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

More documents

Recommendations

Info

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
Page 7 and 8: ContentsList of FiguresFigure 1. Th
Page 9 and 10: ContentsList of TablesTable 1 How e
Page 11: Director-General’s Messagelie ahe
Page 14 and 15: The World Health Report 2008Primary
Page 22: The World Health Report 2008Primary
Page 47: Advancing and sustaininguniversal c
Page 56: The World Health Report 2008Primary
Page 59: Chapter 2. Advancing and sustaining
Page 65 and 66: Primary carePutting people firstThi
Page 67 and 68: Chapter 3. Primary care: putting pe
Page 87 and 88:
Public policiesfor the public’s h
Page 89 and 90:
Chapter 4. Public policies for the
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 105 and 106:
Leadership andeffective governmentT
Page 107 and 108:
Chapter 5. Leadership and effective
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 123 and 124:
The wayforwardThe starkly different
Page 125 and 126:
Chapter 6. The way forwardsame rate
Page 127 and 128:
Chapter 6. The way forwardfamily ph
Page 129 and 130:
Chapter 6. The way forwardhas defin
Page 131 and 132:
Chapter 6. The way forwardBox 6.2 T
Page 133 and 134:
Chapter 6. The way forwardIn a glob
Page 135 and 136:
Chapter 6. The way forwardof a poli
Page 137 and 138:
IndexAAboriginal populations, healt
Page 139 and 140:
IndexGGDPgrowth in GDP xviiilife ex
Page 141 and 142:
IndexNigerinequalities in health/he
Page 143:
Indextropical diseases 109Tunisia,
Page 148:
PRIMARYHEALTHCAREREFORMSAs nations
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?