The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever intersectoral action is back on centre stage. Many The legitimacy of health authorities increasingly among today's health authorities no longer see depends on how well they assume responsibility their responsibility for health as being limited to develop and reform the health sector accord- to survival and disease control, but as one of ing to what people value-in terms of health and he key capabilities people and societies valuei. of what is expected of health systems in society References eterminants of health: an intemational perspective. rB, Alma-Ata, USSR, 6-12 September, 1978, jointly sponsored by the Word wildren's Fund. Geneva. World Health val. Annals of intemal Medicine. 2003. 138. 244-2 2. Dahlgren G, Whitehead M. Levelling up(part 2] a discussion paper on European 17. Shiffman J. Has donor prioritization of HIWAIDS displaced aid for other health Organization Regional Office for Europe, 2006(Studies on d economic 18. Kom LT, Corrigan JM, Donaldson MS, eds To enT is human. buildung a safer health system Washington DC, National Academy Press, Committee on Quality of Care in 19. Fries JF et al. Reducing health care costs by reducing the need and demand for medical services. New England Joumal of Medicine, 1993. 329: 321-325. 4. Renewing primary health care in the Americas: a position paper af the Pan American 20. The Ward Health Report 2002-Redurcing risks, promoting heaty lie, Geneva, alth Organization. Washington DC, Pan American Health world Health Organization, 2002. 5. Saltman R,Ric。A,Bo best of times. the worst o England, Open University Press, 2 otion Intemational, 1997, 121): 5- 22. Stevenson D Planning for the future- long term care and the 2008 6. Report on the review af pnmary care in the African Region. Brazzaville, World Health 23. Blendon RJ et al. Inequities in health care: a five-country survey Heath Affairs, 7. Conferance on Primary Health Care, Alma-Ata twenty fifth anniversary Organization, 2003(Fifty-s 24. Tarim E, Webster EG. Primary e concepts and chaLlenges in a changing 8. The Ljubljana Charter on Reforming Heath Care, 1996. Copenhagen, World Health 9. World Health Statistics 2008. Geneva, World Health law. Lancet,1971,1:405-412 Jouma of clinic nf report 2004: making services work far poor peope. Washington Epidemiology, 2007, 60: 540-546. health in a af pubic expenditur Press Institute of Medicine 199 technology. New York, Oxford University Press, 1998. 13. Hanratty B, Zhang T, Whitehead M. How close have universal health systems c 29. StaNT et al, eds Health in a policies. Prospects and potentials. Oslo, Ministry of o on aid effectiveness. ownership, harmonisation, alignment, otecting households from catastrophic health expenditures. Health hins,2007,6972-983 and Development, 2005. 31. Nussbaum MC, Sen A, eds. The quality of life. Oxford, Clarendon Press, 1993. XX
Primary Health Care – Now More Than Ever xx The World Health Report 2008 intersectoral action is back on centre stage. Many among today’s health authorities no longer see their responsibility for health as being limited to survival and disease control, but as one of the key capabilities people and societies value31. The legitimacy of health authorities increasingly depends on how well they assume responsibility to develop and reform the health sector according to what people value – in terms of health and of what is expected of health systems in society. References 1. Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978, jointly sponsored by the World Health Organization and the United Nations Children’s Fund. Geneva, World Health Organization, 1978 (Health for All Series No. 1). 2. Dahlgren G, Whitehead M. Levelling up (part 2): a discussion paper on European strategies for tackling social inequities in health. Copenhagen, World Health Organization Regional Offi ce for Europe, 2006 (Studies on social and economic determinants of population health No. 3). 3. WHO Regional Offi ce for South-East Asia and WHO Regional Offi ce for the Western Pacifi c. People at the centre of health care: harmonizing mind and body, people and systems. Geneva, World Health Organization, 2007. 4. Renewing primary health care in the Americas: a position paper of the Pan American Health Organization. Washington DC, Pan American Health Organization, 2007. 5. Saltman R, Rico A, Boerma W. Primary health care in the driver’s seat: organizational reform in European primary care. Maidenhead, England, Open University Press, 2006 (European Observatory on Health Systems and Policies Series). 6. . Brazzaville, World Health Report on the review of primary care in the African Region Organization Regional Offi ce for Africa, 2003. 7. International Conference on Primary Health Care, Alma-Ata: twenty-fi fth anniversary. Geneva, World Health Organization, 2003 (Fifty-sixth World Health Assembly, Geneva, 19–28 May 2003, WHA56.6, Agenda Item 14.18). 8. . Copenhagen, World Health The Ljubljana Charter on Reforming Health Care, 1996 Organization Regional Offi ce for Europe, 1996. 9. . Geneva, World Health Organization, 2008. World Health Statistics 2008 10. Hart T. The inverse care law. Lancet, 1971, 1:405–412. 