenditure 105low-income countries under stress (LICUS) criteria 5MMadagascarinequalities in health/health care 10life expectancy at birth 4under-fi ve mortality 1975 and 2006 3malaria 109Malawihospital nurses leave for better-paid NGO jobs 13inequalities in health/health care 10Malaysiascaling up of priority cadres of workers 67under-fi ve mortality 1975 and 2006 2Maliinstitutional capacity for health-sector governance 92progressive roll-out of rural coverage 30revitalization of PHC in the 1990s 111virtuous cycle of supply of and demand for primary care107medical equipment and devices, global expenditure 12medical tourism 104medico-industrial complex 85–6Mexicoactive ageing programme 48universal coverage scheme 25Middle East, professionalization of birthing care 17Millennium Development Goals (MDGs) xiii, 2, 106Mongolia, under-fi ve mortality 1975 and 2006 3Moroccoinstitutional capacity for health-sector governance 92trachoma programme 71under-fi ve mortality 1975 and 2006 3mortalitycause-of-death statistics 74reducing under-fi ve mortality by 80, by regions, 1975–2006 2shift towards noncommunicable diseases and accidents 8Mozambique, inequalities in health/health care 10multi-morbidity 8mutual support associations 56NNairobi, under-fi ve mortality rate 7national health information systems, policy dialogue 86–7National Institutes of Public Health (NIPHs) 74–5International Association of National Public Health Institutes(IANPHI) 76Nepalcommunity dynamics of women’s groups 54GDP and life expectancy 4inequalities in health/health care 10New Zealand, annual pharmaceutical spending 66Nicaragua, patterns of exclusion 28116

IndexNigerinequalities in health/health care 10neglect of health infrastructure 27–8patterns of exclusion 28reorganization of work schedules of rural health centres 42staff–clients in PHC, direct relationship 42noncommunicable diseases, mortality 8North Africa, professionalization of birthing care 17Norway, national strategy to reduce social inequalities inhealth 102OOffi cial Development Aid for Health, yearly aid fl ows (2005) 91Onchocerciasis Control Programme (OCP) 107, 109opportunity cost, hospital-centrism 12Osler, W, quoted 42Ottawa Charter for Health Promotion 17outpatient attendance 27PPakistan, Lady Health Workers 67Pan American Health Organization (PAHO) 32, 66, 88patient safety, securing better outcomes 44patterns of exclusion from needed services 32peace, and growth 6people-centred primary care, universal access 104people-centredness 16, 42–3and community participation 85desire for participation 18policy dialogue 85–7vs conventional health care 43person-centred careevidence of quality/better outcomes 47and provider’s job satisfaction 46Peru, inequalities in health/health care 10pharmaceutical industry, global expenditure 12Philippines, inequalities in health/health care 10policy dialogue 85–6innovations from the fi eld 89–90political environmentand health hazards 16organized social demand 35political process, from launching reform to implementation92–3populations, health evidence documentation 74Portugal2004–2010 National Health Plan 92key health indicators 3under-fi ve mortality 1975–2006 2Poverty Reduction Strategy Papers (PRSPs) 92–3pre-payment and pooling 26–7pre-payment systems 106Preston curve, GDP per capita and life expectancy at birth in169 countries 4primary health care (PHC)comprehensive and integrated responses 48–9comprehensiveness and integratedness 48–9continuity of care 49–50dangerously oversimplifi ed in resource-constrainedsettings xviiidistinctive features 43–52, 56–7empowering users 48experience has shifted focus xivgovernments as brokers for PHC reform 82–6monitoring progress 56need for multiple strategies 25networking within the community served 55networks, fi lling availability gap 28organizing PHC networks 52–6people-centredness, vs conventional health care 43person-centred, and provider’s job satisfaction 46political endorsement of PHC reforms 93priority health programmes 67progressive roll-out of PHC, vs scaling up of prioritypreventive interventions 28–9rapid response capacity 68–9reforms, driven by demand 18–19regular and trusted provider as entry point 50–2responsibility for a well-identifi ed population 53–4social values and corresponding reforms 18staff–clients direct relationship 42under-investment 71–2see also health systemsprimary health care (PHC) reformsadapting to country context 100commitment of workforce 110four interlocking sets xvii, 114high-expenditure health economies 101–3low-expenditure, low-growth health economies 105–8mobilizing the drivers of reform 108–10participation of people 110–11rapid-growth health economies 103–5primary-care networks 52–6entry point 50–2relocation 53primary-care providers, responsibilities 56primary-care team, as a hub of coordination 55–6priority preventive interventionsscaling up 28–9vs progressive roll-out of PHC 28–30product development 109professionalizationambulatory care 55birthing care 17, 28participation and negotiation 85project management units 91public funding, conditional cash transfers 33public policy-making xix–xx, 63–75117

