Introduction and overview The focus of these reforms goes well beyond lives, and about the way their society deals with basic"service delivery and cuts across the health and health care. The dynamics of demand established boundaries of the building blocks of must find a voice within the policy and decision national health systems25.For example, aligning making processes.The necessary reorientation of health systems based on the values that drive PHC health systems has to be based on sound scientific will require ambitious human resources policies. evidence and on rational management of uncer However,it would be an illusion to think that tainty, but it should also integrate what people these can be developed in isolation from financing expect of health and health care for themselves or service delivery policies, civil service reform their families and their society. This requires and arrangements dealing with the cross-border delicate trade-offs and negotiation with multiple migration of health professionals stakeholders that imply a stark departure from At the same time, PHC reforms, and the PHC the linear, top-down models of the past. Thus, movement that promotes them, have to be more PHC reforms today are neither primarily defined responsive to social change and rising expecta- by the component elements they address, nor tions that come with development and moderniza. merely by the choice of disease control interven- tion. People all over the world are becoming more tions to be scaled up, but by the social dynamics vocal about health as an integral part of how that define the role of health systems in society they and their families go about their everyday Table 1 How experience has shifted the focus of the PHc movement EARLY ATTEMPTS AT IMPLEMENTING PHC CURRENT CONCERNS OF PHC REFORMS Extended access to a basic package of health interventions Transformation and regulation of existing health system nd essential drugs for the rural poor aiming for universal access and social health protection Concentration on mother and child health Dealing with the health of everyone in the community Focus on a small number of selected diseases, primarily A comprehensive response to people's expectations and infectious and acute needs, spanning the range of risks and illnesses Improvement of hygiene, water, sanitation and health Promotion of healthier lifestyles and mitigation of the health ducation at village level effects of social and environmental hazards Simple technology for volunteer, non-professional Teams of health workers facilitating access to ar community health workers appropriate use of technology and medicines Participation as the mobilization of local resources Institutionalized participation of civil society in policy and health-centre management through local health dialogue and accountability mechanisms committees Government-funded and delivered services with a Pluralistic health systems operating in a globalized contex entralized top-down management Management of growing scarcity and downsizing Guiding the growth of resources for health towards universal coverage Bilateral aid and technical assistance Global solidarity and joint learning Primary care as the antithesis of the hospital Primary care as coordinator of a comprehensive response at all levels PHC is cheap and requires only a modest investment PHC is not cheap: it requires considerable investment, but it provides better value for money than its alternatives
xv Introduction and Overview The focus of these reforms goes well beyond “basic” service delivery and cuts across the established boundaries of the building blocks of national health systems25. For example, aligning health systems based on the values that drive PHC will require ambitious human resources policies. However, it would be an illusion to think that these can be developed in isolation from fi nancing or service delivery policies, civil service reform and arrangements dealing with the cross-border migration of health professionals. At the same time, PHC reforms, and the PHC movement that promotes them, have to be more responsive to social change and rising expectations that come with development and modernization. People all over the world are becoming more vocal about health as an integral part of how they and their families go about their everyday lives, and about the way their society deals with health and health care. The dynamics of demand must fi nd a voice within the policy and decisionmaking processes. The necessary reorientation of health systems has to be based on sound scientifi c evidence and on rational management of uncertainty, but it should also integrate what people expect of health and health care for themselves, their families and their society. This requires delicate trade-offs and negotiation with multiple stakeholders that imply a stark departure from the linear, top-down models of the past. Thus, PHC reforms today are neither primarily defi ned by the component elements they address, nor merely by the choice of disease control interventions to be scaled up, but by the social dynamics that defi ne the role of health systems in society. Table 1 How experience has shifted the focus of the PHC movement EARLY ATTEMPTS AT IMPLEMENTING PHC CURRENT CONCERNS OF PHC REFORMS Extended access to a basic package of health interventions and essential drugs for the rural poor Transformation and regulation of existing health systems, aiming for universal access and social health protection Concentration on mother and child health Dealing with the health of everyone in the community Focus on a small number of selected diseases, primarily infectious and acute A comprehensive response to people’s expectations and needs, spanning the range of risks and illnesses