Social Medicine

Download (Bu linkten indirebilirsiniz !)

https://acrobat.com/#d=-zJSt6cJHOG0P*myyA8JXg and also http://www.who.int/whr/2008/whr08_en.pdf

http://www.snz.unizg.hr/ph-see/Documents/Publications/FPH-SEE_Book_Management_in_Health.pdf




 Conspectus for Social medicine

1. Social medicine as a science – foundation, development, object, tasks and methods.
2. Nature and importance of social etiology, social prophylaxis, social therapy and social rehabilitation of the diseases.
3. Basic aspects of human health. Social factors of health and disease – classification and mechanism of influence.
4. Group and public health – definition, basic groups of indices.
5. Indices of the population health. Demographic indices – mechanical movement of the population: nature, types and health aspects.
6. Indices of the population health. Demographic indices – natural movement of the population: nature, types and health aspects.
7. Indices of the population health. Incidence and prevalence. The International Classification of Diseases (ICD).
8. Indices of the population health. Physical development. Acceleration.
9. Epidemiology - basic terms. The concept of causality. Risk factors and assessment, Bradford Hill’s factors.
10. Epidemiological study designs – types. Observatory epidemiological studies.
11. Epidemiological study designs – types. Experimentory epidemiological studies.
12. Public health services – types, advantages and disadvantages.
13. Health legislation. Law for health.
14. Health legislation. Law for medical institutions.
15. Health legislation. Law for health insurance.
16. Primary health care. Indices. Functions of General Practitioners (GP).
17. Hospital care services. Indices.
18. Dispensary health care services. Dispensary method. Indices.
19.  Medico-social problems of childhood. Children’s consultation. Medico-social problems of the woman and mother. Maternal consultation.
20.  Social history of the patient. Family anamnesis.
21. Temporally and permanent working incapacity. Working incapacity medical expertise.
22.  Methods of sociological research in medicine. Questionnaire. Observatory method.
23.  Methods of sociological research in medicine. Interview and documentary method.

Primary Health Care
Now
More
Than
Ever
The World Health Report 2008
UNIVERSAL
COVERAGE
REFORMS
SERVICE
DELIVERY
REFORMS
LEADERSHIP
REFORMS
PUBLIC
POLICY
REFORMS

Primary Health Care
Now
More
Than
Ever
The World Health Report 2008
WHO Library Cataloguing-in-Publication Data
The world health report 2008 : primary health care now more than ever.
1.World health – trends. 2.Primary health care – trends. 3.Delivery of health care. 4.Health policy.
I.World Health Organization.
ISBN 978 92 4 156373 4 (NLM classifi cation: W 84.6)
ISSN 1020-3311
© World Health Organization 2008
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission
to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the
above address (fax: +41 22 791 4806; e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on
the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.
The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
Information concerning this publication can be obtained from:
World Health Report
World Health Organization
1211 Geneva 27, Switzerland
E-mail: whr@who.int
Copies of this publication can be ordered from: bookorders@who.int
Design: Reda Sadki
Layout: Steve Ewart and Reda Sadki
Figures: Christophe Grangier
Printing Coordination: Pascale Broisin and Frédérique Robin-Wahlin
Printed in Switzerland
The World Health Report 2008 was produced under the overall direction of Tim Evans (Assistant Director-General) and Wim Van Lerberghe (editor-in-chief). The principal writing
team consisted of Wim Van Lerberghe, Tim Evans, Kumanan Rasanathan and Abdelhay Mechbal. Other main contributors to the drafting of the report were: Anne Andermann, David
Evans, Benedicte Galichet, Alec Irwin, Mary Kay Kindhauser, Remo Meloni, Thierry Mertens, Charles Mock, Hernan Montenegro, Denis Porignon and Dheepa Rajan. Organizational
supervision of the report was provided by Ramesh Shademani.
Contributions in the form of boxes, fi gures and data analysis came from: Alayne Adams, Jonathan Abrahams, Fiifi Amoako Johnson, Giovanni Ancona, Chris Bailey, Robert Beaglehole,
Henk Bekedam, Andre Biscaia, Paul Bossyns, Eric Buch, Andrew Cassels, Somnath Chatterji, Mario Dal Poz, Pim De Graaf, Jan De Maeseneer, Nick Drager, Varatharajan Durairaj, Joan
Dzenowagis, Dominique Egger, Ricardo Fabregas, Paulo Ferrinho, Daniel Ferrante, Christopher Fitzpatrick, Gauden Galea, Claudia Garcia Moreno, André Griekspoor, Lieve Goeman,
Miriam Hirschfeld, Ahmadreza Hosseinpoor, Justine Hsu, Chandika Indikadahena, Mie Inoue, Lori Irwin, Andre Isakov, Michel Jancloes, Miloud Kaddar, Hyppolite Kalambaye, Guy Kegels,
Meleckidzedeck Khayesi, Ilona Kickbush, Yohannes Kinfu, Tord Kjellstrom, Rüdiger Krech, Mohamed Laaziri, Colin Mathers, Zoe Matthews, Maureen Mackintosh, Di McIntyre, David
Meddings, Pierre Mercenier, Pat Neuwelt, Paolo Piva, Annie Portela, Yongyut Ponsupap, Amit Prasad, Rob Ridley, Ritu Sadana, David Sanders, Salif Samake, Gerard Schmets, Iqbal
Shah, Shaoguang Wang, Anand Sivasankara Kurup, Kenji Shibuya, Michel Thieren, Nicole Valentine, Nathalie Van de Maele, Jeanette Vega, Jeremy Veillard and Bob Woollard.
Valuable inputs in the form of contributions, peer reviews, suggestions and criticisms were received from the Regional Directors and their staff, from the Deputy Director-General,
Anarfi Asamoah Bah, and from the Assistant Directors-General.
The draft report was peer reviewed at a meeting in Montreux, Switzerland, with the following participants: Azrul Azwar, Tim Evans, Ricardo Fabrega, Sheila Campbell-Forrester,
Antonio Duran, Alec Irwin, Mohamed Ali Jaffer, Safurah Jaafar, Pongpisut Jongudomsuk, Joseph Kasonde, Kamran Lankarini, Abdelhay Mechbal, John Martin, Donald Matheson,
Jan De Maeseneer, Ravi Narayan, Sydney Saul Ndeki, Adrian Ong, Pongsadhorn Pokpermdee, Thomson Prentice, Kumanan Rasanathan, Salman Rawaf, Bijan Sadrizadeh, Hugo
Sanchez, Ramesh Shademani, Barbara Starfi eld, Than Tun Sein, Wim Van Lerberghe, Olga Zeus and Maria Hamlin Zuniga.
The report benefi ted greatly from the inputs of the following participants in a one-week workshop in Bellagio, Italy: Ahmed Abdullatif, Chris Bailey, Douglas Bettcher, John Bryant,
Tim Evans, Marie Therese Feuerstein, Abdelhay Mechbal, Thierry Mertens, Hernan Montenegro, Ronald Labonte, Socrates Litsios, Thelma Narayan, Thomson Prentice, Kumanan
Rasanathan, Myat Htoo Razak, Ramesh Shademani, Viroj Tangcharoensathien, Wim Van Lerberghe, Jeanette Vega and Jeremy Veillard.
WHO working groups provided the initial inputs into the report. These working groups, of both HQ and Regional staff included: Shelly Abdool, Ahmed Abdullatif, Shambhu Acharya,
Chris Bailey, James Bartram, Douglas Bettcher, Eric Blas, Ties Boerma, Robert Bos, Marie-Charlotte Boueseau, Gui Carrin, Venkatraman Chandra-Mouli, Yves Chartier, Alessandro
Colombo, Carlos Corvalan, Bernadette Daelmans, Denis Daumerie, Tarun Dua, Joan Dzenowagis, David Evans, Tim Evans, Bob Fryatt, Michelle Funk, Chad Gardner, Giuliano Gargioni,
Gulin Gedik, Sandy Gove, Kersten Gutschmidt, Alex Kalache, Alim Khan, Ilona Kickbusch, Yunkap Kwankam, Richard Laing, Ornella Lincetto, Daniel Lopez-Acuna, Viviana Mangiaterra,
Colin Mathers, Michael Mbizvo, Abdelhay Mechbal, Kamini Mendis, Shanthi Mendis, Susan Mercado, Charles Mock, Hernan Montenegro, Catherine Mulholland, Peju Olukoya, Annie
Portela, Thomson Prentice, Annette Pruss-Ustun, Kumanan Rasanathan, Myat Htoo Razak, Lina Tucker Reinders, Elil Renganathan, Gojka Roglic, Michael Ryan, Shekhar Saxena,
Robert Scherpbier, Ramesh Shademani, Kenji Shibuya, Sameen Siddiqi, Orielle Solar, Francisco Songane, Claudia Stein, Kwok-Cho Tang, Andreas Ullrich, Mukund Uplekar, Wim Van
Lerberghe, Jeanette Vega, Jeremy Veillard, Eugenio Villar, Diana Weil and Juliana Yartey.
The editorial production team was led by Thomson Prentice, managing editor. The report was edited by Diana Hopkins, assisted by Barbara Campanini. Gaël Kernen assisted on
graphics and produced the web site version and other electronic media. Lina Tucker Reinders provided editorial advice. The index was prepared by June Morrison.
Administrative support in the preparation of the report was provided by Saba Amdeselassie, Maryse Coutty, Melodie Fadriquela, Evelyne Omukubi and Christine Perry.
Photo credits: Director-General’s photograph: WHO (p. viii); introduction and overview: WHO/Marco Kokic (p. x); chapters 1–6: Alayne Adams (p. 1); WHO/Christopher Black (p. 23);
WHO/Karen Robinson (p. 41); International Federation of Red Cross and Red Crescent Societies/John Haskew (p. 63); Alayne Adams (p. 81); WHO/Thomas Moran (p. 99).
iii
Contents
The World Health Report 2008 Primary Health Care – Now More Than Ever
Message from the Director-General viii
Introduction and Overview xi
Responding to the challenges of a changing world xii
Growing expectations for better performance xiii
From the packages of the past to the reforms of the future xiv
Four sets of PHC reforms xvi
Seizing opportunities xviii
Chapter 1. The challenges of a changing world 1
Unequal growth, unequal outcomes 2
Longer lives and better health, but not everywhere 2
Growth and stagnation 4
Adapting to new health challenges 7
A globalized, urbanized and ageing world 7
Little anticipation and slow reactions 9
Trends that undermine the health systems’ response 11
Hospital-centrism: health systems built around hospitals and specialists 11
Fragmentation: health systems built around priority programmes 12
Health systems left to drift towards unregulated commercialization 13
Changing values and rising expectations 14
Health equity 15
Care that puts people fi rst 16
Securing the health of communities 16
Reliable, responsive health authorities 17
Participation 18
PHC reforms: driven by demand 18
Chapter 2. Advancing and sustaining universal coverage 23
The central place of health equity in PHC 24
Moving towards universal coverage 25
Challenges in moving towards universal coverage 27
Rolling out primary-care networks to fi ll the availability gap 28
Overcoming the isolation of dispersed populations 30
Providing alternatives to unregulated commercial services 31
Targeted interventions to complement universal coverage mechanisms 32
Mobilizing for health equity 34
Increasing the visibility of health inequities 34
Creating space for civil society participation and empowerment 35
Primary Health Care – Now More Than Ever
iv
The World Health Report 2008
Chapter 3. Primary care: putting people fi rst 41
Good care is about people 42
The distinctive features of primary care 43
Effectiveness and safety are not just technical matters 43
Understanding people: person-centred care 46
Comprehensive and integrated responses 48
Continuity of care 49
A regular and trusted provider as entry point 50
Organizing primary-care networks 52
Bringing care closer to the people 53
Responsibility for a well-identifi ed population 53
The primary-care team as a hub of coordination 55
Monitoring progress 56
Chapter 4. Public policies for the public’s health 63
The importance of effective public policies for health 64
System policies that are aligned with PHC goals 66
Public-health policies 67
Aligning priority health programmes with PHC 67
Countrywide public-health initiatives 68
Rapid response capacity 68
Towards health in all policies 69
Understanding the under-investment 71
Opportunities for better public policies 73
Better information and evidence 73
A changing institutional landscape 74
Equitable and effi cient global health action 76
Chapter 5. Leadership and effective government 81
Governments as brokers for PHC reform 82
Mediating the social contract for health 82
Disengagement and its consequences 83
Participation and negotiation 85
Effective policy dialogue 86
Information systems to strengthen policy dialogue 86
Strengthening policy dialogue with innovations from the fi eld 89
Building a critical mass of capacity for change 90
Managing the political process: from launching reform to implementing it 92
Chapter 6. The way forward 99
Adapting reforms to country context 100
High-expenditure health economics 101
Rapid-growth health economies 103
Low-expenditure, low-growth health economies 105
Mobilizing the drivers of reform 108
Mobilizing the production of knowledge 108
Mobilizing the commitment of the workforce 110
Mobilizing the participation of people 110
v
Contents
Figure 1. The PHC reforms necessary to refocus health systems
towards health for all
xvi
Figure 1.1 Selected best performing countries in reducing underfi
ve mortality by at least 80%, by regions, 1975–2006
2
Figure 1.2 Factors explaining mortality reduction in Portugal,
1960–2008
3
Figure 1.3 Variable progress in reducing under-fi ve mortality,
1975 and 2006, in selected countries with similar rates in 1975
3
Figure 1.4 GDP per capita and life expectancy at birth in 169
countries, 1975 and 2005
4
Figure 1.5 Trends in GDP per capita and life expectancy at birth
in 133 countries grouped by the 1975 GDP, 1975−2005
5
Figure 1.6 Countries grouped according to their total health
expenditure in 2005 (international $)
6
Figure 1.7 Africa’s children are at more risk of dying from traffi c
accidents than European children: child road-traffi c deaths per
100 000 population
7
Figure 1.8 The shift towards noncommunicable diseases and
accidents as causes of death
8
Figure 1.9 Within-country inequalities in health and health care 10
Figure 1.10 How health systems are diverted from PHC core
values
11
Figure 1.11 Percentage of the population citing health as their
main concern before other issues, such as fi nancial problems,
housing or crime
15
Figure 1.12 The professionalization of birthing care: percentage
of births assisted by professional and other carers in selected
areas, 2000 and 2005 with projections to 2015
17
Figure 1.13 The social values that drive PHC and the
corresponding sets of reforms
18
Figure 2.1 Catastrophic expenditure related to out-of-pocket
payment at the point of service
24
Figure 2.2 Three ways of moving towards universal coverage 26
Figure 2.3 Impact of abolishing user fees on outpatient
attendance in Kisoro district, Uganda: outpatient attendance
1998–2002
27
Figure 2.4 Different patterns of exclusion: massive deprivation
in some countries, marginalization of the poor in others. Births
attended by medically trained personnel (percentage), by income
group
28
Figure 2.5 Under-fi ve mortality in rural and urban areas, the
Islamic Republic of Iran, 1980–2000
29
Figure 2.6 Improving health-care outputs in the midst of
disaster: Rutshuru, the Democratic Republic of the Congo,
1985–2004
31
Figure 3.1 The effect on uptake of contraception of the
reorganization of work schedules of rural health centres in Niger
42
Figure 3.2 Lost opportunities for prevention of mother-to-child
transmission of HIV (MTCT) in Côte d’Ivoire: only a tiny fraction of
the expected transmissions are actually prevented
45
Figure 3.3 More comprehensive health centres have better
vaccination coverage
49
Figure 3.4 Inappropriate investigations prescribed for simulated
patients presenting with a minor stomach complaint in Thailand
53
Figure 3.5 Primary care as a hub of coordination: networking
within the community served and with outside partners
55
Figure 4.1 Deaths attributable to unsafe abortion per 100 000
live births, by legal grounds for abortions
65
Figure 4.2 Annual pharmaceutical spending and number
of prescriptions dispensed in New Zealand since the
Pharmaceutical Management Agency was convened in 1993
66
Figure 4.3 Percentage of births and deaths recorded in countries
with complete civil registration systems, by WHO region,
1975–2004
74
Figure 4.4 Essential public-health functions that 30 national
public-health institutions view as being part of their portfolio
75
Figure 5.1 Percentage of GDP used for health, 2005 82
Figure 5.2 Health expenditure in China: withdrawal of the State
in the 1980s and 1990s and recent re-engagement
84
Figure 5.3 Transforming information systems into instruments
for PHC reform
87
Figure 5.4 Mutual reinforcement between innovation in the fi eld
and policy development in the health reform process
89
Figure 5.5 A growing market: technical cooperation as part of
Offi cial Development Aid for Health. Yearly aid fl ows in 2005,
defl ator adjusted
91
Figure 5.6 Re-emerging national leadership in health: the shift
in donor funding towards integrated health systems support, and
its impact on the Democratic Republic of the Congo’s 2004 PHC
strategy
94
Figure 6.1 Contribution of general government, private pre-paid
and private out-of-pocket expenditure to the yearly growth
in total health expenditure per capita, percentage, weighted
averages
101
Figure 6.2 Projected per capita health expenditure in 2015,
rapid-growth health economies (weighted averages)
103
Figure 6.3 Projected per capita health expenditure in 2015, low
expenditure, low-growth health economies (weighted averages)
105
Figure 6.4 The progressive extension of coverage by communityowned,
community–operated health centres in Mali, 1998–2007
107
List of Figures
Primary Health Care – Now More Than Ever
vi
The World Health Report 2008
Box 1 Five common shortcomings of health-care delivery xiv
Box 2 What has been considered primary care in well-resourced
contexts has been dangerously oversimplifi ed in resourceconstrained
settings
xvii
Box 1.1 Economic development and investment choices in health
care: the improvement of key health indicators in Portugal
3
Box 1.2 Higher spending on health is associated with better
outcomes, but with large differences between countries
6
Box 1.3 As information improves, the multiple dimensions of
growing health inequality are becoming more apparent
10
Box 1.4 Medical equipment and pharmaceutical industries are
major economic forces
12
Box 1.5 Health is among the top personal concerns 15
Box 2.1 Best practices in moving towards universal coverage 26
Box 2.2 Defi ning “essential packages”: what needs to be done to
go beyond a paper exercise?
27
Box 2.3 Closing the urban-rural gap through progressive
expansion of PHC coverage in rural areas in the Islamic Republic
of Iran
29
Box 2.4 The robustness of PHC-led health systems: 20 years of
expanding performance in Rutshuru, the Democratic Republic of
the Congo
31
Box 2.5 Targeting social protection in Chile 33
Box 2.6 Social policy in the city of Ghent, Belgium: how local
authorities can support intersectoral collaboration between
health and welfare organizations
35
Box 3.1 Towards a science and culture of improvement: evidence
to promote patient safety and better outcomes
44
Box 3.2 When supplier-induced and consumer-driven demand
determine medical advice: ambulatory care in India
44
Box 3.3 The health-care response to partner violence against
women
47
Box 3.4 Empowering users to contribute to their own health 48
Box 3.5 Using information and communication technologies to
improve access, quality and effi ciency in primary care
51
Box 4.1 Rallying society’s resources for health in Cuba 65
Box 4.2 Recommendations of the Commission on Social
Determinants of Health
69
Box 4.3 How to make unpopular public policy decisions 72
Box 4.4 The scandal of invisibility: where births and deaths are
not counted
74
Box 4.5 European Union impact assessment guidelines 75
Box 5.1 From withdrawal to re-engagement in China 84
Box 5.2 Steering national directions with the help of policy
dialogue: experience from three countries
86
Box 5.3 Equity Gauges: stakeholder collaboration to tackle health
inequalities
88
Box 5.4 Limitations of conventional capacity building in low- and
middle-income countries
91
Box 5.5 Rebuilding leadership in health in the aftermath of war
and economic collapse
94
Box 6.1 Norway’s national strategy to reduce social inequalities
in health
102
Box 6.2 The virtuous cycle of supply of and demand for primary
care
107
Box 6.3. From product development to fi eld implementation −
research makes the link
109
List of Boxes
vii
Contents
Table 1 How experience has shifted the focus of the PHC
movement
xv
Table 3.1 Aspects of care that distinguish conventional health
care from people-centred primary care
43
Table 3.2 Person-centredness: evidence of its contribution to
quality of care and better outcomes
47
Table 3.3 Comprehensiveness: evidence of its contribution to
quality of care and better outcomes
48
Table 3.4 Continuity of care: evidence of its contribution to
quality of care and better outcomes
50
Table 3.5 Regular entry point: evidence of its contribution to
quality of care and better outcomes
52
Table 4.1 Adverse health effects of changing work
circumstances
70
Table 5.1 Roles and functions of public-health observatories in
England
89
Table 5.2 Signifi cant factors in improving institutional capacity
for health-sector governance in six countries
92
List of Tables
Primary Health Care – Now More Than Ever
viii
The World Health Report 2008
Director-General’s
Message
When I took offi ce in 2007, I made
clear my commitment to direct
WHO’s attention towards primary
health care. More important than
my own conviction, this refl ects
the widespread and growing
demand for primary health
care from Member States. This
demand in turn displays a
growing appetite among policymakers
for knowledge related to
how health systems can become
more equitable, inclusive and fair.
It also
refl ects, more fundamentally, a
shift towards the need for more comprehensive
thinking about the performance
of the health system as a whole.
This
year marks both the 60th birthday
of WHO and the 30th anniversary of
the Declaration of Alma-Ata on Primary
Health Care in 1978. While our global health context has changed remarkably over six decades, the
values that lie at the core of the WHO Constitution and those that informed the Alma-Ata Declaration
have been tested and remain true. Yet, despite enormous progress in health globally, our collective failures
to deliver in line with these values are painfully obvious and deserve our greatest attention.
We see a mother suffering complications of labour without access to qualifi ed support, a child
missing out on essential vaccinations, an inner-city slum dweller living in squalor. We see the absence
of protection for pedestrians alongside traffi c-laden roads and highways, and the impoverishment
arising from direct payment for care because of a lack of health insurance. These and many other
everyday realities of life personify the unacceptable and avoidable shortfalls in the performance of
our health systems.
In moving forward, it is important to learn from the past and, in looking back, it is clear that we
can do better in the future. Thus, this World Health Report revisits the ambitious vision of primary
health care as a set of values and principles for guiding the development of health systems. The Report
represents an important opportunity to draw on the lessons of the past, consider the challenges that
Wh
cle
W
m
tow
hensive
h
day W
ix
Director-General’s Message
lie ahead, and identify major avenues for health
systems to narrow the intolerable gaps between
aspiration and implementation.
These avenues are defi ned in the Report as
four sets of reforms that refl ect a convergence
between the values of primary health care, the
expectations of citizens and the common health
performance challenges that cut across all contexts.
They include:
universal c �� overage 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;
�� service delivery reforms that re-organize
health services 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;
�� public policy reforms that secure healthier
communities, by integrating public health
actions with primary care, by pursuing healthy
public policies across sectors and by strengthening
national and transnational public health
interventions; and
�� leadership 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 indicated
by the complexity of contemporary health
systems.
While universally applicable, these reforms
do not constitute a blueprint or a manifesto for
action. The details required to give them life in
each country must be driven by specifi c conditions
and contexts, drawing on the best available
evidence. Nevertheless, there are no reasons why
any country − rich or poor − should wait to begin
moving forward with these reforms. As the last
three decades have demonstrated, substantial
progress is possible.
Doing better in the next 30 years means that
we need to invest now in our ability to bring
actual performance in line with our aspirations,
expectations and the rapidly changing realities of
our interdependent health world. United by the
common challenge of primary health care, the
time is ripe, now more than ever, to foster joint
learning and sharing across nations to chart the
most direct course towards health for all.
Dr Margaret Chan
Director-General
World Health Organization

Introduction
and Overview
Why a renewal of primary health care (PHC), and why
now, more than ever? The immediate answer is the
palpable demand for it from Member States – not just
from health professionals, but from the
political arena as well.
Globalization is putting the social
cohesion of many countries under stress,
and health systems, as key constituents
of the architecture of contemporary
societies, are clearly not performing as
well as they could and as they should.
People are increasingly impatient with
the inability of health services to deliver levels of national
coverage that meet stated demands and changing needs,
and with their failure to provide services in ways that
correspond to their expectations. Few would disagree that
health systems need to respond better – and faster – to the
challenges of a changing world. PHC can do that.
Responding to the
challenges of a
changing world
xii
Growing expectations
for better performance xiii
From the packages of
the past to the
reforms of the future
xiv
Four sets of PHC reforms xvi
Seizing opportunities xviii
xi
Primary Health Care – Now More Than Ever
xii
The World Health Report 2008
There is today a recognition that populations are
left behind and a sense of lost opportunities that
are reminiscent of what gave rise, thirty years
ago, to Alma-Ata’s paradigm shift in thinking
about health. The Alma-Ata Conference
mobilized a “Primary Health Care movement”
of professionals and institutions, governments
and civil society organizations, researchers and
grassroots organizations that undertook to tackle
the “politically, socially and economically unacceptable”
1 health inequalities in all countries.
The Declaration of Alma-Ata was clear about the
values pursued: social justice and the right to
better health for all, participation and solidarity1.
There was a sense that progress towards these
values required fundamental changes in the way
health-care systems operated and harnessed the
potential of other sectors.
The translation of these values into tangible
reforms has been uneven. Nevertheless, today,
health equity enjoys increased prominence in
the discourse of political leaders and ministries
of health2, as well as of local government structures,
professional organizations and civil society
organizations.
The PHC values to achieve health for all
require health systems that “Put people at the
centre of health care”3. What people consider
desirable ways of living as individuals and what
they expect for their societies – i.e. what people
value – constitute important parameters for
governing the health sector. PHC has remained
the benchmark for most countries’ discourse on
health precisely because the PHC movement tried
to provide rational, evidence-based and anticipatory
responses to health needs and to these
social expectations4,5,6,7. Achieving this requires
trade-offs that must start by taking into account
citizens’ “expectations about health and health
care” and ensuring “that [their] voice and choice
decisively infl uence the way in which health services
are designed and operate”8. A recent PHC
review echoes this perspective as the “right to
the highest attainable level of health”, “maximizing
equity and solidarity” while being guided
by “responsiveness to people’s needs”4. Moving
towards health for all requires that health systems
respond to the challenges of a changing
world and growing expectations for better performance.
This involves substantial reorientation
and reform of the ways health systems operate
in society today: those reforms constitute the
agenda of the renewal of PHC.
Responding to the challenges of a
changing world
On the whole, people are healthier, wealthier and
live longer today than 30 years ago. 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 deaths9. This
difference of 6.7 million is equivalent to 18 329
children’s lives being saved every day. The once
revolutionary notion of essential drugs has
become commonplace. There have been signifi -
cant improvements in access to water, sanitation
and antenatal care.
This shows that progress is possible. It can
also be accelerated. There have never been more
resources available for health than now. The global
health economy is growing faster than gross
domestic product (GDP), having increased its
share from 8% to 8.6% of the world’s GDP between
2000 and 2005. In absolute terms, adjusted for
infl ation, this represents a 35% growth in the
world’s expenditure on health over a fi ve-year
period. Knowledge and understanding of health
are growing rapidly. The accelerated technological
revolution is multiplying the potential
for improving health and transforming health
literacy in a better-educated and modernizing
global society. A global stewardship is emerging:
from intensifi ed exchanges between countries,
often in recognition of shared threats, challenges
or opportunities; from growing solidarity; and
from the global commitment to eliminate poverty
exemplifi ed in the Millennium Development Goals
(MDGs).
However, there are other trends that must
not be ignored. First, the substantial progress
in health over recent decades has been deeply
unequal, with convergence towards improved
health in a large part of the world, but at the same
time, with a considerable number of countries
increasingly lagging behind or losing ground.
Furthermore, there is now ample documentation
– not available 30 years ago – of considerable
and often growing health inequalities within
countries.
xiii
Introduction and Overview
Second, the nature of health problems is changing
in ways that were only partially anticipated,
and at a rate that was wholly unexpected. Ageing
and the effects of ill-managed urbanization and
globalization accelerate worldwide transmission
of communicable diseases, and increase
the burden of chronic and noncommunicable
disorders. The growing reality that many individuals
present with complex symptoms and
multiple illnesses challenges service delivery
to develop more integrated and comprehensive
case management. A complex web of interrelated
factors is at work, involving gradual but longterm
increases in income and population, climate
change, challenges to food security, and social
tensions, all with defi nite, but largely unpredictable,
implications for health in the years ahead.
Third, health systems are not insulated from
the rapid pace of change and transformation
that is an essential part of today’s globalization.
Economic and political crises challenge
state and institutional roles to ensure access,
delivery and fi nancing. Unregulated commercialization
is accompanied by a blurring of the
boundaries between public and private actors,
while the negotiation of entitlement and rights
is increasingly politicized. The information age
has transformed the relations between citizens,
professionals and politicians.
In many regards, the responses of the health
sector to the changing world have been inadequate
and naïve. Inadequate, insofar as they
not only fail to anticipate, but also to respond
appropriately: too often with too little, too late
or too much in the wrong place. Naïve insofar as
a system’s failure requires a system’s solution –
not a temporary remedy. Problems with human
resources for public health and health care,
fi nance, infrastructure or information systems
invariably extend beyond the narrowly defi ned
health sector, beyond a single level of policy purview
and, increasingly, across borders: this raises
the benchmark in terms of working effectively
across government and stakeholders.
While the health sector remains massively
under-resourced in far too many countries,
the resource base for health has been growing
consistently over the last decade. The opportunities
this growth offers for inducing structural
changes and making health systems more effective
and equitable are often missed. Global and,
increasingly, national policy formulation processes
have focused on single issues, with various
constituencies competing for scarce resources,
while scant attention is given to the underlying
constraints that hold up health systems development
in national contexts. Rather than improving
their response capacity and anticipating new
challenges, health systems seem to be drifting
from one short-term priority to another, increasingly
fragmented and without a clear sense of
direction.
Today, it is clear that left to their own devices,
health systems do not gravitate naturally towards
the goals of health for all through primary health
care as articulated in the Declaration of Alma-
Ata. Health systems are developing in directions
that contribute little to equity and social justice
and fail to get the best health outcomes for their
money. Three particularly worrisome trends can
be characterized as follows:
health systems that focus �� disproportionately on
a narrow offer of specialized curative care;
�� health systems where a command-and-control
approach to disease control, focused on shortterm
results, is fragmenting service delivery;
�� health systems where a hands-off or laissezfaire
approach to governance has allowed
unregulated commercialization of health to
fl ourish.
These trends fl y in the face of a comprehensive
and balanced response to health needs. In a number
of countries, the resulting inequitable access,
impoverishing costs, and erosion of trust in health
care constitute a threat to social stability.
Growing expectations for better
performance
The support for a renewal of PHC stems from the
growing realization among health policy-makers
that it can provide a stronger sense of direction
and unity in the current context of fragmentation
of health systems, and an alternative to the
assorted quick fi xes currently touted as cures
for the health sector’s ills. There is also a growing
realization that conventional health-care
Primary Health Care – Now More Than Ever
xiv
The World Health Report 2008
delivery, through different mechanisms and for
different reasons, is not only less effective than
it could be, but suffers from a set of ubiquitous
shortcomings and contradictions that are summarized
in Box 1.
The mismatch between expectations and
performance is a cause of concern for health
authorities. Given the growing economic weight
and social signifi cance of the health sector, it
is also an increasing cause for concern among
politicians: it is telling that health-care issues
were, on average, mentioned more than 28 times
in each of the recent primary election debates in
the United States22. Business as usual for health
systems is not a viable option. If these shortfalls
in performance are to be redressed, the health
problems of today and tomorrow will require
stronger collective management and accountability
guided by a clearer sense of overall direction
and purpose.
Indeed, this is what people expect to happen.
As societies modernize, people demand more
from their health systems, for themselves and
their families, as well as for the society in which
they live. Thus, there is increasingly popular
support for better health equity and an end to
exclusion; for health services that are centred
on people’s needs and expectations; for health
security for the communities in which they live;
and for a say in what affects their health and that
of their communities23.
These expectations resonate with the values
that were at the core of the Declaration of Alma-
Ata. They explain the current demand for a better
alignment of health systems with these values
and provide today’s PHC movement with reinvigorated
social and political backing for its attempts
to reform health systems.
From the packages of the past to
the reforms of the future
Rising expectations and broad support for the
vision set forth in Alma-Ata’s values have not
always easily translated into effective transformation
of health systems. There have been circumstances
and trends from beyond the health
sector – structural adjustment, for example –
over which the PHC movement had little infl uence
or control. Furthermore, all too often, the
PHC movement has oversimplifi ed its message,
resulting in one-size-fi ts-all recipes, ill-adapted
to different contexts and problems24. As a result,
national and global health authorities have at
times seen PHC not as a set of reforms, as was
intended, but as one health-care delivery programme
among many, providing poor care for
poor people. Table 1 looks at different dimensions
of early attempts at implementing PHC and
contrasts this with current approaches. Inherent
in this evolution is recognition that providing a
sense of direction to health systems requires a
set of specifi c and context-sensitive reforms that
respond to the health challenges of today and
prepare for those of tomorrow.
Box 1 Five common shortcomings of
health-care delivery
Inverse care. People with the most means – whose needs for
health care are often less – consume the most care, whereas
those with the least means and greatest health problems consume
the least10. Public spending on health services most
often benefi ts the rich more than the poor11 in high- and lowincome
countries alike12,13.
Impoverishing care. Wherever people lack social protection
and payment for care is largely out-of-pocket at the point of
service, they can be confronted with catastrophic expenses.
Over 100 million people annually fall into poverty because they
have to pay for health care14.
Fragmented and fragmenting care. The excessive specialization
of health-care providers and the narrow focus of many
disease control programmes discourage a holistic approach
to the individuals and the families they deal with and do not
appreciate the need for continuity in care15. Health services
for poor and marginalized groups are often highly fragmented
and severely under-resourced16, while development aid often
adds to the fragmentation17.
Unsafe care. Poor system design that is unable to ensure safety
and hygiene standards leads to high rates of hospital-acquired
infections, along with medication errors and other avoidable
adverse effects that are an underestimated cause of death
and ill-health18.
Misdirected care. Resource allocation clusters around curative
services at great cost, neglecting the potential of primary
prevention and health promotion to prevent up to 70% of the
disease burden19,20. At the same time, the health sector lacks
the expertise to mitigate the adverse effects on health from
other sectors and make the most of what these other sectors
can contribute to health21.
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
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):
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;
�� 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;
�� reforms that secure healthier communities, by
integrating public health actions with primary
care and by pursuing healthy public policies
across sectors – public policy reforms;
�� 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
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:
primary care provides a place to which people can bring a wide range of health problems – it is not a �� cceptable that in low-income
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;
�� 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 ailments;
�� 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;
�� 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.
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
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,
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
Primary health care: report of the International Conference 1. 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. Report on the review of primary care in the African Region. Brazzaville, World Health
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. The Ljubljana Charter on Reforming Health Care, 1996. Copenhagen, World Health
Organization Regional Offi ce for Europe, 1996.
9. World Health Statistics 2008. Geneva, World Health Organization, 2008.
10. Hart T. The inverse care law. Lancet, 1971, 1:405–412.
11. World development report 2004: making services work for poor people. Washington
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. The World Health Report 2002 – Reducing risks, promoting healthy life. Geneva,
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. Primary care. America’s health in a new era. Washington DC, National Academy
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.


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
Social, demographic
transformations fed by
and ageing populations,
magnitude that was not
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
describ
re
a
sha
t
cha
he
a
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
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.
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 sub-
Saharan 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
The World Health Report 2008
4
Primary Health Care – Now More Than Ever
in the world where access to qualifi ed providers
at childbirth is not progressing18.
Mirroring the overall trends in child survival,
global trends in life expectancy point
to a rise throughout the world of almost eight
years between 1950 and 1978, and seven more
years since: a refl ection of the growth in average
income per capita. As with child survival, widening
income inequality (income increases faster
in high-income than in low-income countries)
is refl ected in increasing disparities between
the least and most healthy19. Between the mid-
1970s and 2005, the difference in life expectancy
between high-income countries and countries in
sub-Saharan Africa, or fragile states, has widened
by 3.8 and 2.1 years, respectively.
The unmistakable relation between health and
wealth, summarized in the classic Preston curve
(Figure 1.4), needs to be qualifi ed20.
Firstly, the Preston curve continues to shift12.
An income per capita of I$ 1000 in 1975 was
associated with a life expectancy of 48.8 years.
In 2005, it was almost four years higher for the
same income. This suggests that improvements
in nutrition, education21, health technologies22,
the institutional capacity to obtain and use
information, and in society’s ability to translate
this knowledge into effective health and social
action23, allow for greater production of health
for the same level of wealth.
Secondly, there is considerable variation in
achievement across countries with the same
income, particularly among poorer countries. For
example, life expectancy in Côte d’Ivoire (GDP I$
1465) is nearly 17 years lower than in Nepal (GDP
I$ 1379), and between Madagascar and Zambia,
the difference is 18 years. The presence of high
performers in each income band shows that
the actual level of income per capita at a given
moment is not the absolute rate limiting factor
the average curve seems to imply.
Growth and stagnation
Over the last 30 years the relation between economic
growth and life expectancy at birth has
shown three distinct patterns (Figure 1.5).
In 1978, about two thirds of the world’s population
lived in countries that went on to experience
increases in life expectancy at birth and considerable
economic growth. The most impressive relative
gains were in a number of low-income countries
in Asia (including India), Latin America and
northern Africa, totalling 1.1 billion inhabitants
30 years ago and nearly 2 billion today. These
countries increased life expectancy at birth by
12 years, while GDP per capita was multiplied by
a factor of 2.6. High-income countries and countries
with a GDP between I$ 3000 and I$ 10 000
in 1975 also saw substantial economic growth
and increased life expectancy.
In other parts of the world, GDP growth was
not accompanied by similar gains in life expectancy.
The Russian Federation and Newly Independent
States increased average GDP per capita
substantially, but, with the widespread poverty
that accompanied the transition from the former
Soviet Union, women’s life expectancy stagnated
from the late 1980s and men’s plummeted, particularly
for those lacking education and job
security24,25. After a period of technological and
organizational stagnation, the health system collapsed12.
Public expenditure on health declined
in the 1990s to levels that made running a basic
system virtually impossible in several countries.
Unhealthy lifestyles, combined with the disintegration
of public health programmes, and the
unregulated commercialization of clinical services
combined with the elimination of safety
nets has offset any gains from the increase in
average GDP26. China had already increased its
Figure 1.4 GDP per capita and life expectancy at birth in 169 countriesa,
1975 and 2005
Life expectancy at birth (years)
GDP per capita, constant 2000 international $
a Only outlying countries are named.
35
85
0
Namibia
5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000
South Africa
Botswana
Swaziland
75
65
55
45
2005
1975
5
Chapter 1. The challenges of a changing world
life expectancy substantially in the period before
1980 to levels far above that of other low-income
countries in the 1970s, despite the 1961–1963
famine and the 1966–1976 Cultural Revolution.
The contribution of rural primary care and
urban health insurance to this has been well
documented27,28. With the economic reforms of
the early 1980s, however, average GDP per capita
increased spectacularly, but access to care and
social protection deteriorated, particularly in
rural areas. This slowed down improvements to
a modest rate, suggesting that only the improved
living conditions associated with the spectacular
economic growth avoided a regression of average
life expectancy29.
Finally, there is a set of low-income countries,
representing roughly 10% of the world’s
population, where both GDP and life expectancy
stagnated30. These are the countries that are
considered as “fragile states” according to the
“low-income countries under stress” (LICUS)
criteria for 2003–200631. As much as 66% of the
population in these countries is in Africa. Poor
governance and extended internal confl icts are
common among these countries, which all face
similar hurdles: weak security, fractured societal
relations, corruption, breakdown in the rule
of law, and lack of mechanisms for generating
legitimate power and authority32. They have a
huge backlog of investment needs and limited
government resources to meet them. Half of
them experienced negative GDP growth during
the period 1995–2004 (all the others remained
below the average growth of low-income countries),
while their external debt was above average33.
These countries were among those with
the lowest life expectancy at birth in 1975 and
have experienced minimal increases since then.
The other low-income African countries share
many of the characteristics and circumstances
of the fragile states – in fact many of them have
suffered protracted periods of confl ict over the
last 30 years that would have classifi ed them as
fragile states had the LICUS classifi cation existed
at that time. Their economic growth has been
very limited, as has been their life-expectancy
gain, not least because of the presence, in this
group, of a number of southern African countries
that are disproportionally confronted by the HIV/
AIDS pandemic. On average, the latter have seen
some economic growth since 1975, but a marked
reversal in terms of life expectancy.
What has been strikingly common to fragile
states and sub-Saharan African countries for
Life expectancy (years)
0
Figure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975–2005*
50
45
Chinah
55
60
65
70
75
80
1000 2000 3000 4000 5000 6000 7000 8000 9000 10 000
Middle-income
countriesb
Russian Federation
and NISg
Low-income African countriesf
Low-income
coutriesd
Indiac
Fragile statese
20 000 25 000 30 000
a 27 countries, 766 million (M) inhabitants in 1975, 953 M in 2005.
b 43 countries, 587 M inhabitants in 1975, 986 M in 2005 .
c India, 621 M inhabitants in 1975, 1 103 M in 2005.
d 17 Low-income countries, non-African, fragile states excluded, 471 M inhabitants in 1975, 872 M in 2005.
e 20 Fragile states, 169 M inhabitants in 1975, 374 M in 2005.
f 13 Low-income African countries, fragile states excluded, 71 M inhabitants in 1975, 872 M in 2005.
g Russian Federation and 10 Newly Independent States (NIS), 186 M inhabitants in 1985, 204 M in 2005.
h China, 928 M inhabitants in 1975, 1 316 M in 2005.
High-income countriesa
* No data for 1975 for the Newly Independant States. No historical data for the remaining countries.
Sources: Life expectancy, 1975, 1985: UN World Population Prospects 2006; 1995, 2005: WHO, 9 November 2008 (draft); China: 3rd, 4th and 5th National Population censuses, 1981, 1990 and 2000. GPD: 200737.
The World Health Report 2008
6
Primary Health Care – Now More Than Ever
much of the last three decades, and differentiates
them from the others that started out with less
than I$ 3000 per capita in 1975, is the combination
of stagnating economic growth, political instability
and lack of progress in life expectancy. They
accumulate characteristics that hamper improvement
of health. Education, particularly of females,
develops more slowly, as does access to modern
communications and knowledge-intensive work
that broadens people’s intellectual resources elsewhere.
People are more exposed and more vulnerable
to environmental and other health threats
that, in today’s globalized world, include lifestyle
threats, such as smoking, obesity and urban violence.
They lack the material security required to
invest in their own health and their governments
lack the necessary resources and/or commitment
to public investment. They are at much greater risk
of war and civil confl ict than richer countries30.
Without growth, peace is considerably more diffi
cult and without peace, growth stagnates: on
average, a civil war reduces a country’s growth
by around 2.3% per year for a typical duration of
seven years, leaving it 15% poorer34.
The impact of the combination of stagnation
and confl icts cannot be overstated. Confl icts are a
direct source of considerable excessive suffering,
disease and mortality. In the Democratic Republic
of the Congo, for example, the 1998–2004 confl ict
caused an excess mortality of 450 000 deaths
per year35. Any strategy to close the health gaps
between countries – and to correct inequalities
within countries – has to give consideration to
the creation of an environment of peace, stability
and prosperity that allows for investment in the
health sector.