11. . Washington World development report 2004: making services work for poor people DC, The World Bank, 2003. 12. Filmer D. The incidence of public expenditures on health and education. Washington DC, The World Bank, 2003 (background note for World development report 2004 – making services work for poor people). 13. Hanratty B, Zhang T, Whitehead M. How close have universal health systems come to achieving equity in use of curative services? A systematic review. International Journal of Health Services, 2007, 37:89–109. 14. Xu K et al. Protecting households from catastrophic health expenditures. Health Affairs, 2007, 6:972–983. 15. Starfi eld B. Policy relevant determinants of health: an international perspective. Health Policy, 2002, 60:201–218. 16. Moore G, Showstack J. Primary care medicine in crisis: towards reconstruction and renewal. Annals of Internal Medicine, 2003, 138:244–247. 17. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health issues? Health Policy and Planning, 2008, 23:95–100. 18. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington DC, National Academy Press, Committee on Quality of Care in America, Institute of Medicine, 1999. 19. Fries JF et al. Reducing health care costs by reducing the need and demand for medical services. New England Journal of Medicine, 1993, 329:321–325. 20. Geneva, The World Health Report 2002 – Reducing risks, promoting healthy life. World Health Organization, 2002. 21. Sindall C. Intersectoral collaboration: the best of times, the worst of times. Health Promotion International, 1997, 12(1):5–6. 22. Stevenson D. Planning for the future – long term care and the 2008 election. New England Journal of Medicine, 2008, 358:19. 23. Blendon RJ et al. Inequities in health care: a fi ve-country survey. Health Affairs, 2002, 21:182–191. 24. Tarimo E, Webster EG. Primary health care concepts and challenges in a changing world: Alma-Ata revisited. Geneva, World Health Organization, 1997 (Current concerns ARA paper No. 7). 25. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World Health Organization, 2007. 26. Dans A et al. Assessing equity in clinical practice guidelines. Journal of Clinical Epidemiology, 2007, 60:540–546. 27. . Washington DC, National Academy Primary care. America’s health in a new era Press, Institute of Medicine 1996. 28. Starfi eld B. Primary care: balancing health needs, services, and technology. New York, Oxford University Press, 1998. 29. Ståhl T et al, eds. Health in all policies. Prospects and potentials. Oslo, Ministry of Social Affairs and Health, 2006. 30. The Paris declaration on aid effectiveness: ownership, harmonisation, alignment, results and mutual accountability. Paris, Organisation for Economic Co-operation and Development, 2005. 31. Nussbaum MC, Sen A, eds. The quality of life. Oxford, Clarendon Press, 1993
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be challenges of a changing world ◇ This chapter describes the context in which 国 the contemporary renewal of primary bealth care is unfolding. Tbe chapter reviews current challenges to bealth and bealth systems and describes a set of broadly shared social expectations that set th Chapter I agenda for bealth systems change unequal outcomes in today s tuor ld dapting to It shores bowe many countries new health challenges Trends that undermine the II bave registered significant bealth health systems' response progress over recent decades and Changing values and rising expectations bowe gains have been unevenly PHC reforms driven by demand 18 shared. Health gaps betwee countries and among social groups touton countries bave widened. Social, demographic and epidemiological transformations fed b globalization, urbanization and ageing populations, pose challenges of a magnitude that weas not anticipated three decades ago
This chapter describes the context in which the contemporary renewal of primary health care is unfolding. The chapter reviews current challenges to health and health systems and describes a set of broadly shared social expectations that set the agenda for health systems change in today’s world. It shows how many countries have registered signifi cant health progress over recent decades and how gains have been unevenly shared. Health gaps between countries and among social groups within countries have widened. Social, demographic and epidemiological transformations fed by globalization, urbanization and ageing populations, pose challenges of a magnitude that was not anticipated three decades ago. Chapter 1 Unequal growth, unequal outcomes 2 Adapting to new health challenges 7 Trends that undermine the health systems’ response 11 Changing values and rising expectations 14 PHC reforms: driven by demand 18 The challenges of a changing world 1 This chapter describ the contemporary re health care is unfolding. The current challenges to health a describes a set of broadly sha social expectations that set t agenda for health systems cha in today’s world. It shows how many countries have registered significant he progress over recent decades a how gains have been unevenly shared. Health gaps between countries and among social g countries have widened. Soc and epidemiological transfor globalization, urbanization a pose challenges of a magnitud anticipated three decades ago