The World Health Report 2008Primary Health Care – Now More Than Everinstitutional capacity for development 74–5opportunities for better public policies 73–4policies in other sectors 64, 70systems policies 64towards health in all policies 69–70under-investment 71–2unpopular public policy decisions 72–3public-health interventions 64, 67–8essential public-health functions (30 NIPHs) 75impact assessment guidelines (EU) 75initiatives 68Rrapid-growth health economies 103–5Regional Network on Equity in Health (EQUINET) 109researchGAVI Health System Strengthening grants 110product development to fi eld implementation 109Research and Training in Tropical Diseases (TDR) 109response-to-demand approach 53–4risk factorsdeveloping countries chronic disease burden 65in terms of overall disease burden 8risk reductionpatient safety and better outcomes 44vs hospital-centrism 11river blindness, Onchocerciasis Control Programme (OCP) 107,109road-traffi c accidents 7, 8, 71rural health centresinformation and communication technologies 51reorganization of work schedules 42Russian Federation, GDP and health 4–5Ssalt, dietary reduction 65SARS pandemic, establishment of national public healthagencies 64scaling up, limited number of interventions 28–9Senegal, lead poisoning 71Seventh Futures Forum, senior health executives 72Singapore, Medisave accounts 50skills base, extension workers 28social cohesion 111social contract for health 82–3social demand, and political environment 35social determinants of health 69social inequities 36social protection schemes, Latin America 33South AfricaEquity Gauges 88family empowerment and parent training programmes 48South-East Asia, professionalization of birthing care 17South-East Asian Region (SEARO) 76stakeholder collaboration, to tackle health inequalities 88state and health-care system 83absence/withdrawal from health provision 83disengagement and its consequences 83–4Sub-Saharan Africaabortions, increased, in unsafe conditions 3Abuja Declaration target of 15 106contraceptive prevalence 3GDP per capita 7increase in external funds 106professionalization of birthing care 17Sultanate of Omaninvestment in a national health service 2under-fi ve mortality 1975 and 2006 3systems policies, for human resources 66TTajikistan, under-fi ve mortality 1975 and 2006 3Tanzaniabudget allocation formulae/contract specifi cations 30inequalities in health/health care 10treatment plans for safe motherhood 48targeting, social protection schemes 33technical cooperation, Offi cial Development Aid for Health,yearly aid fl ows (2005) 91Thailand30 Baht universal coverage reform 89Decade of Health Centre Development 86Declaration of Patients’ Rights 48First Health Care Reform Forum (1997) 86inappropriate investigations prescribed 53policy dialogue 86strengthening policy dialogue with fi eld model innovations89under-fi ve mortality 1975–2006 2universal coverage scheme 25tobacco industry, efforts to limit tobacco control 73tobacco taxes 65tobacco-attributable deaths 9, 71–2total health expenditure (THE), 2000–2005 100conditional cash transfers 33contribution of general government, private pre-paid andprivate out-of-pocket expenditure 101countries/groups 6projected per capita health expenditure in 2015 103rate of growth 100toxic waste disposal 108trachoma programme 71Trade-Related Aspects of Intellectual Property Rights (TRIPS)76traffi c accidents 7, 8, 71118

Indextropical diseases 109Tunisia, institutional capacity for health-sector governance 92Turkeypatterns of exclusion 28retraining of nurses and physicians 67universal coverage scheme 25UUgandaallocations to districts 30outpatient attendance 27UNICEF/WHO Integrated Management of Childhood Illnessinitiatives 46United Kingdomcareer in primary care, fi nancial competitiveness 67Health Action Zones 36Poor Laws Commission 34public-health observatories in England 89United StatesAlaska, staff–clients in PHC, direct relationship 42in favour of health equity 15magnetic resonance imaging (MRI) units per capita 12per capita expenditure on drugs 12universal access, people-centred primary care 104universal coverage schemes 25–6best practices 26challenges in moving towards 27–8targeted interventions to complement 32–3three ways of moving towards 26unregulated commercial services 31–2Vvaccination, comprehensiveness/coverage 49Wwomen’s healthabortion, legal access vs unsafe abortion 65birthing care, professionalization 17, 28contraceptive prevalence, sub-Saharan Africa 3empowering users to contribute to their own health 48health-care response to partner violence 47work circumstances, change and adverse health effects 70work schedules, reorganization in rural health centres 42workforce, critical to PHC reforms 110World Health OrganizationList of Essential Medicines 66offi ces 113Seventh Futures Forum of senior health executives 72World Trade Organization (WTO), consideration of health intrade agreements 76ZZaire, health budget cuts 7Zambiahealth budget cuts 7incentives to health workers to serve in rural areas 67life expectancy at birth 4under-fi ve mortality 1975 and 2006 3119