A history of poor economic growth is also a
history of stagnating resources for health. What
In many countries, the total amount spent on health is insuffi cient
to fi nance access for all to even a very limited package of essential
health care39. This is bound to make a difference to health and
survival. Figure 1.6 shows that Kenya has a health-adjusted life
expectancy (HALE) of 44.4 years, the median for countries that
currently spend less than I$ 100 per capita on health. This is 27
years less than Germany, the median for countries that spend
more than I$ 2500 per capita. Every I$ 100
per capita spent on heath corresponds to a
1.1-year gain in HALE.
However, this masks large differences in
outcomes at comparable levels of spending.
There are up to fi ve years difference in HALE
between countries that spend more than
I$ 2500 per capita per year on health. The
spread is wider at lower expenditure levels,
even within rather narrow spending bands.
Inhabitants of Moldova, for example, enjoy 24
more HALE years than those of Haiti, yet they
are both among the 28 countries that spend I$
250–500 per capita on health. These gaps can
even be wider if one also considers countries
that are heavily affected by HIV/AIDS. Lesotho
spends more on health than Jamaica, yet its
people have a HALE that is 34 years shorter.
In contrast, the differences in HALE between
the countries with the best outcomes in each
Box 1.2 Higher spending on health is associated with better outcomes, but with large
differences between countries
spending band are comparatively small. Tajikistan, for example,
has a HALE that is 4.3 years less than that of Sweden – less than
the difference between Sweden and the United States. These differences
suggest that how, for what and for whom money is spent
matters considerably. Particularly in countries where the envelope
for health is very small, every dollar that is allocated sub-optimally
seems to make a disproportionate difference.
Figure 1.6 Countries grouped according to their total health expenditure
in 2005 (international $)38,40
HALE (years)
Total health expenditure (no. of countries)
20
80
70
50
30
THE < I$ 100
(30)
40
60
Tajikistan
Sierra Leone
THE I$ 100–250
(28)
Moldova
Haiti
Lesotho
THE I$ 250–500
(30)
Panama
Swaziland
THE I$ 500–1000
(23)
Finland
Botswana
THE I$ 1000–2500
(16)
Japan
THE > I$ 2500
(15)
Germany
Phillippines
Gabon
Colombia
Iran
United Kingdom /
New Zealand
Hungary
Sweden
USA
Kenya
Saint Vincent
and the
Grenadines
Highest
Median
Lowest
Outliers
7
Chapter 1. The challenges of a changing world
happened in sub-Saharan Africa during the years
following Alma-Ata exemplifi es this predicament.
After adjusting for infl ation, GDP per capita in
sub-Saharan Africa fell in most years from 1980–
199436, leaving little room to expand access to
health care or transform health systems. By the
early 1980s, for example, the medicines budget
in the Democratic Republic of the Congo, then
Zaïre, was reduced to zero and government disbursements
to health districts dropped below
US$ 0.1 per inhabitant; Zambia’s public sector
health budget was cut by two thirds; and funds
available for operating expenses and salaries for
the expanding government workforce dropped by
up to 70% in countries such as Cameroon, Ghana,
Sudan and the United Republic of Tanzania36. For
health authorities in this part of the world, the
1980s and 1990s were a time of managing shrinking
government budgets and disinvestment. For
the people, this period of fi scal contraction was
a time of crippling out-of-pocket payments for
under-funded and inadequate health services.
In much of the world, the health sector is often
massively under-funded. In 2005, 45 countries spent
less than I$ 100 per capita on health, including
external assistance38. In contrast, 16 high-income
countries spent more than I$ 3000 per capita. Lowincome
countries generally allocate a smaller proportion
of their GDP to health than high-income
countries, while their GDP is smaller to start with
and they have higher disease burdens.
Higher health expenditure is associated with
better health outcomes, but sensitive to policy
choices and context (Box 1.2): where money is
scarce, the effects of errors, by omission and by
commission, are amplifi ed. Where expenditure
increases rapidly, however, this offers perspectives
for transforming and adapting health systems
which are much more limited in a context
of stagnation.
Adapting to new health challenges
A globalized, urbanized and ageing world
The world has changed over the last 30 years:
few would have imagined that children in Africa
would now be at far more risk of dying from traffi
c accidents than in either the high- or the lowand
middle-income countries of the European
region (Figure 1.7).
Many of the changes that affect health were
already under way in 1978, but they have accelerated
and will continue to do so.
Thirty years ago, some 38% of the world’s
population lived in cities; in 2008, it is more than
50%, 3.3 billion people. By 2030, almost 5 billion
people will live in urban areas. Most of the
growth will be in the smaller cities of developing
countries and metropolises of unprecedented size
and complexity in southern and eastern Asia42.
Although on average health indicators in
cities score better than in rural areas, the
enormous social and economic stratification
within urban areas results in signifi cant health
inequities43,44,45,46. In the high-income area of Nairobi,
the under-fi ve mortality rate is below 15
per thousand, but in the Emabakasi slum of the
same city the rate is 254 per thousand47. These
and other similar examples lead to the more
general observation that within developing countries,
the best local governance can help produce
75 years or more of life expectancy; with poor
urban governance, life expectancy can be as low
as 35 years48. One third of the urban population
today – over one billion people – lives in slums: in
places that lack durable housing, suffi cient living
area, access to clean water and sanitation, and
secure tenure49. Slums are prone to fi re, fl oods
and landslides; their inhabitants are disproportionately
exposed to pollution, accidents, workplace
hazards and urban violence. Loss of social
Figure 1.7 Africa’s children are at more risk of dying from traffic accidents than
European children: child road-traffic deaths per 100 000 population41
0
50
30
20
10
40
0–4 5–9 10–14 15–19
Africa Europe, low- and middle-income countries Europe, high-income countries
The World Health Report 2008
8
Primary Health Care – Now More Than Ever
cohesion and globalization of unhealthy lifestyles
contribute to an environment that is decidedly
unfavourable for health.
These cities are where many of the world’s
nearly 200 million international migrants are
found50. They constitute at least 20% of the population
in 41 countries, 31% of which have less
than a million inhabitants. Excluding migrants
from access to care is the equivalent of denying
all the inhabitants of a country similar to Brazil
their rights to health. Some of the countries that
have made very signifi cant strides towards ensuring
access to care for their citizens fail to offer
the same rights to other residents. As migration
continues to gain momentum, the entitlements of
non-citizen residents and the ability of the healthcare
system to deal with growing linguistic and
cultural diversity in equitable and effective ways
are no longer marginal issues.
This mobile and urbanized world is ageing fast
and will continue to do so. By 2050, the world will
count 2 billion people over the age of 60, around
85% of whom will be living in today’s developing
countries, mostly in urban areas. Contrary to
today’s rich countries, low- and middle-income
countries are ageing fast before having become
rich, adding to the challenge.
Urbanization, ageing and globalized lifestyle
changes combine to make chronic and noncommunicable
diseases – including depression, diabetes,
cardiovascular disease and cancers – and
injuries increasingly important causes of morbidity
and mortality (Figure 1.8)51. There is a striking
shift in distribution of death and disease from
younger to older ages and from infectious, perinatal
and maternal causes to noncommunicable
diseases. Traffi c accident rates will increase;
tobacco-related deaths will overtake HIV/AIDSrelated
deaths. Even in Africa, where the population
remains younger, smoking, elevated blood
pressure and cholesterol are among the top 10 risk
factors in terms of overall disease burden52. In
the last few decades, much of the lack of progress
and virtually all reversals in life expectancy were
associated with adult health crises, such as in the
Russian Federation or southern Africa. Improved
health in the future will increasingly be a question
of better adult health.
Ageing has drawn attention to an issue that is
of particular relevance to the organization of service
delivery: the increasing frequency of multimorbidity.
In the industrialized world, as many
as 25% of 65–69 year olds and 50% of 80–84 year
olds are affected by two or more chronic health
conditions simultaneously. In socially deprived
populations, children and younger adults are
also likely to be affected53,54,55. The frequency of
multi-morbidity in low-income countries is less
well described except in the context of the HIV/
AIDS epidemic, malnutrition or malaria, but it is
probably greatly underestimated56,57. As diseases
of poverty are inter-related, sharing causes that
Cerebrovascular diseases
Ischaemic heart diseases
Cancers
Figure 1.8 The shift towards noncommunicable diseases and accidents as causes of death*
Perinatal causes
Acute respiratory infections
Diarrhoeal diseases
Malaria
HIV/AIDS
Tuberculosis
* Selected causes.
Deaths (millions)
0
2004
35
30
25
20
15
10
5
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2018 2020 2022 2024 2026 2028 2030
Road-traffic accidents
9
Chapter 1. The challenges of a changing world
are multiple and act together to produce greater
disability and ill health, multi-morbidity is
probably more rather than less frequent in poor
countries. Addressing co-morbidity – including
mental health problems, addictions and violence
– emphasizes the importance of dealing
with the person as a whole. This is as important
in developing countries as in the industrialized
world58.
It is insuffi ciently appreciated that the shift to
chronic diseases or adult health has to come on
top of an unfi nished agenda related to communicable
diseases, and maternal, newborn and child
health. Efforts directed at the latter, especially
in the poorest countries where coverage is still
insuffi cient, will have to expand12. But all health
systems, including those in the poorest countries,
will also have to deal with the expanding need and
demand for care for chronic and noncommunicable
diseases: this is not possible without much more
attention being paid to establishing a continuum
of comprehensive care than is the case today. It
is equally impossible without much more attention
being paid to addressing the pervasive health
inequalities within each country (Box 1.3).
Little anticipation and slow reactions
Over the past few decades, health authorities have
shown little evidence of their ability to anticipate
such changes, prepare for them or even adapt to
them when they have become an everyday reality.
This is worrying because the rate of change
is accelerating. Globalization, urbanization and
ageing will be compounded by the health effects of
other global phenomena, such as climate change,
the impact of which is expected to be greatest
among the most vulnerable communities living
in the poorest countries. Precisely how these will
affect health in the coming years is more diffi cult
to predict, but rapid changes in disease burden,
growing health inequalities and disruption of
social cohesion and health sector resilience are
to be expected. The current food crisis has shown
how unprepared health authorities often are for
changes in the broader environment, even after
other sectors have been sounding the alarm bell
for quite some time. All too often, the accelerated
pace and the global scale of the changes in the
challenges to health is in contrast with the sluggish
response of national health systems.
Even for well-known and documented trends,
such as those resulting from the demographic and
epidemiologic transitions, the level of response
often remains inadequate64. Data from WHO’s
World Health Surveys, covering 18 low-income
countries, show low coverage of the treatment of
asthma, arthritis, angina, diabetes and depression,
and of the screening for cervical and breast
cancer: less than 15% in the lowest income quintile
and less than 25% in the highest65. Public-health
interventions to remove the major risk factors of
disease are often neglected, even when they are
particularly cost effective: they have the potential
to reduce premature deaths by 47% and increase
global healthy life expectancy by 9.3 years64,66.
For example, premature tobacco-attributable
deaths from ischaemic heart disease, cerebrovascular
disease, chronic obstructive pulmonary
disease and other diseases are projected to rise
from 5.4 million in 2004 to 8.3 million in 2030,
almost 10% of all deaths worldwide67, with more
than 80% in developing countries12. Yet, two out
of every three countries are still without, or only
have minimal, tobacco control policies12.
With a few exceptions – the SARS epidemic, for
example – the health sector has often been slow
in dealing with new or previously underestimated
health challenges. For example, awareness of the
emerging health threats posed by climate change
and environmental hazards dates back at least to
the 1990 Earth Summit68, but only in recent years
have these begun to be translated into plans and
strategies69,70.
Health authorities have also often failed to
assess, in a timely way, the signifi cance of changes
in their political environment that affect the sector’s
response capacity. Global and national policy
environments have often taken health issues into
consideration, initiating hasty and disruptive
interventions, such as structural adjustment,
decentralization, blueprint poverty reduction
strategies, insensitive trade policies, new tax
regimes, fi scal policies and the withdrawal of
the state. Health authorities have a poor track
record in infl uencing such developments, and
have been ineffective in leveraging the economic
weight of the health sector. Many of the critical
systems issues affecting health require skills
and competencies that are not found within the
medical/public health establishment. The failure
The World Health Report 2008
10
Primary Health Care – Now More Than Ever
Box 1.3 As information improves, the multiple dimensions of growing health inequality are
becoming more apparent
In recent years, the extent of within-country disparities in vulnerability, access to care and health outcomes has been described in much
greater detail (Figure 1.9)59. Better information shows that health inequalities tend to increase, thereby highlighting how inadequate
and 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 and
consequences of health inequity.
0
20
40
60
80
100
Figure 1.9 Within-country inequalities in health and health care
Per capita household spending on health
as percentage of total household spending,
by income group
0
Côte d’Ivoire
1988
1
2
3
4
5
6
Ghana
1992
Madagascar
1993–4
Lowest quintile Quintile 2 Quintile 3 Quintile 4 Highest quintile
Mean time (minutes) taken to
reach an ambulatory health facility,
by income group
0
Bosnia and Herzegovina
2003–4
Comoros
2003–4
Ecuador
2003–4
10
20
30
40
50
Women using malaria prophylaxis (%),
by income group
Lowest quintile Quintile 2 Quintile 3 Quintile 4 Highest quintile
Full basic immunization coverage (%),
by income group
Guinea
2005
Malawi
2004
Niger
2006
Tanzania
2004
0
20
40
60
80
100
Bangladesh
2004
Colombia
2005
Indonesia
2002–3
Mozambique
2003
0
20
40
60
80
100
Neonatal mortality rate,
by education of mother
No education Primary education Secondary or higher education
Bolivia
2003
Colombia
2005
Lesotho
2003
Nepal
2006
Philippines
2003
0
20
40
60
80
100
Births attended by health professional (%),
by education of mother
Benin
2001
Bolivia
2003
Botswana
1998
Cambodia
2005
Peru
2000
Sources: (60, 61, 62, 63).
11
Chapter 1. The challenges of a changing world
to recognize the need for expertise from beyond
traditional health disciplines has condemned the
health sector to unusually high levels of systems
incompetence and ineffi ciency which society can
ill afford.
Trends that undermine the health
systems’ response
Without strong policies and leadership, health
systems do not spontaneously gravitate towards
PHC values or effi ciently respond to evolving
health challenges. As most health leaders know,
health systems are subject to powerful forces and
infl uences that often override rational priority
setting or policy formation, thereby pulling health
systems away from their intended directions71.
Characteristic trends that shape conventional
health systems today include (Figure 1.10):
a disproportionate focus on s �� pecialist, tertiary
care, often referred to as “hospital-centrism”;
�� fragmentation, as a result of the multiplication
of programmes and projects; and
�� the pervasive commercialization of health care
in unregulated health systems.
With their focus on cost containment and
deregulation, many of the health-sector reforms
of the 1980s and 1990s have reinforced these
trends. High-income countries have often been
able to regulate to contain some of the adverse
consequences of these trends. However, in
countries where under-funding compounds
limited regulatory capacity, they have had more
damaging effects.
Hospital-centrism: health systems built around
hospitals and specialists
For much of the 20th century, hospitals, with
their technology and sub-specialists, have gained
a pivotal role in most health systems throughout
the world72,73. Today, the disproportionate focus
on hospitals and sub-specialization has become
a major source of ineffi ciency and inequality, and
one that has proved remarkably resilient. Health
authorities may voice their concern more insistently
than they used to, but sub-specialization
continues to prevail74. For example, in Member
countries of the Organisation of Economic Cooperation
and Development (OECD), the 35%
growth in the number of doctors in the last 15
years was driven by rising numbers of specialists
(up by nearly 50% between 1990 and 2005
– compared with only a 20% increase in general
practitioners)75. In Thailand, less than 20% of
doctors were specialists 30 years ago; by 2003
they represented 70%76.
The forces driving this growth include professional
traditions and interests as well as the
considerable economic weight of the health industry
– technology and pharmaceuticals (Box 1.4).
Obviously, well functioning specialized tertiary
care responds to a real demand (albeit, at least in
part, induced): it is necessary, at the very least,
for the political credibility of the health system.
However, the experience of industrialized countries
has shown that a disproportionate focus on
specialist, tertiary care provides poor value for
money72. Hospital-centrism carries a considerable
cost in terms of unnecessary medicalization and
iatrogenesis77, and compromises the human and
social dimensions of health73,78. It also carries an
opportunity cost: Lebanon, for example, counts
more cardiac surgery units per inhabitant than
Germany, but lacks programmes aimed at reducing
the risk factors for cardiovascular disease79.
Ineffi cient ways of dealing with health problems
are thus crowding out more effective, effi cient –
and more equitable80 – ways of organizing health
care and improving health81.
Since the 1980s, a majority of OECD countries
has been trying to decrease reliance on hospitals,
Figure 1.10 How health systems are diverted from PHC core values
Commercialization
Hospital-centrism
Fragmentation
PHC Reform
PHC Reform
Current trends
Health equity
Universal access to
people-centred care
Healthy communities
Health
systems
The World Health Report 2008
12
Primary Health Care – Now More Than Ever
specialists and technologies, and keep costs
under control. They have done this by introducing
supply-side measures including reduction of
hospital beds, substitution of hospitalization by
home care, rationing of medical equipment, and
a multitude of fi nancial incentives and disincentives
to promote micro-level effi ciency. The results
of these efforts have been mixed, but the evolving
technology is accelerating the shift from specialized
hospital to primary care. In many highincome
countries (but not all), the PHC efforts
of the 1980s and 1990s have been able to reach
Box 1.4 Medical equipment and
pharmaceutical industries are major
economic forces
Global expenditure on medical equipment and devices has
grown from US$ 145 billion in 1998 to US$ 220 billion in 2006:
the United States accounts for 39% of the total, the European
Union for 27%, and Japan for 16%90. The industry employs
more than 411 400 workers in the United States alone, occupying
nearly one third of all the country’s bioscience jobs91. In
2006, the United States, the European Union and Japan spent
US$ 287, US$ 250 and US$ 273 per capita, respectively, on
medical equipment. In the rest of the world, the average of
such expenditure is in the order of US$ 6 per capita, and
in sub-Saharan Africa – a market with much potential for
expansion – it is US$ 2.5 per capita. The annual growth rate
of the equipment market is over 10% a year92.
The pharmaceutical industry weighs even more heavily in the
global economy, with global pharmaceutical sales expected
to expand to US$ 735–745 billion in 2008, with a growth rate
of 6–7%93. Here, too, the United States is the world’s largest
market, accounting for around 48% of the world total: per
capita expenditure on drugs was US$ 1141 in 2005, twice
the level of Canada, Germany or the United Kingdom, and 10
times that of Mexico94.
Specialized and hospital care is vital to these industries, which
depend on pre-payment and risk pooling for sustainable funding
of their expansion. While this market grows everywhere,
there are large differences from country to country. For
example, Japan and the United States have 5–8 times more
magnetic resonance imaging (MRI) units per million inhabitants
than Canada and the Netherlands. For computerized
tomography (CT) scanners, the differences are even more
pronounced: Japan had 92.6 per million in 2002, the Netherlands
5.8 in 200595. These differences show that the market
can be infl uenced, principally by using appropriate payment
and reimbursement incentives and by careful consideration
of the organization of regulatory control96.
a better balance between specialized curative
care, fi rst contact care and health promotion81.
Over the last 30 years, this has contributed to
signifi cant improvements in health outcomes81,82.
More recently, middle-income countries, such as
Chile with its Atención Primaria de Salud (Primary
Health Care)83, Brazil with its family health
initiative and Thailand under its universal coverage
scheme84 have shifted the balance between
specialized hospital and primary care in the
same way85. The initial results are encouraging:
improvement of outcome indicators86 combined
with a marked improvement in patient satisfaction87.
In each of these cases, the shift took place
as part of a move towards universal coverage,
with expanded citizen’s rights to access and social
protection. These processes are very similar to
what occurred in Malaysia and Portugal: right
to access, social protection, and a better balance
between reliance on hospitals and on generalist
primary care, including prevention and health
promotion6.
Industrialized countries are, 50 years later,
trying to reduce their reliance on hospitals,
having realized the opportunity cost of hospitalcentrism
in terms of effectiveness and equity.
Yet, many low- and middle-income countries
are creating the same distortions. The pressure
from consumer demand, the medical professions
and the medico-industrial complex88 is such that
private and public health resources fl ow disproportionately
towards specialized hospital care
at the expense of investment in primary care.
National health authorities have often lacked the
fi nancial and political clout to curb this trend and
achieve a better balance. Donors have also used
their infl uence more towards setting up disease
control programmes than towards reforms that
would make primary care the hub of the health
system89.
Fragmentation: health systems built around
priority programmes
While urban health by and large revolves around
hospitals, the rural poor are increasingly confronted
with the progressive fragmentation of
their health services, as “selective” or “vertical”
approaches focus on individual disease control
programmes and projects. Originally considered
13
Chapter 1. The challenges of a changing world
as an interim strategy to achieve equitable health
outcomes, they sprang from a concern for the
slow expansion of access to health care in a context
of persistent severe excess mortality and
morbidity for which cost-effective interventions
exist97. A focus on programmes and projects is
particularly attractive to an international community
concerned with getting a visible return
on investment. It is well adapted to commandand-
control management: a way of working that
also appeals to traditional ministries of health.
With little tradition of collaboration with other
stakeholders and participation of the public, and
with poor capacity for regulation, programmatic
approaches have been a natural channel for developing
governmental action in severely resourceconstrained
and donor-dependent countries. They
have had the merit of focusing on health care in
severely resource-constrained circumstances,
with welcome attention to reaching the poorest
and those most deprived of services.
Many have hoped that single-disease control
initiatives would maximize return on investment
and somehow strengthen health systems
as interventions were delivered to large numbers
of people, or would be the entry point to start
building health systems where none existed.
Often the opposite has proved true. The limited
sustainability of a narrow focus on disease control,
and the distortions it causes in weak and
under-funded health systems have been criticized
extensively in recent years98. Short-term
advances have been short-lived and have fragmented
health services to a degree that is now of
major concern to health authorities. With parallel
chains of command and funding mechanisms,
duplicated supervision and training schemes,
and multiplied transaction costs, they have led to
situations where programmes compete for scarce
resources, staff and donor attention, while the
structural problems of health systems – funding,
payment and human resources − are hardly
addressed. The discrepancy in salaries between
regular public sector jobs and better-funded
programmes and projects has exacerbated the
human resource crisis in fragile health systems.
In Ethiopia, contract staff hired to help implement
programmes were paid three times more
than regular government employees99, while in
Malawi, a hospital saw 88 nurses leave for better
paid nongovernmental organization (NGO) programmes
in an 18-month period100.
Eventually, service delivery ends up dealing
only with the diseases for which a (funded) programme
exists – overlooking people who have the
misfortune not to fi t in with current programme
priorities. It is diffi cult to maintain the people’s
trust if they are considered as mere programme
targets: services then lack social sustainability.
This is not just a problem for the population. It
puts health workers in the unenviable position of
having to turn down people with “the wrong kind
of problem” – something that fi ts ill with the selfimage
of professionalism and caring many cherish.
Health authorities may at fi rst be seduced by
the straightforwardness of programme funding
and management, yet once programmes multiply
and fragmentation becomes unmanageable and
unsustainable, the merits of more integrated
approaches are much more evident. The re-integration
of programmes once they have been well
established is no easy task.
Health systems left to drift towards
unregulated commercialization
In many, if not most low- and middle-income
countries, under-resourcing and fragmentation
of health services has accelerated the development
of commercialized health care, defi ned here
as the unregulated fee-for-service sale of health
care, regardless of whether or not it is supplied
by public, private or NGO providers.
Commercialization of health care has reached
previously unheard of proportions in countries
that, by choice or due to a lack of capacity, fail to
regulate the health sector. Originally limited to
an urban phenomenon, small-scale unregulated
fee-for-service health care offered by a multitude of
different independent providers now dominates the
health-care landscape from sub-Saharan Africa to
the transitional economies in Asia or Europe.
Commercialization often cuts across the
public-private divide101. Health-care delivery in
many governmental and even in traditionally
not-for-profi t NGO facilities has been de facto
commercialized, as informal payment systems
and cost-recovery systems have shifted the cost
of services to users in an attempt to compensate
The World Health Report 2008
14
Primary Health Care – Now More Than Ever
for the chronic under-funding of the public
health sector and the fi scal stringency of structural
adjustment102,103. In these same countries,
moonlighting civil servants make up a considerable
part of the unregulated commercial sector104,
while others resort to under-the-counter
payments105,106,107. The public-private debate of the
last decades has, thus, largely missed the point:
for the people, the real issue is not whether their
health-care provider is a public employee or a
private entrepreneur, nor whether health facilities
are publicly or privately owned. Rather, it is
whether or not health services are reduced to a
commodity that can be bought and sold on a feefor-
service basis without regulation or consumer
protection108.
Commercialization has consequences for quality
as well as for access to care. The reasons are
straightforward: the provider has the knowledge;
the patient has little or none. The provider has
an interest in selling what is most profi table,
but not necessarily what is best for the patient.
Without effective systems of checks and balances,
the results can be read in consumer organization
reports or newspaper articles that express
outrage at the breach of the implicit contract of
trust between caregiver and client109. Those who
cannot afford care are excluded; those who can
may not get the care they need, often get care they
do not need, and invariably pay too much.
Unregulated commercialized health systems
are highly ineffi cient and costly110: they exacerbate
inequality111, and they provide poor quality
and, at times, dangerous care that is bad for
health (in the Democratic Republic of the Congo,
for example, “la chirurgie safari” (safari surgery)
refers to a common practice of health workers
moonlighting by performing appendectomies
or other surgical interventions at the patients’
homes, often for crippling fees).
Thus, commercialization of health care is an
important contributor to the erosion of trust
in health services and in the ability of health
authorities to protect the public111. This is what
makes it a matter of concern for politicians and,
much more than was the case 30 years ago, one
of the main reasons for increasing support for
reforms that would bring health systems more
in line not only with current health challenges,
but also with people’s expectations.
Changing values
and rising expectations
The reason why health systems are organized
around hospitals or are commercialized is largely
because they are supply-driven and also correspond
to demand: genuine as well as supplyinduced.
Health systems are also a refl ection
of a globalizing consumer culture. Yet, at the
same time, there are indications that people are
aware that such health systems do not provide
an adequate response to need and demand, and
that they are driven by interests and goals that
are disconnected from people’s expectations. As
societies modernize and become more affl uent
and knowledgeable, what people consider to be
desirable ways of living as individuals and as
members of societies, i.e. what people value,
changes112. People tend to regard health services
more as a commodity today, but they also have
other, rising expectations regarding health and
health care. People care more about health as
an integral part of how they and their families
go about their everyday lives than is commonly
thought (Box 1.5)113. They expect their families
and communities to be protected from risks and
dangers to health. They want health care that
deals with people as individuals with rights and
not as mere targets for programmes or benefi ciaries
of charity. They are willing to respect health
professionals but want to be respected in turn,
in a climate of mutual trust 114.
People also have expectations about the way
their society deals with health and health care.
They aspire to greater health equity and solidarity
and are increasingly intolerant of social exclusion
– even if individually they may be reluctant to
act on these values115. They expect health authorities
– whether in government or other bodies –
to do more to protect their right to health. The
social values surveys that have been conducted
since the 1980s show increasing convergence
in this regard between the values of developing
countries and of more affl uent societies, where
protection of health and access to care is often
taken for granted112,115,116. Increasing prosperity,
access to knowledge and social connectivity are
associated with rising expectations. People want
to have more say about what happens in their
workplace, in the communities in which they live
and also in important government decisions that
15
Chapter 1. The challenges of a changing world
affect their lives117. The desire for better care and
protection of health, for less health inequity and
for participation in decisions that affect health
is more widespread and more intense now than
it was 30 years ago. Therefore, much more is
expected of health authorities today.
Health equity
Equity, whether in health, wealth or power is
rarely, if ever, fully achieved. Some societies are
more egalitarian than others, but on the whole
the world is “unequal”. Value surveys, however,
clearly demonstrate that people care about these
inequalities – considering a substantial proportion
to be unfair “inequities” that can and should
be avoided. Data going back to the early 1980s
show that people increasingly disagree with the
way in which income is distributed and believe
that a “just society” should work to correct
these imbalances120,121,122,123. This gives policymakers
less leeway to ignore the social dimensions
of their policies than they might have had
previously120,124.
People are often unaware of the full scope of
health inequalities. Most Swedish citizens, for
example, were probably unaware that the difference
in life expectancy between 20-year-old
men from the highest and lowest socioeconomic
groups was 3.97 years in 1997: a gap that had
widened by 88% compared to 1980125. However,
while people’s knowledge on these topics may be
partial, research shows that people regard social
gradients in health as profoundly unjust126. Intolerance
to inequality in health and to the exclusion
of population groups from health benefi ts and
social protection mirrors or exceeds intolerance
to inequality in income. In most societies, there is
wide consensus that everybody should be able to
take care of their health and to receive treatment
when ill or injured – without being bankrupted
and pushed into poverty127.
As societies become wealthier, popular support
for equitable access to health care and social
protection to meet basic health and social needs
gains stronger ground. Social surveys show that,
in the European region, 93% of the populations
support comprehensive health coverage117. In the
United States, long reputed for its reluctance to
adopt a national health insurance system, more
than 80% of the population is in favour of it115,
while basic care for all continues to be a widely
distributed, intensely held, social goal128. The
attitudes in lower income countries are less well
known, but extrapolating from their views on
income inequality, it is reasonable to assume
that increasing prosperity is coupled with rising
concern for health equity – even if consensus
about how this should be achieved may be as
contentious as in richer countries.
Box 1.5 Health is among the top
personal concerns
When people are asked to name the most important problems
that they and their families are currently facing, fi nancial worries
often come out on top, with health a close second118. In
one country out of two, personal illness, health-care costs,
poor quality care or other health issues are the top personal
concerns of over one third of the population surveyed
(Figure 1.11). It is, therefore, not surprising that a breakdown
of the health-care system – or even the hint of a breakdown
– can lead to popular discontent that threatens the ambitions
of the politicians seen to be responsible119.
Figure 1.11 Percentage of the population citing health as their main concern
before other issues, such as financial problems, housing or crime118
Poland
Ukraine
Russian Federation
Bulgaria
Germany
Italy
Sweden
Israel
Turkey
Spain
Czech Republic
France
Slovakia
United Kingdom
Mexico
Chile
Canada
Peru
Argentina
Brazil
United States
Venezuela
Bolivia
Republic of Korea
China
Japan
Malaysia
Bangladesh
India
Indonesia
Morocco
Pakistan
Egypt
Lebanon
Kuwait
Jordan
Occupied Palestinian Territory
Uganda
Mali
United Republic of Tanzania
Côte d’Ivoire
Senegal
Nigeria
Ghana
South Africa
Kenya
Ethiopia
0 10 20 30 40 50 60 70
The World Health Report 2008
16
Primary Health Care – Now More Than Ever
Care that puts people fi rst
People obviously want effective health care
when they are sick or injured. They want it to
come from providers with the integrity to act
in their best interests, equi tably and honestly,
with knowledge and compe tence. The demand
for competence is not trivial: it fuels the health
economy with steadily increased demand for
professional care (doctors, nurses and other
non-physician clinicians who play an increasing
role in both industrialized and developing
countries)129. For example, throughout the world,
women are switching from the use of traditional
birth attendants to midwives, doctors and obstetricians
(Figure 1.12)130.
The PHC movement has underestimated the
speed with which the transition in demand from
traditional caregivers to professional care would
bypass initial attempts to rapidly expand access
to health care by relying on non-professional
“community health workers”, with their added
value of cultural competence. Where strategies
for extending PHC coverage proposed lay workers
as an alternative rather than as a complement to
professionals, the care provided has often been
perceived to be poor131. This has pushed people
towards commercial care, which they, rightly or
wrongly, perceived to be more competent, while
attention was diverted from the challenge of more
effectively incorporating professionals under the
umbrella of PHC.
Proponents of PHC were right about the importance
of cultural and relational competence,
which was to be the key comparative advantage of
community health workers. Citizens in the developing
world, like those in rich countries, are not
looking for technical competence alone: they also
want health-care providers to be understanding,
respectful and trustworthy132. They want health
care to be organized around their needs, respectful
of their beliefs and sensitive to their particular
situation in life. They do not want to be taken
advantage of by unscrupulous providers, nor do
they want to be considered mere targets for disease
control programmes (they may never have
liked that, but they are now certainly becoming
more vocal about it). In poor and rich countries,
people want more from health care than interventions.
Increasingly, there is recognition that the
resolution of health problems should take into
account the socio-cultural context of the families
and communities where they occur133.
Much public and private health care today is
organized around what providers consider to be
effective and convenient, often with little attention
to or understanding of what is important
for their clients134. Things do not have to be that
way. As experience – particularly from industrialized
countries – has shown, health services
can be made more people-centred. This makes
them more effective and also provides a more
rewarding working environment135. Regrettably,
developing countries have often put less emphasis
on making services more people-centred, as if
this were less relevant in resource-constrained
circumstances. However, neglecting people’s
needs and expectations is a recipe for disconnecting
health services from the communities they
serve. People-centredness is not a luxury, it is a
necessity, also for services catering to the poor.
Only people-centred services will minimize social
exclusion and avoid leaving people at the mercy of
unregulated commercialized health care, where
the illusion of a more responsive environment
carries a hefty price in terms of fi nancial expense
and iatrogenesis.
Securing the health of communities
People do not think about health only in terms of
sickness or injury, but also in terms of what they
perceive as endangering their health and that of
their community118. Whereas cultural and political
explanations for health hazards vary widely,
there is a general and growing tendency to hold
the authorities responsible for offering protection
against, or rapidly responding to such dangers136.
This is an essential part of the social contract
that gives legitimacy to the state. Politicians in
rich as well as poor countries increasingly ignore
their duty to protect people from health hazards
at their peril: witness the political fall-out of the
poor management of the hurricane Katrina disaster
in the United States in 2005, or of the 2008
garbage disposal crisis in Naples, Italy.
Access to information about health hazards in
our globalizing world is increasing. Knowledge
is spreading beyond the community of health
professionals and scientifi c experts. Concerns
about health hazards are no longer limited to
the traditional public health agenda of improving
17
Chapter 1. The challenges of a changing world
the quality of drinking water and sanitation to
prevent and control infectious diseases. In the
wake of the 1986 Ottawa Charter for Health
Promotion137, a much wider array of issues constitute
the health promotion agenda, including
food safety and environmental hazards as well as
collective lifestyles, and the social environment
that affects health and quality of life138. In recent
years, it has been complemented by growing concerns
for a health hazard that used to enjoy little
visibility, but is increasingly the object of media
coverage: the risks to the safety of patients139.
Reliable, responsive health authorities
During the 20th century, health has progressively
been incorporated as a public good guaranteed
by government entitlement. There may be disagreement
as to how broadly to defi ne the welfare
state and the collective goods that go with it140,141,
but, in modernizing states, the social and political
responsibility entrusted to health authorities
– not just ministries of health, but also local
governmental structures, professional organizations
and civil society organizations with a quasigovernmental
role – is expanding.
Circumstances or short-term political expediency
may at times tempt governments to withdraw
from their social responsibilities for fi nancing
and regulating the health sector, or from service
delivery and essential public health functions.
Predictably, this creates more problems than it
solves. Whether by choice or because of external
pressure, the withdrawal of the state that
occurred in the 1980s and 1990s in China and the
former Soviet Union, as well as in a considerable
number of low-income countries, has had visible
and worrisome consequences for health and for
the functioning of health services. Signifi cantly,
it has created social tensions that affected the
legitimacy of political leadership119.
In many parts of the world, there is considerable
skepticism about the way and the extent to
which health authorities assume their responsibilities
for health. Surveys show a trend of
diminishing trust in public institutions as guarantors
of the equity, honesty and integrity of the
health sector123,142,143. Nevertheless, on the whole,
people expect their health authorities to work
for the common good, to do this well and with
foresight144. There is a multiplication of scoring
Figure 1.12 The professionalization of birthing care: percentage of births assisted
by professional and other carers in selected areas, 2000 and 2005
with projections to 2015a
Percentage of births
a Source: Pooled data from 88 DHS surveys 1995–2006, linear projection to 2015.
Lay person
0
100
Sub-Saharan
Africa
60
40
20
2000 2005 2015
South and South-East
Asia
2000 2005 2015
Middle East, North Africa
and Central Asia
2000 2005 2015
Latin America and
the Caribbean
2000 2005 2015
80
Traditional birth
attendant
Other health
professional
Doctor
The World Health Report 2008
18
Primary Health Care – Now More Than Ever
cards, rankings and other league tables of public
action used either at the national or global level141,
while consumer organizations are addressing
health sector problems111, and national and
global civil society watchdog organizations are
emerging146,147,148,149. These recent trends attest to
prevailing doubts about how well health authorities
are able to provide stewardship for the health
system, as well as to the rising expectations for
them to do even better.
Participation
At the same time, however, surveys show that, as
societies modernize, people increasingly want to
“have a say” in “important decisions that affect
their lives”123,112, which would include issues such
as resource allocation and the organization and
regulation of care. Experience from countries as
diverse as Chile, Sweden and Thailand shows,
however, that people are more concerned with
having guarantees for fair and transparent processes
than with the actual technicalities of priority
setting150,151. In other words, an optimum
response to aspirations for a bigger say in health
policy matters would be evidence of a structured
and functional system of checks and balances.
This would include relevant stakeholders and
would guarantee that the policy agenda could
not be hijacked by particular interest groups152.
PHC reforms:
driven by demand
The core values articulated by the PHC movement
three decades ago are, thus, more powerfully
present in many settings now than at the time
of Alma-Ata. They are not just there in the form
of moral convictions espoused by an intellectual
vanguard. Increasingly, they exist as concrete
social expectations felt and asserted by broad
groups of ordinary citizens within modernizing
societies. Thirty years ago, the values of equity,
people-centredness, community participation and
self-determination embraced by the PHC movement
were considered radical by many. Today,
these values have become widely shared social
expectations for health that increasingly pervade
many of the world’s societies – though the language
people use to express these expectations
may differ from that of Alma-Ata.
This evolution from formal ethical principles
to generalized social expectations fundamentally
alters the political dynamics around health systems
change. It opens fresh opportunities for generating
social and political momentum to move
health systems in the directions people want them
to go, and that are summarized in Figure 1.13.
It moves the debate from a purely technical discussion
on the relative effi ciency of various ways
of “treating” health problems to include political
considerations on the social goals that defi ne
the direction in which to steer health systems.
The subsequent chapters outline a set of reforms
aimed at aligning specialist-based, fragmented
and commercialized health systems with these
rising social expectations. These PHC reforms
aim to channel society’s resources towards more
equity and an end to exclusion; towards health
services that revolve around people’s needs and
expectations; and towards public policies that
secure the health of communities. Across these
reforms is the imperative of engaging citizens and
other stakeholders: recognizing that vested interests
that tend to pull health systems in different
directions raises the premium on leadership and
vision and on sustained learning to do better.
Figure 1.13 The social values that drive PHC
and the corresponding sets of reforms
Health equity
Solidarity
Social inclusion
People-centred care
Health authorities that
can be relied on
Communities where
health is promoted
and protected
Universal coverage reforms
Chapter 2
Service delivery reforms
Chapter 3
Leadership reforms
Chapter 5
Public policy reforms
Chapter 4
19
Chapter 1. The challenges of a changing world
References
Smith R. Oman: leaping a 1. cross the centuries. British Medical Journal, 1988,
297:540–544.
2. Sultanate of Oman: second primary health care review mission. Geneva, World Health
Organization, 2006.
3. Primary health care performance. Muscat, Sultanate of Oman. Directorate General of
Health Affairs, Department of Primary Health Care, 2006.
4. Infante A. The post military government reforms to the Chilean health system. A case
study commissioned by the Health Systems Knowledge Network. Paper presented in
the Health Services Knowledge Network Meeting, London, October 2006. Geneva,
World Health Organization, Commission on the Social Determinants of Health, 2007.
5. Pathmanathan I, Dhairiam S. Malaysia: moving from infectious to chronic diseases.
In: Tarimo E, ed. Achieving health for all by the year 2000: midway reports of country
experiences. Geneva, World Health Organization, 1990.
6. Biscaia A et al. Cuidados de saúde primários em Portugal: reformar para novos
sucessos. Lisbon, Padrões Culturais Editora, 2006.
7. Pongsupap Y. Introducing a human dimension to Thai health care: the case for family
practice. Brussels, Vrije Universiteit Brussel Press, 2007.
8. Barros P, Simões J. Portugal: health system review. Geneva, World Health
Organization Regional Offi ce for Europe on behalf of the European Observatory of
Health Systems and Policies, 2007 (Health Systems in Transition No. 9; http://www.
euro.who.int/Document/E90670.pdf, accessed 1 July 2008).
9. Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health care systems in
transition: Portugal. Copenhagen, World Health Organization Regional Offi ce for
Europe on behalf of the European Observatory on Health Systems and Policies,
2004 (Health Care Systems in Transition No. 1; http://www.euro.who.int/document/
e82937.pdf, accessed 1 July 2008).
10. Ferrinho P, Bugalho M, Miguel JP. eds. For better health in Europe, Vol. 1. Lisbon,
Fundação Merck Sharp & Dohme, 2004.
11. Biscaia A et al. Cuidados de saúde primários portugueses e a mortalidade vulnerável
às intervenções dos serviços de saúde – o caso português [Portuguese primary
health care and health services intervention in mortality amenable to health service
intervention. Geneva, World Health Organization 2008 (unpublished background
paper for the World Health Report 2008 − Primary health care: now more than ever,
Geneva, World Health Organization, 2008).
12. World Health Statistics 2008. Geneva, World Health Organization, 2008.
13. Murray CJL et al. Can we achieve Millennium Development Goal 4? New analysis
of country trends and forecasts of under-5 mortality to 2015. Lancet 2007,
370:1040–1054.
14. The Millennium Development Goals report 2007. New York, United Nations, 2007
(http://www.un.org/millenniumgoals/pdf/mdg2007.pdf, accessed 1 July 2008).
15. Levels and trends of contraceptive use as assessed in 2002. New York, United
Nations, Department of Economic and Social Affairs, Population Division, 2004
(Sales No. E.04.XIII.9).
16. World contraceptive use 2007, wall chart. New York, United Nations, Department of
Economic and Social Affairs, Population Division, 2008 (Sales No. E.08.XIII.6).
17. Sedgh G et al. Induced abortion: estimated rates and trends worldwide. Lancet,
2007, 370:1338–1345.
18. Koblinsky M et al. Going to scale with professional skilled care. Lancet, 2006,
368:1377–1386.
19. Goesling B, Ferebaugh G. The trend in international health inequality. Population and
Development Review, 2004, 30:131−146.
20. Preston S. The changing relation between mortality and level of economic
development. Population Studies, 1975, 29:231–248.
21. The state of the world’s children 2008. Paris, United Nations Children’s Fund, 2008.
22. Cutler DM, Deaton A, Lleras-Muney A. The determinants of mortality. Cambridge,
MA, National Bureau of Economic Research, 2006 (NBER Working Paper No. 11963).
23. Deaton A. Global patterns of income and health: facts, interpretations, and policies,
WIDER Annual Lecture, Helsinki, September 29th, 2006. Princeton NJ, Princeton
University Press, 2006.