The World Health Report 2008 Primary Healtb Care-Now More Tban Ever The chapter argues that, in general, the The under-five mortality rate has dropped by a response of the health sector and societies tostaggering94% these challenges has been slow and inadequate. In each region (except in the African region) This reflects both an inability to mobilize the there are countries where mortality rates are now requisite resources and institutions to transform less than one fifth of what they were 30 years health around the values of primary health care ago. Leading examples are Chile, Malaysia as well as a failure to either counter or substan- Portugal and Thailand?(Figure 1.1).These tially modify forces that pull the health sector results were associated with improved access to in other directions, namely: a disproportionate expanded health-care networks, made possible focus on specialist hospital care; fragmentation of by sustained political commitment and by eco- health systems; and the proliferation of unregu- nomic growth that allowed them to back up their lated commercial care. Ironically, these power- commitment by maintaining investment in the ful trends lead health systems away from what health sector(Box 1.1) people expect from health and health care. When the Declaration of Alma-Ata enshrined the prin- ciples of health equity, people-centred care and Figure 1.1 Selected best performing countries in reducing under-five a central role for communities in health action ortality by at least 80%, by regions, 1975-2006 they were considered radical. Social research Deaths per 1000 children under five 口1975口2006 suggests, however, that these values are becom- ing mainstream in modernizing societies: they correspond e way people look at health ane what they expect from their health systems Rising social expectations regarding health and health care, therefore, must be seen as a major50 driver of phc reforms Unequal growth 显累 382 unequal outcomes b Total health expenditure Longer lives and better health, Intemational do tars are deriv local currency units by an estimate of their purchasing power parity compared to the Us dollar. but not everywhere In the late 1970s, the Sultanate of Oman had only a handful of health professionals. People had to Overall, progress in the world has been consid travel up to four days just to reach a hospital, erable. If children were still dying at 1978 rates. where hundreds of patients would already be there would have been 16.2 million deaths glo aiting in line to see one of the few (expatriate) bally in 2006, In fact, there were only 9.5 million doctors. All this changed in less than a genera- such deaths 2. This difference of 6.7 million is tion. Oman invested consistently in a national equivalent to 18 329 children's lives being saved health service and sustained that investment over time. There is now a dense network of 180 local, But these figures mask significant variations district and regional health facilities staffed by across countries. Since 1975. the rate of decline in over 5000 health workers providing almost uni- under-five mortality rates has been much slower low-income countries as a whole than in the citizens, with coverage now being extended to for- richer countries'". Apart from Eritrea and Mon- eign residents. Over 98% of births in Oman are golia, none of today's low-income countries has now attended by trained personnel and over 98% reduced under-five mortality by as much as 70% of infants are fully immunized. Life expectancy The countries that make up today's middle-income at birth, which was less than 60 years towards countries have done better, but, as Figure 1.3 the end of the 1970s, now surpasses 74 years. ustrates, progress has been quite uneven
The World Health Report 2008 2 Primary Health Care – Now More Than Ever The chapter argues that, in general, the response of the health sector and societies to these challenges has been slow and inadequate. This refl ects both an inability to mobilize the requisite resources and institutions to transform health around the values of primary health care as well as a failure to either counter or substantially modify forces that pull the health sector in other directions, namely: a disproportionate focus on specialist hospital care; fragmentation of health systems; and the proliferation of unregulated commercial care. Ironically, these powerful trends lead health systems away from what people expect from health and health care. When the Declaration of Alma-Ata enshrined the principles of health equity, people-centred care and a central role for communities in health action, they were considered radical. Social research suggests, however, that these values are becoming mainstream in modernizing societies: they correspond to the way people look at health and what they expect from their health systems. Rising social expectations regarding health and health care, therefore, must be seen as a major driver of PHC reforms. Unequal growth, unequal outcomes Longer lives and better health, but not everywhere In the