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

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