24. Field M, Shkolnikov V. Russia: socioeconomic dimensions of the gender gap in
mortality. In: Evans et al. Challenging inequities in health: from ethics to action. New
York, Oxford University Press 2001.
25. WHO mortality database: tables [online database]. Geneva, World Health
Organization, 2007 (http://www.who.int/healthinfo/morttables/en/index.html,
accessed 1 July 2008).
26. Suhrcke M, Rocco L, McKee M. Health: a vital investment for economic development
in eastern Europe and central Asia. European Observatory on Health Systems and
Policies, 2008 (http://www.euro.who.int/observatory/Publications/20070618_1,
accessed 1 July 2008).
27. Banister J, Zhang X. China, economic development and mortality decline. World
Development, 2005, 33:21−41.
28. Banister J, Hill K. Mortality in China, 1964-2000. Population studies, 2004,
58:55−75.
29. Gu D et al. Decomposing changes in life expectancy at birth by age, sex and
residence from 1929 to 2000 in China. Paper present at the American Population
Association 2007 annual meeting, New York, 29-31 March 2007 (unpublished).
30. Milanovic B. Why did the poorest countries fail to catch up? Washington DC, Carnegie
Endowment for International Peace, 2005 (Carnegie Paper No. 62).
31. Carvalho S. Engaging with fragile states: an IEG review of World Bank support to
low-income countries under stress. Appendix B: LICUS, fi scal 2003-06. Washington
DC, The World Bank, 2006 (http://www.worldbank.org/ieg/licus/docs/appendix_b.
pdf, accessed 1 July 2008).
32. Carvalho S. Engaging with fragile states: an IEG review of World Bank support
to low-income countries under stress. Chapter 3: Operational utility of the LICUS
identifi cation, classifi cation, and aid-allocation system. Washington DC, The World
Bank, 2006 (http://www.worldbank.org/ieg/licus/docs/licus_chap3.pdf, accessed
1 July 2008).
33. Ikpe, E. Challenging the discourse on fragile states. Confl ict, Security and
Development, 2007, 77:84–124.
34. Collier P. The bottom billion: why the poorest countries are failing and what can be
done about it. New York, Oxford University Press, 2007.
35. Coghlan B et al. Mortality in the Democratic Republic of Congo: a nationwide survey.
Lancet, 2006, 367:44–51.
36. World development indicators 2007. Washington DC, The World Bank, 2007 (http://
go.worldbank.org/3JU2HA60D0, accessed 1 July 2008).
37. Van Lerberghe W, De Brouwere V. Etat de santé et santé de l’Etat en Afrique
subsaharienne [State of health and health of the state in sub-Saharan Africa],
Afrique Contemporaine, 2000, 135:175–190.
38. National health accounts country information for 2002–2005. Geneva, World Health
Organization, 2008 (http://www.who.int/nha/country/en, accessed 2 July 2008).
39. Xu K et al. Protecting households from catastrophic health expenditures, Health
Affairs, 2007, 26:972−983.
40. The World Health Report 2004 − Changing history: overview. Annex table 4: healthy
life expectancy in WHO Member States, estimates for 2002. Geneva, World Health
Organization, 2004 (http://www.who.int/whr/2004/annex/topic/en/annex_4_
en.pdf, accessed 2 July 2008).
41. WHO global burden of disease estimates: 2004 update. Geneva, World Health
Organization, 2008 (http://www.who.int/healthinfo/bodestimates/en/index.html,
accessed 2 July 2008).
42. State of world population 2007. Unleashing the potential of urban growth. New York,
United Nations Population Fund, 2007.
43. Vlahov D et al. Urban as a determinant of health. Journal of Urban Health, 2007,
84(Suppl. 1):16–26.
44. Montgomery M, Hewett, PC. Urban poverty and health in developing countries:
household and neighborhood effects demography. New York, The Population Council,
2004 (Policy Research Division Working paper No. 184; http://www.popcouncil.org/
pdfs/wp/184.pdf, accessed 1 July 2008).
45. Satterthwaite D. Coping with rapid urban growth. London, Royal Institution of
Chartered Surveyors, 2002 (RICS Leading Edge Series; POPLINE Document No.
180006).
46. Garenne M, Gakusi E. Health transitions in sub-Saharan Africa: overview of mortality
trends in children under 5 years old (1950–2000). Bulletin of the World Health
Organization, 2006, 84:470–478.
47. Population and health dynamics in Nairobi’s informal settlements. Nairobi, African
Population and Health Research Center Inc., 2002.
48. Report of the knowledge network on urban settlement. Geneva, World Health
Organization, Commission on Social Determinants of Health, 2008.
49. State of world population 2007. Unleashing the potential of urban growth. New York,
United Nations Population Fund, 2007.
50. International Migration Report 2006. 2006. New York, United Nations, Department
of Economic and Social Affairs, 2006.
51. Abegunde D et al. The burden and costs of chronic diseases in low-income and
middle-income countries. Lancet, 2007, 370:1929–1938.
52. The World Health Report 2002 − Reducing risks, promoting health life. Geneva, World
Health Organization, 2002.
53. Amaducci L, Scarlato G, Candalese L. Italian longitudinal study on ageing. ILSA
resource data book. Rome, Consiglio Nazionale per le Ricerche, 1996.
The World Health Report 2008
20
Primary Health Care – Now More Than Ever
54. Marengoni A. Prevalence and impact of chronic diseases and multimorbidity in the
ageing population: a clinical and epidemiological approach. Stockholm, Karolinska
Institutet, 2008.
55. McWhinney I. The essence of general practice. In: Lakhani M, ed. A celebration of
general practice. London, Royal College of General Practitioners, 2003.
56. Kazembe LN, Namangale JJ. A Bayesian multinomial model to analyse spatial
patterns of childhood co-morbidity in Malawi. European Journal of Epidemiology,
2007, 22:545−556.
57. Gwer S, Newton CR, Berkley JA. Over-diagnosis and co-morbidity of severe malaria
in African children: a guide for clinicians. American Journal of Tropical Medicine and
Hygiene. 2007 77(Suppl. 6):6–13.
58. Starfi eld B et al. Comorbidity: implications for the importance of primary care in
‘case’ management. Annals of Family Medicine, 2003, 1:814.
59. Gwatkin D et al. Socio-economic differences in health nutrition and population.
Washington DC, The World Bank, 2000 (Health Nutrition and Population Discussion
Paper).
60. Castro-Leal F et al. Public spending on health care in Africa: do the poor benefi t?
Bulletin of the World Health Organization, 2000, 78:66−74.
61. World Health Surveys. Geneva, World Health Organization, 2008.
62. STATcompiler [online database]. Calverton MD, Demographic Health Surveys, 2008
(http://www.statcompiler.com/, accessed 22 July 2008).
63. Davidson R et al. Country report on HNP and poverty − socio-economic differences in
health, nutrition, and population within developing countries: an overview. Produced
by the World Bank in collaboration with the government of the Netherlands and the
Swedish International Development Cooperation Agency. Washington DC, The World
Bank, 2007.
64. Strong K et al. Preventing chronic diseases: how many lives can we save?
Lancet, 366:1578–1582.
65. World health survey: internal calculations. Geneva, World Health Organization, 2008
(unpublished).
66. Ezzati M et al. Comparative risk assessment collaborating group. Estimates of global
and regional potential health gains from reducing multiple major risk factors. Lancet,
2003, 362:271−280.
67. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva,
World Health Organization, 2008.
68. Bettcher DW, Sapirie S, Goon EH. Essential public health functions: results of the
international Delphi study, World Health Stat Q, 1998, 51:44−54.
69. The World Health Report 2007 − A safer future, global public health security in the
21st century. Geneva, World Health Organization, 2007.
70. Rockenschaub G, Pukkila J, Profi li M. Towards health security. A discussion paper
on recent health crises in the WHO European Region. Copenhagen, World Health
Organization Regional Offi ce for Europe, 2007.
71. Moran M. Governing the health care state. A comparative study of the United
Kingdom, the United States and Germany. Manchester, Manchester University Press,
1999.
72. Starfi eld B. Primary care. Balancing health needs, services and technology. New
York, Oxford University Press, 1998.
73. Pongsupap Y. Introducing a human dimension to Thai health care: the case for family
practice. Brussels, Vrije Universiteit Brussel Press, 2007.
74. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005:
trends in primary care specialties. Journal of the American Medical Association,
2005, 294:1075–1082.
75. OECD Health Data 2007. SourceOECD [online database]. Paris, Organisation for
Economic Co-operation and Development, 18 July 2007 (http://www.oecd.org/doc
ument/10/0,3343,en_2649_37407_38976778_1_1_1_37407,00.html, accessed
1 July 2008).
76. Jindawatthana A, Jongudomsul P. Human resources for health and universal health
care coverage. Thailand’s experience. Journal for Human Resources for Health
(forthcoming).
77. The Research Priority Setting Working Group of the WHO World Alliance for Patient
Safety. Summary of the evidence on patient safety. Implications for research. Geneva,
World Health Organization, 2008.
78. Liamputtong P. Giving birth in the hospital: childbirth experiences of Thai women in
northern Thailand. Health Care for Women International, 2004, 25:454–480.
79. Ammar W. Health system and reform in Lebanon. Beirut, World Health Organization
Regional Offi ce for the Eastern Mediterranean, 2003.
80. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in
health: Levelling up part 1. Copenhagen, World Health Organization Regional Offi ce
for Europe, 2006. (Studies on Social and Economic Determinants of Population
Health No. 2; http://www.euro.who.int/document/e89383.pdf, accessed 15 July
2008).
81. Starfi eld B, Shi L. Policy relevant determinants of health: an international
perspective. Health Policy, 2002, 60:201–218.
82. Schoen C et al. 2006 US health system performance: a national scorecard. Health
Affairs, 20 September 2006 (Web Exclusive, w457–w475).
83. Gobierno de Chile. Ministerio de Salud. Orientaciones para la programación en
red. Santiago, Subsecretaria de Redes Asistenciales, Division de Gestion de Red
Asistencial, 2006.
84. Suraratdecha C, Saithanu S, Tangcharoensathien V. Is universal coverage a solution
for disparities in health care? Findings from three low-income provinces of Thailand.
Health Policy, 73:272–284.
85. Tangcharoensathien V et al. Knowledge-based changes to the Thai health system.
Bulletin of the World Health Organization, 2004, 82:750–756.
86. Macinko J et al. Going to scale with community-based primary care: an analysis of
the family health program and infant mortality in Brazil, 1999–2004. Social Science
& Medicine, 2007, 65:2070–2080.
87. Pongsupap Y, Boonyapaisarnchoaroen T, Van Lerberghe W. The perception of
patients using primary care units in comparison with conventional public hospital
outpatient departments and “prime mover family practices”: an exit survey. Journal
of Health Science, 2005, 14:475–483.
88. Relman AS. The new medical-industrial complex. New England Journal of Medicine,
1980, 303:963−970.
89. Aid effectiveness and health. Making health systems work. Geneva, World Health
Organization, 2007 (Working Paper 9; WHO/HSS/healthsystems/2007.2).
90. Lifestyle and health. EurActiv, 2006 (http://www.euractiv.com/en/health/medicaldevices/
article-117519, accessed 1 July2008).
91. Medical Device Statistics, PharmaMedDevice’s Bulletin, 2006 (http://www.
pharmameddevice.com/App/homepage.cfm?appname=100485&linkid=23294&mo
duleid=3162#Medical_Device, accessed 1 July 2008).
92. Medical technology industry at a glance. Washington DC, Advanced Medical
Technology Association, 2004 (http://www.advamed.org/NR/rdonlyres/0A261055-
827C-4CC6-80B6-CC2D8FA04A33/0/ChartbookSept2004.pdf, accessed 15 July
2008).
93. Press room: IMS health predicts 5 to 6 percent growth for global
pharmaceutical market in 2008, according to annual forecast. IMS Intelligence
Applied, 1 November 2007 (http://www.imshealth.com/ims/portal/front/
articleC/0,2777,6599_3665_82713022,00.html, accessed 1 July 2008).
94. Danzon PM, Furukawa MF. International prices and availability of pharmaceuticals in
2005. Health Affairs, 2005, 27:221–233.
95. Health at a glance 2007: OECD indicators. Paris, Organisation for Economic
Co-operation and Development, 2007.
96. Moran M. Governing the health care state. A comparative study of the United
Kingdom, the United States and Germany. Manchester, Manchester University Press,
1999.
97. Walsh JA, Warren KS. Selective primary health care: an interim strategy for
disease control in developing countries. New England Journal of Medicine, 1979,
301:967–974.
98. Buse K, Harmer AM. Seven habits of highly effective global public–private health
partnerships: Practice and potential, Social Science & Medicine, 2007, 64:259−271.
99. Stillman K, Bennet S. System wide effects of the Global Fund interim fi ndings
from three country studies. Washington DC, United States Agency for Aid and
Development, 2005.
100. Malawi Ministry of Health and The World Bank. Human resources and fi nancing in
the health sector in Malawi. Washington DC, World Bank, 2004.
101. Giusti D, Criel B, de Béthune X. Viewpoint: public versus private health care delivery:
beyond slogans. Health Policy and Planning, 1997, 12:193–198.
102. Périn I, Attaran A. Trading ideology for dialogue: an opportunity to fi x international
aid for health. Lancet, 2003, 362:1216–1219.
103. Creese AL. User charges for health care: a review of recent experience. Geneva,
World Health Organization, 1990 (Strengthening Health Systems Paper No. 1).
104. Macq J et al. Managing health services in developing countries: between the ethics
of the civil servant and the need for moonlighting. Human Resources for Health
Development Journal, 2001, 5:17−24.
105. Delcheva E, Balabanova D, McKee M. Under-the-counter payments for health care:
evidence from Bulgaria. Health Policy, 1997, 42:89–100.
106. João Schwalbach et al. Good Samaritan or exploiter of illness? Coping strategies of
Mozambican health care providers. In: Ferrinho P, Van Lerberghe W. eds. Providing
health care under adverse conditions. Health personnel performance and individual
coping strategies. Antwerp, ITGPress, 2000.
107. Ferrinho P et al. Pilfering for survival: how health workers use access to drugs as a
coping strategy. Human Resources for Health, 2004, 2:4.
108. McIntyre D et al. Commercialisation and extreme inequality in health: the
policy challenges in South Africa. Journal of International Development, 2006,
18:435–446.
109. Sakboon M et al. Case studies in litigation between patients and doctors. Bangkok,
The Foundation of Consumer Protection, 1999.
21
Chapter 1. The challenges of a changing world
110. Ammar, W. Health system and reform in Lebanon. Beirut, World Health Organization
Regional Offi ce for the Eastern Mediterranean, 2003.
111. Macintosh M. Planning and market regulation: strengths, weaknesses and
interactions in the provision of less inequitable and better quality health care. Geneva,
World Health Organization, Health Systems Knowledge Network, Commission on the
Social Determinants of Health, 2007.
112. Inglehart R, Welzel C. Modernization, cultural change and democracy: the human
development sequence. Cambridge, Cambridge University Press, 2005.
113. Kickbush I. Innovation in health policy: responding to the health society. Gaceta
Sanitaria, 2007, 21:338−342.
114. Anand S. The concern for equity in health. Journal of Epidemiology and Community
Health, 2002, 56:485–487.
115. Road map for a health justice majority. Oakland, CA, American Environics, 2006
(http://www.americanenvironics.com/PDF/Road_Map_for_Health_Justice_
Majority_AE.pdf, accessed 1 July 2008).
116. Welzel I. A human development view on value change trends (1981–2006). World
Value Surveys, 2007 (http://www.worldvaluessurvey.org/, accessed on 1 July 2008).
117. World values surveys database. Madrid, World Value Surveys, 2008 (http://www.
worldvaluessurvey.com, accessed 2 July 2008).
118. A global look at public perceptions of health problems, priorities and donors: the
Kaiser/Pew global health survey. Kaiser Family Foundation, December 2007 (http://
www.kff.org/kaiserpolls/upload/7716.pdf , accessed 1 July 2008).
119. Blumenthal D, Hsiao W. Privatization and its discontents – the evolving Chinese
health care system. New England Journal of Medicine, 2005, 353:1165–1170.
120. Lübker M. Globalization and perceptions of social inequality. International Labour
Review, 2004, 143:191.
121. Taylor, B, Thomson, K. Understanding change in social attitudes. Aldershot, England,
Dartmouth Publishing, 1996.
122. Gajdos T, Lhommeau B. L’attitude à l’égard des inegalités en France à la lumière du
système de prélèvement socio-fi scal. Mai 1999 (http://thibault.gajdos.free.fr/pdf/
cserc.pdf, accessed 2 July 2008).
123. Halman L et al. Changing values and beliefs in 85 countries. Trends from the values
surveys from 1981 to 2004. Leiden and Boston, Brill, 2008 (European values studies
11; http://www.worldvaluessurvey.org/, accessed 2 July 2008).
124. De Maeseneer J et al. Primary health care as a strategy for achieving equitable care:
a literature review commissioned by the Health Systems Knowledge Network. Geneva,
World Health Organization, Commission on the Social Determinants of Health, 2007.
125. Burstrôm K, Johannesson M, Didericksen E. Increasing socio-economic inequalities
in life expectancy and QALYs in Sweden 1980-1997. Health Economics, 2005,
14:831–850.
126. Marmot M. Achieving health equity: from root causes to fair outcomes. Lancet,
2007, 370:1153–1163.
127. Health care: the stories we tell. Framing review. Oakland CA, American Environics,
2006 (http.www.americanenvironics.com, accessed 2 July 2008).
128. Garland M, Oliver J. Oregon health values survey 2004. Tualatin, Oregon Health
Decisions, 2004.
129. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries.
Lancet, 2007, 370:2158–2163.
130. Koblinsky M et al. Going to scale with professional skilled care. Lancet, 2006,
368:1377–1386.
131. Lehmann U, Sanders D. Community health workers: what do we know about them?
The state of the evidence on programmes, activities, costs and impact on health
outcomes of using community health workers. Geneva, World Health Organization,
Department of Human Resources for Health, Evidence and Information for Policy,
2007.
132. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as
constraints to referral by isolated nurses in rural Niger. Human Resources for Health,
2004, 2:1–8.
133. Cheragi-Sohi S et al. What are the key attributes of primary care for patients?
Building a conceptual map of patient preferences. Health Expect, 2006, 9:275−284.
134. Pongsupap Y, Van Lerberghe W. Choosing between public and private or between
hospital and primary care? Responsiveness, patient-centredness and prescribing
patterns in outpatient consultations in Bangkok. Tropical Medicine & International
Health, 2006, 11:81–89.
135. Allen J et al. The European defi nition of general practice/family practice. Ljubljana,
European Society of General Practice/Family Medicine, 2002 (http://www.
globalfamilydoctor.com/publications/Euro_Def.pdf/, accessed 21 July 2008).
136. Gostin LO. Public health law in a new century. Part I: law as a tool to advance
the community’s health. Journal of the American Medical Association, 2000,
283:2837−2841.
137. Canadian Public Health Association and Welfare Canada and the World Health
Organization. Ottawa Charter for Health Promotion. First International Conference on
Health Promotion, Ottawa, 17–21 November 1986. Geneva, Department of Human
Resources for Health, World Health Organization, 1986 (WHO/HPR/HEP/95.1; http://
www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf, accessed 2 July 2008).
138. Kickbusch I. The contribution of the World Health Organization to a new public
health and health promotion. American Journal of Public Health, 2003, 93:3.
139. Jaffré Y, Olivier de Sardan JP. Une médecine inhospitalière. Paris, APAD-Karthala
(Hommes et sociétés), 2003.
140. Blank RH. The price of life: the future of American health care. New York, Colombia
University Press, 1997.
141. Weissert C, Weissert W. Governing health: the politics of health policy. Baltimore MD,
Johns Hopkins University Press, 2006.
142. Millenson ML. How the US news media made patient safety a priority. BMJ, 2002.
324:1044.
143. Davies H. Falling public trust in health services: Implications for accountability.
Journal of Health Services Research and Policy, 1999, 4:193–194.
144. Gilson L. Trust and the development of health care as a social institution. Social
Science and Medicine, 2003, 56:1453–1468.
145. Nutley S, Smith PC. League tables for performance improvement in health care.
Journal of Health Services & Research Policy, 1998, 3:50−57.
146. Allsop J, Baggott R, Jones K. Health consumer groups and the national policy
process. In: Henderson S, Petersen AR, eds. Consuming health: the commodifi cation
of health care, London, Routledge, 2002.
147. Rao H. Caveat emptor: the construction of non-profi t consumer watchdog
organizations. American Journal of Sociology, 1998, 103:912–961.
148. Larkin M. Public health watchdog embraces the web. Lancet, 2000,
356:1283–1283.
149. Lee K. Globalisation and the need for a strong public health response. The European
Journal of Public Health, 1999 9:249–250.
150. McKee M, Figueras J. Set ting priorities: can Britain learn from Sweden? British
Medical Journal, 1996, 312:691–694.
151. Daniels N. Accountability for reasonableness. Establishing a fair process for priority
setting is easier than agreeing on principles. BMJ, 2000, 321:1300–1301.
152. Martin D. Fairness, accountability for reasonableness, and the views of priority
setting decision-makers. Health Policy, 2002, 61:279–290.

Advancing and sustaining
universal coverage
People expect their health systems to be
equitable. The roots of health inequities
lie in social conditions outside the health system’s
direct control. These root causes have to be tackled
through intersectoral and cross-government action.
At the same time, the health sector can take
signifi cant actions to advance
health equity internally. The basis
for this is the set of reforms that
aim at moving towards universal
coverage, i.e. towards universal
access to health services with
social health protection.
Chapter 2
The central place of
health equity in PHC 24
Moving towards
universal coverage 25
Challenges in moving
towards universal coverage 27
Targeted interventions
to complement universal
coverage mechanisms
32
Mobilizing for health equity 34
23
The World Health Report 2008 Primary Health Care – Now More Than Ever
24
The central place of
health equity in PHC
“If you get sick, you have to choose: you either
go without treatment or you lose the farm.”1
Nearly a century ago, the unforgiving reality of
life in rural Canada prompted Matthew Anderson
(1882–1974) to launch a tax-based health insurance
scheme that eventually led to countrywide
adoption of universal health care across Canada
in 1965. Unfortunately, equally shocking lose-lose
situations abound today across the world. More
than 30 years after the clarion call of Alma-Ata
for greater equity in health, most of the world’s
health-care systems continue to rely on the most
inequitable method for fi nancing health-care services:
out-of-pocket payments by the sick or their
families at the point of service. For 5.6 billion
people in low- and middle-income countries, over
half of all health-care expenditure is through outof-
pocket payments. This deprives many families
of needed care because they cannot afford it. Also,
more than 100 million people around the world
are pushed into poverty each year because of
catastrophic health-care expenditures2. There is
a wealth of evidence demonstrating that fi nancial
protection is better, and catastrophic expenditure
less frequent, in those countries in which there
is more pre-payment for health care and less
out-of-pocket payment. Conversely, catastrophic
expenditure is more frequent when health care
has to be paid for out-of-pocket at the point of
service (Figure 2.1).
While equity marks one of PHC’s boldest features,
it is one of the areas where results have
been most uneven and where the premium for
more effective reforms is perhaps the greatest.
Out-of-pocket payments for health care are but
one of the sources of health inequity. Deeply
unequal opportunities for health combined with
endemic inequalities in health care provision
lead to pervasive inequities in health outcomes3.
Growing awareness of these regressive patterns
is causing increasing intolerance of the whole
spectrum of unnecessary, avoidable and unfair
differences in health4.
The extent of health inequities is documented
in much more detail today. They stem from
social stratifi cation and political inequalities
that lie outside the boundaries of the health system.
Income and social status matter, as do the
neighbourhoods where people live, their employment
conditions and factors, such as personal
behaviour, race and stress5. Health inequities
also fi nd their roots in the way health systems
exclude people, such as inequities in availability,
access, quality and burden of payment, and even
in the way clinical practice is conducted6. Left to
their own devices, health systems do not move
towards greater equity. Most health services –
hospitals in particular, but also fi rst-level care
– are consistently inequitable providing more
and higher quality services to the well-off than
to the poor, who are in greater need7,8,9,10. Differences
in vulnerability and exposure combine
with inequalities in health care to lead to unequal
health outcomes; the latter further contribute to
the social stratifi cation that led to the inequalities
in the fi rst place. People are rarely indifferent to
this cycle of inequalities, making their concerns
as relevant to politicians as they are to healthsystem
managers.
It takes a wide range of interventions to tackle
the social determinants of health and make health
systems contribute to more health equity11. These
interventions reach well beyond the traditional
realm of health-service policies, relying on the
mobilization of stakeholders and constituencies
outside the health sector12. They include13:
reduction of social stratifi �� cation, e.g. by reducing
income inequality through taxes and subsidized
public services, providing jobs with
Households with catastrophic expenditure (%)
0
0
Figure 2.1 Catastrophic expenditure related to out-of-pocket payment
at the point of service1
Out-of-pocket payment as percentage of total health expenditure
10
10 20 30 40 50 60 70 80 90 100
OECD countries Other countries
5
25
Chapter 2. Advancing and sustaining universal coverage
adequate pay, using labour intensive growth
strategies, promoting equal opportunities for
women and making free education available,
etc.;
reduction of vulnerabilities, �� e.g. by providing
social security for the unemployed or disabled,
developing social networks at community level,
introducing social inclusion policies and policies
that protect mothers while working or
studying, offering cash benefi ts or transfers,
providing free healthy lunches at school,
etc.;
�� protection, particularly of the disadvantaged,
against exposure to health hazards, e.g. by
introducing safety regulations for the physical
and social environment, providing safe water
and sanitation, promoting healthy lifestyles,
establishing healthy housing policies, etc.);
�� mitigation of the consequences of unequal
health outcomes that contribute to further
social stratifi cation, e.g. by protecting the sick
from unfair dismissal from their jobs.
The need for such multiple strategies could
discourage some health leaders who might feel
that health inequality is a societal problem over
which they have little infl uence. Yet, they do
have a responsibility to address health inequality.
The policy choices they make for the health
sector defi ne the extent to which health systems
exacerbate or mitigate health inequalities and
their capacity to mobilize around the equity
agenda within government and civil society.
These choices also play a key part in society’s
response to citizens’ aspirations for more equity
and solidarity. The question, therefore, is not
if, but how health leaders can more effectively
pursue strategies that will build greater equity
in the provision of health services.
Moving towards universal coverage
The fundamental step a country can take to promote
health equity is to move towards universal
coverage: universal access to the full range of
personal and non-personal health services they
need, with social health protection. Whether the
arrangements for universal coverage are taxbased
or are organized through social health
insurance, or a mix of both, the principles are
the same: pooling pre-paid contributions collected
on the basis of ability to pay, and using
these funds to ensure that services are available,
accessible and produce quality care for those who
need them, without exposing them to the risk of
catastrophic expenditures14,15,16. Universal coverage
is not, by itself, suffi cient to ensure health
for all and health equity – inequalities persist in
countries with universal or near-universal coverage
– but it provides the necessary foundation9.
While universal coverage is fundamental to
building health equity, it has rarely been the object
of an easy social consensus. Indeed, in countries
where universal coverage has been achieved or
embraced as a political goal, the idea has often
met with strong initial resistance, for example,
from associations of medical professionals concerned
about the impact of government-managed
health insurance schemes on their incomes and
working conditions, or from fi nancial experts
determined to rein in public spending. As with
other entitlements that are now taken for granted
in almost all high-income countries, universal
health coverage has generally been struggled for
and won by social movements, not spontaneously
bestowed by political leaders. There is now widespread
consensus that providing such coverage is
simply part of the package of core obligations that
any legitimate government must fulfi l vis-à-vis its
citizens. In itself, this is a political achievement
that shapes the modernization of society.
Industrialized countries, particularly in
Europe, began to put social health protection
schemes in place in the late 19th century, moving
towards universalism in the second half of
the 20th century. The opportunity now exists for
low- and middle-income countries to implement
comparable approaches. Costa Rica, Mexico,
the Rebublic of Korea, Thailand and Turkey are
among the countries that have already introduced
ambitious universal coverage schemes, moving
signifi cantly faster than industrialized countries
did in the past. Other countries are weighing similar
options14. The technical challenge of moving
towards universal coverage is to expand coverage
in three ways (Figure 2.2).
The breadth of coverage – the proportion of
the population that enjoys social health protection
– must expand progressively to encompass
The World Health Report 2008 Primary Health Care – Now More Than Ever
26
the uninsured, i.e. the population groups that
lack access to services and/or social protection
against the fi nancial consequences of taking up
health care. Expanding the breadth of coverage
is a complex process of progressive expansion
and merging of coverage models (Box 2.1). During
this process, care must be taken to ensure
safety nets for the poorest and most vulnerable
until they also are covered. It may take years to
cover the entire population but, as recent experience
from a number of middle-income countries
shows, it is possible to move much faster than
was the case for industrialized countries during
the 20th century.
Meanwhile, the depth of coverage must also
grow, expanding the range of essential services
that are necessary to address people’s health
needs effectively, taking into account demand and
expectations, and the resources society is willing
and able to allocate to health. The determination
of the corresponding “essential package” of benefi
ts can play a key role here, provided the process
is conducted appropriately (Box 2.2).
The third dimension, the height of coverage,
i.e. the portion of health-care costs covered
through pooling and pre-payment mechanisms
must also rise, diminishing reliance on out-ofpocket
co-payments at the point of service delivery.
In the 1980s and 1990s, many countries
introduced user fees in an effort to infuse new
resources into struggling services, often in a
context of disengagement of the state and dwindling
public resources for health. Most undertook
these measures without anticipating the extent
of the damage they would do. In many settings,
dramatic declines in service use ensued, particularly
among vulnerable groups20, while the
frequency of catastrophic expenditure increased.
Some countries have since reconsidered their
position and have started phasing out user fees
and replacing the lost income from pooled funds
(government subsidies or contracts, insurance
Box 2.1 Best practices in moving towards universal coverage
Emphasize pre-payment from the start. It may take many years before access to health services and fi nancial protection against the
costs involved in their use are available for all: it took Japan and the United Kingdom 36 years14. The road may seem discouragingly long,
particularly for the poorest countries, where health-care networks are sparsely developed, fi nancial protection schemes embryonic and
the health sector highly dependent on external funds. Particularly in these countries, however, it is crucial to move towards pre-payment
systems from a very early stage and to resist the temptation to rely on user fees. Setting up and maintaining appropriate mechanisms
for pre-payment builds the institutional capacity to manage the fi nancing of the system along with the extension of service supply that
is usually lacking in such contexts.
Coordinate funding sources. In order to organize universal coverage, it is necessary to consider all sources of funding in a country:
public, private, external and domestic. In low-income countries, it is particularly important that international funding be channelled
through nascent pre-payment and pooling schemes and institutions rather than through project or programme funding. Routing funds in
this way has two purposes. It makes external funding more stable and predictable and helps build the institutional capacity to develop
and extend supply, access and fi nancial protection in a balanced way.
Combine schemes to build towards full coverage. Many countries with limited resources and administrative capacity have experimented
with a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes, as a
way to foster pre-payment and pooling in preparation for the move towards more comprehensive national systems18. Such schemes are
no substitute for universal coverage although they can become building blocks of the universal system18. Realizing universal coverage
means coordinating or combining these schemes progressively into a coherent whole that ensures coverage to all population groups15
and builds bridges with broader social protection programmes19.
Figure 2.2 Three ways of moving towards universal coverage17
Height:
what
proportion
of the costs
is covered?
Depth:
which benefits
Breadth: who is insured? are covered?
Include
other
services
Extend to
uninsured
Reduce
cost sharing
Public expenditure
on health
Total health expenditure
27
Chapter 2. Advancing and sustaining universal coverage
or pre-payment schemes)21. This has resulted
in substantial increases in the use of services,
especially by the poor20. In Uganda, for example,
service use increased suddenly and dramatically
and the increase was sustained after the elimination
of user fees (Figure 2.3)22,23.
Pre-payment and pooling institutionalizes
solidarity between the rich and the less well-off,
and between the healthy and the sick. It lifts barriers
to the uptake of services and reduces the
risk that people will incur catastrophic expenses
when they are sick. Finally, it provides the means
to re-invest in the availability, range and quality
of services.
Challenges in moving
towards universal coverage
All universal coverage reforms have to fi nd compromises
between the speed with which they
increase coverage and the breadth, depth and
height of coverage. However, the way countries
devise their strategies and focus their reforms
very much depends on their specifi c national
contexts.
In some countries, a very large part of the population
lives in extremely deprived areas, with
an absent or dysfunctional health-care infrastructure.
These are countries of mass exclusion
typically brought to mind when one talks
about “scaling up”: the poor and remote rural
areas where health-care networks have not been
deployed yet or where, after years of neglect, the
health infrastructure continues to exist in name
only. Such patterns occur in low-income countries
Box 2.2 Defi ning “essential packages”:
what needs to be done to go beyond a paper exercise?
In recent years, many low- and midde-income countries (55 out of a sample of 69 reviewed in 2007) have gone through exercises to
defi ne the package of benefi ts they feel should be available to all their citizens. This has been one of the key strategies in improving the
effectiveness of health systems and the equitable distribution of resources. It is supposed to make priority setting, rationing of care,
and trade-offs between breadth and depth of coverage explicit.
On the whole, attempts to rationalize service delivery by defi ning packages have not been particularly successful24. In most cases, their
scope has been limited to maternal and child health care, and to health problems considered as global health priorities. The lack of
attention, for example, to chronic and noncommunicable diseases confi rms the under-valuation of the demographic and epidemiological
transitions and the lack of consideration for perceived needs and demand. The packages rarely give guidance on the division of tasks
and responsibilities, or on the defi ning features of primary care, such as comprehensiveness, continuity or person-centredness.
A more sophisticated approach is required to make the defi nition of benefi t packages more relevant. The way Chile has provided a
detailed specifi cation of the health rights of its citizens25 suggests a number of principles of good practice.
The exercise should not be limited to a set of predefi ned priorities: it should look at demand as well �� as at the full range of health
needs.
�� It should specify what should be provided at primary and secondary levels.
�� The implementation of the package should be costed so that political decision-makers are aware of what will not be included if
health care remains under-funded.
�� There have to be institutionalized mechanisms for evidence-based review of the package of benefi ts.
�� People need to be informed about the benefi ts they can claim, with mechanisms of mediation when claims are being denied. Chile
went to great lengths to ensure that the package of benefi ts corresponds to people’s expectations, with studies, surveys and systems
to capture the complaints and misgivings of users26.
Outpatients per month
1998
Figure 2.3 Impact of abolishing user fees on outpatient attendance in
Kisoro district, Uganda: outpatient attendance 1998–200223
10 000
0
20 000
30 000
User fees abolished
1999 2000 2001 2002
The World Health Report 2008 Primary Health Care – Now More Than Ever
28
such as Bangladesh, Chad and Niger (Figure 2.4),
and are common in confl ict and post-confl ict
areas where health workers have departed and
the health infrastructure has been destroyed and
needs to be rebuilt from scratch.
In other parts of the world, the challenge is
in providing health support to widely dispersed
populations, for example, in small island states,
remote desert or mountainous regions, and
among nomadic and some indigenous populations.
Ensuring access to quality care in these
settings entails grappling with the diseconomies
of scale connected with small, scattered populations;
logistical constraints on referral; diffi culties
linked to limited infrastructure and communications
capacities; and, in some cases, more specifi c
technical complications, such as maintaining
patient records for nomadic groups.
A different challenge is extending coverage in
settings where inequalities do not result from the
lack of available health infrastructure, but from
the way health care is organized, regulated and,
above all, paid for by offi cial or under-the-counter
user charges. These are situations where underutilization
of available services is concentrated
among the poor, whereas users are exposed to
the risks of catastrophic expenditure. Such patterns
of exclusion occur in countries such as
Colombia, Nicaragua and Turkey (Figure 2.4). It
is particularly striking in the many urban areas
of low- and middle-income countries where a
plethora of assorted, unregulated, commercial
health-care providers charge users prohibitive
fees while providing inadequate services.
Ways of tackling the situations described in
this section are elaborated below.
Rolling out primary-care networks to
fi ll the availability gap
In areas where no health services are available
for large population groups, or where such services
are grossly inadequate or fragmented, the
basic health-care infrastructure needs to be built
or rebuilt, often from the ground up. These areas
are always severely resource-constrained and
frequently affected by confl icts or complex emergencies,
while the scale of under-servicing, also
in other sectors, engenders logistical diffi culties
and problems in deploying health professionals.
Health planners in these settings face a fundamental
strategic dilemma: whether to prioritize a
massive scale-up of a limited set of interventions
to the entire population or a progressive roll-out
of more comprehensive primary-care systems on
a district-by-district basis.
Some would advocate, in the name of speed
and equity, an approach in which a restricted
number of priority programmes is rolled out
simultaneously to all the inhabitants in the
deprived areas. This allows for task shifting to
low-skilled personnel, lay workers and volunteers
and, consequently, rapid extension of coverage.
It is still central to what the global community
often prescribes for the rural areas of the poorest
countries28, and quite a number of countries
have chosen this option over the last 30 years.
Ethiopia, for example, is currently deploying
30 000 health extension workers to provide massive
numbers of people with a limited package
of priority preventive interventions. The poor
skills base is often well recognized as a limiting
factor29, but Ethiopia’s extension workers are
no longer as low skilled as they once were, and
currently benefi t from a year of post-Grade 10
training. Nevertheless, skill limitations reinforce
the focus on a limited number of effective but
simple interventions.
Scaling up a limited number of interventions
has the advantage of rapidly covering the entire
population and focusing resources on what is
known to be cost effective. The downside is that
Quintille 1
(lowest)
Figure 2.4 Different patterns of exclusion: massive deprivation in some
countries, marginalization of the poor in others. Births attended by medically
trained personnel (percentage), by income group27
100
80
60
40
20
0
Quintille 2 Quintille 3 Quintille 4 Quintille 5
(highest)
Turkey (1998)
Colombia (2005)
Nigaragua (2001)
Niger (1998)
Chad (2004)
Bangladesh (2004)
29
Chapter 2. Advancing and sustaining universal coverage
when people experience health problems, they
want them to be dealt with, whether or not they
fi t nicely within the programmatic priorities that
are being proposed. Ignoring this dimension of
demand too much opens the door to “drug peddlers”,
“injectors” and other types of providers,
who can capitalize on commercial opportunities
arising from unmet health needs. They offer
patients an appealing alternative, but one that is
often exploitative and harmful. Compared with
a situation of utter lack of health action, there
is an indisputable benefi t in scaling up even a
very limited package of interventions and the
possibility of relying on low-skilled staff makes
it an attractive option. However, upgrading often
proves more diffi cult than initially envisaged30
and, in the meantime, valuable time, resources
and credibility are lost which might have allowed
for investment in a more ambitious, but also
more sustainable and effective primary-care
infrastructure.
The alternative is a progressive roll-out of
primary care, district-by-district, of a network
of health centres with the necessary hospital
support. Such a response obviously includes the
priority interventions, but integrated in a comprehensive
primary-care package. The extension
platform is the primary-care centre: a professionalized
infrastructure where the interface with the
community is organized, with a problem solving
capacity and modular expansion of the range of
activities. The Islamic Republic of Iran’s progressive
roll-out of rural coverage is an impressive
example of this model. As one of the fathers of
the country’s PHC strategy put it: “Since it was
impossible to launch the project in all provinces
at the same time, we decided to focus on a single
province each year” (Box 2.3).
The limiting factors for a progressive roll-out
of primary-care networks are the lack of a stable
cadre of mid-level staff with the leadership
qualities to organize health districts and with the
ability to maintain, over the years, the constant
effort required to build sustainable results for the
entire population. Where the roll-out has been
conducted as an administrative exercise, it has
led to disappointment: many health districts exist
in name only. But where impatience and pressure
for short-term visibility has been managed
Box 2.3 Closing the urban-rural gap through
progressive expansion of PHC coverage in rural
areas in the Islamic Republic of Iran31
In the 1970s, the Iranian Government’s policies emphasized prevention
as a long-term investment, allocation of resources to rural and
under-privileged areas, and prioritizing ambulatory care over hospitalization.
A network of district teams to manage and oversee almost 2500
village-based rural health centres was established. These centres are
staffed by a team that includes a general practitioner, midwife, nurse and
several health technicians. Each of the rural health centres oversees 1–5
smaller points of care known as “health houses”. With 17 000 of these
health houses, over 90% of the rural population has access to health
care. In remote rural areas, these health houses are staffed by Behvarz
(multi-purpose health workers) who are selected by the community,
receive between 12 and 18 months training and are then recruited by
the Government. The district teams provide training based on problemsolving,
as well as ongoing supervision and support.
The Government deployed this strategy progressively, extending coverage
to one province at a time. Over the years, the PHC network has grown
and is now able to provide services to over 24 million people in rural
villages and small cities by bringing the points of care closer to where
people live and work, as well as by training the necessary auxiliary health
staff to provide family planning, preventive care services, and essential
curative care for the majority of health problems. Rural health service
utilization rates are now the same as in urban areas. The progressive
roll-out of this system has helped to reduce the urban-rural gap in child
mortality (Figure 2.5).
Mortality per 1000 children under five
1980
Figure 2.5 Under-five mortality in rural and urban areas, the Islamic Republic
of Iran, 1980–200032
80
Urban
60
40
20
0
Rural
1985 1990 1995 2000
adequately, a blend of response to need and
demand, and participation of the population and
key actors has made it possible to build robust
primary-care networks, even in very diffi cult and
resource-constrained settings of confl ict, and
post-confl ict environments (Box 2.4).
The World Health Report 2008 Primary Health Care – Now More Than Ever
30
The distinction between rapid deployment of
priority interventions and progressive roll-out of
primary-care networks is, in practice, often not
as straightforward as described above. However,
for all the convergence, trying to balance speed
and sustainability is a real political dilemma30.
Mali, among others, has shown that, given the
choice, people willingly opt for progressive rollout,
making community health centres – whose
infrastructure is owned and personnel employed
by the local community – the basis of functional
health districts.
Crucially, concern for equity should not be
translated into a “lowest common denominator”
approach: equal access for all to a set of largely
unsatisfactory services. Quality and sustainability
are important, particularly since nowadays
the multitude of varied and dynamic governmental,
not-for-profi t and for-profi t private providers
of various kinds are in dire need of alignment.
Progressive roll-out of health services provides
the opportunity to establish welcome leadership
coherence in health-care provision at district level.
Typical large-scale examples of this approach
in developing countries are the contracting out
of district health services in Cambodia, or the
incorporation of missionary “designated district
hospitals” in East Africa. Nevertheless, there is
no getting away from the need for massive and
sustained investment to expand and maintain
health districts in the long term and from the
fact that this represents a considerable challenge
in a context of sluggish economic growth and
stagnating health expenditure.
Extending health-care networks to underserved
areas depends on public initiative and
incentives. One way to accelerate the extension
of coverage is to adjust budget allocation formulae
(or contract specifi cations) to refl ect the
extra efforts required to contact hard-to-reach
populations. Several countries have taken steps in
this direction. In January 2004, for example, the
United Republic of Tanzania adopted a revised
formula for the allocation of basket funds to districts
that includes population size and underfi
ve mortality as a proxy for disease burden and
poverty level, while adjusting for the differential
costs of providing health services in rural and
low-density areas. Similarly, allocations to districts
under Uganda’s PHC budget factor in the
districts’ Human Development Index and levels
of external health funding, in addition to population
size. Supplements are paid to districts with
diffi cult security situations or lacking a district
hospital20. In Chile, budgets are allocated on a
capitation basis but, as part of the PHC reforms,
these were adjusted using municipal human
development indices and a factor to refl ect the
isolation of underserved areas.