late 1970s, the Sultanate of Oman had only a handful of health professionals. People had to travel up to four days just to reach a hospital, where hundreds of patients would already be waiting in line to see one of the few (expatriate) doctors. All this changed in less than a generation1 . Oman invested consistently in a national health service and sustained that investment over time. There is now a dense network of 180 local, district and regional health facilities staffed by over 5000 health workers providing almost universal access to health care for Oman’s 2.2 million citizens, with coverage now being extended to foreign residents2 . Over 98% of births in Oman are now attended by trained personnel and over 98% of infants are fully immunized. Life expectancy at birth, which was less than 60 years towards the end of the 1970s, now surpasses 74 years. The under-fi ve mortality rate has dropped by a staggering 94%3 . In each region (except in the African region) there are countries where mortality rates are now less than one fi fth of what they were 30 years ago. Leading examples are Chile4 , Malaysia5 , Portugal6 and Thailand7 (Figure 1.1). These results were associated with improved access to expanded health-care networks, made possible by sustained political commitment and by economic growth that allowed them to back up their commitment by maintaining investment in the health sector (Box 1.1). Overall, progress in the world has been considerable. If children were still dying at 1978 rates, there would have been 16.2 million deaths globally in 2006. In fact, there were only 9.5 million such deaths12. This difference of 6.7 million is equivalent to 18 329 children’s lives being saved every day. But these fi gures mask signifi cant variations across countries. Since 1975, the rate of decline in under-fi ve mortality rates has been much slower in low-income countries as a whole than in the richer countries13. Apart from Eritrea and Mongolia, none of today’s low-income countries has reduced under-fi ve mortality by as much as 70%. The countries that make up today’s middle-income countries have done better, but, as Figure 1.3 illustrates, progress has been quite uneven. Deaths per 1000 children under five a No country in the African region achieved an 80% reduction. 50 0 100 150 Chile (THE 2006: I$ 697)b Malaysia (THE 2006: I$ 500)b Portugal (THE 2006: I$ 2080)b Oman (THE 2006: I$ 382)b Thailand (THE 2006: I$ 346)b 1975 2006 Figure 1.1 Selected best performing countries in reducing under-five mortality by at least 80%, by regions, 1975–2006a,* b Total health expenditure per capita 2006, international $. * International dollars are derived by dividing local currency units by an estimate of their purchasing power parity compared to the US dollar
Chapter 1. Tbe challenges of a changing world Box 1.1 Economic development and investment choices in health care: the improvement of key health indicators in portugal Portugal recognized the right to health in its 1976 Constitution, following its democratic revolution. Political pressure to reduce large health inequalities within the country led to the creation of a national health system, funded by taxation and complemented by public and private insurance schemes and out-of-pocket payments. 9. The system was fully established between 1979 and 1983 and explicitly organized around PHC principles: a network of health centres staffed by family physicians and nurses progressively cov the entire country. Eligibility for benefits under the national health requires patients to register with a family physician in a Figure 1.2 Factors explaning mortality reduction in Portugal, 1960-2008 entre as the first point of contact. Portugal considers this Relative weight s%) to care and health gaines success in terms of improved access D Growth in GDP per capita (constant prices) k to be its greate Life expectancy at birth is now 9.2 years more than it was 30 O Development of hospital networks(hospital years ago, while the GDP per capita has doubled. Portugal's physicians and nurses per inhabitant performance in reducing mortality in various age groups has 100 een among the worid s most consistently successful over the last 30 years, for example halving infant mortality rates every ight years. This performance has led to a marked convergence of the health of Portugal's population with that of other countries in the region multivariate analysis of the time series of the various mortality dices since 1960 shows that the decision to base Portugal's ealth policy on PHC principles, with the development of a 40 network of comprehensive primary care services", has played major role in the reduction of maternal and child mortality, whereas the reduction of perinatal mortality was linked to the 20 development of the hospital network. The relative roles of the development of primary care, hospital networks and economic growth to the improvement of mortality indices since 1960 are 0 1% reduction of 86% reduction of 89% reduction in 96/eduction in shown in Figure 1.2. perinatal mortality infant mortality chad mortality maternal mortality Some countries have made great improvements I are in sub-Saharan