Improvement of hygiene, water, sanitation and health education at village level Promotion of healthier lifestyles and mitigation of the health effects of social and environmental hazards Simple technology for volunteer, non-professional community health workers Teams of health workers facilitating access to and appropriate use of technology and medicines Participation as the mobilization of local resources and health-centre management through local health committees Institutionalized participation of civil society in policy dialogue and accountability mechanisms Government-funded and delivered services with a centralized top-down management Pluralistic health systems operating in a globalized context Management of growing scarcity and downsizing Guiding the growth of resources for health towards universal coverage Bilateral aid and technical assistance Global solidarity and joint learning Primary care as the antithesis of the hospital Primary care as coordinator of a comprehensive response at all levels PHC is cheap and requires only a modest investment PHC is not cheap: it requires considerable investment, but it provides better value for money than its alternatives
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever Four sets of phc reforms Figure 1 The PHC reforms necessary to refocus This report structures the PHc reforms in four health systems towards health for all groups that reflect the convergence between the evidence on what is needed for an effective UNIVERSAL SERVICE response to the health challenges of todays world, the values of equity, solidarity and social justice COVERAGE DELIVERY that drive the PHC movement, and the growing REFORMS expectations of the population in modernizing to improve to make health systems societies ( Figure 1) health equity people-centred a reforms that ensure that health systems con- ribute to health equity, social justice and the end of exclusion, primarily by moving toward universal access and social health protection EADERSHIP PUBLIC POLICY universal coverage reforms REFORMS REFORMS a reforms that reorganize health services as to make health primary care, i.e. around people's needs and to promote and expectations, so as to make them more socially authorities more protect the health of communities relevant and more responsive to the changing reliable world while producing better outcomes-serv. ice delivery reforms than they were 30 years ago, but large population a reforms that secure healthier communities, by groups have been left behind. In some places integrating public health actions with primary war and civil strife have destroyed infrastruc care and by pursuing healthy public policies ture, in others, unregulated commercialization across sectors- public policy reforms has made services available, but not necessarily reforms that replace disproportionate reli- those that are needed. Supply gaps are still a ance on command and control on one hand,I reality in many countries, making extension of and laissez-faire disengagement of the state their service networks a priority concern, as was on the other, by the inclusive, participatory, the case 30 years ago negotiation-based leadership required by the As the overall supply of health services has complexity of contemporary health systems- improved, it has become more obvious that bar leadership reforms riers to access are important factors of inequity user fees, in particular, are important sources of The first of these four sets of reforms aims at exclusion from needed care. Moreover, when peo- diminishing exclusion and social disparities in ple have to purchase health care at a price thatis health.Ultimately,the determinants of health beyond their means, a health problem can quickly inequality require a societal response, with precipitate them into poverty or bankruptcy political and technical choices that affect many That is why extension of the supply of services different sectors. Health inequalities are also has to go hand-in-hand with social health protec- shaped by the inequalities in availability, access tion, through pooling and pre-payment instead of and quality of services, by the financial burden out-of-pocket payment of user fees. The reforms these impose on people, and even by the lin- to bring about universal coverage -i.e. universal guistic, cultural and gender-based barriers that access combined with social health protection are often embedded in the way in which clinical-constitute a necessary condition to improved practice is conducted health equity. As systems that have achieved near If health systems are to reduce health inequi. universal coverage show, such reforms need to ties, a precondition is to make services available to be complemented with another set of proactive Il, i.e. to bridge the gap in the supply of services. measures to reach the unreached: those for Service networks are much more extensive today I whom service availability and social protection
