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

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

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