Overcoming the isolation of
dispersed populations
Although providing access to services for dispersed
populations is often a daunting logistical
challenge, some countries have dealt with
it by developing creative approaches. Devising
mechanisms to share innovative experiences and
results has clearly been a key step, for example,
through the “Healthy Islands” initiative, launched
at the meeting of Ministers and Heads of Health
in Yanuca, Fiji, in 199534. The initiative brings
together health policy-makers and practitioners
to address challenges to islanders’ health and
well-being from an explicitly multi-sectoral perspective,
with a focus on expanding coverage of
curative health-care services, but also reinforcing
promotive strategies and cross-sectoral action on
the determinants of health and health equity.
Through the Healthy Islands initiative and
related experiences, a number of principles have
emerged as crucial to the advancement of universal
coverage in these settings. The fi rst concerns
collaboration in organizing infrastructure that
maximizes scales of effi ciency. An isolated community
may be unable to afford key inputs to
expand coverage, which includes infrastructure,
technologies and human resources (particularly
the training of personnel). However, when communities
join forces, they can secure such inputs
at manageable costs35. A second strategic focus is
on “mobile resources” or those that can overcome
distance and geographical obstacles effi ciently
and affordably. Depending on the setting, this
strategic focus may include transportation, radio
communications, and other information and communications
technologies. Telecommunications
31
Chapter 2. Advancing and sustaining universal coverage
Rutshuru is a health district in the east of the country. It has a
network of health centres, a referral hospital and a district management
team where community participation has been fostered
for years through local committees. Rutshuru has experienced
severe stress over the years, testing the robustness of the district
health system.
Over the last 30 years, the economy of the country has gone
into a sharp decline. GDP dropped from US$ 300 per capita in
the 1980s to below US$ 100 at the end of the 1990s. Massive
impoverishment was made worse as the State retreated from the
health sector. This was compounded by an interruption of overseas
development aid in the early 1990s. In that context, Rutshuru
suffered inter-ethnic strife, a massive infl ux of refugees and two
successive wars. This complex of disasters severely affected the
working conditions of health professionals and access to health
services for the 200 000 people living in the district.
Nevertheless, instead of
collapsing, PHC services
continued their expansion
over the years. The
number of health centres
and their output increased
(Figure 2.6), and quality
of care improved for
acute cases (case-fatality
rate after caesarean section
dropped from 7% to
less than 3%) as well as
for chronic patients (at
least 60% of tuberculosis
patients were treated
successfully). With no
more than 70 nurses and
three medical doctors at
a time, and in the midst
of war and havoc, the
Box 2.4 The robustness of PHC-led health systems: 20 years of expanding performance in
Rutshuru, the Democratic Republic of the Congo
health centres and the district hospital took care of more than
1 500 000 disease episodes in 20 years, immunized more than
100 000 infants, provided midwifery care to 70 000 women and
carried out 8 000 surgical procedures. This shows that, even in
disastrous circumstances, a robust district health system can
improve health-care outputs.
These results were achieved with modest means. Out-of-pocket
payments amounted to US$ 0.5 per capita per year. Nongovernmental
organizations subsidized the district with an average of US$
1.5 per capita per year. The Government’s contribution was virtually
nil during most of these 20 years. The continuity of the work
under extremely diffi cult circumstances can be explained by team
work and collegial decision-making, unrelenting efforts to build up
and maintain a critical mass of dedicated human resources, and
limited but constant nongovernmental support, which provided a
minimum of resources for health facilities and gave the district
management team the opportunity to maintain contact with the
outside world.
Three lessons can be learnt
from this experience. In
the long run, PHC-led
health districts are an
organizational model that
has the robustness to
resist extremely adverse
conditions. Maintaining
minimal fi nancial support
and supervision to such
districts can yield very
significant results, while
empowering and retaining
national health professionals.
Local health services
have a considerable
potential for coping with
crises33.
1985
Figure 2.6 Improving health-care outputs in the midst of disaster:
Rutshuru, the Democratic Republic of the Congo, 1985–200433
100
70
50
20
0
External aid
90 interrupted
80
60
40
30
10
1990 1995 2000
Refugee
crisis
First
War
Second
War
Coverage DPT3 vaccination (%)
Birth attended by medically
trained personnel (%)
New cases curative care
per 100 inhabitants per year
can enable less skilled frontline health-centre
staff to be advised and guided by experts at a
distance in real time36. Finally, the fi nancing
of health care for dispersed populations poses
specifi c challenges, which often require larger
per capita expenditure compared to more clustered
populations. In countries whose territories
include both high-density and low-density populations,
it is expected that dispersed populations
will receive some subsidy of care. After all, equity
does not come without solidarity.
Providing alternatives to
unregulated commercial services
In urban and periurban contexts, health services
are physically within reach of the poor and other
vulnerable populations. The presence of multiple
health-care providers does not mean, however,
that these groups are protected from diseases,
nor that they can get quality care when they need
it: the more privileged tend to get better access to
the best services, public and private, easily coming
out on top in a de facto competition for scarce
The World Health Report 2008 Primary Health Care – Now More Than Ever
32
resources. In the urban and increasingly in the
rural areas of many low- and middle-income
countries – from India and Viet Nam to sub-
Saharan Africa – much health care for the poor
is provided by small-scale, largely unregulated
and often unlicenced providers, both commercial
and not-for-profi t. Often, they work alongside
dysfunctional public services and capture
an overwhelmingly large part of the health-care
market, while the health promotion and prevention
agenda is totally ignored. Vested interests
make the promotion of universal coverage paradoxically
more diffi cult in these circumstances
than in areas where the challenge is to build
health-care delivery networks from scratch.
These contexts often combine problems of fi nancial
exploitation, bad quality and unsafe care, and
exclusion from needed services37,38,39,40,41,42,43,44,45.46.
The Pan American Health Organization (PAHO)
has estimated that 47% of Latin America’s population
is excluded from needed services47. This
may be for broader reasons of poverty, ethnicity
or gender, or because the resources of the
health system are not correctly targeted. It may
be because there are no adequate systems to protect
people against catastrophic expenditure or
from fi nancial exploitation by unscrupulous or
insensitive providers. It may have to do with the
way people, rightly or wrongly, perceive health
services: lack of trust, the expectation of ill-treatment
or discrimination, uncertainty about the
cost-of-care, or the anticipation that the cost will
be unaffordable or catastrophic. Services may
also be untimely, ineffective, unresponsive or
plain discriminatory, providing poorer patients
with inferior treatment48,49,21. As a result, health
outcomes vary considerably by social class, even
in well-regulated and well-funded health-care
systems.
In addressing these patterns of exclusion
within the health-care sector, the starting point
is to create or strengthen networks of accessible
quality primary-care services that rely on pooled
pre-payment or public resources for their funding.
Whether these networks are expanded by
contracting commercial or not-for-profi t providers,
or by revitalizing dysfunctional public facilities
is not the critical issue. The point is to ensure
that they offer care of an acceptable standard. A
critical mass of primary-care centres that provide
an essential package of quality services free-ofcharge,
provides an important alternative to substandard,
exploitative commercial care. Furthermore,
peer pressure and consumer demand can
help to create an environment in which regulation
of the commercial sector becomes possible.
More active involvement of municipal authorities
in pre-payment and pooling schemes to improve
the supply of quality care is probably one of the
avenues to follow, particularly where ministries
of health with budgetary constraints also have to
extend services to underserved rural areas.
Targeted interventions to
complement universal coverage
mechanisms
Rising average national income, a growing supply
of health-care providers and accelerated progress
towards universal coverage are, unfortunately, not
suffi cient to eliminate health inequities. Socially
determined health differences among population
groups persist in high-income countries with
robust, universal health-care and social-service
systems, such as Finland and France11,50. Health
inequalities do not just exist between the poor and
the non-poor, but across the entire socioeconomic
gradient. There are circumstances where other
forms of exclusion are of prime concern, including
the exclusion of adolescents, ethnic groups,
drug users and those affected by stigmatizing
diseases51. In Australia, Canada and New Zealand,
among others, health equity gaps between
Aboriginal and non-Aboriginal populations have
emerged as national political issues52,53,54. In other
settings, inequalities in women’s access to health
care merit attention55. In the United States, for
example, declines in female life expectancy of up
to fi ve years in over 1000 counties point to differential
exposure and clustering of risks to health
even as the country’s economy and health sector
continues to grow56. For a variety of reasons,
some groups within these societies are either not
reached or insuffi ciently reached by opportunities
for health or services and continue to experience
health outcomes systematically inferior to those
of more advantaged groups.
33
Chapter 2. Advancing and sustaining universal coverage
Thus, it is necessary to embed universal coverage
in wider social protection schemes and to
complement it with specially designed, targeted
forms of outreach to vulnerable and excluded
groups57. Established health-care networks often
do not make all possible efforts to ensure that
everyone in their target population has access
to the full range of health benefi ts they need, as
this requires extra efforts, such as home visits,
outreach services, specialized language and
cultural facilitation, evening consultations, etc.
These may, however, mitigate the effect of social
stratifi cation and inequalities in the uptake of
services58. They may also offer the opportunity
to construct comprehensive support packages to
foster social inclusion of historically marginalized
populations, in collaboration with other government
sectors and with affected communities.
Chile’s Chile Solidario (Chilean Solidarity) model
of outreach to families in long-term poverty is one
example (Box 2.5)59. Such targeted measures may
include subsidizing people – not services – to take
up specifi c health services, for example, through
vouchers60,61 for maternal care as in India and
Yemen, for bednets as in the United Republic of
Tanzania62,63, for contraceptive uptake by adolescents64
or care for the elderly uninsured as in
the United States65. Conditional cash transfers,
where the benefi ciary is not only enabled, but
compelled to take up services is another model,
which has been introduced in several countries in
Latin America. A recent systematic review of six
such programmes suggests that conditional cash
transfers can be effective in increasing the use of
preventive services and improving nutritional and
anthropometric outcomes, sometimes improving
health status66. However, their overall effect on
health status remains less clear and so does their
comparative advantage over traditional, unconditional,
income maintenance, through universal
entitlements, social insurance or – less-effective
– means-tested social assistance.
Targeted measures are not substitutes for the
long-term drive towards universal coverage. They
can be useful and necessary complements, but
without simultaneous institutionalization of the
fi nancing models and system structures that support
universal coverage, targeted approaches are
unlikely to overcome the inequalities generated
by socioeconomic stratifi cation and exclusion.
This is all the more important since systematic
evaluation of methods to target the excluded is
scarce and marred by the limited number of
documented experiences and a bias towards
reporting preferentially on successful pilots67. If
anything defi nite can be said today, it is that the
strategies for reaching the unreached will have
to be multiple and contextualized, and that no
single targeting measure will suffi ce to correct
health inequalities effectively, certainly not in the
absence of a universal coverage policy.
Box 2.5 Targeting social protection in Chile59
Established by law, the Chilean social protection programme (Chile Solidario) involves three main components to improve conditions for
people living in extreme poverty: direct psycho-social support, fi nancial support and priority access to social programmes. The direct
psycho-social support component involves families in extreme poverty being identifi ed according to pre-defi ned criteria and invited to
enter into an agreement with a designated social worker. The social worker assists them to build individual and family capacities that
help them to strengthen their links with social networks and to gain access to the social benefi ts to which they are entitled. In addition
to psycho-social support, there is also fi nancial support in terms of cash transfers and pensions, as well as subsidies for raising
families or covering water and sanitation costs. Finally, the social protection programme also provides preferential access to pre-school
programmes, adult literacy courses, employment programmes and preventive health visits for women and children.
This social protection programme complements a multisectoral effort targeting all children aged 0–18 years (Chile Crece Contigo – Chile
Grows with You). The aim is to promote early childhood development through pre-school education programmes, preventive health
checks, improved parental leave and increased child benefi ts. Better access to child-care services is also included as is enforcing the
right of working mothers to nurse their babies, which is designed to stimulate women’s insertion into the employment market.
The World Health Report 2008 Primary Health Care – Now More Than Ever
34
Mobilizing for health equity
Health systems are invariably inequitable. More
and higher quality services gravitate to the
well-off who need them less than the poor and
marginalized8. The universal coverage reforms
required to move towards greater equity demand
the enduring commitment of the highest political
levels of society. Two levers may be especially
important in accelerating action on health equity
and maintaining momentum over time. The fi rst
is raising the visibility of health inequities in public
awareness and policy debates: the history of
progress in the health of populations is intimately
linked to the measurement of health inequalities.
It was the observation of excess mortality among
the working class that informed the “Great Sanitary
Awakening” reforms of the Poor Laws Commission
in the United Kingdom in the 1830s68. The
second is the creation of space for civil society
participation in shaping the PHC reforms that are
to advance health equity: the history of progress
in universal coverage is intimately linked to that
of social movements.
Increasing the visibility of
health inequities
With the economic optimism of the 1960s and
1970s (and the expansion of social insurance in
industrialized countries), poverty ceased being
a priority issue for many policy-makers. It took
Alma-Ata to put equity back on the political
agenda. The lack of systematic measurement and
monitoring to translate this agenda into concrete
challenges has long been a major constraint in
advancing the PHC agenda. In recent years,
income-related and other health inequalities have
been studied in greater depth. The introduction of
composite asset indices has made it possible to reanalyze
demographic and health surveys from an
equity viewpoint69. This has generated a wealth
of documentary evidence on socioeconomic differentials
in health outcomes and access to care.
It took this acceleration of the measurement of
poverty and inequalities, particularly since the
mid-1990s, to bring fi rst poverty and then, more
generally, the challenge of persisting inequalities
to the centre of the health policy debate.
Measurement of health inequities is paramount
when confronting the common misperceptions
that strongly infl uence health policy
debates70,71.
Simple population averages �� are suffi cient to
assess progress – they are not.
�� Health systems designed for universal access
are equitable – they are a necessary, but not
a suffi cient condition.
�� In poor countries, everybody is equally poor
and equally unhealthy – all societies are
stratifi ed.
�� The main concern is between countries’ differences
– inequalities within countries matter
most to people.
�� Well-intended reforms to improve effi ciency
will ultimately benefi t everybody – they often
have unintended inequitable consequences.
Measurement mat ters for a variety of
reasons2.
�� It is important to know the extent and understand
the nature of health inequalities and
exclusion in a given society, so as to be able
to share that information and translate it into
objectives for change.
�� It is equally important, for the same reasons,
to identify and understand the determinants
of health inequality not only in general terms,
but also within each specifi c national context.
Health authorities must be informed of the
extent to which current or planned health
policies contribute to inequalities, so as to be
able to correct them.
�� Progress with reforms designed to reduce
health inequalities, i.e. progress in moving
towards universal coverage, needs to be monitored,
so as to steer and correct these reforms
as they unfold.
Despite policy-makers’ long-held commitment to
the value of equity in health, its defi nition and
measurement represent a more recent public
health science. Unless health information systems
collect data using standardized social stratifi ers,
such as socioeconomic status, gender, ethnicity
and geographical area, it is diffi cult to identify
and locate inequalities and, unless their magnitude
and nature are uncovered, it is unlikely
that they will be adequately addressed72. The
now widely available analyses of Demographic
and Health Survey (DHS) data by asset quintiles
35
Chapter 2. Advancing and sustaining universal coverage
have made a major difference in the awareness
of policy-makers about health equity problems
in their countries. There are also examples of
how domestic capacities and capabilities can be
strengthened to better understand and manage
equity problems. For example, Chile has recently
embarked on integrating health sector information
systems in order to have more comprehensive
information on determinants and to improve
the ability to disaggregate information according
to socioeconomic groups. Indonesia has added
health modules to household expenditure and
demographic surveys. Building in capabilities,
across administrative database systems, to link
health and socioeconomic data through unique
identifi ers (national insurance numbers or census
geo-codes) is key to socioeconomic stratifi cation
and provides information that is usually inaccessible.
However, this is more than a technical
challenge. Measuring health systems’ progress
towards equity requires an explicit deliberative
process to identify what constitutes a fair distribution
of health against shortfalls and gaps that
can be measured73. It relies on the development
of institutional collaboration between multiple
stakeholders to ensure that measurement and
monitoring translates into concrete political proposals
for better equity and solidarity.
Creating space for civil society
participation and empowerment
Knowledge about health inequalities can only
be translated into political proposals if there is
organized social demand. Demand from the communities
that bear the burden of existing inequities
and other concerned groups in civil society
are among the most powerful motors driving
universal coverage reforms and efforts to reach
the unreached and the excluded.
The amount of grassroots advocacy to improve
the health and welfare of populations in need has
grown enormously in the last 30 years, mostly
within countries, but also globally. There are
now thousands of groups around the world, large
and small, local and global, calling for action to
improve the health of particularly deprived social
groups or those suffering from specifi c health
conditions. These groups, which were virtually
non-existent in the days of the Alma-Ata,
constitute a powerful voice of collective action.
Box 2.6 Social policy in the city of
Ghent, Belgium: how local authorities
can support intersectoral collaboration
between health and welfare
organizations76
In 2004, a regional government decree in Flanders, Belgium,
institutionalized the direct participation of local stakeholders
and citizens in intersectoral collaboration on social rights. This
now applies at the level of cities and villages in the region. In
one of these cities, Ghent, some 450 local actors of the health
and welfare sector have been clustered in 11 thematic forums:
legal help; support and security of minors; services for young
people and adolescents; child care; ethnic cultural minorities;
people with a handicap; the elderly; housing; work and employment;
people living on a “critical income”; and health.
The local authorities facilitate and support the collaboration
of the various organizations and sectors, for example, through
the collection and monitoring of data, information and communication,
access to services, and efforts to make services
more pro-active. They are also responsible for networking
between all the sectors with a view to improving coordination.
They pick up the signals, bottlenecks, proposals and plans,
and are responsible for channelling them, if appropriate, to
the province, region, federal state or the European Union for
translation into relevant political decisions and legislation.
A steering committee reports directly to the city council and
integrates the work of the 11 forums. The support of the administration
and a permanent working party is critical for the
sustainability and quality of the work in the different groups.
Participation of all stakeholders is particularly prominent in
the health forum: it includes local hospitals, family physicians,
primary-care services, pharmacists, mental health facilities,
self-help groups, home care, health promotion agencies,
academia sector, psychiatric home care, and community
health centres.
This complex web of collaboration is showing results. Intersectoral
coordination contributes to a more effi cient local social
policy. For the period 2008–2013, four priority themes have
been identifi ed in a bottom-up process: sustainable housing,
access to health care, reduced thresholds to social rights, and
optimization of growth and development. The yearly action plan
operationalizes the policy through improvement projects in
areas that include fi nancial access to health care, educational
support, care for the homeless, and affordable and fl exible
child care. Among the concrete realizations is the creation
of Ghent’s “social house”, a network of service entry points
situated in the different neighbourhoods of the city, where
delivery of primary care is organized with special attention
to the most vulnerable groups of people. The participating
organizations report that the creation of the sectoral forums,
in conjunction with the organization of intersectoral cooperation,
has signifi cantly improved the way social determinants
of health are tackled in the city.
The World Health Report 2008 Primary Health Care – Now More Than Ever
36
The mobilization of groups and communities
to address what they consider to be their most
important health problems and health-related
inequalities is a necessary complement to the
more technocratic and top-down approach to
assessing social inequalities and determining
priorities for action.
Many of these groups have become capable
lobbyists, for example, by gaining access to HIV/
AIDS treatment, abolishing user fees and promoting
universal coverage. However, these achievements
should not mask the contributions that the
direct engagement of affected communities and
civil society organizations can have in eliminating
sources of exclusion within local health services.
Costa Rica’s “bias-free framework” is one
example among many. It has been used successfully
to foster dialogue with and among members
of vulnerable communities by uncovering local
practices of exclusion and barriers to access not
readily perceived by providers and by spurring
action to address the underlying causes of illhealth.
Concrete results, such as the reorganization
of a maternity hospital around the people’s
needs and expectations can transcend the local
dimension, as was the case in Costa Rica when
local reorganization was used as a template for
a national effort74.
However, there is much the health system itself
can do to mitigate the effects of social inequities
and promote fairer access to health services at
local level. Social participation in health action
becomes a reality at the local level and, at times,
it is there that intersectoral action most effectively
engages the material and social factors that shape
people’s health prospects, widening or reducing
health equity gaps. One such example is the
Health Action Zones in the United Kingdom, which
were partner-based entities whose mission was to
improve the well-being of disadvantaged groups.
Another example is the work of the municipality
of Barcelona, in Spain, where a set of interventions,
including the reform of primary care, was
followed by health improvements in a number of
disadvantaged groups, showing that local governments
can help reduce health inequities75.
Local action can also be the starting point for
broader structural changes, if it feeds into relevant
political decisions and legislation (Box 2.6).
Local health services have a critical role to play
in this regard, as it is at this level that universal
coverage and service delivery reforms meet. Primary
care is the way of organizing health-care
delivery that is best geared not only to improving
health equity, but also to meeting people’s other
basic needs and expectations.
37
Chapter 2. Advancing and sustaining universal coverage
References
Houston S. Matt Anderson’s 1939 health plan: how effective a 1. nd how economical?
Saskatchewan History, 2005, 57:4–14
2. Xu K et al. Protecting households from catastrophic health spending,
Health Affairs,
2007, 26:972–983.
3. A conceptual framework for action on the social determinants of health; discussion
paper for the Commission on Social Determinants for Health. Geneva, World
Health Organization, 2007 (http://www.who.int/social_determinants/resources/
csdh_framework_action_05_07.pdf, accessed 19 July 2008)
4. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in
health: levelling up part 1. Copenhagen, World Health Organization Regional Offi ce
for Europe, 2006 (Studies on Social and Economic Determinants of Population
Health No. 2; http://www.euro.who.int/document/e89383.pdf, accessed 15 July
2008).
5. Adler N, Stewart J. Reaching for a healthier life. Facts on socioeconomic status and
health in the US. Chicago, JD and CT MacArthur Foundation Research Network on
Socioeconomic Status and Health, 2007.
6. Dans A et al. Assessing equity in clinical practice guidelines. Journal of Clinical
Epidemiology, 2007, 60:540–546.
7. Hart JT. The inverse care law. Lancet, 1971, 1:405–412.
8. Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable.
Lancet, 2004, 364:1273–1280.
9. Gilson L, McIntyre D. Post-apartheid challenges: household access and use of care.
International Journal of Health Services, 2007, 37:673–691.
10. 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.
11. Mackenbach JP et al. Strategies to reduce socioeconomic inequalities in health.
In: Mackenbach JP, Bakker M, eds. Reducing inequalities in health: a European
perspective. London, Routledge, 2002.
12. Report No. 20 (2006-2007): National strategy to reduce social inequalities in health.
Paper presented to the Storting. Oslo, Norwegian Ministry of Health and Care
Services, 2007 (http://www.regjeringen.no/en/dep/hod/Documents/regpubl/
stmeld/2006-2007/Report-No-20-2006-2007-to-the-Storting.html?id=466505,
accessed 19 July 2008).
13. Diderichsen F, Hallqvist J. Social inequalities in health: some methodological
considerations for the study of social position and social context. In: Arve-Parès B,
ed. Inequality in health – a Swedish perspective. Stockholm, Swedish Council for
Social Research, 1998.
14. International Labour Offi ce, Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ) Gmbh and World Health Organization. Extending social protection in health:
developing countries, experiences, lessons learnt and recommendations. International
Conference on Social Health Insurance in Developing Countries, Berlin, 5–7
December 2005. Eschborn, Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ) Gmbh, 2007 (http://www2.gtz.de/dokumente/bib/07-0378.pdf, accessed 19
July 2008).
15. Achieving universal health coverage: developing the health fi nancing system.
Geneva, World Health Organization, Department of Health Systems Financing, 2005
(Technical Briefs for Policy Makers No. 1).
16. The World Health Report 2000 – Health systems: improving performance. Geneva,
World Health Organization, 2000.
17. Busse R, Schlette S, eds. Focus on prevention, health and aging and health
professions. Gütersloh, Verlag Bertelsmann Stiftung, 2007 (Health Policy
Developments 7/8).
18. Carrin G, Waelkens MP, Criel B. Community-based health insurance in developing
countries: a study of its contribution to the performance of health fi nancing systems.
Tropical Medicine and International Health, 2005, 10:799–811.
19. Jacobs B et al. Bridging community-based health insurance and social protection
for health care – a step in the direction of universal coverage? Tropical Medicine and
International Health, 2008, 13:140–143.
20. Reclaiming the resources for health. A regional analysis of equity in health in East and
Southern Africa. Kampala, Regional Network on Equity in Health in Southern Africa
(EQUINET), 2007.
21. Gilson L. The lessons of user fee experience in Africa. Health Policy and Planning,
1997, 12:273–285.
22. Ke X et al. The elimination of user fees in Uganda: impact on utilization and
catastrophic health expenditures. Geneva, World Health Organization, Department
of Health System Financing, Evidence, Information and Policy Cluster, 2005
(Discussion Paper No. 4).
23. Hutton G. Charting the path to the World Bank’s “No blanket policy on user fees”.
A look over the past 25 years at the shifting support for user fees in health and
education, and refl ections on the future. London, Department for International
Development (DFID) Health Resource Systems Resource Centre, 2004 (http:www.
dfi dhealthrc.org/publications/health_sector_fi nancing/04hut01.pdf, accessed 19
July 2008).
24. Tarimo E. Essential health service packages: uses, abuse and future directions.
Current concerns. Geneva, World Health Organization, 1997 (ARA Paper No. 15;
WHO/ARA/CC/97.7).
25. Republica de Chile. Ley 19.966. Projecto de ley: título I del régimen general de
garantías en salud. Santiago, Ministerio de Salud, 2008 (http://webhosting.redsalud.
gov.cl/minsal/archivos/guiasges/leyauge.pdf accessed 19 July 2008).
26. Moccero D. Delivering cost-effi cient public services in health care, education and
housing in Chile. Paris, Organisation for Economic Co-operation and Development,
2008 (Economics Department Working Papers No. 606).
27. Gwatkin DR et al. Socio-economic differences in health, nutrition, and population
within developing countries. An overview. Washington DC, The World Bank, Human
Development Network, Health, Population and Nutrition, and Population Family,
2007 (POPLINE Document Number: 324740).
28. Conway MD, Gupta S, Khajavi K. Addressing Africa’s health workforce crisis. The
Mckinsey Quarterly, November 2007.
29. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as
constraints to referral by isolated nurses in rural Niger. Human Resources for Health,
2004, 2:1.
30. Maiga Z, Traoré Nafo F, El Abassi A. La Réforme du secteur santé au Mali, 1989-
1996. Studies in Health Services Organisation & Policy, 1999, 12:1–132.
31. Abolhassani F. Primary health care in the Islamic Republic of Iran. Teheran, Teheran
University of Medical Sciences, Health Network Development Centre (unpublished).
32. Naghavi M. Demographic and health surveys in Iran, 2008 (personal communication).
33. Porignon D et al. How robust are district health systems? Coping with crisis and
disasters in Rutshuru, Democratic Republic of Congo. Tropical Medicine and
International Health, 1998, 3:559–565.
34. Gauden GI, Powis B, Tamplin SA. Healthy Islands in the Western Pacifi c –
international settings development. Health Promotion International, 2000,
15:169–178.
35. The World Health Report 2006: Working together for health. Geneva, World Health
Organization, 2006.
36. Bossyns P et al. Unaffordable or cost-effective? Introducing an emergency referral
system in rural Niger. Tropical Medicine & International Health, 2005, 10:879–887.
37. Tibandebage P, Mackintosh M. The market shaping of charges, trust and abuse:
health care transactions in Tanzania. Social Science and Medicine, 2005,
61:1385–1395.
38. Segall, M et al. Health care seeking by the poor in transitional economies: the case
of Vietnam. Brighton, Institute of Development Studies, 2000 (IDS Research Reports
No. 43).
39. Baru RV. Private health care in India: social characteristics and trends. New Delhi,
Sage Publications, 1998.
40. Tu NTH, Huong NTL, Diep NB. Globalisation and its effects on health care and
occupational health in Viet Nam. Geneva, United Nations Research Institute for Social
Development, 2003 (http://www.unrisd.org, accessed 19 July 2008).
41. Narayana K. The role of the state in the privatisation and corporatisation of medical
care in Andhra Pradesh, India. In: Sen K, ed. Restructuring health services: changing
contexts and comparative perspectives. London and New Jersey, Zed Books, 2003.
42. Bennett S, McPake B, Mills A. The public/private mix debate in health care. In:
Bennett S, McPake B, Mills A, eds. Private health providers in developing countries.
Serving the public interest? London and New Jersey, Zed Books, 1997.
43. Ogunbekun I, Ogunbekun A, Orobaton N. Private health care in Nigeria: walking the
tightrope. Health Policy and Planning, 1999, 14:174–181.
44. Mills A, Bennett S, Russell S. The challenge of health sector reform: what must
governments do? Basingstoke, Palgrave Macmillan, 2001.
45. The unbearable cost of illness: poverty, ill health and access to healthcare - evidence
from Lindi Rural District, Tanzania, London, Save the Children, 2001.
46. Ferrinho P, Bugalho AM, Van Lerberghe W. Is there a case for privatising
reproductive health? Patchy evidence and much wishful thinking. Studies in Health
Services Organisation & Policy, 2001, 17:343–370.
47. Pan American Health Organization and Swedish International Development Agency.
Exclusion in health in Latin America and the Caribbean. Washington DC, Pan
American Health Organization, 2003 (Extension of Social Protection in Health Series
No. 1).
The World Health Report 2008 Primary Health Care – Now More Than Ever
38
48. Jaffré Y, Olivier de Sardan J-P, eds. Une médecine inhospitalière. Les diffi ciles relations
entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest. Paris, Karthala,
2003.
49. Schellenberg JA et al. Inequalities among the very poor: health care for children in
rural southern Tanzania. Ifakara, Ifakara Health Research and Development Centre,
2002.
50. Oliver A, ed. Health care priority setting: implications for health inequalities.
Proceedings from a meeting of the Health Equity Network. London, The Nuffi eld
Trust, 2003.
51. Overcoming obstacles to health: report from the Robert Wood Johnson Foundation to
the Commission to Build a Healthier America. Princeton NJ, Robert Wood Johnson
Foundation, 2008.
52. Franks A. Self-determination background paper. Aboriginal health promotion project.
Lismore NSW, Northern Rivers Area Health Service, Division of Population Health,
Health Promotion Unit, 2001 (http://www.ncahs.nsw.gov.au/docs/echidna/ABpaper.
pdf, accessed 19 July 2008).
53. Gathering strength – Canada’s Aboriginal action plan: a progress report. Ottawa,
Ministry of Indian Affairs and Northern Development, 2000.
54. King A, Turia T. He korowai orange – Maori Health Strategy. Wellington, Ministry of
Health of New Zealand, 2002.
55. Cecile MT et al. Gender perspectives and quality of care: towards appropriate and
adequate health care for women. Social Science & Medicine, 1996, 43:707–720.
56. Murray C, Kulkarni S, Ezzati M. Eight Americas: new perspectives on U.S. health
disparities. American Journal of Preventive Medicine, 2005, 29:4–10.
57. Paterson I, Judge K. Equality of access to healthcare. In: Mackenbach JP, Bakker
M, eds. Reducing inequalities in health: a European perspective. London, Routledge,
2002.
58. Doblin L, Leake BD. Ambulatory health services provided to low-income and
homeless adult patients in a major community health center. Journal of General
Internal Medicine, 1996 11:156–162.
59. Frenz P. Innovative practices for intersectoral action on health: a case study of four
programs for social equity. Chilean case study prepared for the CSDH. Santiago,
Ministry of Health, Division of Health Planning, Social Determinants of Health
Initiative, 2007.
60. Emanuel EJ, Fuchs VR. Health care vouchers – a proposal for universal coverage.
New England Journal of Medicine, 2005, 352:1255–1260.
61. Morris S et al. Monetary incentives in primary health care and effects on use
and coverage of preventive health care interventions in rural Honduras: cluster
randomised trial. Lancet, 2004, 364:2030–2037.
62. Armstrong JRM et al. KINET: a social marketing programme of treated nets and net
treatment for malaria control in Tanzania, with evaluation of child health and longterm
survival. Transactions of the Royal Society of Tropical Medicine and Hygiene,
1999, 93:225–231.
63. Adiel K et al. Targeted subsidy for malaria control with treated nets using a discount
voucher system in Tanzania. Health Policy and Planning, 2003, 18:163–171.
64. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health
services and impact on sexual behavior. Family Planning Perspectives, 1991,
23:6–16.
65. Meng H et al. Effect of a consumer-directed voucher and a disease-managementhealth-
promotion nurse intervention on home care use. The Gerontologist, 2005,
45:167–176.
66. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake
of health interventions in low- and middle-income countries. A systematic review.
Journal of the American Medical Association, 2007, 298:1900–1910.
67. Gwatkin DR, Wagstaff A, Yazbeck A, eds. Reaching the poor with health, nutrition
and population services. What works, what doesn’t and why. Washington DC, The
World Bank, 2005.
68. Sretzer, S. The importance of social intervention in Britain’s mortality decline,
c.1850–1914: a reinterpretation of the role of public health. Society for the Social
History of Medicine, 1988, 1:1–41.
69. Gwatkin DR. 10 best resources on ... health equity. Health Policy and Planning, 2007,
22:348–351.
70. Burström B. Increasing inequalities in health care utilisation across income groups
in Sweden during the 1990s? Health Policy, 2002, 62:117–129.
71. Whitehead M et al. As the health divide widens in Sweden and Britain, what’s
happening to access to care? British Medical Journal, 1997, 315:1006–1009.
72. Nolen LB et al. Strengthening health information systems to address health equity
challenges, Bulletin of the World Health Organization, 2005, 83:597–603.
73. Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can lowincome
countries escape the medical poverty trap. Lancet, 2001, 358:833–836.
74. Burke MA, Eichler M. The BIAS FREE framework: a practical tool for identifying
and eliminating social biases in health research. Geneva, Global Forum for Health
Research, 2006 (http://www.globalforumhealth.org/Site/002__What%20we%20
do/005__Publications/010__BIAS%20FREE.php, accessed 19 July 2008).
75. Benach J, Borell C, Daponte A. Spain. In: Mackenbach JP, Bakker M, eds. Reducing
inequalities in health: a European perspective. London, Routledge, 2002.
76. Balthazar T, Versnick G. Lokaal sociaal beleidsplan, Gent. Strategisch meerjarenplan
2008-2013. Gent, Lokaal Sociaal Beleid, 2008 (http://www.lokaalsociaalbeleidgent.
be/documenten/publicaties%20LSB-Gent/LSB-plan%20Gent.pdf, accessed 23
July 2008).


Primary care
Putting people fi rst
This chapter describes how primary care brings
promotion and prevention, cure and care together in
a safe, effective and socially productive way at the interface
between the population and the health
system. In short, what needs to be done to
achieve this is “to put people fi rst”: to give
balanced consideration to health and wellbeing
as well as to the values and capacities
of the population and the health workers1.
The chapter starts by describing features of
health care that, along with effectiveness and safety, are essential
in ensuring improved health and social outcomes.
l
Chapter 3
Good care is about people 42
The distinctive features of
primary care 43
Organizing
primary-care networks 52
Monitoring progress 56
41
The World Health Report 2008 Primary Health Care – Now More Than Ever
42
These features are person-centredness, comprehensiveness
and integration, and continuity of
care, with a regular point of entry into the health
system, so that it becomes possible to build an
enduring relationship of trust between people
and their health-care providers. The chapter
then defi nes what this implies for the organization
of health-care delivery: the necessary
switch from specialized to generalist ambulatory
care, with responsibility for a defi ned population
and the ability to coordinate support from
hospitals, specialized services and civil society
organizations.
Good care is about people
Biomedical science is, and should be, at the heart
of modern medicine. Yet, as William Osler, one of
its founders, pointed out, “it is much more important
to know what sort of patient has a disease
than what sort of disease a patient has”2. Insuffi
cient recognition of the human dimension in
health and of the need to tailor the health service’s
response to the specifi city of each community and
individual situation represent major shortcomings
in contemporary health care, resulting not
only in inequity and poor social outcomes, but
also diminishing the health outcome returns on
the investment in health services.
Putting people fi rst, the focus of service delivery
reforms is not a trivial principle. It can require
signifi cant – even if often simple – departures
from business as usual. The reorganization of
a medical centre in Alaska in the United States,
accommodating 45 000 patient contacts per year,
illustrates how far-reaching the effects can be.
The centre functioned to no great satisfaction of
either staff or clients until it decided to establish
a direct relationship between each individual
and family in the community and a specifi c staff
member3. The staff were then in a position to
know “their” patients’ medical history and understand
their personal and family situation. People
were in a position to get to know and trust their
health-care provider: they no longer had to deal
with an institution but with their personal caregiver.
Complaints about compartmentalized and
fragmented services abated4. Emergency room
visits were reduced by approximately 50% and
referrals to specialty care by 30%; waiting times
shortened signifi cantly. With fewer “rebound”
visits for unresolved health problems, the workload
actually decreased and staff job satisfaction
improved. Most importantly, people felt that
they were being listened to and respected – a key
aspect of what people value about health care5,6. A
slow bureaucratic system was thus transformed
into one that is customer-responsive, customerowned
and customer-driven4.
In a very different setting, the health centres
of Ouallam, a rural district in Niger, implemented
an equally straightforward reorganization of
their way of working in order to put people fi rst.
Rather than the traditional morning curative care
consultation and specialized afternoon clinics
(growth monitoring, family planning, etc.), the
full range of services was offered at all times,
while the nurses were instructed to engage in an
active dialogue with their patients. For example,
they no longer waited for women to ask for contraceptives,
but informed them, at every contact,
about the range of services available. Within a few
months, the very low uptake of family planning,
previously attributed to cultural constraints, was
a thing of the past (Figure 3.1)7.
People’s experiences of care provided by the
health system are determined fi rst and foremost
by the way they are treated when they experience
a problem and look for help: by the responsiveness
of the health-worker interface between population
Women attending the health centre (%)
Source: 7
60
0
80
Year before reorganization
Figure 3.1 The effect on uptake of contraception of the reorganization
of work schedules of rural health centres in Niger
40
20
Year after reorganization
100
Informed Interested Contraception started
43
Chapter 3. Primary care: putting people fi rst
and health services. People value some freedom
in choosing a health provider because they want
one they can trust and who will attend to them
promptly and in an adequate environment, with
respect and confi dentiality8.
Health-care delivery can be made more effective
by making it more considerate and convenient,
as in Ouallam district. However, primary
care is about more than shortening waiting
times, adapting opening hours or getting staff
to be more polite. Health workers have to care
for people throughout the course of their lives,
as individuals and as members of a family and a
community whose health must be protected and
enhanced9, and not merely as body parts with
symptoms or disorders that require treating10.
The service delivery reforms advocated by the
PHC movement aim to put people at the centre of
health care, so as to make services more effective,
effi cient and equitable. Health services that
do this start from a close and direct relationship
between individuals and communities and their
caregivers. This, then, provides the basis for person-
centredness, continuity, comprehensiveness
and integration, which constitute the distinctive
features of primary care. Table 3.1 summarizes
the differences between primary care and care
provided in conventional settings, such as in
clinics or hospital outpatient departments, or
through the disease control programmes that
shape many health services in resource-limited
settings. The section that follows reviews these
defi ning features of primary care, and describes
how they contribute to better health and social
outcomes.
The distinctive features of
primary care
Effectiveness and safety are not just
technical matters
Health care should be effective and safe. Professionals
as well as the general public often
over-rate the performance of their health services.
The emergence of evidence-based medicine
in the 1980s has helped to bring the power
and discipline of scientifi c evidence to healthcare
decision-making11, while still taking into
consideration patient values and preferences12.
Over the last decade, several hundred reviews of
Table 3.1 Aspects of care that distinguish conventional health care from people-centred primary care
Conventional ambulatory
medical care in clinics or
outpatient departments Disease control programmes People-centred primary care
Focus on illness and cure Focus on priority diseases Focus on health needs
Relationship limited to the moment of
consultation
Relationship limited to programme
implementation
Enduring personal relationship
Episodic curative care Programme-defi ned disease control
interventions
Comprehensive, continuous and personcentred
care
Responsibility limited to effective
and safe advice to the patient at the
moment of consultation
Responsibility for disease-control
targets among the target population
Responsibility for the health of all in
the community along the life cycle;
responsibility for tackling determinants
of ill-health
Users are consumers of the care they
purchase
Population groups are targets of
disease-control interventions
People are partners in managing their
own health and that of their community
The World Health Report 2008 Primary Health Care – Now More Than Ever
44
effectiveness have been conducted13, which have
led to better information on the choices available
to health practitioners when caring for their
patients.
Evidence-based medicine, however, cannot
in itself ensure that health care is effective and
safe. Growing awareness of the multiple ways in
which care may be compromised is contributing
to a gradual rise in standards of quality and
safety (Box 3.1). Thus far, however, such efforts
have concentrated disproportionately on hospital
and specialist care, mainly in high- and middleincome
countries. The effectiveness and safety of
generalist ambulatory care, where most interactions
between people and health services take
place, has been given much less attention14. This
is a particularly important issue in the unregulated
commercial settings of many developing
countries where people often get poor value for
money (Box 3.2)15.
Technical and safety parameters are not the
only determinants of the outcomes of health care.
The disappointingly low success rate in preventing
mother-to-child transmission (MTCT) of HIV
in a study in the Côte d’Ivoire (Figure 3.2) illustrates
that other features of the organization of
health care are equally critical – good drugs are
Box 3.1 Towards a science and culture
of improvement: evidence to promote
patient safety and better outcomes
The outcome of health care results from the balance between
the added value of treatment or intervention, and the harm it
causes to the patient16. Until recently, the extent of such harm
has been underestimated. In industrialized countries, approximately
1 in 10 patients suffers harm caused by avoidable
adverse events while receiving care17: up to 98 000 deaths per
year are caused by such events in the United States alone18.
Multiple factors contribute to this situation19, ranging from
systemic faults to problems of competence, social pressure on
patients to undergo risky procedures, to incorrect technology
usage20. For example, almost 40% of the 16 billion injections
administered worldwide each year are given with syringes
and needles that are reused without sterilization14. Each year,
unsafe injections thus cause 1.3 million deaths and almost 26
million years of life lost, mainly because of transmission of
hepatitis B and C, and HIV21.
Especially disquieting is the paucity of information on the
extent and determinants of unsafe care in low- and middleincome
countries. With unregulated commercialization of care,
weaker quality control and health resource limitations, healthcare
users in low-income countries may well be even more
exposed to the risk of unintended patient harm than patients in
high-income countries. The World Alliance for Patient Safety22,
among others, advocates making patients safer through systemic
interventions and a change in organizational culture
rather than through the denunciation of individual health-care
practitioners or administrators23.