Primary Health Care – Now More Than Ever xvi The World Health Report 2008 Four sets of PHC reforms This report structures the PHC reforms in four groups that refl ect the convergence between the evidence on what is needed for an effective response to the health challenges of today’s world, the values of equity, solidarity and social justice that drive the PHC movement, and the growing expectations of the population in modernizing societies (Figure 1): Q reforms that ensure that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection – universal coverage reforms; Q reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes – service delivery reforms; Q reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors – public policy reforms; Q reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems – leadership reforms. The fi rst of these four sets of reforms aims at diminishing exclusion and social disparities in health. Ultimately, the determinants of health inequality require a societal response, with political and technical choices that affect many different sectors. Health inequalities are also shaped by the inequalities in availability, access and quality of services, by the fi nancial burden these impose on people, and even by the linguistic, cultural and gender-based barriers that are often embedded in the way in which clinical practice is conducted26. If health systems are to reduce health inequities, a precondition is to make services available to all, i.e. to bridge the gap in the supply of services. Service networks are much more extensive today than they were 30 years ago, but large population groups have been left behind. In some places, war and civil strife have destroyed infrastructure, in others, unregulated commercialization has made services available, but not necessarily those that are needed. Supply gaps are still a reality in many countries, making extension of their service networks a priority concern, as was the case 30 years ago. As the overall supply of health services has improved, it has become more obvious that barriers to access are important factors of inequity: user fees, in particular, are important sources of exclusion from needed care. Moreover, when people have to purchase health care at a price that is beyond their means, a health problem can quickly precipitate them into poverty or bankruptcy14. That is why extension of the supply of services has to go hand-in-hand with social health protection, through pooling and pre-payment instead of out-of-pocket payment of user fees. The reforms to bring about universal coverage – i.e. universal access combined with social health protection – constitute a necessary condition to improved health equity. As systems that have achieved near universal coverage show, such reforms need to be complemented with another set of proactive measures to reach the unreached: those for whom service availability and social protection Figure 1 The PHC reforms necessary to refocus health systems towards health for all UNIVERSAL COVERAGE REFORMS SERVICE DELIVERY REFORMS LEADERSHIP REFORMS PUBLIC POLICY REFORMS to improve health equity to make health systems people-centred to make health authorities more reliable to promote and protect the health of communities
Introduction and overview does too little to offset the health consequences(person-centredness, comprehensiveness and of social stratification. Many individuals in this integration, continuity of care, and participa- group rely on health-care networks that assume tion of patients, families and communities)are the responsibility for the health of entire com- well identified.7.Care that exhibits these fea- munities. This is where a second set of reforms, tures requires health services that are organ the service delivery reforms, comes in ized accordingly, with close-to-client multidisc These service delivery reforms are meant plinary teams that are responsible for a defined to transform conventional health-care delivery population, collaborate with social services and nto primary care, optimizing the contribution of other sectors, and coordinate the contributions health services-local health systems, health-care of hospitals, specialists and community organi networks, health districts-to health and equity zations. Recent economic growth has brought while responding to the growing expectations for additional resources to health. Combined with " putting people at the centre of health care, har. the growing demand for better performance, this monizing mind and body, people and systems". creates major opportunities to reorient existing These service delivery reforms are but one subset health services towards primary care- not only of PHC reforms, but one with such a high profile in well-resourced settings, but also where money that it has often masked the broader PHC agenda. is tight and needs are high. In the many low The resulting confusion has been compounded and middle-income countries where the supply by the oversimplification of what primary care of services is in a phase of accelerated expansion, entails and of what distinguishes it from conven- there is an opportunity now to chart a course that tional health-care delivery (Box 2)- may avoid repeating some of the mistakes high There is a substantial body of evidence on the income countries have made in the past omparative advantages, in terms of effectiveness Primary care can do much to improve th and efficiency, of health care organized as people- health of communities, but it is not sufficient to centred primary care. Despite variations in the respond to peoples desires to live in conditions specific terminology, its characteristic features that protect their health, support health equity Box 2 What has been considered primary care in well-resourced contexts has beer dangerously oversimplified in resource-constrained settings imary care has been defined, described and studied extensively in well-resourced contexts, often with reference to physicians with restrictive and off-putting primary-care recipes that have been touted for low-income countries / agenda than the unacceptably a primary care provides a place to which people can bring a wide range of health problems-it is not acceptable that in low-incol countries 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 a primary care facilitates ongoing relationships between patients and clinicians, within which patients participate in decision-making about their health and health care; it builds bridges between personal health care and patients' families and communities-it is not acceptable that, in low-income countries, primary care would be restricted to a one-way delivery channel for priority health interventions primary care opens opportunities for disease prevention and health promotion as well as early detection of disease-it is not acceptable that, in low-income countries, primary care would just be about treating common a a primary care requires teams of health professionals: physicians, nurse practitioners, and assista specific and sophisticated omedical 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; a 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 financed through out-of-pocket payments on the erroneous assumption that it is cheap and the poor should be able to afford it