Offices of the World Health OrganizationHeadquartersWorld Health OrganizationAvenue Appia 201211 Geneva 27, SwitzerlandTelephone: (41) 22 791 21 11Facsimile: (41) 22 791 31 11E-mail: inf@who.intWeb site: http://www.who.intWHO Regional Office for AfricaCité du DjoueP.O. Box 06Brazzaville, CongoTelephone: (47) 241 39100Facsimile: (47) 241 39503E-mail: webmaster@afro.who.intWeb site: http://www.afro.who.intWHO Regional Office for the Americas/Pan American Sanitary Bureau525, 23rd Street N.W.Washington, D.C. 20037, USATelephone: (1) 202 974 3000Facsimile: (1) 202 974 3663E-mail: webmaster@paho.orgWeb site: http://www.paho.orgWHO Regional Office for South-East AsiaWorld Health HouseIndraprastha EstateMahatma Gandhi RoadNew Delhi 110002, IndiaTelephone: (91) 112 337 0804/09/10/11Facsimile: (91) 112 337 0197/337 9395E-mail: registry@searo.who.intWeb site: http://www.searo.who.intWHO Regional Office for Europe8, Scherfigsvej2100 Copenhagen Ø, DenmarkTelephone: (45) 39 17 17 17Facsimile: (45) 39 17 18 18E-mail: postmaster@euro.who.intWeb site: http://www.euro.who.intWHO Regional Office for the EasternMediterraneanAbdul Razzak Al Sanhouri StreetP.O. Box 7608Nasr CityCairo 11371, EgyptTelephone: (202) 670 25 35Facsimile: (202) 670 2492/94E-mail: webmaster@emro.who.intWeb site: http://www.emro.who.intWHO Regional Office for theWestern PacificP.O. Box 2932Manila 1000, PhilippinesTelephone: (632) 528 9991Facsimile: (632) 521 1036 or 526 0279E-mail: pio@wpro.who.intWeb site: http://www.wpro.who.intInternational Agency forResearch on Cancer150, cours Albert-Thomas69372 Lyon Cédex 08, FranceTelephone: (33) 472 73 84 85Facsimile: (33) 472 73 85 75E-mail: www@iarc.frWeb site: http://www.iarc.fr

PRIMARYHEALTHCAREREFORMSAs nations seek to strengthen their health systems, they are increasinglylooking to primary health care (PHC) to provide a clear and comprehensivesense of direction. The World Health Report 2008 analyses how primaryhealth care reforms, that embody the principles of universal access, equityand social justice, are an essential response to the health challenges ofa rapidly changing world and the growing expectations of countries andtheir citizens for health and health care.The Report identifies four interlocking sets of PHC reforms that aimto: achieve universal access and social protection, so as to improvehealth equity; re-organize service delivery around people’s needs andexpectations; secure healthier communities through better public policies;and remodel leadership for health around more effective government andthe active participation of key stakeholders.This Report comes 30 years after the Alma-Ata Conference of 1978 onprimary health care, which agreed to tackle the “politically, socially andeconomically unacceptable” health inequalities in all countries. Much hasbeen accomplished in this regard: if children were still dying at 1978 rates,there would have been 16.2 million child deaths globally in 2006 insteadof the actual 9.5 million. Yet, progress in health has been deeply andunacceptably unequal, with many disadvantaged populations increasinglylagging behind or even losing ground.Meanwhile, the nature of health problems is changing dramatically.Urbanization, globalization and other factors speed the worldwidetransmission of communicable diseases, and increase the burden ofchronic disorders. Climate change and food insecurity will have majorimplications for health in the years ahead thereby creating enormouschallenges for an effective and equitable response.In the face of all this, business as usual for health systems is not aviable option. Many systems seem to be drifting from one short-termpriority to another, increasingly fragmented and without a strong senseof preparedness for what lies ahead.Fortunately, the current international environment is favourable to arenewal of PHC. Global health is receiving unprecedented attention. Thereis growing interest in united action, with greater calls for comprehensive,universal care and health in all policies. Expectations have never beenso high.By capitalizing on this momentum, investment in primary healthcare reforms can transform health systems and improve the health ofindividuals, families and communities everywhere. For everyone interestedin how progress in health can be made in the 21st century, the WorldHealth Report 2008 is indispensable reading.