Africa. Slow progress has and are on track to achieve the health-related been associated with disappointing advances in MDGs. Others, particularly in the African region, access to health care. Despite recent change for ave stagnated or even lost ground/f. Globally, the better, vaccination coverage in sub-Saharan 20 of the 25 countries where under-five mortal- Africa is still significantly lower than in the rest ity is still two thirds or more of the 1975 level of the world". Current contraceptive prevalence Figure 1.3 Variable progress in reducing under-five mortality, 1975 and 2006 remains as low as 21%, while in other developing in selected countries with similar rates in 1975 regions increases have been substantial over the past 30 years and now reach 61%. Increased Deaths per 1000 children under five □1975□2006 contraceptive use has been accompanied by decreased abortion rates everywhere. In sub- Saharan africa. however the absolute numbers of abortions has increased, and almost all are being performed in unsafe conditions". Childbirth care for mothers and newborns also continues to face problems: in 33 countries, less than half of all births each year are attended by skilled health THE 2006( H 2006 (THE 200d如 (HE 2006: T座2 personnel, with coverage in one country as low as 6%4. Sub-Saharan Africa is also the only region re per capita 2006, internationals
3 Chapter 1. The challenges of a changing world Some countries have made great improvements and are on track to achieve the health-related MDGs. Others, particularly in the African region, have stagnated or even lost ground14. Globally, 20 of the 25 countries where under-fi ve mortality is still two thirds or more of the 1975 level are in sub-Saharan Africa. Slow progress has been associated with disappointing advances in access to health care. Despite recent change for the better, vaccination coverage in sub-Saharan Africa is still signifi cantly lower than in the rest of the world14. Current contraceptive prevalence remains as low as 21%, while in other developing regions increases have been substantial over the past 30 years and now reach 61%15,16. Increased contraceptive use has been accompanied by decreased abortion rates everywhere. In subSaharan Africa, however, the absolute numbers of abortions has increased, and almost all are being performed in unsafe conditions17. Childbirth care for mothers and newborns also continues to face problems: in 33 countries, less than half of all births each year are attended by skilled health personnel, with coverage in one country as low as 6%14. Sub-Saharan Africa is also the only region Box 1.1 Economic development and investment choices in health care: the improvement of key health indicators in Portugal Portugal recognized the right to health in its 1976 Constitution, following its democratic revolution. Political pressure to reduce large health inequalities within the country led to the creation of a national health system, funded by taxation and complemented by public and private insurance schemes and out-of-pocket payments8,9. The system was fully established between 1979 and 1983 and explicitly organized around PHC principles: a network of health centres staffed by family physicians and nurses progressively covered the entire country. Eligibility for benefi ts under the national health system requires patients to register with a family physician in a health centre as the fi rst point of contact. Portugal considers this network to be its greatest success in terms of improved access to care and health gains6 . Life expectancy at birth is now 9.2 years more than it was 30 years ago, while the GDP per capita has doubled. Portugal’s performance in reducing mortality in various age groups has been among the world’s most consistently successful over the last 30 years, for example halving infant mortality rates every eight years. This performance has led to a marked convergence of the health of Portugal’s population with that of other countries in the region10. Multivariate analysis of the time series of the various mortality indices since 1960 shows that the decision to base Portugal’s health policy on PHC principles, with the development of a network of comprehensive primary care services11, has played a major role in the reduction of maternal and child mortality, whereas the reduction of perinatal mortality was linked to the development of the hospital network. The relative roles of the development of primary care, hospital networks and economic growth to the improvement of mortality indices since 1960 are shown in Figure 1.2. Figure 1.2 Factors explaning mortality reduction in Portugal, 1960–2008 Relative weight of factors (%) Growth in GDP per capita (constant prices) Development of hospital networks (hospital physicians and nurses per inhabitant) Development of primary care networks (primary care physicians and nurses per inhabitant) 0 100 20 40 60 80 86% reduction of infant mortality 71% reduction of perinatal mortality 89% reduction in child mortality 96% reduction in maternal mortality ! " #$%& ' () *+ , ( #$%& ' () , - #$%& ' () * , - #$%& ' () ., - #$%& ' () *, $/0 #$%& ' () , 1 #$%& ' () , 2! ! $ !! 3 )4