xvii Introduction and Overview does too little to offset the health consequences of social stratifi cation. Many individuals in this group rely on health-care networks that assume the 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 meant to transform conventional health-care delivery into primary care, optimizing the contribution of health services – local health systems, health-care networks, health districts – to health and equity while responding to the growing expectations for “putting people at the centre of health care, harmonizing mind and body, people and systems”3 . These service delivery reforms are but one subset of PHC reforms, but one with such a high profi le that it has often masked the broader PHC agenda. The resulting confusion has been compounded by the oversimplifi cation of what primary care entails and of what distinguishes it from conventional health-care delivery (Box 2)24. There is a substantial body of evidence on the comparative advantages, in terms of effectiveness and effi ciency, of health care organized as peoplecentred primary care. Despite variations in the specifi c terminology, its characteristic features (person-centredness, comprehensiveness and integration, continuity of care, and participation of patients, families and communities) are well identifi ed15,27. Care that exhibits these features requires health services that are organized accordingly, with close-to-client multidisciplinary teams that are responsible for a defi ned population, collaborate with social services and other sectors, and coordinate the contributions of hospitals, specialists and community organizations. Recent economic growth has brought additional resources to health. Combined with the growing demand for better performance, this creates major opportunities to reorient existing health services towards primary care – not only in well-resourced settings, but also where money is tight and needs are high. In the many lowand middle-income countries where the supply of services is in a phase of accelerated expansion, there is an opportunity now to chart a course that may avoid repeating some of the mistakes highincome countries have made in the past. Primary care can do much to improve the health of communities, but it is not suffi cient to respond to people’s desires to live in conditions that protect their health, support health equity Box 2 What has been considered primary care in well-resourced contexts has been dangerously oversimplifi ed in resource-constrained settings Primary care has been defi ned, described and studied extensively in well-resourced contexts, often with reference to physicians with a specialization in family medicine or general practice. These descriptions provide a far more ambitious agenda than the unacceptably restrictive and off-putting primary-care recipes that have been touted for low-income countries27,28: Q primary care provides a place to which people can bring a wide range of health problems – it is not acceptable that in low-income countries primary care would only deal with a few “priority diseases”; Q 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; Q primary care facilitates ongoing relationships between patients and clinicians, within which patients participate in decision-making about their health and health care; it builds bridges between personal health care and patients’ families and communities – it is not acceptable that, in low-income countries, primary care would be restricted to a one-way delivery channel for priority health interventions; Q primary care opens opportunities for disease prevention and health promotion as well as early detection of disease – it is not acceptable that, in low-income countries, primary care would just be about treating common ailments; Q primary care requires teams of health professionals: physicians, nurse practitioners, and assistants with specifi c and sophisticated biomedical 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; Q 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 on the erroneous assumption that it is cheap and the poor should be able to afford it
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever and enable them to lead the lives that they value."health in all policies"2to ensure that, along with People also expect their governments to put into the other sectors'goals and objectives, health place an array of public policies to deal with effects play a role in public policy decisions health challenges, such as those posed by urbani- In order to bring about such reforms in the zation, climate change, gender discrimination or extraordinarily complex environment of the social stratification health sector, it will be necessary to reinvest in These public policies encompass the technical public leadership in a way that pursues collabo olicies and programmes dealing with priority rative models of policy dialogue with multiple health problems. These programmes can be stakeholders-because this is what people expect, designed to work through, support and give a and