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

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