Box 3.2 When supplier-induced and
consumer-driven demand determine
medical advice: ambulatory care in India
“Ms. S is a typical patient who lives in urban Delhi. There
are over 70 private-sector medical care providers within a
15-minute walk from her house (and virtually any household
in her city). She chooses the private clinic run by Dr. SM and
his wife. Above the clinic a prominent sign says “Ms. MM,
Gold Medalist, MBBS”, suggesting that the clinic is staffed by
a highly profi cient doctor (an MBBS is the basic degree for a
medical doctor as in the British 2 system). As it turns out, Ms.
MM is rarely at the clinic. We were told that she sometimes
comes at 4 a.m. to avoid the long lines that form if people know
she is there. We later discover that she has “franchised” her
name to a number of different clinics. Therefore, Ms. S sees
Dr. SM and his wife, both of whom were trained in traditional
Ayurvedic medicine through a six-month long-distance course.
The doctor and his wife sit at a small table surrounded, on one
side, by a large number of bottles full of pills, and on the other,
a bench with patients on them, which extends into the street.
Ms. S sits at the end of this bench. Dr. SM and his wife are the
most popular medical care providers in the neighbourhood,
with more than 200 patients every day. The doctor spends an
average of 3.5 minutes with each patient, asks 3.2 questions,
and performs an average of 2.5 examinations. Following the
diagnosis, the doctor takes two or three different pills, crushes
them using a mortar and pestle, and makes small paper packets
from the resulting powder which he gives to Ms. S and
asks her to take for two or three days. These medicines usually
include one antibiotic and one analgesic and anti-infl ammatory
drug. Dr. SM tells us that he constantly faces unrealistic patient
expectations, both because of the high volume of patients and
their demands for treatments that even Dr. SM knows are
inappropriate. Dr. SM and his wife seem highly motivated to
provide care to their patients and even with a very crowded
consultation room they spend more time with their patients
than a public sector doctor would. However, they are not bound
by their knowledge […] and instead deliver health care like
the crushed pills in a paper packet, which will result in more
patients willing to pay more for their services”24.
45
Chapter 3. Primary care: putting people fi rst
not enough. How services deal with people is also
vitally important. Surveys in Australia, Canada,
Germany, New Zealand, the United Kingdom and
the United States show that a high number of
patients report safety risks, poor care coordination
and defi ciencies in care for chronic conditions25.
Communication is often inadequate and
lacking in information on treatment schedules.
Nearly one in every two patients feels that doctors
only rarely or never asked their opinion about
treatment. Patients may consult different providers
for related or even for the same conditions
which, given the lack of coordination among these
providers, results in duplication and contradictions25.
This situation is similar to that reported
in other countries, such as Ethiopia26, Pakistan27
and Zimbabwe28.
There has, however, been progress in recent
years. In high-income countries, confrontation
with chronic disease, mental health problems,
multi-morbidity and the social dimension of disease
has focused attention on the need for more
comprehensive and person-centred approaches
and continuity of care. This resulted not only
from client pressure, but also from professionals
who realized the critical importance of such
Figure 3.2 Lost opportunities for prevention of mother-to-child transmission of HIV (MTCT) in
Côte d’Ivoire29: only a tiny fraction of the expected transmissions are
actually prevented
450 failures to prevent transmission
Did not attend
antenatal care
Lack of
coverage:
77 lost
462 mother-to-child
transmissions of HIV
(expected among 11 582
pregnant women)
Mother
attends
antenatal
care
HIV testing
offered
Did not
accept
test
Bad
communication:
107 lost
Counselling
recommends
treatment
12 mother-to-child
transmissions
successfully
prevented
Were not
counselled
Lack of
follow-up:
153 lost
Consent
obtained
Did not
agree to
be treated
Bad
communication:
50 lost
Treatment
offered
Did not get
the treatment
Access to
drugs: 40 lost
Treatment
taken
Treatment
ineffective
23 lost
Treatment
effective
The World Health Report 2008 Primary Health Care – Now More Than Ever
46
features of care in achieving better outcomes for
their patients. Many health professionals have
begun to appreciate the limitations of narrow
clinical approaches, for example, to cardiovascular
disease. As a result there has been a welcome
blurring of the traditional boundaries between
curative care, preventive medicine and health
promotion.
In low-income countries, this evolution is also
visible. In recent years, many of the programmes
targeting infectious disease priorities have given
careful consideration to comprehensiveness,
continuity and patient-centredness. Maternal
and child health services have often been at the
forefront of these attempts, organizing a continuum
of care and a comprehensive approach.
This process has been consolidated through the
joint UNICEF/WHO Integrated Management of
Childhood Illness initiatives30. Their experience
with programmes such as the WHO’s Extended
Programme for Immunization has put health professionals
in many developing countries a step
ahead compared to their high-income country
colleagues, as they more readily see themselves
responsible not just for patients, but also for
population coverage. More recently, HIV/AIDS
programmes have drawn the attention of providers
and policy-makers to the importance of
counselling, continuity of care, the complementarity
of prevention, treatment and palliation and
critically, to the value of empathy and listening
to patients.
Understanding people:
person-centred care
When people are sick they are a great deal less
concerned about managerial considerations of
productivity, health targets, cost-effectiveness
and rational organization than about their own
predicament. Each individual has his or her own
way of experiencing and coping with health problems
within their specifi c life circumstances31.
Health workers have to be able to handle that
diversity. For health workers at the interface
between the population and the health services,
the challenge is much more complicated than for
a specialized referral service: managing a welldefi
ned disease is a relatively straightforward
technical challenge. Dealing with health problems,
however, is complicated as people need to
be understood holistically: their physical, emotional
and social concerns, their past and their
future, and the realities of the world in which they
live. Failure to deal with the whole person in their
specifi c familial and community contexts misses
out on important aspects of health that do not
immediately fi t into disease categories. Partner
violence against women (Box 3.3), for example,
can be detected, prevented or mitigated by health
services that are suffi ciently close to the communities
they serve and by health workers who
know the people in their community.
People want to know that their health worker
understands them, their suffering and the constraints
they face. Unfortunately, many providers
neglect this aspect of the therapeutic relation,
particularly when they are dealing with
disadvantaged groups. In many health services,
responsiveness and person-centredness are
treated as luxury goods to be handed out only
to a selected few.
Over the last 30 years, a considerable body
of research evidence has shown that personcentredness
is not only important to relieve
the patient’s anxiety but also to improve the
provider’s job satisfaction50. The response to
a health problem is more likely to be effective
if the provider understands its various dimensions51.
For a start, simply asking patients how
they feel about their illness, how it affects their
lives, rather than focusing only on the disease,
results in measurably increased trust and compliance52
that allows patient and provider to
fi nd a common ground on clinical management,
and facilitates the integration of prevention and
health promotion in the therapeutic response50,51.
Thus, person-centredness becomes the “clinical
method of participatory democracy”53, measurably
improving the quality of care, the success of
treatment and the quality of life of those benefi ting
from such care (Table 3.2).
In practice, clinicians rarely address their
patients’ concerns, beliefs and understanding
of illness, and seldom share problem management
options with them58. They limit themselves
to simple technical prescriptions, ignoring the
complex human dimensions that are critical to
the appropriateness and effectiveness of the care
they provide59.
47
Chapter 3. Primary care: putting people fi rst
Thus, technical advice on lifestyle, treatment
schedule or referral all too often neglects
not only the constraints of the environment in
which people live, but also their potential for selfhelp
in dealing with a host of health problems
ranging from diarrhoeal disease60 to diabetes
management61. Yet, neither the nurse in Niger’s
rural health centre nor the general practitioner
in Belgium can, for example, refer a patient to
hospital without negotiating62,63: along with medical
criteria, they have to take into account the
patient’s values, the family’s values, and their
lifestyle and life perspective64.
Few health providers have been trained for
person-centred care. Lack of proper preparation
is compounded by cross-cultural confl icts, social
stratifi cation, discrimination and stigma63. As a
consequence, the considerable potential of people
to contribute to their own health through lifestyle,
behaviour and self-care, and by adapting
Table 3.2 Person-centredness: evidence of its
contribution to quality of care and better outcomes
Improved treatment intensity and quality of life − Ferrer
(2005)54
Better understanding of the psychological aspects of a
patient's problems − Gulbrandsen (1997)55
Improved satisfaction with communication −
Jaturapatporn (2007)56
Improved patient confi dence regarding sensitive
problems − Kovess-Masféty (2007)57
Increased trust and treatment compliance − Fiscella
(2004)52
Better integration of preventive and promotive care −
Mead (1982)50
Box 3.3 The health-care response to partner violence against women
Intimate partner violence has numerous well-documented consequences for women’s health (and for the health of their children), including
injuries, chronic pain syndromes, unintended and unwanted pregnancies, pregnancy complications, sexually transmitted infections and
a wide range of mental health problems32,33,34,35,36,37. Women suffering from violence are frequent health-care users 38,39.
Health workers are, therefore, well placed to identify and provide care to the victims of violence, including referral for psychosocial,
legal and other support. Their interventions can reduce the impact of violence on a woman’s health and well-being, and that of her
children, and can also help prevent further violence.
Research has shown that most women think health-care providers should ask about violence40. While they do not expect them to solve
their problem, they would like to be listened to and treated in a non-judgemental way and get the support they need to take control over
their decisions. Health-care providers often fi nd it diffi cult to ask women about violence. They lack the time and the training and skills
to do it properly, and are reluctant to be involved in judicial proceedings.
The most effective approach for health providers to use when responding to violence is still a matter of debate41. They are generally
advised to ask all women about intimate partner abuse as a routine part of any health assessment, usually referred to as “screening”
or routine enquiry42. Several reviews found that this technique increased the rate of identifi cation of women experiencing violence in
antenatal and primary-care clinics, but there was little evidence that this was sustained40, or was effective in terms of health outcomes43.
Among women who have stayed in shelters, there is evidence that those who received a specifi c counselling and advocacy service
reported a lower rate of re-abuse and an improved quality of life44. Similarly, among women experiencing violence during pregnancy,
those who received “empowerment counselling” reported improved functioning and less psychological and non-severe physical abuse,
and had lower postnatal depression scores45.
While there is still no consensus on the most effective strategy, there is growing agreement that health services should aim to identify
and support women experiencing violence46, and that health-care providers should be well educated about these issues, as they are
essential in building capacity and skills. Health-care providers should, as a minimum, be informed about violence against women, its
prevalence and impact on health, when to suspect it and how to best respond. Clearly, there are technical dimensions to this. For example,
in the case of sexual assault, providers need to be able to provide the necessary treatment and care, including provision of emergency
contraception and prophylaxis for sexually transmitted infections, including HIV where relevant, as well as psychosocial support. There
are other dimensions too: health workers need to be able to document any injuries as completely and carefully as possible47,48,49 and
they need to know how to work with communities – in particular with men and boys – on changing attitudes and practices related to
gender inequality and violence.
The World Health Report 2008 Primary Health Care – Now More Than Ever
48
professional advice optimally to their life circumstances
is underutilized. There are numerous,
albeit often missed, opportunities to empower
people to participate in decisions that affect
their own health and that of their families (Box
3.4). They require health-care providers who
can relate to people and assist them in making
informed choices. The current payment systems
and incentives in community health-care delivery
often work against establishing this type of
dialogue65. Confl icts of interest between provider
and patient, particularly in unregulated commercial
settings, are a major disincentive to personcentred
care. Commercial providers may be more
courteous and client-friendly than in the average
health centre, but this is no substitute for personcentredness.
Comprehensive and integrated responses
The diversity of health needs and challenges that
people face does not fi t neatly into the discrete
diagnostic categories of textbook promotive, preventive,
curative or rehabilitative care78,79. They
call for the mobilization of a comprehensive range
of resources that may include health promotion
and prevention interventions as well as diagnosis
and treatment or referral, chronic or long-term
home care, and, in some models, social services80.
It is at the entry point of the system, where people
fi rst present their problem, that the need for a
comprehensive and integrated offer of care is
most critical.
Comprehensiveness makes managerial and
operational sense and adds value (Table 3.3).
People take up services more readily if they know
a comprehensive spectrum of care is on offer.
Moreover, it maximizes opportunities for preventive
care and health promotion while reducing
unnecessary reliance on specialized or hospital
care81. Specialization has its comforts, but the
fragmentation it induces is often visibly counterproductive
and ineffi cient: it makes no sense to
monitor the growth of children and neglect the
health of their mothers (and vice versa), or to treat
someone’s tuberculosis without considering their
HIV status or whether they smoke.
Table 3.3 Comprehensiveness: evidence of its
contribution to quality of care and better outcomes
Better health outcomes − Forrest (1996)82, Chande
(1996)83, Starfi eld (1998)84
Increased uptake of disease-focused preventive care
(e.g. blood pressure screen, mammograms, pap smears)
− Bindman (1996)85
Fewer patients admitted for preventable complications of
chronic conditions − Shea (1992)86
Box 3.4 Empowering users to contribute to their own health
Families can be empowered to make choices that are relevant to their health. Birth and emergency plans66, for example, are based on
a joint examination between the expectant mother and health staff − well before the birth − of her expectations regarding childbirth.
Issues discussed include where the birth will take place, and how support for care of the home and any other children will be organized
while the woman is giving birth. The discussion can cover planning for expenses, arrangements for transport and medical supplies, as
well as identifi cation of a compatible blood donor in case of haemorrhage. Such birth plans are being implemented in countries as diverse
as Egypt, Guatemala, Indonesia, the Netherlands and the United Republic of Tanzania. They constitute one example of how people can
participate in decisions relating to their health in a way that empowers them67. Empowerment strategies can improve health and social
outcomes through several pathways; the condition for success is that they are embedded in local contexts and based on a strong and
direct relationship between people and their health workers68. The strategies can relate to a variety of areas, as shown below:
developing household capacities to stay healthy, make healthy decisions and respond to emergencies �� − France’s self-help organization
of diabetics69, South Africa’s family empowerment and parent training programmes70, the United Republic of Tanzania’s negotiated
treatment plans for safe motherhood71, and Mexico’s active ageing programme72;
�� increasing citizens’ awareness of their rights, needs and potential problems − Chile’s information on entitlements73 and Thailand’s
Declaration of Patients’ Rights74;
�� strengthening linkages for social support within communities and with the health system − support and advice to family caregivers
dealing with dementia in developing country settings75, Bangladesh’s rural credit programmes and their impact on care-seeking
behaviour76, and Lebanon’s neighbourhood environment initiatives77.
49
Chapter 3. Primary care: putting people fi rst
That does not mean that entry-point health
workers should solve all the health problems
that are presented there, nor that all health programmes
always need to be delivered through
a single integrated service-delivery point. Nevertheless,
the primary-care team has to be able
to respond to the bulk of health problems in the
community. When it cannot do so, it has to be
able to mobilize other resources, by referring or
by calling for support from specialists, hospitals,
specialized diagnostic and treatment centres,
public-health programmes, long-term care services,
home-care or social services, or self-help
and other community organizations. This cannot
mean giving up responsibility: the primary-care
team remains responsible for helping people to
navigate this complex environment.
Comprehensive and integrated care for the
bulk of the assorted health problems in the community
is more effi cient than relying on separate
services for selected problems, partly because it
leads to a better knowledge of the population and
builds greater trust. One activity reinforces the
other. Health services that offer a comprehensive
range of services increase the uptake and coverage
of, for example, preventive programmes, such
as cancer screening or vaccination (Figure 3.3).
They prevent complications and improve health
outcomes.
Comprehesive services also facilitate early
detection and prevention of problems, even in the
absence of explicit demand. There are individuals
and groups who could benefi t from care even if
they express no explicit spontaneous demand, as
in the case of women attending the health centres
in Ouallam district, Niger, or people with undiagnosed
high blood pressure or depression. Early
detection of disease, preventive care to reduce
the incidence of poor health, health promotion
to reduce risky behaviour, and addressing social
and other determinants of health all require the
health service to take the initiative. For many
problems, local health workers are the only ones
who are in a position to effectively address problems
in the community: they are the only ones,
for example, in a position to assist parents with
care in early childhood development, itself an
important determinant of later health, well-being
and productivity87. Such interventions require
proactive health teams offering a comprehensive
range of services. They depend on a close and
trusting relationship between the health services
and the communities they serve, and, thus, on
health workers who know the people in their
community88.
Continuity of care
Understanding people and the context in which
they live is not only important in order to provide
a comprehensive, person-centred response,
it also conditions continuity of care. Providers
often behave as if their responsibility starts when
a patient walks in and ends when they leave the
premises. Care should not, however, be limited to
the moment a patient consults nor be confi ned to
the four walls of the consultation room. Concern
for outcomes mandates a consistent and coherent
approach to the management of the patient’s problem,
until the problem is resolved or the risk that
justifi ed follow-up has disappeared. Continuity
of care is an important determinant of effectiveness,
whether for chronic disease management,
reproductive health, mental health or for making
sure children grow up healthily (Table 3.4).
Figure 3.3 More comprehensive health centres have better
vaccination coveragea,b
DPT3 vaccination coverage (%)
Facility performance score
0
20% health centres
with lowest overall
performance
a Total 1227 health centres, covering a population of 16 million people.
b Vaccination coverage was not included in the assessment of overall health-centre
performance across a range of services.
20
40
60
80
100
120
Quintile 2 Quintile 3 Quintile 4 20% health centres
with highest overall
performance
c Includes vaccination of children not belonging to target population.
Democratic Republic of the Congo
(380 health centres, 2004)
Madagascar (534 health centres, 2006)
Weighted average of coverage
in each country quintile
Rwanda (313 health centres, 1999)
c
The World Health Report 2008 Primary Health Care – Now More Than Ever
50
capitation or by fee-for-episode, out-of-pocket
fee-for-service payment is a common deterrent,
not only to access, but also to continuity of care107.
In Singapore, for example, patients were formerly
not allowed to use their health savings account
(Medisave) for outpatient treatment, resulting
in patient delays and lack of treatment compliance
for the chronically ill. This had become so
problematic that regulations were changed. Hospitals
are now encouraged to transfer patients
with diabetes, high blood pressure, lipid disorder
and stroke to registered general practitioners,
with Medisave accounts covering ambulatory
care108.
Other barriers to continuity include treatment
schedules requiring frequent clinic attendance
that carry a heavy cost in time, travel expenses
or lost wages. They may be ill-understood and
patient motivation may be lacking. Patients may
get lost in the complicated institutional environment
of referral hospitals or social services. Such
problems need to be anticipated and recognized
at an early stage. The effort required from health
workers is not negligible: negotiating the modalities
of the treatment schedule with the patients
so as to maximize the chances that it can be
completed; keeping registries of clients with
chronic conditions; and creating communication
channels through home visits, liaison with community
workers, telephonic reminders and text
messages to re-establish interrupted continuity.
These mundane tasks often make the difference
between a successful outcome and a treatment
failure, but are rarely rewarded. They are much
easier to implement when patient and caregiver
have clearly identifi ed how and by whom followup
will be organized.
A regular and trusted provider as
entry point
Comprehensiveness, continuity and person-centredness
are critical to better health outcomes.
They all depend on a stable, long-term, personal
relat ionship (a feature also cal led
“longitudinality”84) between the population and
the professionals who are their entry point to the
health system.
Most ambulatory care in conventional settings
is not organized to build such relationships. The
Table 3.4 Continuity of care: evidence of its
contribution to quality of care and better outcomes
Lower all-cause mortality − Shi (2003)90, Franks
(1998)91, Villalbi (1999)92, PAHO (2005)93
Better access to care − Weinick (2000)94, Forrest
(1998)95
Less re-hospitalization − Weinberger (1996)96
Fewer consultations with specialists − Woodward
(2004)97
Less use of emergency services − Gill (2000)98
Better detection of adverse effects of medical
interventions − Rothwell (2005)99, Kravitz (2004)100
Continuity of care depends on ensuring continuity
of information as people get older, when
they move from one residence to another, or when
different professionals interact with one particular
individual or household. Access to medical
records and discharge summaries, electronic,
conventional or client-held, improves the choice
of the course of treatment and of coordination
of care. In Canada, for example, one in seven
people attending an emergency department had
medical information missing that was very likely
to result in patient harm101. Missing information
is a common cause of delayed care and uptake
of unnecessary services102. In the United States,
it is associated with 15.6% of all reported errors
in ambulatory care103. Today’s information and
communication technologies, albeit underutilized,
gives unprecedented possibilities to
improve the circulation of medical information
at an affordable cost104, thus enhancing continuity,
safety and learning (Box 3.5). Moreover, it is
no longer the exclusive privilege of high-resource
environments, as the Open Medical Record System
demonstrates: electronic health records
developed through communities of practice and
open-source software are facilitating continuity
and quality of care for patients with HIV/AIDS in
many low-income countries105.
Better patient records are necessary but not
suffi cient. Health services need to make active
efforts to minimize the numerous obstacles to
continuity of care. Compared to payment by
51
Chapter 3. Primary care: putting people fi rst
busy, anonymous and technical environment of
hospital outpatient departments, with their many
specialists and sub-specialists, produce mechanical
interactions between nameless individuals
and an institution – not people-centred care.
Smaller clinics are less anonymous, but the care
they provide is often more akin to a commercial
or administrative transaction that starts and
ends with the consultation than to a responsive
problem-solving exercise. In this regard, private
clinics do not perform differently than public
health centres64. In the rural areas of low-income
countries, governmental health centres are usually
designed to work in close relationship with
the community they serve. The reality is often
different. Earmarking of resources and staff for
selected programmes is increasingly leading to
fragmentation109, while the lack of funds, the
pauperization of the health staff and rampant
commercialization makes building such relationships
diffi cult110. There are many examples to the
contrary, but the relationship between providers
and their clients, particularly the poorer ones, is
often not conducive to building relationships of
understanding, empathy and trust62.
Building enduring relationships requires time.
Studies indicate that it takes two to fi ve years
before its full potential is achieved84 but, as the
Alaska health centre mentioned at the beginning
of this chapter shows, it drastically changes the
way care is being provided. Access to the same
team of health-care providers over time fosters
the development of a relationship of trust
between the individual and their health-care provider97,111,112.
Health professionals are more likely
to respect and understand patients they know
Box 3.5 Using information and communication technologies to improve access, quality and
effi ciency in primary care
Information and communication technologies enable people in remote and underserved areas to have access to services and expertise
otherwise unavailable to them, especially in countries with uneven distribution or chronic shortages of physicians, nurses and health
technicians or where access to facilities and expert advice requires travel over long distances. In such contexts, the goal of improved
access to health care has stimulated the adoption of technology for remote diagnosis, monitoring and consultation. Experience in Chile
of immediate transmission of electrocardiograms in cases of suspected myocardial infarction is a noteworthy example: examination
is carried out in an ambulatory setting and the data are sent to a national centre where specialists confi rm the diagnosis via fax or
e-mail. This technology-facilitated consultation with experts allows rapid response and appropriate treatment where previously it
was unavailable. The Internet is a key factor in its success, as is the telephone connectivity that has been made available to all health
facilities in the country.
A further benefi t of using information and communication technologies in primary-care services is the improved quality of care. Healthcare
providers are not only striving to deliver more effective care, they are also striving to deliver safer care. Tools, such as electronic
health records, computerized prescribing systems and clinical decision aids, support practitioners in providing safer care in a range
of settings. For example, in a village in western Kenya, electronic health records integrated with laboratory, drug procurement and
reporting systems have drastically reduced clerical labour and errors, and have improved follow-up care.
As the costs of delivering health care continue to rise, information and communication technologies provide new avenues for personalized,
citizen-centred and home-centred care. Towards this end, there has been signifi cant investment in research and development of
consumer-friendly applications. In Cape Town, South Africa, an “on cue compliance service” takes the names and mobile telephone
numbers of patients with tuberculosis (supplied by a clinic) and enters them into a database. Every half an hour, the on cue server
reads the database and sends personalized SMS messages to the patients, reminding them to take their medication. The technology
is low-cost and robust. Cure and completion rates are similar to those of patients receiving clinic-based DOTS, but at lower cost to
both clinic and patient, and in a way that interferes much less with everyday life than the visits to the clinic106. In the same concept of
supporting lifestyles linked to primary care, network devices have become a key element of an innovative community programme in
the Netherlands, where monitoring and communication devices are built into smart apartments for senior citizens. This system reduces
clinic visits and facilitates living independently with chronic diseases that require frequent checks and adjustment of medications.
Many clinicians who want to promote health and prevent illness are placing high hopes in the Internet as the place to go for health advice
to complement or replace the need to seek the advice of a health professional. New applications, services and access to information
have permanently altered the relationships between consumers and health professionals, putting knowledge directly into people’s
own hands.
The World Health Report 2008 Primary Health Care – Now More Than Ever
52
well, which creates more positive interaction and
better communication113. They can more readily
understand and anticipate obstacles to continuity
of care, follow up on the progress and assess how
the experience of illness or disability is affecting
the individual’s daily life. More mindful of
the circumstances in which people live, they can
tailor care to the specifi c needs of the person and
recognize health problems at earlier stages.
This is not merely a question of building trust
and patient satisfaction, however important these
may be114,115. It is worthwhile because it leads to
better quality and better outcomes (Table 3.5).
People who use the same source of care for most
of their health-care needs tend to comply better
with advice given, rely less on emergency services,
require less hospitalization and are more
satisfi ed with care98 116,117,118. Providers save consultation
time, reduce the use of laboratory tests
and costs95,119,120, and increase uptake of preventive
care121. Motivation improves through the
social recognition built up by such relationships.
Still, even dedicated health professionals will not
seize all these opportunities spontaneously122,123.
The interface between the population and their
health services needs to be designed in a way that
not only makes this possible, but also the most
likely course of action.
Organizing primary-care networks
A health service that provides entry point ambulatory
care for health- and health-related problems
should, thus, offer a comprehensive range
of integrated diagnostic, curative, rehabilitative
and palliative services. In contrast to most conventional
health-care delivery models, the offer
of services should include prevention and promotion
as well as efforts to tackle determinants of
ill-health locally. A direct and enduring relationship
between the provider and the people in the
community served is essential to be able to take
into account the personal and social context of
patients and their families, ensuring continuity
of care over time as well as across services.
In order for conventional health services to
be transformed into primary care, i.e. to ensure
that these distinctive features get due prominence,
they must reorganized. A precondition
is to ensure that they become directly and permanently
accessible, without undue reliance on
out-of-pocket payments and with social protection
offered by universal coverage schemes. But
another set of arrangements is critical for the
transformation of conventional care – ambulatory-
and institution-based, generalist and
specialist – into local networks of primary-care
centres135,136,137,138,139,140 :
bringing care closer �� to people, in settings in
close proximity and direct relationship with
the community, relocating the entry point to
the health system from hospitals and specialists
to close-to-client generalist primary-care
centres;
�� giving primary-care providers the responsibility
for the health of a defi ned population, in its
entirety: the sick and the healthy, those who
choose to consult the services and those who
choose not to do so;
�� strengthening primary-care providers’ role as
coordinators of the inputs of other levels of
care by giving them administrative authority
and purchasing power.
Table 3.5 Regular entry point: evidence of its
contribution to quality of care and better outcomes
Increased satisfaction with services − Weiss (1996)116,
Rosenblatt (1998)117, Freeman (1997)124, Miller (2000)125
Better compliance and lower hospitalization rate − Weiss
(1996)116, Rosenblatt (1998)117, Freeman (1997)124,
Mainous (1998)126
Less use of specialists and emergency services −
Starfi eld (1998)82, Parchman (1994)127, Hurley (1989)128,
Martin (1989)129, Gadomski (1998)130
Fewer consultations with specialists − Hurley (1989)128,
Martin (1989)129
More effi cient use of resources − Forrest (1996)82,
Forrest (1998)95, Hjortdahl (1991)131, Roos (1998)132
Better understanding of the psychological aspects of a
patient's problem − Gulbrandsen (1997)55
Better uptake of preventive care by adolescents − Ryan
(2001)133
Protection against over-treatment − Schoen (2007)134
53
Chapter 3. Primary care: putting people fi rst
Bringing care closer to the people
A fi rst step is to relocate the entry point to the
health system from specialized clinics, hospital
outpatient departments and emergency services,
to generalist ambulatory care in close-to-client
settings. Evidence has been accumulating that
this transfer carries measurable benefi ts in terms
of relief from suffering, prevention of illness and
death, and improved health equity. These fi ndings
hold true in both national and cross-national
studies, even if all of the distinguishing features
of primary care are not fully realized31.
Generalist ambulatory care is more likely or
as likely to identify common life-threatening
conditions as specialist care141,142. Generalists
adhere to clinical practice guidelines to the same
extent as specialists143, although they are slower
to adopt them144,145. They prescribe fewer invasive
interventions146,147,148,149, fewer and shorter
hospitalizations127,133,149 and have a greater focus
on preventive care133,150. This results in lower
overall health-care costs82 for similar health
outcomes146,151,152,153,154,155 and greater patient
satisfaction125,150,156. Evidence from comparisons
between high-income countries shows that higher
proportions of generalist professionals working
in ambulatory settings are associated with
lower overall costs and higher quality rankings157.
Conversely, countries that increase reliance on
specialists have stagnating or declining health
outcomes when measured at the population
level, while fragmentation of care exacerbates
user dissatisfaction and contributes to a growing
divide between health and social services157,158,159.
Information on low- and middle-income countries
is harder to obtain160, but there are indications
that patterns are similar. Some studies estimate
that in Latin America and the Caribbean more
reliance on generalist care could avoid one out of
two hospital admissions161. In Thailand, generalist
ambulatory care outside a hospital context
has been shown to be more patient-centred and
responsive as well as cheaper and less inclined
to over-medicalization162 (Figure 3.4).
The relocation of the entry point into the system
from specialist hospital to generalist ambulatory
care creates the conditions for more comprehensiveness,
continuity and person-centredness.
This amplifi es the benefi ts of the relocation. It
is particularly the case when services are organized
as a dense network of small, close-to-client
service delivery points. This makes it easier to
have teams that are small enough to know their
communities and be known by them, and stable
enough to establish an enduring relationship.
These teams require relational and organizational
capacities as much as the technical competencies
to solve the bulk of health problems
locally.
Responsibility for a well-identifi ed
population
In conventional ambulatory care, the provider
assumes responsibility for the person attending
the consultation for the duration of the consultation
and, in the best of circumstances, that
responsibility extends to ensuring continuity of
care. This passive, response-to-demand approach
fails to help a considerable number of people who
could benefi t from care. There are people who,
for various reasons, are, or feel, excluded from
access to services and do not take up care even
when they are in need. There are people who suffer
illness but delay seeking care. Others present
risk factors and could benefi t from screening or
prevention programmes (e.g. for cervical cancer
or for childhood obesity), but are left out because
they do not consult: preventive services that are
limited to service users often leave out those
most in need163. A passive, response-to-demand
Patients for whom inappropriate investigations were prescribed (%)
0
Public health centre,
general practitioner
(US $ 5.7)b
Figure 3.4 Inappropriate investigations prescribed for simulated patients
presenting with a minor stomach complaint, Thailanda,b,162
a Observation made in 2000, before introduction of Thailand’s universal coverage scheme.
b Cost to the patient, including doctor’s fees, drugs, laboratory and technical investigations.
20
40
60
Private hospital,
outpatient
department (US $ 43.7)b
Public hospital,
outpatient department
(US $15.2)b
Private clinic,
specialist
(US $ 16.4)b
Private clinic,
general practitioner
(US $ 11.1)b
Biopsy
X-ray
Gastroscopy
Gastroscopy + X-ray
The World Health Report 2008 Primary Health Care – Now More Than Ever
54
approach has a second untoward consequence: it
lacks the ambition to deal with local determinants
of ill-health – whether social, environmental or
work-related. All this represents lost opportunities
for generating health: providers that only
assume responsibility for their customers concentrate
on repairing rather than on maintaining
and promoting health.
The alternative is to entrust each primary-care
team with the explicit responsibility for a welldefi
ned community or population. They can then
be held accountable, through administrative measures
or contractual arrangements, for providing
comprehensive, continuous and person-centred
care to that population, and for mobilizing a
comprehensive range of support services – from
promotive through to palliative. The simplest
way of assigning responsibility is to identify the
community served on the basis of geographical
criteria – the classic approach in rural areas. The
simplicity of geographical assignment, however,
is deceptive. It follows an administrative, public
sector logic that often has problems adapting to
the emergence of a multitude of other providers.
Furthermore, administrative geography may not
coincide with sociological reality, especially in
urban areas. People move around and may work
in a different area than where they live, making
the health unit closest to home actually an inconvenient
source of care. More importantly, people
value choice and may resent an administrative
assignment to a particular health unit. Some
countries fi nd geographical criteria of proximity
the most appropriate to defi ne who fi ts in the
population of responsibility, others rely on active
registration or patient lists. The important point
is not how but whether the population is well
identifi ed and mechanisms exist to ensure that
nobody is left out.
Once such explicit comprehensive responsibilities
for the health of a well-identifi ed and defi ned
population are assigned, with the related fi nancial
and administrative accountability mechanisms,
the rules change.
The primary-care �� team has to broaden the
portfolio of care it offers, developing activities
and programmes that can improve outcomes,
but which they might otherwise neglect164. This
sets the stage for investment in prevention and
promotion activities, and for venturing into
areas that are often overlooked, such as health
in schools and in the workplace. It forces the
primary-care team to reach out to and work
with organizations and individuals within the
community: volunteers and community health
workers who act as the liaison with patients or
animate grassroots community groups, social
workers, self-help groups, etc.
�� It forces the team to move out of the four walls
of their consultation room and reach out to
the people in the community. This can bring
signifi cant health benefi ts. For example, largescale
programmes, based on home-visits and
community animation, have been shown to be
effective in reducing risk factors for neonatal
mortality and actual mortality rates. In the
United States, such programmes have reduced
neonatal mortality by 60% in some settings165.
Part of the benefi t is due to better uptake of
effective care by people who would otherwise
remain deprived. In Nepal, for example, the
community dynamics of women’s groups led
to the better uptake of care, with neonatal and
maternal mortality lower than in control communities
by 29% and 80%, respectively166.
�� It forces the team to take targeted initiatives,
in collaboration with other sectors, to reach
the excluded and the unreached and tackle
broader determinants of ill-health. As Chapter
2 has shown, this is a necessary complement to
establishing universal coverage and one where
local health services play a vital role. The 2003
heatwave in western Europe, for example,
highlighted the importance of reaching out to
the isolated elderly and the dramatic consequences
of failing to do so: an excess mortality
of more than 50 000 people167.
For people and communities, formal links with
an identifi able source of care enhance the likelihood
that long-term relationships will develop;
that services are encouraged to pay more attention
to the defi ning features of primary care; and
that lines of communication are more intelligible.
At the same time, coordination linkages can be
formalized with other levels of care – specialists,
hospitals or other technical services – and with
social services.
55
Chapter 3. Primary care: putting people fi rst
The primary-care team as a hub
of coordination
Primary-care teams cannot ensure comprehensive
responsibility for their population without
support from specialized services, organizations
and institutions that are based outside the community
served. In resource-constrained circumstances,
these sources of support will typically
be concentrated in a “fi rst referral level district
hospital”. Indeed, the classic image of a healthcare
system based on PHC is that of a pyramid
with the district hospital at the top and a set of
(public) health centres that refer to the higher
authority.
In conventional settings, ambulatory care professionals
have little say in how hospitals and
specialized services contribute – or fail to contribute
– to the health of their patients, and feel
little inclination to reach out to other institutions
and stakeholders that are relevant to the health
of the local community. This changes if they are
entrusted with responsibility for a defi ned population
and are recognized as the regular point of
entry for that population. As health-care networks
expand, the health-care landscape becomes far
more crowded and pluralistic. More resources
allow for diversifi cation: the range of specialized
services that comes within reach may include
emergency services, specialists, diagnostic
infrastructure, dialysis centres, cancer screening,
environmental technicians, long-term care
institutions, pharmacies, etc. This represents
new opportunities, provided the primary-care
teams can assist their community in making the
best use of that potential, which is particularly
critical to public health, mental health and longterm
care168.
The coordination (or gatekeeping) role this
entails effectively transforms the primary-care
pyramid into a network, where the relations
between the primary-care team and the other
institutions and services are no longer based only
on top-down hierarchy and bottom-up referral,
but on cooperation and coordination (Figure 3.5).
The primary-care team then becomes the mediator
between the community and the other levels
Surgery
Maternity
Figure 3.5 Primary care as a hub of coordination: networking within the community served
and with outside partners173,174
Environmental
health lab
Training Training centre
support
Cancer
screening
centre
Women’s
shelter
Alcoholics
anonymous
Community
mental
health unit
Emergency
department
Specialized care Hospital
Diagnostic services
TB
control
centre
Diabetes clinic
CT
Scan
Cytology
lab
Diagnostic support
Self-help
group
Liaison
community
health worker
Other
Other
Social
services
Specialized NGOs
prevention services
Community
Primary-care team:
continuous,
comprehensive,
person-centred care
Pap smears
Waste disposal
inspection
Mammography
Gender
violence
Alcoholism
Hernia
Placenta
praevia
Traffic
accident
Consultant
Referral for support
multi-drug resistance
Referral for
complications
The World Health Report 2008 Primary Health Care – Now More Than Ever
56
of the health system, helping people navigate the
maze of health services and mobilizing the support
of other facilities by referring patients or
calling on the support of specialized services.
This coordination and mediation role also
extends to collaboration with other types of
organizations, often nongovernmental. These
can provide signifi cant support to local primary
care. They can help ensure that people know what
they are entitled to and have the information to
avoid substandard providers169,170. Independent
ombudsman structures or consumer organizations
can help users handle complaints. Most
importantly, there is a wealth of self-help and
mutual support associations for diabet ics, people
living with handicaps and chronic diseases that
can help people to help themselves171. In the
United States alone, more than fi ve million people
belong to mutual help groups while, in recent
years, civil society organizations dealing with
health and health-related issues, from self-help
to patient’s rights, have been mushrooming in
many low- and middle-income countries. These
groups do much more than just inform patients.
They help people take charge of their own situation,
improve their health, cope better with illhealth,
increase self-confi dence and diminish
over-medicalization172. Primary-care teams can
only be strengthened by reinforcing their linkages
with such groups.
Where primary-care teams are in a position
to take on this coordinator role, their work
becomes more rewarding and attractive, while
the overall effects on health are positive. Reliance
on specialists and hospitalization is reduced by
fi ltering out unnecessary uptake, whereas patient
delay is reduced for those who do need referral
care, the duration of their hospitalization is
shortened, and post-hospitalization follow-up is
improved83,128,129.
The coordination function provides the institutional
framework for mobilizing across sectors to
secure the health of local communities. It is not an
optional extra but an essential part of the remit of
primary-care teams. This has policy implications:
coordination will remain wishful thinking unless
the primary-care team has some form of either
administrative or fi nancial leverage. Coordination
also depends on the different institutions’
recognition of the key role of the primary-care
teams. Current professional education systems,
career structure and remuneration mechanisms
most often give signals to the contrary. Reversing
these well-entrenched disincentives to primary
care requires strong leadership.
Monitoring progress
The switch from conventional to primary care is
a complex process that cannot be captured in a
single, universal metric. Only in recent years has
it been possible to start disentangling the effects
of the various features that defi ne primary care.
In part, this is because the identifi cation of the
features that make the difference between primary
care and conventional health-care delivery
has taken years of trial and error, and the instruments
to measure them have not been generalized.
This is because these features are never all
put into place as a single package of reforms, but
are the result of a gradual shaping and transformation
of the health system. Yet, for all this
complexity, it is possible to measure progress, as
a complement to the follow-up required for measuring
progress towards universal coverage.
The fi rst dimension to consider is the extent
to which the organizational measures required
to switch to primary care are being put into
place.
Is the predominant t �� ype of fi rst-contact provider
being shifted from specialists and hospitals
to generalist primary-care teams in close
proximity to where the people live?
�� Are primary-care providers being made
responsible for the health of all the members of
a well-identifi ed population: those who attend
health services and those who do not?
�� Are primary-care providers being empowered
to coordinate the various inputs of specialized,
hospital and social services, by strengthening
their administrative authority and purchasing
power?
The second dimension to consider is the extent
to which the distinctive features of primary care
are gaining prominence.
�� Person-centredness: is there evidence of
improvement, as shown by direct observation
and user surveys?
57
Chapter 3. Primary care: putting people fi rst
Comprehensiveness: i �� s the portfolio of primary-
care services expanding and becoming
more comprehensive, reaching the full essential
benefi ts package, from promotion through
to palliation, for all age groups?
�� Continuity: is information for individuals being
recorded over the life-course, and transferred
between levels of care in cases of referral and
to a primary-care unit elsewhere when people
relocate?
�� Regular entry point: are measures taken to
ensure that providers know their clients and
vice versa?
This should provide the guidance to policy-makers
as to the progress they are making with the transformation
of health-care delivery. However, they
do not immediately make it possible to attribute
References
1. People at the centre of health care: harmonizing mind and body, people and systems.
New Delhi, World Health Organization Regional Offi ce for South-East Asia, Manila,
World Health Organization Regional Offi ce for the Western Pacifi c, 2007.
2. Osler W. Aequanimitas. Philadelphia PA, Blakiston, 1904.
3. Eby D. Primary care at the Alaska Native Medical Centre: a fully deployed “new
model” of primary care. International Journal of Circumpolar Health, 2007,
66(Suppl. 1):4−13.
4. Eby D. Integrated primary care. International Journal of Circumpolar Health, 1998,
57(Suppl. 1):665−667.
5. Gottlieb K, Sylvester I, Eby D. Transforming your practice: what matters most. Family
Practice Management, 2008, 15:32−38.
6. Kerssens JJ et al. Comparison of patient evaluations of health care quality in relation
to WHO measures of achievement in 12 European countries. Bulletin of the World
Health Organization, 2004 82:106−114.
7. Bossyns P, Miye M, Van Lerberghe W. Supply-level measures to increase uptake of
family planning services in Niger: the effectiveness of improving responsiveness.
Tropical Medicine and International Health, 2002, 7:383−390.
8. The World Health Report 2000 − Health systems: improving performance. Geneva,
World Health Organization, 2000.
9. Mercer SW, Cawston PG, Bikker AP. Quality in general practice consultations: a
qualitative study of the views of patients living in an area of high socio-economic
deprivation in Scotland. BMC Family Practice, 2007, 8:22.
10. Scherger JE. What patients want. Journal of Family Practice, 2001, 50:137.
11. Sackett DL et al. Evidence based medicine: what it is and what it isn’t. British
Medical Journal, 1996, 312:71–72.
12. Guyatt G, Cook D, Haynes B. Evidence based medicine has come a long way: The
second decade will be as exciting as the fi rst. BMJ, 2004, 329:990−991.
13. Cochrane database of systematic reviews. The Cochrane Library, 2008 (http://www.
cochrane.org, accessed 27 July 2008).
14. Iha A, ed. Summary of the evidence on patient safety: implications for research.
Geneva, World Health Organization, The Research Priority Setting Working Group of
the World Alliance for Patient Safety, 2008.
15. Smith GD, Mertens T. What’s said and what’s done: the reality of sexually
transmitted disease consultations. Public Health, 2004, 118:96–103.
16. Berwick DM. The science of improvement. JAMA, 2008, 299:1182–1184.
17. Donaldson L, Philip P. Patient safety: a global priority. Bulletin of the World Health
Organization, 2004, 82:892−893
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 Health
Care in America, Institute of Medicine, 1999.