because this is what works best. Health boost to primary care, or they can neglect to do authorities can do a much better job of formu this and, however unwillingly, undermine efforts lating and implementing PHC reforms adapted to reform service delivery. Health authorities to specific national contexts and constraint have a major responsibility to make the right if the mobilization around PHC is informed by design decisions. Programmes to target prior- the lessons of past successes and failures. The ity health problems through primary care need governance of health is a major challenge for to be complemented by public-health interven- ministries of health and the other institutions tions at national or international level. These governmental and nongovernmental, that pro- may offer scale efficiencies; for some problems, vide health leadership. They can no longer be they may be the only workable option. The evi- content with mere administration of the system dence is overwhelming that action on that scale, they have to become learning organizations.This for selected interventions, which may range requires inclusive leadership that engages with from public hygiene and disease prevention to a variety of stakeholders beyond the bounda health promotion, can have a major contribution ries of the public sector, from clinicians to civil to health. Yet, they are surprisingly neglected, I society, and from communities to researchers across all countries, regardless of income level. and academia. Strategic areas for investment to This is particularly visible at moments of crisis improve the capacity of health authorities to lead and acute threats to the public's health, when PHC reforms include making health information rapid response capacity is essential not only to systems instrumental to reform; harnessing the secure health,but also to maintain the public innovations in the health sector and the related trust in the health system dynamics in all societies; and building capacity than classical public health. Primary care and of others-within and across Dorerperience Public policy-making, however, is about more through exchange and exposure to the e social protection reforms critically depend choosing health-systems policies, such as those Seizing opportunities related to essential drugs, technology, human These four sets of PHC reforms are driven by resources and financing, which are supportive on shared values that enjoy large support and chal- the reforms that promote equity and people-cer lenges that are common to a globalizing world tred care. Furthermore, it is clear that population Yet, the starkly different realities faced by indi- health can be improved through policies that are vidual countries must inform the way they are controlled by sectors other than health. School taken forward. The operationalization of univer curricula, the industrys policy towards gender sal coverage, service delivery, public policy and equality, the safety of food and consumer goods, leadership reforms cannot be implemented as a or the transport of toxic waste are allissues that blueprint or as a standardized package can profoundly influence or even determine the In high-expenditure health economies, which health of entire communities, positivel tively, depending on what choices are made with ely or nega- is the case of most high-income countries, there is deliberate efforts towards intersectoral collabo ample financial room to accelerate the shift from ration, it is possible to give due consideration to tertiary to primary care, create a healthier policy lll
Primary Health Care – Now More Than Ever xviii The World Health Report 2008 and enable them to lead the lives that they value. People also expect their governments to put into place an array of public policies to deal with health challenges, such as those posed by urbanization, climate change, gender discrimination or social stratifi cation. These public policies encompass the technical policies and programmes dealing with priority health problems. These programmes can be designed to work through, support and give a boost to primary care, or they can neglect to do this and, however unwillingly, undermine efforts to reform service delivery. Health authorities have a major responsibility to make the right design decisions. Programmes to target priority health problems through primary care need to be complemented by public-health interventions at national or international level. These may offer scale effi ciencies; for some problems, they may be the only workable option. The evidence is overwhelming that action on that scale, for selected interventions, which may range from public hygiene and disease prevention to health promotion, can have a major contribution to health. Yet, they are surprisingly neglected, across all countries, regardless of income level. This is particularly visible at moments of crisis and acute threats to the public’s health, when rapid response capacity is essential not only to secure health, but also to maintain the public trust in the health system. Public policy-making, however, is about more than classical public health. Primary care and social protection reforms critically depend on choosing health-systems policies, such as those related to essential drugs, technology, human resources and fi nancing, which are supportive of the reforms that promote equity and people-centred care. Furthermore, it is clear that population health can be improved through policies that are controlled by sectors other than health. School curricula, the industry’s policy towards gender equality, the safety of food and consumer goods, or the transport of toxic waste are all issues that can profoundly infl uence or even determine the health of entire communities, positively or negatively, depending on what choices are made. With deliberate efforts towards intersectoral collaboration, it is possible to give due consideration to “health in all policies”29 to ensure that, along with the other sectors’ goals and objectives, health effects play a role in public policy decisions. In order to bring about such reforms in the extraordinarily complex environment of the health sector, it will be necessary to reinvest in public leadership in a way that pursues collaborative models of policy dialogue with multiple stakeholders – because this is what people expect, and because this is what works best. Health authorities can do a much better job of formulating and implementing PHC reforms adapted to specifi c national contexts and constraints if the mobilization around PHC is informed by the lessons of past successes and failures. The governance of health is a major challenge for ministries of health and the other institutions, governmental and nongovernmental, that provide health leadership. They can no longer be content with mere administration of the system: they have to become learning organizations. This requires inclusive leadership that engages with a variety of stakeholders beyond the boundaries of the public sector, from clinicians to civil society, and from communities to researchers and academia. Strategic areas for investment to improve the capacity of health authorities to lead PHC reforms include making health information systems instrumental to reform; harnessing the innovations in the health sector and the related dynamics in all societies; and building capacity through exchange and exposure to the experience of others – within and across borders. Seizing opportunities These four sets of PHC reforms are driven by shared values that enjoy large support and challenges that are common to a globalizing world. Yet, the starkly different realities faced by individual countries must inform the way they are taken forward. The operationalization of universal coverage, service delivery, public policy and leadership reforms cannot be implemented as a blueprint or as a standardized package. In high-expenditure health economies, which is the case of most high-income countries, there is ample fi nancial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established
Introduction and overview universal coverage system with targeted mea- health spending currently goes to correcting sures to reduce exclusion. In the large number of common distortions in the way health systems fast-growing health economies-which is where function or to overcoming system bottlenecks that 3 billion people live-that very growth provides constrain service delivery, but the potential is opportunities to base health systems on sound there and is growing fast primary care and universal coverage principles Global solidarity-and aid-will remain impor at a stage where it is in full expansion, avoiding tant to supplement and suppport countries mak- the errors by omission, such as failing to invest ing slow progress, but it will become less impor in healthy public policies, and by commission, tant per se than exchange, joint learning and such as investing disproportionately in tertiary global governance. This transition has already care, that have characterized health systems in taken place in most of the world: most developing high-income countries in the recent past. The countries are not aid-dependent. International challenge is, admittedly, more daunting for the cooperation can accelerate the conversion ofthe 2 billion people living in the low-growth health I worlds health systems, including through better economies of Africa and South-East Asia, as channelling of aid, but real progress will come well as for the more than 500 million who live in from better health governance in countries-low fragile states. Yet, even here, there are signs of and high-income alike rowth-and evidence of a potential to accelerate The health authorities and political leaders it through other means than through the counter- are ill at ease with current trends in the devel productive reliance on inequitable out-of-pocket opment of health systems and with the obvious payments at points of delivery-that offer pos- need to adapt to the changing health challenges sibilities to expand health systems and services. demands and rising expectations.This is shap- Indeed,more than in other countries, they cannot ing the current opportunity to implement PHC afford not to opt for PHC and, as elsewhere, they reforms. People's frustration and pressure for dif- can start doing so right away ferent, more equitable health care and for better The current international environment is health protection for society is building up: never favourable to a renewal of PHC. Global health is before have expectations been so high about what receiving unprecedented attention, with growing health authorities and, specifically, ministries of interest in united action, greater calls for com- health should be doing about this prehensive and universal care-be it from people By capitalizing on this momentum, investment living with HIV and those concerned with provid- in PHC reforms can accelerate the transformation ng treatment and care, ministers of health, or of health systems so as to yield better and more the Group of Eight(G8)-and a mushrooming of equitably distributed health outcomes. The world innovative global funding mechanisms related has better technology and better information to to global solidarity. There are clear and welcome allow it to maximize the return on transforming the signs of a desire to work together in building sus- functioning ofhealth systems. Growing civil society tainable systems for health rather than relying on