19. Reason J. Human error: models and management. BMJ, 2000, 320:768−770.
20. Kripalani S et al. Defi cits in communication and information transfer between
hospital-based and primary care physicians: implications for patient safety and
continuity of care. JAMA, 2007, 297:831−841.
21. Miller MA, Pisani E. The cost of unsafe injections. Bulletin of the World Health
Organization, 1999, 77:808–811.
22. The purpose of a world alliance. Geneva, World Health Organization, World Alliance
for Patient Safety, 2008 (http://www.who.int/patientsafety/worldalliance/alliance/
en/, accessed 28 July 2008).
23. Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA
2008, 299:445−447.
24. Das J, Hammer JS, Kenneth LL. The quality of medical advice in low-income
countries. Washington DC, The World Bank, 2008 (World Bank Policy Research
Working Paper No. 4501; http://ssrn.com/abstract=1089272, accessed 28 Jul
2008).
25. Schoen C et al. Taking the pulse of health care systems: experiences of patients with
health problems in six countries. Health Affairs, 2005 (web exclusive W 5-5 0 9 DOI
10.1377/hlthaff.W5.509).
26. Mekbib TA, Teferi B. Caesarean section and foetal outcome at Yekatit 12 hospital,
Addis Abba, Ethiopia, 1987-1992. Ethiopian Medical Journal, 1994, 32:173−179.
27. Siddiqi S et al. The effectiveness of patient referral in Pakistan. Health Policy and
Planning, 2001, 16:193−198.
28. Sanders D et al. Zimbabwe’s hospital referral system: does it work? Health Policy
and Planning, 1998, 13:359−370.
29. Data reported at World Aids Day Meeting, Antwerp, Belgium, 2000.
30. The World Health Report 2005 − Make every mother and child count. Geneva, World
Health Organization, 2005.
31. Starfi eld B, Shi L, Macinko J. Contributions of primary care to health systems and
health. The Milbank Quarterly, 2005, 83:457−502.
32. Heise L, Garcia-Moreno C. Intimate partner violence. In: Krug EG et al, eds. World
report on violence and health. Geneva, World Health Organization, 2002.
33. Ellsberg M et al. Intimate partner violence and women’s physical and mental health
in the WHO multi-country study on women’s health and domestic violence: an
observational study. Lancet, 2008, 371:1165−1172.
health and social outcomes to specifi c aspects of
the reform efforts. In order to do so, the monitoring
of the reform effort needs to be complemented
with a much more vigorous research agenda. It is
revealing that the Cochrane Review on strategies
for integrating primary-health services in lowand
middle-income countries could identify only
one valid study that took the user’s perspective
into account160. There has been a welcome surge
of research on primary care in high-income countries
and, more recently, in the middle-income
countries that have launched major PHC reforms.
Nevertheless, it is remarkable that an industry
that currently mobilizes 8.6% of the world’s GDP
invests so little in research on two of its most
effective and cost-effective strategies: primary
care and the public policies that underpin and
complement it.
The World Health Report 2008 Primary Health Care – Now More Than Ever
58
Campbell JC. Health consequences of intimate 34. partner violence. Lancet, 2002,
359:1331−1336.
35. Edleson JL. Children’s witnessing of domestic violence. Journal of Interpersonal
Violence, 1996, 14: 839–870.
36. Dube SR et al. Exposure to abuse, neglect, and household dysfunction among adults
who witnessed intimate partner violence as children: implications for health and
social services. Violence and Victims, 2002, 17: 3–17.
37. Åsling-Monemi K et al. Violence against women increases the risk of infant and
child mortality: a case-referent study in Nicaragua. Bulletin of the World Health
Organization, 2003, 81:10−18.
38. Bonomi A et al. Intimate partner violence and women’s physical, mental and social
functioning. American Journal of Preventive Medicine, 2006, 30:458-466.
39. National Centre for Injury Prevention and Control. Costs of intimate partner violence
against women in the United States. Atlanta GA, Centres for Disease Control and
Prevention, 2003.
40. Ramsay J et al. Should health professionals screen women for domestic violence?
Systematic review. BMJ, 2002, 325:314−318.
41. Nelson HD et al. Screening women and elderly adults for family and intimate partner
violence: a review of the evidence for the U.S. Preventive Services Task force.
Annals of Internal Medicine, 2004, 140:387−403.
42. Garcia-Moreno C. Dilemmas and opportunities for an appropriate health-service
response to violence against women. Lancet, 2002, 359:1509−1514.
43. Wathan NC, MacMillan HL. Interventions for violence against women. Scientifi c
review. JAMA, 2003, 289:589−600.
44. Sullivan CM, Bybee DI. Reducing violence using community-based advocacy for
women with abusive partners. Journal of Consulting and Clinical Psychology, 1999,
67:43−53.
45. Tiwari A et al. A randomized controlled trial of empowerment training for
Chinese abused pregnant women in Hong Kong. British Journal of Obstetrics and
Gynaecology, 2005, 112:1249−1256.
46. Taket A et al. Routinely asking women about domestic violence in health settings.
BMJ, 2003, 327:673−676.
47. MacDonald R. Time to talk about rape. BMJ, 2000, 321:1034−1035.
48. Basile KC, Hertz FM, Back SE. Intimate partner and sexual violence victimization
instruments for use in healthcare settings. 2008. Atlanta GA, Centers for Disease
Control and Prevention, 2008.
49. Guidelines for the medico-legal care of victims of sexual violence. Geneva, World
Health Organization, 2003.
50. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the
empirical literature. Social Science and Medicine, 51:1087−1110.
51. Stewart M. Towards a global defi nition of patient centred care. BMJ, 2001,
322:444−445.
52. Fiscella K et al. Patient trust: is it related to patient-centred behavior of primary care
physicians? Medical Care, 2004, 42:1049−1055.
53. Marincowitz GJO, Fehrsen GS. Caring, learning, improving quality and doing
research: Different faces of the same process. Paper presented at: 11th South
African Family Practice Congress, Sun City, South Africa, August 1998.
54. Ferrer RL, Hambidge SJ, Maly RC. The essential role of generalists in health care
systems. Annals of Internal Medicine, 2005, 142:691−699.
55. Gulbrandsen P, Hjortdahl P, Fugelli P. General practitioners’ knowledge of their
patients’ psychosocial problems: multipractice questionnaire survey. British Medical
Journal, 1997, 314:1014–1018.
56. Jaturapatporn D, Dellow A. Does family medicine training in Thailand affect patient
satisfaction with primary care doctors? BMC Family Practice, 2007, 8:14.
57. Kovess-Masféty V et al. What makes people decide who to turn to when faced with
a mental health problem? Results from a French survey. BMC Public Health, 2007,
7:188.
58. Bergeson D. A systems approach to patient-centred care. JAMA, 2006, 296:23.
59. Kravitz RL et al. Recall of recommendations and adherence to advice among
patients with chronic medical conditions. Archives of Internal Medicine, 1993,
153:1869−1878.
60. Werner D et al. Questioning the solution: the politics of primary health care and child
survival, with an in-depth critique of oral rehydration therapy. Palo Alto CA, Health
Wrights, 1997.
61. Norris et al. Increasing diabetes self-management education in community settings.
A systematic review. American Journal of Preventive Medicine, 2002, 22:39−66.
62. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as
constraints to referral by isolated nurses in rural Niger. Human Resources for Health,
2004, 2:1.
63. Willems S et al. Socio-economic status of the patient and doctor-patient
communication: does it make a difference. Patient Eucation and Counseling, 2005,
56:139−146.
64. Pongsupap Y. Introducing a human dimension to Thai health care: the case for family
practice. Brussels, Vrije Universiteit Brussel Press. 2007.
65. Renewing primary health care in the Americas. A Position paper of the Pan American
Health Organization. Washington DC, Pan American Health Organization, 2007.
66. Penny Simkin, PT. Birth plans: after 25 years, women still want to be heard.
Birth, 34:49–51.
67. Portela A, Santarelli C. Empowerment of women, men, families and communities:
true partners for improving maternal and newborn health. British Medical Bulletin,
2003, 67:59−72.
68. Wallerstein N. What is the evidence on effectiveness of empowerment to improve
health? Copenhagen, World Health Organization Regional Offi ce for Europe 2006
(Health Evidence Network report; (http://www.euro.who.int/Document/E88086.pdf,
accessed 21-11-07).
69. Diabète-France.com − portail du diabète et des diabetiques en France, 2008 (http://
www.diabete-france.com, accessed 30 July 2008).
70. Barlow J, Cohen E, Stewart-Brown SSB. Parent training for improving maternal
psychosocial health. Cochrane Database of Systematic Reviews,2003,
(4):CD002020.
71. Ahluwalia I. An evaluation of a community-based approach to safe motherhood in
northwestern Tanzania. International Journal of Gynecology and Obstetrics, 2003,
82:231.
72. De la Luz Martínez-Maldonado M, Correa-Muñoz E, Mendoza-Núñez VM. Program
of active aging in a rural Mexican community: a qualitative approach. BMC Public
Health, 2007, 7:276 (DOI:10.1186/1471-2458-7-276).
73. Frenz P. Innovative practices for intersectoral action on health: a case study of four
programs for social equity. Chilean case study prepared for the CSDH. Santiago,
Ministry of Health, Division of Health Planning, Social Determinants of Health
Initiative, 2007.
74. Paetthayasapaa. Kam Prakard Sitti Pu Paui, 2003? (http://www.tmc.or.th/,
accessed 30 July 2008).
75. Prince M, Livingston G, Katona C. Mental health care for the elderly in low-income
countries: a health systems approach. World Psychiatry, 2007, 6:5−13.
76. Nanda P. Women’s participation in rural credit programmes in Bangladesh and their
demand for formal health care: is there a positive impact? Health Economics, 1999,
8:415−428.
77. Nakkash R et al. The development of a feasible community-specifi c cardiovascular
disease prevention program: triangulation of methods and sources. Health Education
and Behaviour, 2003, 30:723−739.
78. Stange KC. The paradox of the parts and the whole in understanding and improving
general practice. International Journal for Quality in Health Care, 2002, 14:267−268.
79. Gill JM. The structure of primary care: framing a big picture. Family Medicine, 2004,
36:65−68.
80. Pan-Canadian Primary Health Care Indicator Development Project. Pan-Canadian
primary health care indicators, Report 1, Volume 1. Ottawa, Canadian Institute for
Health Information 2008 (http:www.cihi.ca).
81. Bindman AB et al. Primary care and receipt of preventive services. Journal of
General Internal Medicine, 1996, 11:269−276.
82. Forrest CB, Starfi eld B. The effect of fi rst-contact care with primary care clinicians
on ambulatory health care expenditures. Journal of Family Practice, 1996,
43:40–48.
83. Chande VT, Kinane JM. Role of the primary care provider in expediting children
with acute appendicitis. Achives of Pediatrics and Adolescent Medicine, 1996,
150:703−706.
84. Starfi eld B. Primary care: balancing health needs, services, and technology. New
York, Oxford University Press 1998.
85. Bindman AB et al. Primary care and receipt of preventive services. Journal of
General Internal Medicine, 1996, 11:269–276.
86. Shea S et al. Predisposing factors for severe, uncontrolled hypertension in an innercity
minority population. New England Journal of Medicine, 1992, 327:776–781.
87. Galobardes B, Lynch JW, Davey Smith G. Is the association between childhood
socioeconomic circumstances and cause-specifi c mortality established? Update
of a systematic review. Journal of Epidemiology and Community Health, 2008,
62:387−390.
88. Guide to clinical preventive services, 2007. Rockville MD, Agency for Healthcare
Research and Quality, 2007 (AHRQ Publication No. 07-05100; http://www.ahrq.gov/
clinic/pocketgd.htm).
89. Porignon D et al. Comprehensive is effective: vaccination coverage and health system
performance in Sub-Saharan Africa, 2008 (forthcoming).
90. Shi L et al. The relationship between primary care, income inequality, and mortality
in the United States, 1980–1995. Journal of the American Board of Family Practice,
2003, 16:412–422.
91. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians.
Health care expenditures and mortality experience. Journal of Family Practice, 1998,
47:105–109.
92. Villalbi JR et al. An evaluation of the impact of primary care reform on health.
Atenci´on Primaria, 1999, 24:468–474.
59
Chapter 3. Primary care: putting people fi rst
93. Regional core health data initiative. Washington DC, Pan American Health
Organization, 2005 (http://www.paho.org/English/SHA/coredata/tabulator/
newTabulator.htm).
94. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care.
American Journal of Public Health, 2000, 90:1771–1774.
95. Forrest CB, Starfi eld B. Entry into primary care and continuity: the effects of access.
American Journal of Public Health, 1998, 88:1330–1336.
96. Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care
reduce hospital readmissions? For The Veterans Affairs Cooperative Study Group on
Primary Care and Hospital Readmission. New England Journal of Medicine, 1996,
334:1441–1447.
97. Woodward CA et al. What is important to continuity in home care? Perspectives of
key stakeholders. Social Science and Medicine, 2004, 58:177–192.
98. Gill JM, Mainous AGI, Nsereko M. The effect of continuity of care on emergency
department use. Archives of Family Medicine, 2000, 9:333−338.
99. Rothwell P. Subgroup analysis in randomised controlled trials: importance,
indications, and interpretation, Lancet, 2005, 365:176−186.
100. Kravitz RL, Duan N, Braslow J. Evidence-based medicine, heterogeneity of
treatment effects, and the trouble with averages. The Milbank Quarterly, 2004,
82:661–687.
101. Stiell A. et al. Prevalence of information gaps in the emergency department and
the effect on patient outcomes. Canadian Medical Association Journal, 2003,
169:1023−1028.
102. Smith PC et al. Missing clinical information during primary care visits. JAMA, 2005,
293:565−571.
103. Elder NC, Vonder Meulen MB, Cassedy A. The identifi cation of medical errors
by family physicians during outpatient visits. Annals of Family Medicine, 2004,
2:125−129.
104. Elwyn G. Safety from numbers: identifying drug related morbidity using electronic
records in primary care. Quality and Safety in Health Care, 2004, 13:170−171.
105. Open Medical Records System (OpenMRS) [online database]. Cape Town, South
African Medical Research Council, 2008 (http://openmrs.org/wiki/OpenMRS,
accessed 29 July 2008).
106. Hüsler J, Peters T. Evaluation of the On Cue Compliance Service pilot: testing
the use of SMS reminders in the treatment of tuberculosis in Cape Town, South
Africa. Prepared for the City of Cape Town Health Directorate and the International
Development Research Council (IDRC). Cape Town, Bridges Organization, 2005.
107. Smith-Rohrberg Maru D et al. Poor follow-up rates at a self-pay northern Indian
tertiary AIDS clinic. International Journal for Equity in Health, 2007, 6:14.
108. Busse R, Schlette S, eds. Focus on prevention, health and aging, and health
professions. Gütersloh, Verlag Bertelsmann Stiftung, 2007 (Health policy
developments 7/8).
109. James Pfeiffer International. NGOs and primary health care in Mozambique:
the need for a new model of collaboration. Social Science and Medicine, 2003,
56:725–738.
110. Jaffré Y, Olivier de Sardan J-P. Une médecine inhospitalière. Les diffi ciles relations
entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest. Paris, Karthala,
2003.
111. Naithani S, Gulliford M, Morgan M. Patients’ perceptions and experiences of
“continuity of care” in diabetes. Health Expectations, 2006, 9:118−129.
112. Schoenbaum SC. The medical home: a practical way to improve care and cut costs.
Medscape Journal of Medicine , 2007, 9:28.
113. Beach MC. Are physicians’ attitudes of respect accurately perceived by patients
and associated with more positive communication behaviors? Patient Education and
Counselling, 2006, 62:347−354 (Epub 2006 Jul 21).
114. Farmer JE et al. Comprehensive primary care for children with special health care
needs in rural areas. Pediatrics, 2005, 116:649−656.
115. Pongsupap Y, Van Lerberghe W. Patient experience with self-styled family practices
and conventional primary care in Thailand. Asia Pacifi c Family Medicine Journal,
2006, Vol 5.
116. Weiss LJ, Blustein J. Faithful patients: the effect of long term physician–patient
relationships on the costs and use of health care by older Americans. American
Journal of Public Health, 1996, 86:1742–1747.
117. Rosenblatt RL et al. The generalist role of specialty physicians: is there a hidden
system of primary care? JAMA,1998, 279:1364−1370.
118. Kempe A et al. Quality of care and use of the medical home in a state-funded
capitated primary care plan for low-income children. Pediatrics, 2000,
105:1020−1028.
119. Raddish MS et al. Continuity of care: is it cost effective? American Journal of
Managed Care, 1999, 5:727−734.
120. De Maeseneer JM et al. Provider continuity in family medicine: does it make a
difference for total health care costs? Annals of Family Medicine, 2003, 1:131−133.
121. Saver B. Financing and organization fi ndings brief. Academy for Research and Health
Care Policy, 2002, 5:1−2.
122. Tudiver F, Herbert C, Goel V. Why don’t family physicians follow clinical practice
guidelines for cancer screening? Canadian Medical Association Journal, 1998,
159:797−798.
123. Oxman AD et al. No magic bullets: a systematic review of 102 trials of interventions
to improve professional practice. Canadian Medical Association Journal, 1995,
153:1423−1431.
124. Freeman G, Hjortdahl P. What future for continuity of care in general practice? British
Medical Journal, 1997, 314: 1870−1873.
125. Miller MR et al. Parental preferences for primary and specialty care collaboration
in the management of teenagers with congenital heart disease. Pediatrics, 2000,
106:264−269.
126. Mainous AG III, Gill JM. The importance of continuity of care in the likelihood of
future hospitalization: is site of care equivalent to a primary clinician? American
Journal of Public Health, 1998, 88:1539−1541.
127. Parchman ML, Culler SD. Primary care physicians and avoidable hospitalizations.
Journal of Family Practice, 1994, 39:123−128.
128. Hurley RE, Freund DA, Taylor DE. Emergency room use and primary care case
management: evidence from four medicaid demonstration programs. American
Journal of Public Health, 1989, 79: 834−836.
129. Martin DP et al. Effect of a gatekeeper plan on health services use and charges: a
randomized trial. American Journal of Public Health, 1989, 79:1628–1632.
130. Gadomski A, Jenkins P, Nichols M. Impact of a Medicaid Primary Care Provider
and Preventive Care on pediatric hospitalization. Pediatrics, 1998, 101:E1 (http://
pediatrics.aappublications.org/cgi/reprint/101/3/e1, accessed 29 July 2008).
131. Hjortdahl P, Borchgrevink CF. Continuity of care: infl uence of general practitioners’
knowledge about their patients on use of resources in consultations. British Medical
Journal, 1991, 303:1181–1184.
132. Roos NP, Carriere KC, Friesen D. Factors infl uencing the frequency of visits by
hypertensive patients to primary care physicians in Winnipeg. Canadian Medical
Association Journal, 1998, 159:777–783.
133. Ryan S et al. The effects of regular source of care and health need on medical care
use among rural adolescents. Archives of Pediatric and Adolescent Medicine, 2001,
155:184–190.
134. Schoen C et al. Towards higher-performance health systems: adults’ health care
experiences in seven countries, 2007. Health Affairs, 2007, 26:w717−w734.
135. Saltman R, Rico A, Boerma W, eds. Primary 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).
136. Nutting PA. Population-based family practice: the next challenge of primary care.
Journal of Family Practice, 1987, 24:83−88.
137. Strategies for population health: investing in the health of Canadians. Ottawa, Health
Canada, Advisory Committee on Population Health, 1994.
138. Lasker R. Medicine and public health: the power of collaboration. New York, New
York Academy of Medicine, 1997.
139. Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: historical
perspective. Journal of the American Board of Family Practice, 2001,14:54−563.
140. Improving health for New Zealanders by investing in primary health care. Wellington,
National Health Committee, 2000.
141. Provenzale D et al. Gastroenterologist specialist care and care provided by
generalists − an evaluation of effectiveness and effi ciency. American Journal of
Gastroenterology, 2003, 98:21-8.
142. Smetana GW et al. A comparison of outcomes resulting from generalist vs specialist
care for a single discrete medical condition: a systematic review and methodologic
critique. Archives of Internal Medicine, 2007, 167:10−20.
143. Beck CA et al. Discharge prescriptions following admission for acute myocardial
infarction at tertiary care and community hospitals in Quebec. Canadian Journal of
Cardiology, 2001, 17:33−40.
144. Fendrick AM, Hirth RA, Chernew ME. Differences between generalist and specialist
physicians regarding Helicobacter pylori and peptic ulcer disease. American Journal
of Gastroenterology, 1996, 91:1544−1548.
145. Zoorob RJ et al. Practice patterns for peptic ulcer disease: are family physicians
testing for H. pylori? Helicobacter, 1999, 4:243−248.
146. Rose JH et al. Generalists and oncologists show similar care practices and outcomes
for hospitalized late-stage cancer patients. For SUPPORT Investigators (Study to
Understand Prognoses and Preferences for Outcomes and Risks for Treatment).
Medical Care, 2000, 38:1103−1118.
147. Krikke EH, Bell NR. Relation of family physician or specialist care to obstetric
interventions and outcomes in patients at low risk: a western Canadian cohort study.
Canadian Medical Association Journal, 1989, 140:637−643.
148. MacDonald SE, Voaklander K, Birtwhistle RV. A comparison of family physicians’ and
obstetricians’ intrapartum management of low-risk pregnancies. Journal of Family
Practice, 1993, 37:457-462.
149. Abyad A, Homsi R. A comparison of pregnancy care delivered by family physicians
versus obstetricians in Lebanon. Family Medicine, 1993 25:465−470.
The World Health Report 2008 Primary Health Care – Now More Than Ever
60
150. Grunfeld E et al. Comparison of breast cancer patient satisfaction with follow-up
in primary care versus specialist care: results from a randomized controlled trial.
British Journal of General Practice, 1999, 49:705−710.
151. Grunfeld E et al. Randomized trial of long-term follow-up for early-stage breast
cancer: a comparison of family physician versus specialist care. Journal of Clinical
Oncology, 2006, 24:848−855.
152. Scott IA et al. An Australian comparison of specialist care of acute myocardial
infarction. International Journal for Quality in Health Care, 2003, 15:155−161..
153. Regueiro CR et al. A comparison of generalist and pulmonologist care for patients
hospitalized with severe chronic obstructive pulmonary disease: resource intensity,
hospital costs, and survival. For SUPPORT Investigators (Study to Understand
Prognoses and Preferences for Outcomes and Risks of Treatment). American Journal
of Medicine, 1998, 105:366−372.
154. McAlister FA et al. The effect of specialist care within the fi rst year on subsequent
outcomes in 24,232 adults with new-onset diabetes mellitus: population-based
cohort study. Quality and Safety in Health Care, 2007, 16:6−11.
155. Greenfi eld S et al. Outcomes of patients with hypertension and non-insulin
dependent diabetes mellitus treated by different systems and specialties. Results
from the medical outcomes study. Journal of the American Medical Association,
1995, 274:1436−1444.
156. Pongsupap Y, Boonyapaisarnchoaroen T, Van Lerberghe W. The perception of
patients using primary care units in comparison with conventional public hospital
outpatient departments and “prime mover family practices”: an exit survey. Journal
of Health Science, 2005, 14:3.
157. Baicker K, Chandra A. Medicare spending, the physician workforce, and
benefi ciaries’ quality of care. Health Affairs, 2004 (Suppl. web exclusive:
W4-184−197).
158. Shi, L. Primary care, specialty care, and life chances. International Journal of Health
Services, 1994, 24:431−458.
159. Baicker K et al. Who you are and where you live: how race and geography affect
the treatment of Medicare benefi ciaries. Health Affairs, 2004 (web exclusive:
VAR33−V44).
160. Briggs CJ, Garner P. Strategies for integrating primary health services in middle
and low-income countries at the point of delivery. Cochrane Database of Systematic
Reviews, 2006, (3):CD003318.
161. Estudo regional sobre assistencia hospitalar e ambulatorial especializada na America
Latina e Caribe. Washington DC, Pan American Health Organization, Unidad de
Organización de Servicios de Salud, Area de Tecnología y Prestación de Servicios
de Salud, 2004.
162. Pongsupap Y, Van Lerberghe W. Choosing between public and private or between
hospital and primary care? Responsiveness, patient-centredness and prescribing
patterns in outpatient consultations in Bangkok. Tropical Medicine and International
Health, 2006, 11:81−89.
163. Guide to clinical preventive services, 2007. Rockville MD, Agency for Healthcare
Research and Quality, 2007 (AHRQ Publication No. 07-05100; http://www.ahrq.gov/
clinic/pocketgd.htm).
164. Margolis PA et al. From concept to application: the impact of a community-wide
intervention to improve the delivery of preventive services to children. Pediatrics,
2001, 108:E42.
165. Donovan EF et al. Intensive home visiting is associated with decreased risk of infant
death. Pediatrics, 2007, 119:1145−1151.
166. Manandhar D et al. Effect of a participatory intervention with women’s groups on
birth outcomes in Nepal: cluster-randomised controlled trial. Lancet, 364:970−979.
167. Rockenschaub G, Pukkila J, Profi li MC, eds. Towards health security. A discussion
paper on recent health crises in the WHO European Region. Copenhagen, World
Health Organization Regional Offi ce for Europe, 2007
168. Primary care. America’s health in a new era. Washington DC, National Academy
Press Institute of Medicine, 1996.
169. Tableau d’honneur des 50 meilleurs hôpitaux de France. Palmarès des Hôpitaux.
Le Point, 2008 (http://hopitaux.lepoint.fr/tableau-honneur.php, accessed 29 July
2008).
170. Davidson BN, Sofaer S, Gertler P. Consumer information and biased selection in the
demand for coverage supplementing Medicare. Social Science and Medicine, 1992,
34:1023−1034.
171. Davison KP, Pennebaker JW, Dickerson SS. Who talks? The social psychology of
illness support groups. American Psychology, 2000, 55:205−217.
172. Segal SP, Redman D, Silverman C. Measuring clients’ satisfaction with self-help
agencies. Psychiatric Services, 51:1148−1152.
173. Adapted from Wollast E, Mercenier P. Pour une régionalisation des soins. In: Groupe
d'Etude pour une Réforme de la Médecine. Pour une politique de la santé. Bruxelles,
Editions Vie Ouvrière/La Revue Nouvelle, 1971.
174. Criel B, De Brouwere V, Dugas S. Integration of vertical programmes in multi-function
health services. Antwerp, ITGPress, 1997 (Studies in Health Services Organization
and Policy 3).


Public policies
for the public’s health
Public policies in the health sector, together with
those in other sectors, have a huge potential to
secure the health of communities. They represent an important
complement to universal coverage and
service delivery reforms. Unfortunately,
in most societies, this potential is largely
untapped and failures to effectively
engage other sectors are widespread.
Looking ahead at the diverse range of
challenges associated with the growing
importance of ageing, urbanization and
the social determinants of health, there
is, without question, a need for a greater
capacity to seize this potential. That is why a drive for better
public policies – the theme of this chapter – forms a third
pillar supporting the move towards PHC, along with universal
coverage and primary care.
Chapter 4
The importance of effective
public policies for health 64
System policies that are
aligned with PHC goals 66
Public-health policies 67
Towards health
in all policies 69
Understanding the
under-investment 71
Opportunities for
better public policies 73
63
The World Health Report 2008
64
Primary Health Care – Now More Than Ever
The chapter reviews the policies that must be in
place. These are:
systems policies �� – the arrangements that are
needed across health systems’ building blocks
to support universal coverage and effective
service delivery;
�� public-health policies – the specifi c actions
needed to address priority health problems
through cross-cutting prevention and health
promotion; and
�� policies in other sectors – contributions to
health that can be made through intersectoral
collaboration.
The chapter explains how these different public
policies can be strengthened and aligned with
the goals pursued by PHC.
The importance of effective public
policies for health
People want to live in communities and environments
which secure and promote their health1.
Primary care, with universal access and social
protection represent key responses to these
expectations. People also expect their governments
to put into place an array of public policies
that span local through to supra-national level
arrangements, without which primary care and
universal coverage lose much of their impact and
meaning. These include the policies required to
make health systems function properly; to organize
public-health actions of major benefi t to all;
and, beyond the health sector, the policies that
can contribute to health and a sense of security,
while ensuring that issues, such as urbanization,
climate change, gender discrimination or social
stratifi cation are properly addressed.
A fi rst group of critical public policies are
the health systems policies (related to essential
drugs, technology, quality control, human
resources, accreditation, etc.) on which primary
care and universal coverage reforms depend.
Without functional supply and logistics systems,
for example, a primary-care network cannot
function properly: in Kenya, for example, children
are now much better protected against malaria
as a result of local services providing them with
insecticide-treated bednets2. This has only been
possible because the work of primary care was
supported by a national initiative with strong
political commitment, social marketing and
national support for supply and logistics.
Effective public-health policies that address
priority health problems are a second group without
which primary care and universal coverage
reforms would be hindered. These encompass the
technical policies and programmes that provide
guidance to primary-care teams on how to deal
with priority health problems. They also encompass
the classical public-health interventions,
from public hygiene and disease prevention to
health promotion. Some interventions, such as
the fortifi cation of salt with iodine, are only feasible
at the regional, national or, increasingly at
supra-national level. This may be because it is
only at those levels that there is the necessary
authority to decide upon such policies, or because
it is more effi cient to develop and implement
such policies on a scale that is beyond the local
dimensions of primary-care action. Finally, public
policies encompass the rapid response capacity,
in command-and-control mode, to deal with
acute threats to the public’s health, particularly
epidemics and catastrophes. The latter is of the
utmost political importance, because failures
profoundly affect the public’s trust in its health
authorities. The lack of preparedness and uncoordinated
responses of both the Canadian and
the Chinese health systems to the outbreak of
SARS in 2003, led to public outcries and eventually
to the establishment of a national public
health agency in Canada. In China, a similar lack
of preparedness and transparency led to a crisis
in confi dence – a lesson learned in time for subsequent
events3,4.
The third set of policies that is of critical concern
is known as “health in all policies”, which is
based on the recognition that population health
can be improved through policies that are mainly
controlled by sectors other than health5. The
health content of school curricula, industry’s
policy towards gender equality, or the safety
of food and consumer goods are all issues that
can profoundly infl uence or even determine the
health of entire communities, and that can cut
across national boundaries. It is not possible to
address such issues without intensive intersectoral
collaboration that gives due weight to health
in all policies.
65
Chapter 4. Public policies for the public’s health
Better public policies can make a difference
in very different ways. They can mobilize the
whole of society around health issues, as in Cuba
(Box 4.1). They can provide a legal and social environment
that is more or less favourable to health
outcomes. The degree of legal access to abortion,
for example, co-determines the frequency
and related mortality of unsafe abortion6. In
South Africa, a change in legislation increased
women’s access to a broad range of options for
the prevention and treatment of unwanted pregnancy,
resulting in a 91% drop in abortion-related
deaths7. Public policies can anticipate future
problems. In Bangladesh, for example, the death
toll due to high intensity cyclones and fl ooding
was 240 000 people in 1970. With emergency preparedness
and multisectoral risk reduction programmes,
the death toll of comparable or more
severe storms was reduced to 138 000 people in
1991 and 4500 people in 20078,9,10 .
In the 23 developing countries that comprise
80% of the global chronic disease burden, 8.5
million lives could be saved in a decade by a 15%
dietary salt reduction through manufacturers
voluntarily reducing salt content in processed
foods and a sustained mass-media campaign
encouraging dietary change. Implementation of
four measures from the Framework Convention
on Tobacco Control (increased tobacco taxes;
smoke-free workplaces; convention-compliant
packaging, labelling and awareness campaigns
about health risks; and a comprehensive advertising,
promotion, and sponsorship ban) could
save a further 5.5 million lives in a decade11. As is
often the case when considering social, economic
and political determinants of ill-health, improvements
are dependent on a fruitful collaboration
between the health sector and a variety of other
sectors.
Figure 4.1 Deaths attributable to unsafe abortion per 100 000 live births,
by legal grounds for abortiona,12,13
200
To save
the
women’s
life only,
or no grounds
> 200
150
100
50
0
Also to
preserve
health
Also in
cases
of rape
or
incest
Also in
cases
of fetal
impairment
Also for
economic
or
social
reasons
Also on request
aEvery dot represents one country.
Box 4.1 Rallying society’s resources for
health in Cuba14,15,16
In Cuba, average life expectancy at birth is the second highest
in the Americas: in 2006, it was 78 years, and only 7.1 per
1000 children died before the age of fi ve. Educational indicators
for young children are among the best in Latin America.
Cuba has achieved these results despite signifi cant economic
diffi culties – even today, GDP per capita is only I$ 4500. Cuba’s
success in ensuring child welfare refl ects its commitment to
national public-health action and intersectoral action.
The development of human resources for health has been a
national priority. Cuba has a higher proportion of doctors in
the population than any other country. Training for primary
care gives specifi c attention to the social determinants of
health. They work in multidisciplinary teams in comprehensive
primary-care facilities, where they are accountable for the
health of a geographically defi ned population providing both
curative and preventive services. They work in close contact
with their communities, social services and schools, reviewing
the health of all children twice a year with the teachers.
They also work with organizations such as the Federation of
Cuban Women (FMC) and political structures. These contacts
provide them with the means to act on the social determinants
of health within their communities.
Cuban national policy has also prioritized investing in early
child development. There are three non-compulsory preschool
education programmes, which together are taken up
by almost 100% of children under six years of age. In these
programmes, screening for developmental disorders facilitates
early intervention. Children who are identifi ed with special
needs, and their families, receive individual attention through
multidisciplinary teams that contain both health and educational
specialists. National policy in Cuba has not succumbed
to a false choice between investing in the medical workforce
and acting on the social determinants of health. Instead, it has
promoted intersectoral cooperation to improve health through
a strong preventive approach. In support of this policy, a large
workforce has been trained to be competent in clinical care,
working as an active part of the community it serves.
The World Health Report 2008
66
Primary Health Care – Now More Than Ever
System policies that are
aligned with PHC goals
There is growing awareness that when parts of
the health system malfunction, or are misaligned,
the overall performance suffers. Referred to variously
as “core functions”17 or “building blocks”18,
the components of health systems include infrastructure,
human resources, information, technologies
and fi nancing – all with consequences
for the provision of services. These components
are not aligned naturally or simply with the
intended direction of PHC reforms that promote
primary care and universal coverage: to obtain
that alignment requires deliberate and comprehensive
policy arrangements.
Experience in promoting essential medicines
has shed light on both the opportunities and
obstacles to effective systems policies for PHC.
Since the WHO List of Essential Medicines was
established in 1977, it has become a primary
stimulus to the development of national medicines
policies. Over 75% of the 193 WHO Member
States now claim to have a national list of essential
medicines, and over 100 countries have developed
a national medicine policy. Surveys reveal
that these policies have been effective in making
lower cost and safer medicines available and
more rationally used19,20. This particular policy
has been successfully designed to support PHC,
and it offers lessons on how to handle cross-cutting
challenges of scale effi ciencies and systems
co-dependence. Without such arrangements,
the health costs are enormous: nearly 30 000
children die every day from diseases that could
easily have been treated if they had had access
to essential medicines21.
Medicines policies are indicative of how effi -
ciencies in the scale of organization can be tapped.
Safety, effi cacy and quality of care have universal
properties that make them amenable to globally
agreed international standards. Adoption and
adaptation of these global standards by national
authorities is much more effi cient than each
country inventing its own standards. National
decision-making and purchasing mechanisms
can then guide rational, cost-effectiveness-based
selection of medicines and reduce costs through
bulk purchase. For example, Figure 4.2 shows
how centralized oversight of drug purchasing
and subsidization in New Zealand signifi cantly
improved access to essential medicines while
lowering the average prescription price. On a
larger scale, transnational mechanisms, such as
UNICEF’s international procurement of vaccines,
PAHO’s Revolving Fund and the Global Drug
Facility for tuberculosis treatment, afford considerable
savings as well as quality assurances
that countries on their own would be unlikely to
negotiate22,23,24,25.
A second key lesson of experience with essential
drugs policies is that a policy cannot exist
as an island and expect to be effectively implemented.
Its formulation must identify those other
systems elements, be they fi nancing, information,
infrastructure or human resources, upon which
its implementation is dependent. Procurement
mechanisms for pharmaceuticals, for example,
raise important considerations for systems fi nancing
policies: they are interdependent. Likewise,
human resources issues related to the education
of consumers as well as the training and working
conditions of providers are likely to be key
determinants of the rational use of drugs.
Systems policies for human resources have
long been a neglected area and one of the main
constraints to health systems development27. The
realization that the health MDGs are contingent
on bridging the massive health-worker shortfall
in low-income countries has brought long overdue
attention to a previously neglected area. Furthermore,
the evidence of increasing dependence on
migrant health workers to address shortages in
OECD countries underlines the fact that one country’s
policies may have a signifi cant impact on
another’s. The choices countries make – or fail to
600
500
Net expenditure (NZ$, millions)
0
1993
Figure 4.2 Annual pharmaceutical spending and number of prescriptions
dispensed in New Zealand since the Pharmaceutical Management
Agency was convened in 199326
100
400
200
300
700
Prescriptions (millions)
Average cost
per prescription:
NZ$ 24.3
30
25
0
5
20
10
15
35
Average cost
per prescription:
NZ$ 19.0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
67
Chapter 4. Public policies for the public’s health
make – can have major long-term consequences.
Human resources for health are the indispensable
input to effective implementation of primary
care and universal coverage reforms, and they
are also the personifi cation of the values that
defi ne PHC. Yet, in the absence of a deliberate
choice to guide the health workforce policy by the
PHC goals, market forces within the health-care
system will drive health workers towards greater
sub-specialization in tertiary care institutions,
if not towards migration to large cities or other
countries. PHC-based policy choices, on the other
hand, focus on making staff available for the
extension of coverage to underserved areas and
disadvantaged population groups, as with Malaysia’s
scaling up of 11 priority cadres of workers,
Ethiopia’s training of 30 000 Health Extension
Workers, Zambia’s incentives to health workers
to serve in rural areas, the 80 000 Lady Health
Workers in Pakistan, or the task shifting for the
care of HIV patients. These policies direct investments
towards the establishment of the primarycare
teams that are to be the hub of the PHCbased
health system: the 80 000 health workers
for Brazil’s 30 000 Family Health Teams or the
retraining of over 10 000 nurses and physicians
in Turkey. Furthermore, these policies require
both fi nancial and non-fi nancial incentives to
compete effectively for scarce human resources,
as in the United Kingdom, where measures have
been taken to make a career in primary care
fi nancially competitive with specialization.
The core business of ministries of health
and other public authorities is to put into place,
across the various building blocks of the health
system, the set of arrangements and mechanisms
required to meet their health goals. When a
country chooses to base its health systems on
PHC – when it starts putting into place primary
care and universal coverage reforms – its whole
arsenal of system policies needs to be aligned
behind these reforms: not just those pertaining
to service delivery models or fi nancing. It is possible
to develop system policies that do not take
account of the PHC agenda. It is also possible to
choose to align them to PHC. If a country opts
for PHC, effective implementation allows no half
measures; no health systems building block will
be left untouched.
Public-health policies
Aligning priority health programmes
with PHC
Much action in the health sector is marshalled
around specifi c high-burden diseases, such as
HIV/AIDS, or stages of the life course such as
children – so-called priority health conditions.
The health programmes that are designed around
these priorities are often comprehensive insofar
as they set norms, ensure visibility and quality
assurance, and entail a full range of entry
points to address them locally or at the level of
countries or regions. Responses to these priority
health conditions can be developed in ways that
either strengthen or undercut PHC28.
In 1999 for example, the Primary Care Department
of the Brazilian Paediatrics Society (SBP)
prepared a plan to train its members in the Integrated
Management of Childhood Illness (IMCI)
and to adapt this strategy to regional epidemiological
characteristics29. Despite conducting an
initial training course, the SBP then warned
paediatricians that IMCI was not a substitute for
traditional paediatric care and risked breaching
the basic rights of children and adolescents. In a
next step, it objected to the delegation of tasks to
the nurses, who are part of the multidisciplinary
family health teams, the backbone of Brazil’s PHC
policy. Eventually, the SBP attempted to reclaim
child and adolescent care as the exclusive domain
of paediatricians with the argument that this
ensured the best quality of care.
Experience with priority health programmes
shows that the way they are designed makes the
difference: trying to construct an entire set of
PHC reforms around the unique requirements
of a single disease leads to considerable ineffi -
ciencies. Yet, the reverse is equally true. While
AIDS has been referred to as a metaphor for all
that ails health systems and the wider society30,
the global response to the HIV pandemic can, in
many respects, also be viewed as a pathfi nder for
PHC. From the start, it has had a strong rightsbased
and social justice foundation31. Its links to
often marginalized and disadvantaged high-risk
constituencies, and concerns about stigma, have
led to concerted efforts to secure their rights and
entitlements to employment, social services and
The World Health Report 2008
68
Primary Health Care – Now More Than Ever
health care. Efforts to scale-up services to conform
to the goals of universal access have helped
to expose the critical constraints deriving from
the workforce crisis. The challenge of providing
life-long treatment in resource-constrained
settings has inspired innovations, such as more
effective deployment of scarce human resources
via “task shifting”, the use of “patient advocates”32,
and the unexpected implementation of electronic
health records. Most importantly, the adoption
of a continuum of care approaches for HIV/AIDS
from prevention to treatment to palliation has
helped to revive and reinforce core features of
primary care, such as comprehensiveness, continuity
and person-centredness32.
Countrywide public-health initiatives
While it is essential that primary-care teams
seek to improve the health of populations at local
level, this may be of limited value if national- and
global-level policy-makers fail to take initiatives
for broader, public policy measures, which are
important in changing nutrition patterns and
infl uencing the social determinants of health.
These can rarely be implemented only in the
context of local policies. Classical areas in which
beyond-local-scale public-health interventions
may be benefi cial include: altering individual
behaviours and lifestyles; controlling and preventing
disease; tackling hygiene and the broader
determinants of health; and secondary prevention,
including screening for disease33. This
includes measures such as the fortifi cation of
bread with folate, taxation of alcohol and tobacco,
and ensuring the safety of food, consumer goods
and toxic substances. Such national- and transnational-
scale public-health interventions have the
potential to save millions of lives. The successful
removal of the major risk factors of disease,
which is technically possible, would reduce premature
deaths by an estimated 47% and increase
global healthy life expectancy by an estimated 9.3
years34. However, as is the case for the priority
programmes discussed above, the corresponding
public-health policies must be designed so as to
reinforce the PHC reforms.
Not all such public-health interventions will
improve, for example, equity. Health promotion
efforts that target individual risk behaviours,
such as health education campaigns aimed at
smoking, poor nutrition and sedentary lifestyles,
have often inadvertently exacerbated inequities.
Socioeconomic differences in the uptake of onesize-
fi ts-all public-health interventions have, at
times, not only resulted in increased health inequities,
but also in victim-blaming to explain the
phenomenon35. Well-designed public-health policies
can, however, reduce inequities when they
provide health benefi ts to entire populations or
when they explicitly prioritize groups with poor
health36. The evidence base for privileging public
policies that reduce inequities is increasing, most
notably through the work of the Commission on
Social Determinants of Health (Box 4.2)37.