involvement in health and scale-efficient collective fragmented and piecemeal approaches global thinking (for example, in essential drugs At the same time, there is a perspective of further contributes to the chances of success enhanced domestic investment in re-invigor During the last decade, the global commu ating the health systems around PHC values. nity started to deal with poverty and inequality The growth in GDP - admittedly vulnerable to across the world in a much more systematic way economic slowdown, food and energy crises and-by setting the MDGs and bringing the issue of global warming- is fuelling health spending inequality to the core of social policy-making throughout the world, with the notable excep- Throughout, health has been a central, closely tion of fragile states. Harnessing this economic interlinked concern. This offers opportunities for growth would offer opportunities to effectuate more effective health action. It also creates the necessary PHC reforms that were unavailable necessary social conditions for the establishment during the 1980s and 1990s. Only a fraction of of close alliances beyond the health sector. Thus, XIX
xix Introduction and Overview universal coverage system with targeted measures to reduce exclusion. In the large number of fast-growing health economies – which is where 3 billion people live – that very growth provides opportunities to base health systems on sound primary care and universal coverage principles at a stage where it is in full expansion, avoiding the errors by omission, such as failing to invest in healthy public policies, and by commission, such as investing disproportionately in tertiary care, that have characterized health systems in high-income countries in the recent past. The challenge is, admittedly, more daunting for the 2 billion people living in the low-growth health economies of Africa and South-East Asia, as well as for the more than 500 million who live in fragile states. Yet, even here, there are signs of growth – and evidence of a potential to accelerate it through other means than through the counterproductive reliance on inequitable out-of-pocket payments at points of delivery – that offer possibilities to expand health systems and services. Indeed, more than in other countries, they cannot afford not to opt for PHC and, as elsewhere, they can start doing so right away. The current international environment is favourable to a renewal of PHC. Global health is receiving unprecedented attention, with growing interest in united action, greater calls for comprehensive and universal care – be it from people living with HIV and those concerned with providing treatment and care, ministers of health, or the Group of Eight (G8) – and a mushrooming of innovative global funding mechanisms related to global solidarity. There are clear and welcome signs of a desire to work together in building sustainable systems for health rather than relying on fragmented and piecemeal approaches30. At the same time, there is a perspective of enhanced domestic investment in re-invigorating the health systems around PHC values. The growth in GDP – admittedly vulnerable to economic slowdown, food and energy crises and global warming – is fuelling health spending throughout the world, with the notable exception of fragile states. Harnessing this economic growth would offer opportunities to effectuate necessary PHC reforms that were unavailable during the 1980s and 1990s. Only a fraction of health spending currently goes to correcting common distortions in the way health systems function or to overcoming system bottlenecks that constrain service delivery, but the potential is there and is growing fast. Global solidarity – and aid – will remain important to supplement and suppport countries making slow progress, but it will become less important per se than exchange, joint learning and global governance. This transition has already taken place in most of the world: most developing countries are not aid-dependent. International cooperation can accelerate the conversion of the world’s health systems, including through better channelling of aid, but real progress will come from better health governance in countries – lowand high-income alike. The health authorities and political leaders are ill at ease with current trends in the development of health systems and with the obvious need to adapt to the changing health challenges, demands and rising expectations. This is shaping the current opportunity to implement PHC reforms. People’s frustration and pressure for different, more equitable health care and for better health protection for society is building up: never before have expectations been so high about what health authorities and, specifi cally, ministries of health should be doing about this. By capitalizing on this momentum, investment in PHC reforms can accelerate the transformation of health systems so as to yield better and more equitably distributed health outcomes. The world has better technology and better information to allow it to maximize the return on transforming the functioning of health systems. Growing civil society involvement in health and scale-effi cient collective global thinking (for example, in essential drugs) further contributes to the chances of success. During the last decade, the global community started to deal with poverty and inequality across the world in a much more systematic way – by setting the MDGs and bringing the issue of inequality to the core of social policy-making. Throughout, health has been a central, closely interlinked concern. This offers opportunities for more effective health action. It also creates the necessary social conditions for the establishment of close alliances beyond the health sector. Thus