Rapid response capacity
While PHC reforms emphasize the importance
of participatory and deliberative engagement of
diverse stakeholders, humanitarian disasters
or disease outbreaks demand a rapid response
capacity that is crucial in dealing effectively with
the problem at hand and is an absolute imperative
in maintaining the trust of the population
in their health system. Invoking quarantines or
travel bans, rapidly sequencing the genome of
a new pathogen to inform vaccine or therapeutic
design, and mobilizing health workers and
institutions without delay can be vital. While the
advent of an “emergency” often provides the necessary
good will and fl exibility of these diverse
actors to respond, an effective response is more
likely if there have been signifi cant investments
in preparedness38.
Global efforts related to the threat of pandemic
avian inf luenza (H5N1) provide a number of
interesting insights into how policies that inform
preparedness and response could be guided by
the values of PHC related to equity, universal
coverage and primary-care reforms. In dealing
with seasonal and pandemic infl uenza, 116
national infl uenza laboratories, and fi ve international
collaborating centre laboratories share
infl uenza viruses in a system that was started by
WHO over 50 years ago. The system was implemented
to identify new pandemic virus threats
and inform the optimal annual preparation of a
seasonal infl uenza vaccine that is used primarily
by industrialized countries. With the primarily
69
Chapter 4. Public policies for the public’s health
developing country focus of human zoonotic
infections and the spectre of a global pandemic
associated with H5N1 strains of infl uenza, the
interest in infl uenza now extends to developing
countries, and the long-standing public-private
approach to infl uenza vaccine production and
virus sharing has come under intense scrutiny.
The expectation of developing countries for equitable
access to protection, including affordable
access to anti-virals and vaccines in the event of a
pandemic, is resulting in changes to national and
global capacity strengthening: from surveillance
and laboratories to capacity transfer for vaccine
formulation and production, and capacity for
stock-piling. Thus, the most equitable response
is the most effective response, and the most effective
rapid response capacity can only emerge
from the engagement of multiple stakeholders in
this global process of negotiation.
Towards health in all policies
The health of populations is not merely a product
of health sector activities – be they primary-care
action or countrywide public-health action. It is
to a large extent determined by societal and economic
factors, and hence by policies and actions
that are not within the remit of the health sector.
Changes in the workplace, for example, can have
a range of consequences for health (Table 4.1).
Confronted with these phenomena, the health
authorities may perceive the sector as powerless
to do more than try to mitigate the consequences.
It cannot, of itself, redefi ne labour relations or
unemployment arrangements. Neither can it
increase taxes on alcohol, impose technical
norms on motor vehicles or regulate rural migration
and the development of slums – although all
these measures can yield health benefi ts. Good
urban governance, for example, can lead to 75
years or more of life expectancy, against as few
as 35 years with poor governance39. Thus, it is
important for the health sector to engage with
other sectors, not just in order to obtain collaboration
on tackling pre-identifi ed priority health
problems, as is the case for well-designed publichealth
interventions, but to ensure that health is
recognized as one of the socially valued outcomes
of all policies.
Such intersectoral action was a fundamental
principle of the Alma-Ata Declaration. However,
ministries of health in many countries have struggled
to coordinate with other sectors or wield
infl uence beyond the health system for which
they are formally responsible. A major obstacle
to reaping the rewards of intersectoral action has
been the tendency, within the health sector, to see
such collaboration as “mostly symbolic in trying
to get other sectors to help [health] services”40.
Intersectoral action has often not concentrated
Box 4.2 Recommendations of the
Commission on Social Determinants of
Health37
The Commission on Social Determinants of Health (CSDH)
was a three-year effort begun in 2005 to provide evidencebased
recommendations for action on social determinants to
reduce health inequities. The Commission accumulated an
unprecedented collection of material to guide this process,
drawing from theme-based knowledge networks, civil society
experiences, country partners and departments within WHO.
The fi nal report of the CSDH contains a detailed series of
recommendations for action, organized around the following
three overarching recommendations.
1. Improve daily living conditions
Key improvements required in the well-being of girls and
women; the circumstances in which their children are born,
early child development and education for girls and boys; living
and working conditions; social protection policy; and conditions
for a fl ourishing older life.
2. Tackle the inequitable distribution of power, money and
resources
To address health inequities it is necessary to address inequities
in the way society is organized. This requires a strong
public sector that is committed, capable and adequately
fi nanced. This in turn requires strengthened governance
including stronger civil society and an accountable private
sector. Governance dedicated to pursuing equity is required
at all levels.
3. Measure and understand the problem and assess the impact
of action
It is essential to acknowledge the problem of health inequity
and ensure that it is measured – both within countries and
globally. National and global health equity surveillance systems
for routine monitoring of health inequity and the social determinants
of health are required that also evaluate the health
equity impact of policy and action. Other requirements are the
training of policy-makers and health practitioners, increased
public understanding of social determinants of health, and a
stronger social determinants focus in research.
The World Health Report 2008
70
Primary Health Care – Now More Than Ever
on improving the policies of other sectors, but
on instrumentalizing their resources: mobilizing
teachers to contribute to the distribution
of bednets, police offi cers to trace tuberculosis
treatment defaulters, or using the transport of
the department of agriculture for the emergency
evacuation of sick patients.
A “whole-of-government approach”, aiming for
“health in all policies” follows a different logic41,42.
It does not start from a specifi c health problem
and look at how other sectors can contribute to
solving them – as would be the case, for example,
for tobacco-related disease. It starts by looking
at the effects of agricultural, educational, environmental,
fi scal, housing, transport and other
policies on health. It then seeks to work with
these other sectors to ensure that, while contributing
to well-being and wealth, these policies
also contribute to health5.
Other sector’s public policies, as well as private
sector policies, can be important to health
in two ways.
Some may lead to �� adverse consequences for
health (Table 4.1). Often such adverse consequences
are identifi ed retrospectively, as in the
case of the negative health effects of air pollution
or industrial contamination. Yet, it is also
often possible to foresee them or detect them
at an early stage. Decision-makers in other
sectors may be unaware of the consequences
Table 4.1 Adverse health effects of changing work circumstances5
Adverse health effects
of unemployment
Adverse health effects of
restructuring
Adverse health effects of non-standard
work arrangements
Elevated blood pressure
Increased depression and
anxiety
Increased visits to general
practitioners
Increased symptoms of
coronary disease
Worse mental health and
greater stress
Increased psychological
morbidity and increased
medical visits
Decreased self-reported
health status and an
increase in the number of
health problems
Increase in family
problems, particularly
fi nancial hardships
Reduced job satisfaction, reduced
organizational commitment and
greater stress
Feelings of unfairness in
downsizing process
Survivors face new technologies,
work processes, new physical
and psychological exposures
(reduced autonomy, increased
work intensity, changes in
the characteristics of social
relationships, shifts in the
employment contracts and
changes in personal behaviour)
Changes in the psychological
contract and lost sense of trust
Prolonged stress with
physiological and psychological
signs
Higher rates of occupational injury and disease than
workers with full-time stable employment
High level of stress, low job satisfaction and other
negative health and well-being factors
More common in distributive and personal service
sub-sectors where people in general have lower
educational attainment and low skill levels
Low entitlement to workers’ compensation and low
level of claims by those who are covered
Increased occupational health hazards due to work
intensifi cation motivated by economic pressures
Inadequate training and poor communication caused
by institutional disorganization and inadequate
regulatory control
Inability of workers to organize their own protection
Cumulative trauma claims are diffi cult to show due
to mobility of workers
Reduced ability to improve life conditions due to
inability to obtain credit, fi nd housing, make pension
arrangements, and possibility for training
Fewer concerns for environmental issues and health
and safety at work
71
Chapter 4. Public policies for the public’s health
of the choices they are making, in which case
engagement, with due consideration for the
other sectors’ goals and objectives, may then
be the fi rst step in minimizing the adverse
health effects.
Public policies �� developed by other sectors –
education, gender equality and social inclusion
– may positively contribute to health in ways
that these other sectors are equally unaware
of. They may be further enhanced by more
purposefully pursuing these positive health
outcomes, as an integral part of the policy. For
example, a gender equality policy, developed
in its own right, may produce health benefi ts,
often to a degree that the proponents of the
policy underestimate. By collaborating to give
more formal recognition to these outcomes, the
gender equality policy itself is reinforced, and
the synergies enhance the health outcomes.
In that case, the objective of intersectoral collaboration
is to reinforce the synergies.
Failing to collaborate with other sectors is not
without its consequences. It affects the performance
of health systems and, particularly, primary
care. For example, Morocco’s trachoma
programme relied both on high levels of community
mobilization and on effective collaboration
with the ministries of education, interior and
local affairs. That collaboration has been the key
to the successful elimination of trachoma43. In
contrast, the same country’s tuberculosis control
programme failed to link up with urban development
and poverty reduction efforts and, as a
result, its performance has been disappointing44.
Both were administered by the same Ministry of
Health, by staff with similar capacities working
under similar resource constraints, but with different
strategies.
Failing to collaborate with other sectors has
another consequence, which is that avoidable illhealth
is not avoided. In the NGagne Diaw quarter
of Thiaroye-sur-Mer, Dakar, Senegal, people
make a living from the informal recycling of lead
batteries. This was of little concern to the authorities
until an unexplained cluster of child deaths
prompted an investigation. The area was found to
be contaminated with lead, and the siblings and
mothers of the dead children were found to have
extremely high concentrations of lead in their
blood. Now, major investments are required to
deal with the health and social consequences
and to decontaminate the affected area, including
people’s homes. Before the cluster of deaths
occurred, the health sector had, unfortunately,
not considered it a priority to work with other
sectors to help to avoid this situation45.
Where intersectoral collaboration is successful,
the health benefi ts can be considerable, although
deaths avoided are less readily noticed than lives
lost. For example, pressure from civil society and
professionals led to the development, in France, of
a multi-pronged, high-profi le strategy to improve
road safety as a social and political issue that had
to be confronted (and not primarily as a health
sector issue). Various sectors worked together in a
sustained effort, with high-level political endorsement,
to reduce road-traffic accidents, with
highly publicized monitoring of progress and a
reduction in fatalities of up to 21% per year46.
The health and health equity benefi ts of working
towards health in all policies have become apparent
in programmes such as “Healthy Cities and
Municipalities”, “Sustainable Cities”, and “Cities
Without Slums”, with integrated approaches that
range from engagement in budget hearings and
social accountability mechanisms to data gathering
and environmental intervention47.
In contemporary societies, health tends to
become fragmented into various sub-institutions
dealing with particular aspects of health
or health systems, while the capacity to assemble
the various aspects of public policy that jointly
determine health is underdeveloped. Even in the
well-resourced context of, for example, the European
Union, the institutional basis for doing this
remains poorly developed48. Ministries of health
have a vital role to play in creating such a basis,
which is among the key strategies for making
headway in tackling the socioeconomic determinants
of ill-health49.
Understanding the under-investment
Despite the benefi ts and low relative cost of better
public policies, their potential remains largely
underutilized across the world. One high-profi le
example is that only 5% of the world’s population
live in countries with comprehensive tobacco
The World Health Report 2008
72
Primary Health Care – Now More Than Ever
advertising, promotion and sponsorship bans,
despite their proven effi cacy in reducing health
threats, which are projected to claim one billion
lives this century50.
The health sector’s approach to improving public
policies has been singularly unsystematic and
guided by patchy evidence and muddled decisionmaking
– not least because the health community
has put so little effort into collating and
communicating these facts. For all the progress
that has been made in recent years, information
on the effectiveness of interventions to redress,
for example, health inequities is still hard to come
by and, when it is available, it is confi ned to a
privileged circle of concerned experts. A lack
of information and evidence is, thus, one of the
explanations for under-investment.
Box 4.3 How to make unpopular public policy decisions51
The Seventh Futures Forum of senior health executives organized by the World Health Organization’s Regional Offi ce for Europe in
2004 discussed the diffi culties decision-makers can have in tackling unpopular policy decisions. A popular decision is usually one that
results from broad public demand; an unpopular decision does not often respond to clearly expressed public expectations, but is made
because the minister or the chief medical offi cer knows it is the right action to bring health gains and improve quality. Thus, a potentially
unpopular decision should not seek popularity but, rather, efforts must be made to render it understandable and, therefore, acceptable.
Making decisions more popular is not an academic exercise but one that deals with actual endorsement. When a decision is likely to be
unpopular, participants in the Forum agreed that it is advisable for health executives to apply some of the following approaches.
Talk about health and quality improvement. Health is the core area of expertise and competence, and the explanations of how the
decision will improve the quality of health and health services should therefore come fi rst. Avoiding non-health arguments that are
diffi cult to promote may be useful – for instance, in the case of hospital closures, it is much better to talk about improving quality of
care than about containing costs.
Offer compensation. Explain what people will receive to balance what they will have to give up. Offer some gains in other sectors or in
other services; work to make a win-win interpretation of the coming decision by balancing good and bad news.
Be strong on implementation. If health authorities are not ready to implement the decision, they should refrain from introducing it until
they are ready to do so.
Be transparent. Explain who is taking the decision and the stakes of those involved and those who are affected. Enumerate all the
stakeholders and whether they [are] involved negatively.
Avoid one-shot decisions. Design and propose the decisions as part of an overall plan or strategy.
Ensure good timing. Before making a decision, it is essential to take enough time to prepare and develop a good plan. When the plan
is ready, the best choice may be to act quickly for implementation.
Involve all groups. Bring into the discussion both the disadvantaged groups and the ones who will benefi t from the decision. Diversify
the approach.
Do not expect mass-media support solely because the decision is the right one from the viewpoint of health gains. The mass media
cannot be expected to be always neutral or positive; they may often be brought into the debate by the opponents of the decision. Be
prepared to face problems with the press.
Be modest. Acceptability of the decision is more likely when decision-makers acknowledge in public that there is some uncertainty
about the result and they commit openly to monitoring and evaluating the outcomes. This leaves the door open for adjustments during
the process of implementation.
Be ready for quick changes. Sometimes the feelings of the public change quickly and what was perceived as opposition can turn into
acceptance.
Be ready for crisis and unexpected side-effects. Certain groups of populations can be especially affected by a decision (such as general
practitioners in the case of hospital closures). Public-health decision-makers have to cope with reactions that were not planned.
Stick to good evidence. Public acceptance may be low without being based on any objective grounds. Having good facts is a good way
to shape the debate and avoid resistance.
Use examples from other countries. Decision-makers may look at what is being done elsewhere and explain why other countries deal
with a problem differently; they can use such arguments to make decisions more acceptable in their own country.
Involve health professionals and, above all, be courageous.
73
Chapter 4. Public policies for the public’s health
The fact is, however, that even for wellinformed
political decision-makers, many public
policy issues have a huge potential for unpopularity:
whether it is reducing the number of hospital
beds, imposing seatbelts, culling poultry or
taxing alcohol, resistance is to be expected and
controversy an everyday occurrence. Other decisions
have so little visibility, e.g. measures that
ensure a safe food production chain, that they
offer little political mileage. Consensus on stern
measures may be easy to obtain at a moment
of crisis, but public opinion has a notoriously
short attention span. Politicians often pay more
attention to policies that produce benefi ts within
electoral cycles of two to four years and, therefore,
undervalue efforts where benefi ts, such as
those of environmental protection or early child
development, accrue over a time span of 20 to 40
years. If unpopularity is one intractable disincentive
to political commitment, active opposition
from well-resourced lobbies is another. An obvious
example is the tobacco industry’s efforts to
limit tobacco control. Similar opposition is seen
to the regulation of industrial waste and to the
marketing of food to children. These obstacles
to steering public policy are real and need to be
dealt with in a systematic way (Box 4.3).
Compounding these disincentives to political
commitment is the diffi culty of coordinating
operations across multiple institutions and sectors.
Many countries have limited institutional
capacity to do so and, very often, do not have
enough capable professionals to cope with the
work involved. Crisis management, short-term
planning horizons, lack of understandable
evidence, unclear intersectoral arrangements,
vested interests and inadequate modes of governing
the health sector reinforce the need for comprehensive
policy reforms to realize the potential
of public-health action. Fortunately, there are
promising opportunities to build upon.
Opportunities for better public
policies
Better information and evidence
Although there are strong indications that the
potential gains from better public policies are
enormous, the evidence base on their outcomes
and on their cost-effectiveness is surprisingly
weak52. We know much about the relationship
between certain behaviours – smoking, diet,
exercise, etc. – and health outcomes, but much
less about how to effect behavioural change in a
systematic and sustainable way at population levels.
Even in well-resourced contexts, the obstacles
are many: the time-scale in achieving outcomes;
the complexity of multifactorial disease causation
and intervention effects; the lack of data; the
methodological problems, including the diffi culties
in applying the well-accepted criteria used
in the evaluation of clinical methods; and the
different perspectives of the multiple stakeholders
involved. Infectious disease surveillance is
improving, but information on chronic diseases
and their determinants or on health inequities is
patchy and often lacks systematic focus. Even the
elementary foundations for work on population
health and the collection of statistics on births
and deaths or diseases are defi cient in many
countries (Box 4.4)53.
Over the last 30 years, however, there has been
a quantum leap in the production of evidence for
clinical medicine through collaborative efforts
such as the Cochrane Collaboration and the International
Clinical Epidemiology Network56,57. A
similar advance is possible in the production of
evidence on public policies, although such efforts
are still too tentative compared to the enormous
resources available for research in other areas
of health, e.g. diagnostic and therapeutic medical
technologies. There are, however, signs of progress
in the increasing use of systematic reviews
by policy-makers58,59.
Two tracks offer potential for signifi cantly
strengthening the knowledge base.
Speeding u �� p the organization of systematic
reviews of critical interventions and their
economic evaluation. One way of doing this
is by expanding the remit of existing health
technology assessment agencies to include
the assessment of public-health interventions
and delivery modes, since this would make use
of existing institutional capacities with ringfenced
resources. The emerging collaborative
networks, such as the Campbell Collaboration60,
can play a catalyzing role, exploiting
The World Health Report 2008
74
Primary Health Care – Now More Than Ever
the comparative advantage of scale effi ciency
and international comparisons.
Accelerating t �� he documentation and assessment
of whole-of-government approaches
using techniques that build on the initial
experience with “health impact assessment”
or “health equity impact assessment”
tools61,62,63. Although these tools are still in
development, there is growing demand from
local to supra-national policy-makers for such
analyses (Box 4.5). Evidence of their utility in
infl uencing public policies is building up64,65,66,
and they constitute a strategic way of organizing
more thoughtful cross-sector discussions.
That in itself is an inroad into one of the more
intractable aspects of the use of the available
evidence base: the clear need for more
systematic communication on the potential
health gains to be derived from better public
policies. Decision-makers, particularly in
other sectors, are insuffi ciently aware of the
health consequences of their policies, and of
the potential benefi ts that could be derived
from them. Communication beyond the realm
of the specialist is as important as the production
of evidence and requires far more effective
approaches to the dissemination of evidence
among policy-makers67. Framing population
health evidence in terms of the health impact
of policies, rather than in the classical modes
of communication among health specialists,
has the potential to change radically the type
and quality of policy dialogue.
A changing institutional landscape
Along with lack of evidence, the area where new
opportunities are appearing is in the institutional
capacity for developing public policies that are
aligned with PHC goals. Despite the reluctance,
including from donors, to commit substantial
funds to National Institutes of Public Health
(NIPHs)69, policy-makers rely heavily on them or
Civil registration is both a product of economic and social development,
and a condition for modernization. There has been little
improvement in coverage of vital registration (offi cial recording
of births and deaths) over recent decades (see Figure 4.3).
Almost 40% (48 million) of 128 million global births each year
go uncounted because of
the lack of civil53 registration
systems. The situation
is even worse for deaths
registration. Globally, two
thirds (38 million) of 57 million
annual deaths are not
registered. WHO receives
reliable cause-of-death
statistics from only 31 of
its 193 Member States.
International efforts to
improve vital statistics
infrastructure in developing
countries have been
too limited in size and
scope54. Neither, the global
health community nor the
countries have given the
development of health statistics
and civil registration
systems the same priority
Box 4.4 The scandal of invisibility: where births and deaths are not counted
as health interventions. Within the UN system, civil registration
development has no identifi able home. There are no coordination
mechanisms to tackle the problem and respond to requests
for technical support for mobilizing the necessary fi nancial and
technical resources. Establishing the infrastructure of civil registration
systems to ensure
all births and deaths are
counted requires collaboration
between different
partners in different sectors.
It needs sustained
advocacy, the nurturing
of public trust, supportive
legal frameworks,
incentives, fi nancial support,
human resources
and modernized data
management systems55.
Where it functions well,
vital statistics provide
basic information for priority
setting. The lack of
progress in the registration
of births and deaths
is a major concern for the
design and implementation
of PHC reforms.
100
Percentage of births
and deaths registered
0
Figure 4.3 Percentage of births and deaths recorded in countries with
complete civil registration systems, by WHO region, 1975–2004a
20
40
80
60
1975–84
Africa
Deaths
Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
Africa
Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
Births
1985–94 1995–2004
a Source: adapted from 54.
75
Chapter 4. Public policies for the public’s health
on their functional equivalents. In many countries,
NIPHs have been the primary repositories of
independent technical expertise for public health,
but also, more broadly, for public policies. Some
have a prestigious track record: the Fiocruz in
Brazil, the Instituto de Medicina Tropical “Pedro
Kouri” in Cuba, Kansanterveyslaitos in Finland,
the Centers for Disease Control and Prevention
in the United States, or the National Institute of
Hygiene and Epidemiology in Viet Nam. They
testify to the importance that countries accord
to being able to rely on such capacity69. Increasingly,
however, this capacity is unable to cope
with the multiple new demands for public policies
to protect or promote health. This is leaving
traditional national and global institutes of public
health with an oversized, under-funded mandate,
which poses problems of dispersion and diffi culties
in assembling the critical mass of diversifi ed
and specialized expertise (Figure 4.4).
In the meantime, the institutional landscape
is changing as the capacity for public policy support
is being spread over a multitude of national
and supra-national institutions. The number of
loci of expertise, often specialized in some aspect
of public policy, has increased considerably,
spanning a broad range of institutional forms
including: research centres, foundations, academic
units, independent consortia and think
tanks, projects, technical agencies and assorted
initiatives. Malaysia’s Health Promotion Foundation
Board, New Zealand’s Alcohol Advisory
Box 4.5 European Union impact assessment guidelines68
European Union guidelines suggest that the answers to the following questions can form the basis of an assessment of the impact of
proposed public-health interventions.
Public health and safety
Does the proposed option:
affect the health and safety of individuals or populations, including life expectancy, mortality and morbidity t �� hrough impacts on the
socioeconomic environment, e.g. working environment, income, education, occupation or nutrition?
�� increase or decrease the likelihood of bioterrorism?
�� increase or decrease the likelihood of health risks attributable to substances that are harmful to the natural environment?
�� affect health because of changes in the amount of noise or air, water or soil quality in populated areas?
�� affect health because of changes in energy use or waste disposal?
�� affect lifestyle-related determinants of health such as the consumption of tobacco or alcohol, or physical activity?
�� produce specifi c effects on particular risk groups (determined by age, sex, disability, social group, mobility, region, etc.)?
Access to and effects on social protection, health and educational systems
Does the proposed option:
�� have an impact on services in terms of their quality and access to them?
�� have an effect on the education and mobility of workers (health, education, etc.)?
�� affect the access of individuals to public or private education or vocational and continuing training?
�� affect the cross-border provision of services, referrals across borders and cooperation in border regions?
�� affect the fi nancing and organization of and access to social, health and education systems (including vocational training)?
�� affect universities and academic freedom or self-governance?
20 40 60 80 10
Proportion of institutions surveyed (%)
Evaluation and promotion of coverage
and access to health services
Figure 4.4 Essential public-health functions that 30 national public-health
institutions view as being part of their portfolio69
0
Quality assurance in personal and
population-based health services
Regulation and enforcement
Social participation
and citizen empowerment
Human resource development and training
Reduction of the impact
of disasters on health
Planning and management
Health promotion and prevention programmes
Evaluation and analysis of health status
Public health research
Surveillance, problem investigation,
control of risks and threats to public health
The World Health Report 2008
76
Primary Health Care – Now More Than Ever
Council and Estonia’s Health Promotion Commission
show that funding channels have diversifi ed
and may include research grants and contracts,
government subsidies, endowments, or hypothecated
taxes on tobacco and alcohol sales. This
results in a more complex and diffuse, but also
much richer, network of expertise.
There are important scale effi ciencies to be
obtained from cross-border collaboration on
a variety of public policy issues. For example,
the International Association of National Public
Health Institutes (IANPHI) helps countries to set
up strategies for institutional capacity development70.
In this context, institution building will
have to establish careful strategies for specialization
and complementarity, paying attention to the
challenge of leadership and coordination.
At the same time, this offers perspectives for
transforming the production of the highly diverse
and specialized workforce that better public policies
require. Schools of public health, community
medicine and community nursing have traditionally
been the primary institutional reservoirs for
generating that workforce. However, they produce
too few professionals who are too often focused
on disease control and classical epidemiology,
and are usually ill-prepared for a career of fl exibility,
continuous learning and coordinated
leadership.
The multi-centric institutional development
provides opportunities for a fundamental rethink
of curricula and of the institutional settings
of pre-service education, with on-the-job training
in close contact with the institutions where
the expertise is located and developed71. There
are promising signs of renewal in this regard
in the WHO South-East Asian Region (SEARO)
that should be drawn upon to stimulate similar
thinking and action elsewhere27. The increasing
cross-border exchange of experience and expertise,
combined with a global interest in improving
public policy-making capacity, is creating new
opportunities – not just in order to prepare professionals
in more adequate numbers but, above
all, professionals with a broader outlook and who
are better prepared to address complex public
heath challenges of the future.
Equitable and effi cient global
health action
In many countries, responsibilities for health and
social services are being delegated to local levels. At
the same time, fi nancial, trade, industrial and agricultural
policies are shifting to international level:
health outcomes have to be obtained locally, while
health determinants are being infl uenced at international
level. Countries increasingly align their
public policies with those of a globalized world.
This presents both opportunities and risks.
In adjusting to globalization, fragmented
policy competencies in national governance systems
are fi nding convergence. Various ministries,
including health, agriculture, fi nance, trade and
foreign affairs are now exploring together how
they can best inform pre-negotiation trade positions,
provide input during negotiations, and
weigh the costs and benefi ts of alternative policy
options on health, the economy and the future of
their people. This growing global health “interdependence”
is accompanied by a mushrooming
of activities expressed at the global level. The
challenge is, therefore, to ensure that emerging
networks of governance are adequately inclusive
of all actors and sectors, responsive to local needs
and demands, accountable, and oriented towards
social justice72. The recent emergence of a global
food crisis provides further legitimacy to an input
from the health sector into the evolving global
response. Gradually, a space is opening for the
consideration of health in the trade agreements
negotiated through the World Trade Organization
(WTO). Although implementation has proved
problematic, the fl exibilities agreed at Doha for
provision in the Agreement on Trade-Related
Aspects of Intellectual Property Rights (TRIPS)73
of compulsory licencing of pharmaceuticals are
examples of emerging global policies to protect
health.
There is a growing demand for global norms
and standards as health threats are being shifted
from areas where safety measures are being tightened
to places where they barely exist. Assembling
the required expertise and processes is complex
and expensive. Increasingly, countries are relying
on global mechanisms and collaboration74. This
trend started over 40 years ago with the creation
of the Codex Alimentarius Commission in 1963
77
Chapter 4. Public policies for the public’s health
by the Food and Agriculture Organization (FAO)
and the WHO to coordinate international food
standards and consumer protection. Another
long-standing example is the International Programme
on Chemical Safety, established in 1980
as a joint programme of the WHO, the International
Labour Organization (ILO) and the United
Nations Environment Programme (UNEP). In the
European Union, the construction of health protection
standards is shared between agencies and
applied across Europe. Given the expense and
complexity of drug safety monitoring, many countries
adapt and use the standards of the United
States Food and Drug Administration (FDA). WHO
sets global standards for tolerable levels of many
contaminants. In the meantime, countries must
either undertake these processes themselves or
ensure access to standards from other countries
or international agencies, adapted to their own
context.
The imperative for global public-health action,
thus, places further demands on the capacity and
strength of health leadership to respond to the
need to protect the health of their communities.
Local action needs to be accompanied by the
coordination of different stakeholders and sectors
within countries. It also needs to manage global
health challenges through global collaboration
and negotiation. As the next chapter shows, this
is a key responsibility of the state.
References
1. Sen A. Development as freedom. Oxford, Oxford University Press, 1999.
2. Fegan GW et al. Effect of expanded insecticide-treated bednet coverage on child
survival in rural Kenya: a longitudinal study. Lancet, 2007, 370:1035–1039.
3. Liu Y. China’s public health-care system: facing the challenges. Bulletin of the World
Health Organization, 2004, 82:532–538.
4. Kaufman JA. China’s heath care system and avian infl uenza preparedness. Journal
of Infectious Diseases, 2008, 197(Suppl. 1):S7–S13.
5. Ståhl T et al, eds. Health in all policies: prospects and potentials. Helsinki, Ministry of
Social Affairs and Health, 2006.
6. Berer M. National laws and unsafe abortion: the parameters of change. Reproductive
Health Matters, 2004, 12:1–8.
7. Grimes DA et al. Unsafe abortion: the preventable pandemic. Lancet, 2006,
368:1908–1919.
8. Sommer A, Mosley WH. East Bengal cyclone of November 1970: epidemiological
approach to disaster assessment. Lancet, 1972, 1:1029–1036.
9. Bern C et al. Risk factors for mortality in the Bangladesh cyclone of 1991. Bulletin of
the World Health Organization, 1993, 71:73–78.
10. Chowdhury AM. Personal communication, 2008.
11. Asaria P et al. Chronic disease prevention: health effects and fi nancial costs
of strategies to reduce salt intake and control tobacco use. Lancet, 2007,
370:2044–2053.
12. World abortion policies 2007. New York NY, United Nations, Department of Economic
and Social Affairs, Population Division, 2007 (ST/ESA/SER.A/264, Wallchart).
13. Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion
and associated mortality in 2003, 5th ed. Geneva, World Health Organization, 2007.
14. Maternal health and early childhood development in Cuba. Ottawa, Committee on
Social Affairs, Science and Technology, 2007 (Second Report of the Subcommittee
on Population Health of the Standing Senate).
15. Evans RG. Thomas McKeown, meet Fidel Castro: physicians, population health and
the Cuban paradox. Healthcare Policy, 2008, 3:21–32.
16. Spiegel JM, Yassi A. Lessons from the margins of globalization: appreciating the
Cuban health paradox. Journal of Public Health Policy, 2004, 25:85–110.
17. The World Health Report – Health systems: improving performance. Geneva, World
Health Organization, 2000.
18. Everybody’s business – strengthening health systems to improve health outcomes.
Geneva, World Health Organization, Health Systems Services, 2007.
19. Hogerzeil HV. The concept of essential medicines: lessons for rich countries. BMJ,
2004, 329:1169–1172.
20. Measuring medicine prices, availability, affordability and price components, 2nd ed.
Geneva, Health Action International and World Health Organization, 2008 (http://
www.haiweb.org/medicineprices/, accessed 20 August 2008).
21. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every
year? Lancet, 2003, 361:2226–2234.
22. Supply annual report 2007. Copenhagen, United Nations Children’s Fund Supply
Division, 2008.
23. Tambini G et al. Regional immunization programs as a model for strengthening
cooperation among nations. Revista panamericana de salud pública, 2006,
20:54–59.
24. EPI Revolving Fund: quality vaccines at low cost. EPI Newsletter, 1997, 19:6–7.
25. Matiru R, Ryan T. The global drug facility: a unique, holistic and pioneering approach
to drug procurement and management. Bulletin of the World Health Organization,
2007, 85:348–353.
26. Annual Report. Wellington, Pharmaceutical Management Agency, 2007.
27. The World Health Report 2006 - Working together for health. Geneva, World Health
Organization, 2006.
28. Victora CG et al. Achieving universal coverage with health interventions. Lancet,
2004, 364:1555–1556.
29. Freitas do Amaral JJ et al. Multi-country evaluation of IMCI, Brazil study. Ceará,
Federal University of Ceará, ND.
30. Sontag S. AIDS and its metaphors. New York, NY, Farrar, Straus & Giroux, 1988.
31. Mann JM et al, eds. Health and human rights: a reader. New York NY, Routledge,
1999.
32. Friedman S, Mottiar S. A rewarding engagement? The treatment action campaign
and the politics of HIV/AIDS. Politics and Society, 2005, 33:511–565.
33. Ottawa Charter for Health Promotion. In: First International Conference on Health
Promotion, Ottawa, 21 November 1986. Geneva, World Health Organization,
Department of Human Resources for Health, 1986 (WHO/HPR/HEP/95.1; http://
www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf, accessed 2 July 2008).
34. Ezzati M et al. Comparative risk assessment collaborating group. Estimates of global
and regional potential health gains from reducing multiple major risk factors. Lancet,
2003, 362:271–280..
35. Friel S, Chopra M, Satcher D. Unequal weight: equity oriented policy responses to
the global obesity epidemic. BMJ, 2007, 335:1241–1243.
36. Satcher D, Higginbotham EJ. The public health approach to eliminating disparities in
health. American Journal of Public Health, 2008, 98:400–403.
The World Health Report 2008
78
Primary Health Care – Now More Than Ever
Commission on Social Determinants 37. of Health. Closing the gap in a generation:
health equity through action on the social determinants of health. Final report.
Geneva, World Health Organization, 2008.
38. The World Health Report 2007 – A safer future: global public health security in the
21st century. Geneva, World Health Organization, 2007
39. Satterthwaite D. In pursuit of a healthy urban environment. In: Marcotullkio PJ,
McGranahan G, eds. Scaling urban environmental challenges: from local to global
and back. London, Earthscan, 2007.
40. Taylor CE, Taylor HG. Scaling up community-based primary health care. In: Rohde
J, Wyon J, eds. Community-based health care: lessons from Bangladesh to Boston.
Boston, Management Sciences for Health, 2002.
41. WHO/Public Health Agency Canada Collaborative Project. Improving health equity
through intersectoral action. Geneva, World Health Organization, 2008 (in press).
42. Puska P. Health in all policies. European Journal of Public Health, 2007, 17:328.
43. Chami Y, Hammou J, Mahjour J. Lessons from the Moroccan national trachoma
control programme. Community Eye Health, 2004, 17:59.
44. Dye C et al. The decline of tuberculosis epidemics under chemotherapy: a case
study in Morocco. International Journal of Tuberculosis and Lung Disease, 2007,
11:1225–1231.
45. Senegal: outbreak of lead intoxication in Thiaroye sur Mer 20 June 2008. Geneva,
World Health Organization, 2008 (http://www.who.int/environmental_health_
emergencies/events/Senegal2008/en/index.html, accessed 21 July 2008).
46. Muhlrad N. Road safety management in France: political leadership as a path to
sustainable progress. Paper presented at: Gambit 2004 Road Safety Conference,
Gdansk, April 2004.
47. Our cities, our health, our future: acting on social determinants for health equity in
urban settings. Geneva, World Health Organization, 2007.
48. Koivusalo M. Moving health higher up the European agenda. In: Ståhl T et al, eds.
Health in all policies: prospects and potentials. Helsinki, Ministry of Social Affairs and
Health, 2006:21–40.
49. Gilson L et al. Challenging health inequity through health systems. Geneva, World
Health Organization, 2007.
50. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva,
World Health Organization, 2008.
51. Anaudova A. Seventh Futures Forum on Unpopular Decisions in Public Health.
Copenhagen, World Health Organization Regional Offi ce for Europe, 2005.
52. Allin S et al. Making decisions on public health: a review of eight countries. Geneva,
World Health Organization, European Observatory on Health Systems and Policies,
2004.
53. Setel PW et al. on behalf of the Monitoring of Vital Events (MoVE) writing group. A
scandal of invisibility: making everyone count by counting everyone. Lancet, 2007
(published online: DOI: 10.1016/S0140-6736(07)61307-5).
54. Mahapatra P et al. on behalf of the Monitoring of Vital Events (MoVE) writing group.
Civil registration systems and vital statistics: successes and missed opportunities.
Lancet, 2007 (published online: DOI: 10.1016/S0140-6736(07)61308-7).
55. AbouZahr C et al. on behalf of the Monitoring of Vital Events (MoVE) writing
group. The way forward. Lancet, 2007 (published online: DOI: 10.1016/S0140-
6736(07)61310-5).
56. Volmink J et al. AM. Research synthesis and dissemination as a bridge to knowledge
management: the Cochrane Collaboration. Bulletin of the World Health Organization,
2004, 82:778–783.
57. Halstead SB, Tugwell P, Bennett K. The International Clinical Epidemiology Network
(INCLEN): a progress report. Journal of Clinical Epidemiology, 1991, 44:579–589.
58. Waters E et al. Cochrane Collaboration. Evaluating the effectiveness of public health
interventions: the role and activities of the Cochrane Collaboration. Journal of
Epidemiology and Community Health, 2006, 60:285–289.
59. Sweet M, Moynihan R. Improving population health: the uses of systematic reviews.
New York NY, Milbank Memorial Fund, 2007.
60. Davies P, Boruch R. The Campbell Collaboration does for public policy what
Cochrane does for health. BMJ, 2001, 323:294–295.
61. An idea whose time has come: New opportunities for HIA in New Zealand public
policy and planning. Wellington, Public Health Advisory Committee, 2007.
62. Harris P et al. Health impact assessment: a practical guide. Sydney, University of
New South Wales, 2007.
63. Wismar M et al. Implementing and institutionalizing health impact assessment in
Europe. In: Ståhl T et al, eds. Health in all policies: prospects and potentials. Helsinki,
Ministry of Social Affairs and Health, 2006.
64. Blau J et al. The use of health impact assessment across Europe. In: Ståhl T et
al, eds. Health in all policies: prospects and potentials. Helsinki, Ministry of Social
Affairs and Health, 2006.
65. Dannenberg AL et al. Use of health impact assessment in the US: 27 case studies,
1999–2007. American Journal of Preventive Medicine, 2008, 34:241–256.
66. Wismar M et al, eds. The effectiveness of health impact assessment: scope
and limitations of supporting decision-making in Europe. Geneva, World Health
Organization, 2007.
67. Jewell CJ, Bero LA. Developing good taste in evidence: facilitators of and
hindrances to evidence-informed health policymaking in state government. The
Milbank Quarterly, 2008, 86:177–208.
68. Communication from the Commission on Better Regulation for Growth and Jobs in the
European Union. Brussels, European Commission, 2005 (COM (2005) 97 fi nal).
69. Binder S et al. National public health institutes: contributing to the public good.
Journal of Public Health Policy, 2008, 29:3–21.
70. Framework for the creation and development of national public health institutes.
Helsinki, International Association of National Public Health Institutes, 2007.
71. Khaleghian P, Das Gupta M. Public management and the essential public health
functions. Washington DC, The World Bank, 2004 (World Bank Policy Research
Working Paper 3220).
72. Kickbusch I. A new agenda for health. Perspectives in Health, 2004, 9:8–13.
73. World Trade Organization Declaration on the TRIPS Agreement and Public Health.
Ministerial Conference, 4th Session, Doha, 9–14 November 2001. 2001 (WT/
MIN(01)/DEC/2).
74. Wilk EA van der et al. Learning from our neighbours – cross-national inspiration
for Dutch public health polices: smoking, alcohol, overweight, depression, health
inequalities, youth screening. Bilthoven, National Institute for Public Health and the
Environment, 2008 (RIVM Rapport 270626001; http://www.rivm.nl/bibliotheek/
rapporten/270626001.pdf, accessed 30 July 2008).


Leadership and
effective government
Chapter 5
Governments as brokers for
PHC reform 82
Effective policy dialogue 86
Managing the political
process: from launching
reform to implementing it
92
The preceding chapters have described how health
systems can be transformed to deliver better health
in ways that people value: equitably, people-centred, and with
the knowledge that health authorities administer public-health
functions to secure the well-being of all
communities. These PHC reforms demand
new forms of leadership for health. This
chapter begins by clarifying why the
public sector needs to have a strong role
in leading and steering public health care
reforms, and emphasizes the fact that this
function should be exercised through collaborative models of
policy dialogue with multiple stakeholders, because this is
what people expect and because it is the most effective. It then
considers strategies to improve the effectiveness of reform
efforts and the management of the political processes that
condition them.
81
The World Health Report 2008 Primary Health Care – Now More Than Ever
82
Governments as brokers for
PHC reform
Mediating the social contract
for health
The ultimate responsibility for shaping national
health systems lies with governments. Shaping
does not suggest that governments should − or
even could – reform the entire health sector on
their own. Many different groups have a role to
play: national politicians and local governments,
the health professions, the scientifi c community,
the private sector and civil society organizations,
as well as the global health community. Nevertheless,
the responsibility for health that is entrusted
to government agencies is unique and is rooted
in principled politics as well as in widely held
expectations1.
Politically, the legitimacy of governments and
their popular support depends on their ability to
protect their citizens and play a redistributive
role. The governance of health is among the core
public policy instruments for institutionalized
protection and redistribution. In modern states,
governments are expected to protect health, to
guarantee access to health care and to safeguard
people from the impoverishment that illness can
bring. These responsibilities were progressively
extended, incorporating the correction of market
failures that characterize the health sector2.
Since the beginning of the 20th century, health
protection and health care have progressively
been incorporated as goods that are guaranteed
by governments and are central to the social
contract between the state and its citizens. The
importance of health systems as a key element
of the social contract in modernizing societies is
most acutely evident during reconstruction after
periods of war or disaster: rebuilding health services
counts among the fi rst tangible signs that
society is returning to normal3.
The legitimacy of state intervention is not
only based on social and political considerations.
There are also key economic actors – the
medical equipment industry, the pharmaceutical
industry and the professions – with an interest in
governments taking responsibility for health to
ensure a viable health market: a costly modern
health economy cannot be sustained without risk
sharing and pooling of resources. Indeed, those
countries that spend the most on health are also
those countries with the largest public fi nancing
of the health sector (Figure 5.1).
Even in the United States, its exceptionalism
stems not from lower public expenditure – at 6.9%
of GDP it is no lower than the high-income countries
average of 6.7% – but from its singularly high
additional private expenditure. The persistent
under-performance of the United States health
sector across domains of health outcomes, quality,
access, effi ciency and equity5, explains opinion
polls that show increasing consensus of the
notion of government intervention to secure more
equitable access to essential health care6,7.
A more effective public sector stewardship of
the health sector is, thus, justifi ed on the grounds
of greater effi ciency and equity. This crucial stewardship
role is often misinterpreted as a mandate
for centralized planning and complete administrative
control of the health sector. While some
types of health challenges, e.g. public-health
emergencies or disease eradication, may require
authoritative command-and-control management,
effective stewardship increasingly relies
on “mediation” to address current and future
complex health challenges. The interests of public
authorities, the health sector and the public
are closely intertwined. Over the years, this has
made all the institutions of medical care, such
as training, accreditation, payment, hospitals,
14
12
10
Percentage GDP
0
Low-income
countries,
without India
Figure 5.1 Percentage of GDP used for health, 20054
2
8
4
6
16
External resources
Out-of-pocket expenditure
Other private expenditure
General government expenditure
India Lower
middle-income
countries,
without China
China Upper
middle-income
countries,
without Brazil
Brazil High-income
countries,
without USA
USA
83
Chapter 5. Leadership and effective government
entitlements, etc., the object of intensive bargaining
on how broadly to defi ne the welfare state and
the collective goods that go with it8,9. This means
that public and quasi-public institutions have to
mediate the social contract between institutions
of medicine, health and society10. In high-income
countries today, the health-care system and the
state appear indissolubly bound together. In
low- and middle-income countries, the state has
often had a more visible role, but paradoxically,
one that was less effective in steering the health
sector, particularly when, during the 1980s and
1990s, some countries of them became severely
tested by confl icts and economic recession. This
resulted in their health systems being drawn in
directions quite different from the goals and values
pursued by the PHC movement.
Disengagement and its consequences
In many socialist and post-socialist countries
undergoing economic restructuring, the state
has withdrawn abruptly from its previously predominant
role in health. China’s deregulation of
the health sector in the 1980s, and the subsequent
steep increases in reliance on out-of-pocket
spending, is a case in point and a warning to the
rest of the world11. A spectacular deterioration of
health-care provision and social protection, particularly
in rural areas, led to a marked slowdown
in the increase in life expectancy11,12. This caused
China to re-examine its policies and reassert the
Government’s leadership role − a re-examination
that is far from over (Box 5.1)13.
A similar scenario of disengagement was
observed in many of the countries of central
and eastern Europe and the Commonwealth of
Independent States (CEE-CIS). In the early 1990s,
public expenditure on health declined to levels
that made administering a basic system virtually
impossible. This contributed to a major decline
in life expectancy17. Catastrophic health spending
became a major cause of poverty18. More recently,
funding levels have stabilized or even increased,
but signifi cant improvements in health outcomes
have not followed and socioeconomic inequalities
in health and health-care access are rising.
Evidence and trends related to these rises, as well
as increases in informal payment mechanisms
for health care, indicate that re-engagement is
still insuffi cient.
Elsewhere, but most spectacularly in lowincome
countries and fragile states, the absence
or withdrawal of the state from its responsibilities
for health refl ects broader conditions of
economic stagnation, political and social crisis
and poor governance19. In such conditions, public
leadership has often become dysfunctional and
de-institutionalized20, a weakness that is compounded
by a lack of fi nancial leverage to steer
the health sector. Global development policies
have often added to the diffi culties governments
face in assuming their responsibilities, for at
least two reasons.
�� The global development agenda of the 1980s
and 1990s was dominated by concern for the
problems created by too much state involvement21.
The structural adjustment and downsizing
recipes of these decades still constrain
the reconstruction of leadership capacity
today. Public fi nancing in the poorest countries
became unpredictable, making medium-term
commitments to the growth of the health sector
diffi cult or impossible. Health planning
based on needs became the exception rather
than the rule, since key fi scal decisions were
taken with little understanding of the potential
consequences for the health sector and health
ministries were unable to make an effective
case for prioritizing budget increases22.
�� For decades, the international community’s
health agenda – including that of WHO – has
been structured around diseases and interventions
rather than around the broader challenges
being faced by health systems. While
this agenda has certainly contributed to a
better appreciation of the burden of disease
affecting poor countries, it has also profoundly
infl uenced the structure of governmental and
quasi-governmental institutions in low- and
middle-income countries. The resulting fragmentation
of the governance of the health
sector has diverted attention from important
issues, such as the organization of primary
care, the control of the commercialization of
the health sector and human resources for
health crises.
The World Health Report 2008 Primary Health Care – Now More Than Ever
84
The untoward consequences of this trend are
most marked in aid-dependent countries because
it has shaped the way funds are channelled23.
The disproportionate investment in a limited
number of disease programmes considered as
global priorities in countries that are dependent
on external support has diverted the limited
energies of ministries of health away from their
primary role as mediator in the comprehensive
planning of primary care and the public’s health.
Box 5.1 From withdrawal to re-engagement in China
During the 1980s and 1990s, reduced Government engagement in the health sector exposed increasing numbers of Chinese households
to catastrophic expenditures for health care. As a result, millions of families in both rural and urban areas found themselves unable
to meet the costs and were effectively excluded from health care. In cities, the Government Insurance Scheme (GIS) and Labour
Insurance Scheme (LIS) had previously covered more than half of the population with either full or partial health insurance. However,
the structural weaknesses of these schemes reached critical levels under the impact of accelerating economic change in the 1990s.
The percentage of China’s urban population not covered by any health insurance or health plan rose from 27.3% in 1993 to 44.1% in
199814. By the end of the century, out-of-pocket payments made up more than 60% of health expenditure. This crisis spurred efforts
to invert the trend: pooling and pre-payment schemes were bolstered in 1998 with the introduction of Basic Medical Insurance (BMI)
for urban employees.
Financed through compulsory contributions from workers and employers, the BMI aims to replace the old GIS and LIS systems. The
BMI has aimed for breadth of coverage with a relatively modest depth of benefi ts, linked to fl exibility that can enable the development
of different types of packages according to local needs in the participating municipalities. Structurally, the BMI fund is divided into two
parts: individual savings accounts and social pooling funds. Generally speaking, the fi nancial contribution from an employee’s salary or
wages goes to his or her individual savings account, while the employer’s contribution is split between the individual savings accounts
and the social pooling fund, applying different percentages according to the age group of employees.
Financial resources under the new BMI are pooled at municipal or city level, instead of by individual enterprises, which signifi cantly
strengthens the capacity for risk sharing. Each municipal government has developed its own regulations on the use of the resources
of individual savings accounts and social pooling funds (the two structural parts of the system). The individual savings accounts cover
outpatient services, while the social pooling fund is meant to cover inpatient expenditures14.
Signifi cant diffi culties with the BMI model remain to be ironed out, in particular as regards equity. For example, studies indicate that, in
urban areas, better-off populations have been quicker to benefi t from the provisions of the BMI than households with very low incomes,
while informal sector workers remain on the margins of the scheme. Nonetheless, the BMI has made progress in expanding health
insurance coverage and access to services among China’s urban population, and is instrumental in reversing the deleterious trends of
the 1980s and 1990s and, at the same time, assigning a new, intermediary role to government institutions.
Figure 5.2 Health expenditure in China: withdrawal of the State in the 1980s and 1990s
and recent re-engagement
Percentage of total health expenditure
01965
100
80
60
20
40
Pre-paid private
expenditure
Social security
expenditure
Other general
government
expenditure
Out-of-pocket
expenditure
1978
1979
1980
1997
1998
1999
2000
2001
2002003
2004
2005
2006
1975
1970
1981982
1983
1984
1985
1986
1987
1988
1989
1990
1991992
1993
1994
1995
1996
Sources: 1965 to 197515; 1978 to 199416; 1995 to 20064.
85
Chapter 5. Leadership and effective government
As a result, multiple, fragmented funding streams
and segmented service delivery are leading to
duplication, ineffi ciencies and counterproductive
competition for resources between different
programmes. Consequently, the massive mobilization
of global solidarity has not been able to
offset a growing estrangement between country
needs and global support, and between people’s
expectations for decent care and the priorities set
by their health-sector managers. Moreover, the
growth in aid-fl ow mechanisms and new implementing
institutions has further heightened the
degree of complexity faced by weak government
bureaucracies in donor-dependent countries,
increasing transaction costs for those countries
that can least afford them24. So much effort is
required to respond to international partners’
short-term agendas that little energy is left to deal
with the multiple domestic stakeholders – professions,
civil society organizations, politicians,
and others – where, in the long run, leadership
matters most. As advocates have rightly argued
in recent years, better inter-donor coordination
is not going to solve this problem on its own:
there is also an urgent need for reinvestment in
governance capacity.
Participation and negotiation
The necessary reinvestment in governmental or
quasi-governmental institutions cannot mean
a return to command-and-control health governance.
Health systems are too complex: the
domains of the modern state and civil society are
interconnected, with constantly shifting boundaries25.
Professions play a major role in how health
is governed26, while, as mentioned in Chapter
2, social movements and quasi-governmental
autonomous institutions have become complex
and infl uential political actors27. Patients, professions,
commercial interests and other groups are
organizing themselves in order to improve their
negotiating position and to protect their interests.
Ministries of health are, also, far from homogenous:
individuals and programmes compete for
infl uence and resources, adding to the complexity
of promoting change. Effective mediation in
health must replace overly simplistic management
models of the past and embrace new mechanisms
for multi-stakeholder policy dialogue to work out
the strategic orientations for PHC reforms28.
At the core of policy dialogue is the participation
of the key stakeholders. As countries modernize,
their citizens attribute more value to social
accountability and participation. Throughout the
world, increasing prosperity, intellectual skills
and social connectivity are associated with people’s
rising aspiration to have more say29 in what
happens at their workplaces and in their communities
− hence the importance of people-centredness
and community participation − and in
important government decisions that affect their
lives − hence the importance of involving civil
society in the social debate on health policies30.
Another reason that policy dialogue is so
important is that PHC reforms require a broad
policy dialogue to put the expectations of various
stakeholders in perspective, to weigh up need,
demand and future challenges, and to resolve the
inevitable confrontations such reforms imply31.
Health authorities and ministries of health, which
have a primary role, have to bring together the
decision-making power of the political authorities,
the rationality of the scientifi c community, the
commitment of the professionals, and the values
and resources of civil society32. This is a process
that requires time and effort (Box 5.2). It would
be an illusion to expect PHC policy formation
to be wholly consensual, as there are too many
confl icting interests. However, experience shows
that the legitimacy of policy choices depends less
on total consensus than on procedural fairness
and transparency33,34,35.
Without a structured, participatory policy
dialogue, policy choices are vulnerable to appropriation
by interest groups, changes in political
personnel or donor fi ckleness. Without a social
consensus, it is also much more diffi cult to engage
effectively with stakeholders whose interests
diverge from the options taken by PHC reforms,
including other sectors that compete for society’s
resources; for the “medico-industrial complex”36,
for whom PHC reform may imply a realignment of
their industrial strategy and for vested interests,
such as those of the tobacco or alcohol industries,
where effective PHC reform constitutes a direct
threat.
The World Health Report 2008 Primary Health Care – Now More Than Ever
86
Effective policy dialogue
The institutional capacities to enable a productive
policy dialogue are not a given. They are typically
weak in countries where, by choice or by
default, laissez-faire dominates the approach to
policy formation in health. Even in countries with
mature and well-resourced health systems there
is scope, and need, for more systematic and institutionalized
approaches: negotiation between
health authorities and professional institutions
is often well established, but is much less so with
other stakeholders and usually limited to discussions
on resource allocation for service delivery.
Policy dialogue must be built. How to do that
depends very much on context and background.
Experience from countries that have been able to
accelerate PHC reforms suggests three common
elements of effective policy dialogue:
the importance of �� making information systems
instrumental to PHC reform;
�� systematically harnessing innovations; and
�� sharing lessons on what works.
Information systems to
strengthen policy dialogue
Policy dialogue on PHC reforms needs to be
informed, not just by better data, but also by
information obtained through a departure from
traditional views on the clients, the scope and
the architecture of national health information
systems (Figure 5.3).
Many national health information systems that
are used to inform policy can be characterized as
closed administrative structures through which
there is a limited fl ow of data on resource use,
services and health status. They are often only
used to a limited extent by offi cials at national
and global level when formulating policy reforms,
while little use is made of critical information that
could be extracted from other tools and sources
(census data, household expenditure or opinion
surveys, academic institutions, NGOs, health
insurance agencies, etc.), many of which are
located outside the public system or even outside
the health sector.
Box 5.2 Steering national directions with the help of policy dialogue:
experience from three countries
In Canada, a Commission examining the future of health care drew on inputs from focus group discussions and public hearings. Diverse
stakeholders and groups of the public made clear the value placed by Canadians on equitable access to high-quality care, based on
need and regardless of ability to pay. At the same time, the Commission had to ensure that this debate would be fed by evidence from
top policy experts on the realities of the country’s health system. Of critical importance was the evidence that public fi nancing of
health care not only achieves goals of equity, but also those of effi ciency, in view of the higher administrative costs associated with
private fi nancing. The discussion on values and the relevant evidence were then brought together in a policy report in 2002 that set
out the direction for a responsive, sustainable and publicly funded PHC system, considered to be “the highest expression of Canadians
caring for one another”37. The strong uptake by policy-makers of the Commission’s recommendations refl ects the robustness of the
evidence-informed analysis and public engagement.
In Brazil, the fi rst seven Conferências Nacionais de Saúde, the platform for national policy dialogue in the health sector between 1941
and 1977, had a distinctly top-down and public-sector-only fl avour, with a classic progression from national plans to programmes and
extension of the network of basic health services. The watershed came with the 8th conference in 1980: the number of participants
increased from a few hundred to 4000, from a wide range of constituencies. This and subsequent conferências pursued agendas that
were driven far more than before by values of health democracy, access, quality, humanization of care and social control. The 12th
national conference, in 2003, ushered in a third consolidation phase: 3000 delegates, 80% of them elected, and a focus on health as
a right for all and a duty of the State38.
Thailand went through similar phases. The extension of basic health care coverage by a proactive Ministry of Health, encouraged by
the lobby of the Rural Doctors Association, resulted in the 1992 launch of the Decade of Health Centre Development. After the 1994
economic crisis, ministry offi cials started mobilizing civil society and academia around the universal coverage agenda, convening a
few thousand delegates to the First Health Care Reform Forum in 1997. Liaison with the political world soon followed, with a bold move
towards universal access and social protection known as the “30 Baht policy”39. With the National Health Act of 2007, stakeholder
participation has been institutionalized through a National Health Commission that includes health professionals, civil society members
and politicians.
87
Chapter 5. Leadership and effective government
Routine data from traditional health information
systems fails to respond to the rising demand
for health-related information from a multitude
of constituencies. Citizens need easier access to
their own health records, which should inform
them about the progress being made in their
treatment plans and allow them to participate
in decisions related to their own health and that
of their families and communities. Communities
and civil society organizations need better information
to protect their members’ health, reduce
exclusion and promote equity. Health professionals
need better information to improve the quality
of their work, and to improve coordination and
integration of services. Politicians need information
on how well the health system is meeting
society’s goals and on how public money is being
used.
Information that can be used to steer change
at the policy level is quite different from the
data that most conventional health information
systems currently produce. There is a need to
monitor what the reforms are achieving across
the range of social values and the associated outcomes
that are central to PHC: equity, people-centredness,
protection of the health of communities
and participation. That means asking questions
such as:
is care comprehensive, �� integrated, continuous
and effective?
�� is access guaranteed and are people aware of
what they are entitled to?
�� are people protected against the economic
consequences of ill-health?
�� are authorities effective in ensuring protection
against exclusion from care?
�� are they effective in ensuring protection against
exploitation by commercial providers?
Such questions go well beyond what can be
answered by tracking health outcome indicators,
resource use and service output, which is what
conventional health information systems focus on.
The paradigm shift required to make information
systems instrumental to PHC reform is to refocus
on what is holding up progress in reorienting
the health system. Better identifi cation of priority
health problems and trends is important (and
vital to anticipate future challenges) but, from
a policy point of view, the crucial information is
that which allows identifi cation of the operational
and systemic constraints. In low-income countries
in particular, where planning has long been
structured along epidemiological considerations,
this can provide a new and dynamic basis for
orienting systems development40. The report by
the Bangladesh Health Watch on the state of the
country’s health workforce, for example, identifi
ed such systemic constraints and corresponding
recommendations for the consideration of health
authorities41.
The multiplication of information needs and
users implies that the way health information is
generated, shared and used also has to evolve.
This critically depends on accessibility and transparency,
for example, by making all health-related
information readily accessible via the Internet –
as in Chile, where effective communication was
considered both an outcome
and a motor of their “Regime
of Explicit Health Guarantees”.
PHC reform calls for open and
collaborative models to ensure
that all the best sources of data
are tapped and information
fl ows quickly to those who can
translate it into appropriate
action.
Open and col laborat ive
structures, such as the “Observatories”
or “Equity Gauges”
offer specifi c models of complementing
routine information
From
Figure 5.3 Transforming information systems into instruments for PHC reform
Ministry of health
Multiple users, producers and
stakeholders
Monitor routine data on:
�� morbidity
�� resource usage
�� service production
Information fl owing upwards
within the public sector
hierarchy
�� Produce intelligence to
understand challenges
�� Monitor performance towards
social objectives
�� Identify system constraints
Open knowledge networks
with multiple collaborating
institutions; transparency
essential
To
Clients
Scope
Architecture
The World Health Report 2008 Primary Health Care – Now More Than Ever
88
systems, by directly linking the production and
dissemination of intelligence on health and social
care to policy-making and to the sharing of best
practices42. They refl ect the increasing value
given to cross-agency work, health inequalities
and evidence-based policy-making. They
bring together various constituencies, such as
academia, NGOs, professional associations, corporate
providers, unions, user representatives,
governmental institutions and others, around
a shared agenda of monitoring trends, studies,
information sharing, policy development and
policy dialogue (Box 5.3).
Paradoxically, these open and fl exible confi
gurations provide continuity in settings where
administrative and policy continuity may be
affected by a rapid turnover of decision-makers.
In the Americas, there are observatories that specifi
cally focus on human resource issues in 22
countries. In Brazil, for example, the observatory
is a network of more than a dozen participating
institutions (referred to as “workstations”): university
institutes, research centres and a federal
offi ce, coordinated through a secretariat based
at the Ministry of Health and the Brasilia offi ce
of PAHO44. These networks played a key role in
setting up Brazil’s current PHC initiatives. Such
national and sub-national structures also exist
in various European countries, including France,
Italy and Portugal45. Comparatively autonomous,
such state/non-state multi-stakeholder networks
can cover a wide range of issues and be sensitive
to local agendas. In the United Kingdom, each
regional observatory takes the lead on specifi c
Box 5.3 Equity Gauges: stakeholderholder collaboration to tackle health inequalities43
Equity Gauges are partnerships of multiple stakeholders that organize active monitoring and remedial action around inequity in health
and health care. So far, they have been established in 12 countries on three continents. Some operate at a countrywide level, some
monitor a subset of districts or provinces in a country, a few operate at a regional level and others focus specifi cally on equity within a
city or municipality; nine have a national focus and three work at the municipal level (in Cape Town (South Africa), El Tambo (Ecuador)
and Nairobi (Kenya). The Equity Gauges bring together stakeholders representing a diversity of local contexts, including parliamentarians
and councillors, the media, ministries and departments of health, academic institutions, churches, traditional leaders, women’s
associations, community-based and nongovernmental organizations, local authority organizations and civic groups. Such a diversity of
stakeholders not only encourages wide social and political investment, but also supports capacity development within countries.
Equity Gauges develop an active approach to monitoring and dealing with inequity in health and health care. They move beyond a
mere description or passive monitoring of equity indicators to a set of specifi c actions designed to effect real and sustained change in
reducing unfair disparities in health and health care. This work entails an ongoing set of strategically planned and coordinated actions
that involves a range of different actors who cut across a number of different disciplines and sectors.
The Equity Gauge strategy is explicitly based on three “pillars of action”. Each one is considered to be equally important and essential
to a successful outcome and all three are developed in parallel:
research and monitoring to measure a �� nd describe inequities;
�� advocacy and public participation to promote the use of information to effect change, involving a broad range of stakeholders from
civil society working together in a movement for equity;
�� community involvement to involve poor and marginalized people as active participants in decision-making rather than passive
recipients of measures designed for their benefi t.
The Equity Gauge strategy consists, therefore, of a set of interconnected and overlapping actions – it is not, as the name might suggest,
just a set of measurements. For example, the selection of equity indicators for measurement and monitoring should take account of
the views of community groups and consider what would be useful from an advocacy perspective. In turn, the advocacy pillar relies on
reliable indicators developed by the measurement pillar and may involve community members or public fi gures.
Equity Gauges choose indicators according to the particular needs of the country as well as of the stakeholders. Emphasis is placed,
however, on generating trend data within all Gauges to enable understanding of progress over time. Indicators are measured across a
variety of dimensions of health, including health status; health-care fi nancing and resource allocation; access to health care; and quality
of health care (such as maternal and child health, communicable diseases and trauma). All indicators are disaggregated according to the
“PROGRESS” acronym that describes a broad range of socioeconomic factors often associated with inequities in health determinants:
Place of residence, Religion, Occupation, Gender, Race/ethnicity, Education, Socioeconomic status and Social networks/capital.
89
Chapter 5. Leadership and effective government
issues, such as inequalities, primary care, violence
and health, or the health of older people46.
All cover a wide range of issues of regional
relevance (Table 5.1): they thus institutionalize
the linkages between local developments and
countrywide policy-making.
Strengthening policy dialogue with
innovations from the fi eld
These links between local reality and policy-making
conditions the design and implementation of
PHC reforms. The build up to the introduction of
Thailand’s “30 Baht” universal coverage scheme
provides an example of a deliberate attempt to
infuse policy deliberations with learning from
the fi eld. Leaders of Thailand’s reform process
organized a mutually reinforcing interplay
between policy development at the central level
and “fi eld model development” in the country’s
provinces. Health workers on the periphery and
civil society organizations were given the space
to develop and test innovative approaches to care
delivery, to see how well they met both professional
standards and community expectations
(Figure 5.4). Field model development activities,
which were supported by the Ministry of Health,
were organized and managed at provincial level,
and extensively discussed and negotiated with
provincial contracts. Each province developed its
own strategies to deal with its specifi c problems.
The large amount of fl exibility given to the provinces
in deciding their own work programmes
had the advantage of promoting ownership,
fostering creativity and allowing original ideas
to come forward. It also built local capacities.
The downside to the high level of autonomy of
the provinces was a tendency to multiply initiatives,
making it diffi cult to evaluate the results to
be fed into the policy work in a systematic way.
On balance, however, the diffi culties due to the
locally-driven approach were compensated for
by the positive effects related to reform dynamics
and capacity building. By 2001, nearly half
of Thailand’s 76 provinces were experimenting
with organizational innovation, most of it around
issues of equitable access, local health-care systems
and community health52.
Thailand’s “30 Baht” universal coverage
reform was a bold political initiative to improve
health equity. Its transformation into a concrete
reality was made possible through the accumulated
experience from the fi eld and through the
alliances the fi eldwork had built between health
workers, civil society organizations and the public.
When the scheme was launched in 2001, these
provinces were ready to pilot and implement the
Table 5.1 Roles and functions of public-health
observatories in England42
Roles Functionsa
Monitoring health and
disease trends and
highlighting areas for
action
Study on the inequalities existing
in coronary heart disease, together
with recommendations for action47
Identifying gaps in
health information
Study of current information sources
and gaps on perinatal and infant
health48
Advising on methods
for health and health
inequality impact
assessment
Overview of health impact
assessment49
Drawing together
information from
different sources in
new ways to improve
health
Health profi le using housing and
employment data alongside health
data50
Carrying out projects
to highlight particular
health issues
A study of the dental health of fi veyear-
olds in the Region51
Evaluating progress
by local agencies in
improving health and
eliminating inequality
Baselines and trend data
Looking ahead to give
early warning of future
public health problems
Forum for partners to address likely
future public health issues such as
the ageing population and genetics
a Example: Northern and Yorkshire Public Health Observatory.
Figure 5.4 Mutual reinforcement between innovation in the fi eld and
policy development in the health reform process
Policy
mobilization
and development
Field model
development
a
Demonstration,
diffusion and
pressure for change
Identify opportunities
and alliances
The World Health Report 2008 Primary Health Care – Now More Than Ever
90
scheme. Furthermore, the organizational models
they had developed informed the translation of
political commitment to universal coverage into
concrete measures and regulations53.
This mutually reinforcing process of linking
policy development with learning from the fi eld
is important for several reasons:
it taps the wealth �� of latent knowledge and innovation
within the health sector;
�� bold experiments in the fi eld give front-line
workers, system leaders and the public an
inspiring glimpse of what the future might look
like in a health system shaped by PHC values.
This overcomes one of the greatest obstacles to
bold change in systems − people’s inability to
imagine that things could actually be different
and be an opportunity rather than a threat;
�� the linking of policy development with frontline
action fosters alliances and support from
within the sector, without which far-reaching
reform is not sustainable;
�� such processes engage society both locally and
at national level, generating the demand for
change that is essential in building political
commitment and maintaining the momentum
for reform.
Building a critical mass of
capacity for change
The stimulation of open, collaborative structures
that supply reforms with strategic intelligence
and harness innovation throughout the health
system requires a critical mass of committed and
experienced people and institutions. They must
not only carry out technical and organizational
tasks, but they must also be able to balance fl exibility
and coherence, adapt to new ways of working,
and build credibility and legitimacy54.
However, that critical mass of people and
institutions is often not available31. Institutions
in low-income countries that have suffered
from decades of neglect and disinvestment are
of particular concern. They are often short on
credibility and starved of resources, while key
staff may have found more rewarding working
environments with partner agencies. Poor governance
complicates matters, and is compounded
by international pressure for state minimalism
and the disproportionate infl uence of the donor
community. The conventional responses to leadership
capacity shortfalls in such settings, which
are characterized by a heavy reliance on external
technical assistance, toolkits and training, have
been disappointing (Box 5.4). They need to be
replaced by more systematic and sustainable
approaches in order to institutionalize competencies
that learn from and share experience55.
Documented evidence of how individual and
institutional policy dialogue and leadership
capacities build up over time is hard to fi nd, but
a set of extensive interviews of health sector leaders
in six countries shows that personal career
trajectories are shaped by a combination of three
decisive experiences56.
�� At some point in their careers, all had been
part of a major sectoral programme or project,
particularly in the area of basic health services.
Many of them refer to this as a formative
experience: it is where they learned about
PHC, but also where they forged a commitment
and started building critical alliances
and partnerships.
�� Many became involved in national planning
exercises, which strengthened their capacity to
generate and use information and, again, their
capacity to build alliances and partnerships.
Few had participated personally in major studies
or surveys, but those who had, found it an
opportunity to hone their skills in generating
and analyzing information.
�� All indicated the importance of cooptation and
coaching by their elders: “You have to start out
as a public health doctor and be noticed in one
of the networks that infl uence decision making
in MOH. After that your personal qualities and
learning by doing [determine whether you’ll get
to be in a position of leadership].”56
These personal histories of individual capacity
strengthening are corroborated by more in-depth
analysis of the factors that contributed to the
institutional capacities for steering the health
sector in these same countries. Table 5.2 shows
that opportunities to learn from large-scale
health-systems development programmes have
contributed most, confi rming the importance of
hands-on engagement with the problems of the
health sector in a collaborative environment.
91
Chapter 5. Leadership and effective government
Box 5.4 Limitations of conventional capacity building in low- and middle-income countries55
The development community has always tended to respond to the
consequences of institutional disinvestment in low- and middleincome
countries through its traditional arsenal of technical assistance
and expert support, toolkits and training (Figure 5.5). From
the 1980s onwards, however, it became clear that such “technical
assistance” was no longer relevant 58 and the response re-invented
itself as “project management units” concentrating on planning,
fi nancial management and monitoring.
The stronger health systems were able to benefit from the
resources and innovation that came with projects but, in others,
the picture was much more mixed. As a recurrent irritant to national
authorities, accountability to funding agencies often proved
stronger than commitment to national development: demonstrating
project results took precedence over capacity building and
long-term development59, giving disproportionate weight to project
managers at the expense of policy coherence and country leadership.
In more recent years, the wish to reinforce country ownership
– and changes in the way donors purchase technical assistance
services – paved the way for a shift from project management to
the supply of short-term expertise through external consultants.
In the 1980s and early 1990s, the expertise was essentially provided
by academic institutions and the in-house experts of bilateral
cooperation and United Nations agencies. The increased volume of
funding for technical support
contributed to shifting
the expertise market
to freelance consultants
and consultancy fi rms, so
that expertise has become
increasingly provided on a
one-time basis, by technical
experts whose understanding
of the systemic
and local political context
is necessarily limited60.
In 2006, technical cooperation
constituted 41%
of total overseas development
aid for health.
Adjusted for infl ation, its
volume tripled between
1999 and 2006, particularly
through expansion of
technical cooperation on
HIV/AIDS. Adapting to the complexities of the aid architecture,
experts and consultants now also increasingly act as intermediaries
between countries and the donor community: harmonization
has become a growth business, lack of country capacity fuelling
further disempowerment.
12 000
10 000
Millions I$ 2005
0
2002
Figure 5.5 A growing market: technical cooperation as part of Official
Development Aid for Health. Yearly aid flows in 2005,
deflator adjusted61
2000
8000
4000
6000
14 000
Other health aid
Technical cooperation HIV/AIDS
Technical cooperation health
11%
36%
2003 2004 2005 2006
20%
21%
The second mainstay response to the capacity problem has been the
multiplication of planning, management and programme toolkits.
These toolkits promise to solve technical problems encountered
by countries while aiming for self-reliance. For all their potential,
rigour and evidence base, the usefulness of toolkits in the fi eld has
often not lived up to expectations for four main reasons.
They often underestimate the complexity �� of the problems they
are supposed to deal with62.
�� They often rely on international expertise for their implementation,
thereby defeating one of their main purposes, which is
to equip countries with the ways and means to deal with their
problems themselves.
�� Some have not delivered the promised technical results63 or
led to unexpected untoward side-effects64.
�� The introduction of toolkits is largely supply driven and linked to
institutional interests, which makes it diffi cult for countries to
choose among the multitude of competing tools that are proposed.
The capacity-building prescription that completes the spectrum is
training. Sometimes, this is part of a coherent strategy: Morocco’s
Ministry of Health, for example, has applied a saturation training
approach similar to that of Indonesia’s Ministry of Finance65, sending
out large numbers of young professionals for training in order
to build up a recruitment
base of qualifi ed staff and,
eventually, a critical mass
of leaders. Such deliberate
approaches, however, are
rare. Much more common are
short “hotel” training courses
that mix technical objectives
and exchange with implicit
aims to top-up salaries and
buy political goodwill. The
prevailing scepticism about
the usefulness of such programmes
(systematic evaluation
is uncommon) contrasts
sharply with the resources
they mobilize, at a considerable
opportunity cost.
In the meantime, new markets
in education, training
and virtual learning are
developing, while actors in
low- and middle-income countries can access Internet sites on
most health systems issues and establish electronic communities
of practice. With contemporary information technology and
globalization, traditional recipes for capacity development in poor
countries are quickly becoming obsolete54.
The World Health Report 2008 Primary Health Care – Now More Than Ever
92
Especially noteworthy is the fact that the introduction
of tools was rarely identifi ed as a critical
input, and respondents did not highlight inputs
from experts and training.
The implication is that the key investment
for capacity building for PHC reforms should be
to create opportunities for learning by linking
individuals and institutions to ongoing reform
processes. A further consideration is the importance
of doing so in an environment where
exchange, within and between countries, is
facilitated. Unlike the conventional approaches
to capacity building, exchange and exposure to
the experience of others enhances self-reliance.
This is not just a recipe for under-resourced
and poorly performing countries. Portugal, for
example, has organized a broad societal debate
on its 2004−2010 National Health Plan involving
a pyramid of participation platforms from local
and regional to national level, and 108 substantial
contributions to the plan from sources ranging
from civil society and professional organizations
to local governments and academia. At three critical
moments in the process, international panels
of experts were also invited from other countries
to act as sounding boards for their policy debate:
a collaboration that was a learning exercise for
all parties57.
Managing the political process: from
launching reform to implementing it
PHC reforms change the balance of power within
the health sector and the relationship between
health and society. Success depends not only on
a credible technical vision, but also on the ability
to obtain the high-level political endorsement
and the wider commitment that is necessary to
mobilize governmental, fi nancial and other institutional
machineries.
As a technical sector, health rarely has prominence
in the hierarchy of the political arena.
Ministries of health have often had enough to
deal with simply trying to resolve the technical
challenges internal to the sector. They are
traditionally ill at ease, short of leverage and ill
equipped to make their case in the wider political
arena, particularly in low- and low-middleincome
countries.
The general lack of political infl uence limits
the ability of health authorities, and of other
stakeholders in the PHC movement, to advance
the PHC agenda, especially when it challenges
the interests of other constituencies. It explains
the frequently absent or overly cautious reactions
against the health effects of working conditions
and environmental damage, or the slow implementation
of regulations that may interfere with
the commercial interests of the food and tobacco
industry. Similarly, ambitious reform efforts are
often diluted or watered down under the infl uence
of the donor community, the pharmaceutical
and the health technology industries, or the
professional lobbies26,66.
Lack of political infl uence also has consequences
within governmental spheres. Ministries
of health are in a particularly weak position in
low- and low-middle-income countries, as is
evidenced by the fact that they can claim only
4.5% and 1.7%, respectively, of total government
expenditure (against 10% and 17.7%, respectively,
in upper-middle and high-income countries)67.
The lack of prominence of health priorities in
wider development strategies, such as the Poverty
Reduction Strategy Papers (PRSPs), is another
illustration of that weakness68. Equally, ministries
of health are often absent in discussions
about caps on social (and health) spending, which
Table 5.2 Signifi cant factors in improving institutional
capacity for health-sector governance in six countriesa,56
Factorsb
No. of countries
where factor was an
important contributor
Average score
for strength of
contribution
Sector programmes/
large-scale projects
4 7.25
Establishment of
institutions
3 6.7
National policy
debate events
3 5.6
Research, studies
and situation
analysis
4 5.1
New planning and
management tools
1 5
a Burkina Faso, the Democratic Republic of the Congo, Haiti, Mali, Morocco and Tunisia.
b
Identifi ed through document analysis and interviews with 136 key informants.
93
Chapter 5. Leadership and effective government
are dominated by debates on macroeconomic
stability, infl ation targets or sustainable debt. It
is telling that, in highly indebted countries, the
health sector’s efforts to obtain a share of the debt
relief funds have been generally slow, less than
forceful and unconvincing compared to education,
foregoing possibilities for rapid expansion
of their resource base69.
Despite these challenges, there is a growing
indication that the political will for ambitious
reforms based on PHC is taking place. India’s
health missions − “rural” and subsequently
“urban” − are accompanied by a doubling of public
expenditure on health. China is preparing an
extremely ambitious rural PHC reform that also
includes a major commitment of public resources.
The size and comprehensiveness of PHC-oriented
reforms in Brazil, Chile, Ethiopia, the Islamic
Republic of Iran, New Zealand, Thailand and
many other countries, refl ect very clearly that it
is not unrealistic to mobilize political will. Even
in extremely unfavourable circumstances, it has
proven possible to gain credibility and political
clout through pragmatic engagement with political
and economic forces (Box 5.5).
Experience across these countries shows that
political endorsement of PHC reforms critically
depends on a reform programme that is formulated
in terms that show its potential political
dividends. To do that it has to:
respond explicitly �� to rising demand as well
as to the health challenges and health system
constraints the country faces, showing that it
is not merely a technical programme, but one
rooted in concerns relevant to society;
�� specify the expected health, social and political
returns, as well as the relevant costs, in
order to demonstrate the expected political
mileage as well as its affordability;
�� be visibly based on the key constituencies’
consensus to tackle the obstacles to PHC, providing
reassurance of the reforms’ political
feasibility.
Creating the political alignment and commitment
to reform, however, is only a fi rst step.
Insuffi cient preparation of its implementation is
often the weak point. Of particular importance
is an understanding of resistance to change,
particularly from health workers70,71,72,73. While
the intuition of leadership has its merits, it is also
possible to organize more systematic exercises to
anticipate and respond to the potential reactions
of stakeholders and the public: political mapping
exercises, as in Lebanon34; marketing studies and
opinion polls, as in the United States74; public
hearings, as in Canada; or sector-wide meetings
of stakeholders, as in the Etats Généraux de la
Santé in French-speaking Africa. Delivering on
PHC reforms requires a sustained management
capacity across levels of the system, embedded
in institutions that are fi t for the purpose. In
Chile, for example, administrative structures and
competencies across the whole of the Ministry
of Health are being redefi ned in line with the
PHC reforms. Such structural changes are not
suffi cient. They need to be instigated in conjunction
with changes in the organizational culture,
from one of issuing decrees for change to a more
inclusive collaboration with a variety of stakeholders
across the levels of the health system.
That in turn requires the institutionalization of
policy-dialogue mechanisms drawing practicebased
knowledge up from the ground level to
inform overall systems governance, while reinforcing
social linkages and collaborative action
among constituencies at community level75. This
management capacity should not be assumed, it
requires active investment.
Even with effective political dialogue to gain
consensus on specifi c PHC reforms and the requisite
management for implementation across
levels of the system, many such reforms do not
have their intended impact. The best-planned and
executed policy reforms often run into unanticipated
challenges or rapidly changing contexts.
Broad experience in dealing with complex systems
behaviour suggests that signifi cant shortfalls
or shifts away from articulated goals are to
be expected. An important component to build
into the reform processes is mechanisms that
can pick up signifi cant unintended consequences
or deviations from expected performance benchmarks,
which allow for course corrections during
implementation.
Widespread evidence on inequities in health
and health care in virtually all countries is a
humbling reminder of the diffi culties confronting
The World Health Report 2008 Primary Health Care – Now More Than Ever
94
Recent developments in the Democratic Republic of the Congo
show how renewed leadership can emerge even under extremely
challenging conditions. The beginnings of the reconstruction of
the country’s health system, devastated by economic collapse
and state failure culminating in a brutal war is, above all, a story
of skilful political management.
The Democratic Republic of the Congo had seen a number of successful
experiences in PHC development at the district level during
the 1970s and early 1980s. The economic and political turmoil
from the mid-1980s onwards saw central government authority
in health disintegrate, with an extreme pauperization of the health
system and the workers within it. Health workers developed a
multiplicity of survival strategies, charging patients and capitalizing
on the many aid-funded projects, with little regard for the
consequences for the health system. Donors and international
partners lost confi dence in the district model of integrated service
delivery in the country and instead chose to back stand-alone disease
control and humanitarian aid programmes. While, between
1999 and 2002, the Ministry of Health commanded less than 0.5%
of total government expenditure, its central administration and its
Department of Planning and Studies – 15 staff in total – faced the
overwhelming task of providing guidance to some 25 bilateral and
multilateral agencies, more than 60 international and 200 national
NGOs, 53 disease control programmes (with 13 government donor
coordination committees)
and 13 provincial ministries
of health – not forgetting
health-care structures organized
by private companies and
universities.
As the intensity of civil strife
abated, a number of key
Ministry of Health staff took it
upon themselves to revitalize
and update the district model
of primary health care. Aware
of the marginal position of the
Ministry in the health sector,
they co-opted the “internal
diaspora” (former civil servants
now working for the
many international development
agencies present in the
Box 5.5 Rebuilding leadership in health in the aftermath of war and economic collapse
country) in an open structure around the Ministry. This steering
group drafted a national health systems strengthening strategy.
It included (i) a progressive roll-out of integrated services, district
by district, coordinated through regional plans and backed by a
fundamental shift in funding from programme-specifi c fl ows to
system funding; (ii) a set of protective “damage-control” measures
to halt institutional infl ation and prevent further distortion of the
system; and (iii) an explicit plan to tackle the problem of donor
fragmentation, which had reached critical proportions. In designing
the strategy, the steering group made deliberate efforts to set up
networks within the health sector itself and alliances with other
government actors and social constituencies.
The formal endorsement of the national plan by donors and civil
society sent a strong political signal of the success of this new
mode of working. The national health systems strengthening strategy
became the health component of the national poverty reduction
strategy. Donors and international partners aligned existing
projects, albeit to a variable degree, while others reshaped new
initiatives to fi t the national strategy.
Perhaps the most powerful testimony to the effective management
of this process is the change in the composition of donor
funding for health (Figure 5.6). The proportion of funds dedicated
to general systems strengthening under provincial and district
plans has increased appreciably
in relation to the level
of funding earmarked for
disease control and humanitarian
relief programmes.
The advances remain fragile,
in a context where much of
the health sector – including
its governance – needs to be
reconstructed.
Nevertheless, the national
strategy has strong roots in
fi eldwork and, in a remarkable
turnaround against high
odds, the Ministry of Health
has gained credibility with
other stakeholders and has
improved its position in renegotiating
the fi nances of the
health sector.
250
US$ millions
0
2003
Figure 5.6 Re-emerging national leadership in health: the shift in donor funding
towards integrated health systems support, and its impact on the
Democratic Republic of the Congo’s 2004 PHC strategy
300
Humanitarian aid
Vertical programmes
Support to health districts
50
100
150
200
2004 2005 2006 2007
95
Chapter 5. Leadership and effective government
PHC reforms. This chapter has emphasized that
leadership for greater equity in health must be
an effort undertaken by the whole of society and
engage all relevant stakeholders. Mediating multistakeholder
dialogues around ambitious reforms
be they for universal coverage or primary care
places a high premium on effective government.
This requires re-orienting information systems
the better to inform and evaluate reforms, building
fi eld-based innovations into the design and
redesign of reforms, and drawing on experienced
and committed individuals to manage the
direction and implementation of reforms. While
not a recipe, these elements of leadership and
effective government constitute in and of themselves
a major focus of reform for PHC. Without
reforms in leadership and effective government,
other PHC reforms are very unlikely to succeed.
While necessary, therefore, they are not suffi
cient conditions for PHC reforms to succeed.
The next chapter describes how the four sets of
PHC reforms must be adapted to vastly different
national contexts while mobilizing a common set
of drivers to advance equity in health.
References
1. Porter D. Health, civilization and the state. A history of public health from ancient to
modern times. London and New York, Routledge, 1999.
2. The World Health Report 2000 – Health systems: improving performance. Geneva,
World Health Organization, 2000.
3. Waldman R. Health programming for rebuilding states: a briefi ng paper. Arlington VA,
Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival
(BASICS), 2007.
4. National health accounts. Geneva, World Health Organization (http//www.who.int/
nha/country/en/index.html, accessed May 2008).
5. Schoen C et al. US health system performance: a national scorecard. Health Affairs,
2006, 25(Web Exclusive):w457–w475.
6. Jacobs LR, Shapiro RY. Public opinion’s tilt against private enterprise. Health Affairs,
1994, 13:285–289.
7. Blendon RJ, Menson JM. Americans’ views on health policy: a fi fty year historical
perspective. Health Affairs, 2001, 20:33–46.
8. Fox DM. The medical institutions and the state. In: Bynum WF, Porter R, eds.
Companion encyclopedia of the history of medicine. London and New York,
Routledge, 1993, 50:1204–1230.
9. Blank RH. The price of life: the future of American health care. New York NY,
Colombia University Press, 1997.
10. Frenk J, Donabedian A. State intervention in health care: type, trends and
determinants. Health Policy and Planning, 1987, 2:17–31.
11. Blumenthal D, Hsiao W. Privatization and its discontents – the evolving Chinese
health care system. New England Journal of Medicine, 2005, 353:1165–1170.
12. Liu Y, Hsiao WC, Eggleston K. Equity in health and health care: the Chinese
experience. Social Science and Medicine, 1999, 49:1349–1356.
13. Bloom G, Xingyuan G. Health sector reform: lessons from China. Social Science and
Medicine, 1997, 45:351–360.
14. Tang S, Cheng X, Xu L. Urban social health insurance in China. Eschborn, Gesellschaft
für Technische Zusammenarbeit and International Labour Organization, 2007.
15. China: long-term issues and options in the health transition. Washington DC, The
World Bank, 1992.
16. China statistics 2007. Beijing, Ministry of Health, 2007 (http://moh.gov.cn/open/
statistics/year2007/p83.htm, accessed 31 May 2008).
17. WHO mortality database. Geneva, World Health Organization, 2007 (Tables; http://
www.who.int/healthinfo/morttables/en/index.html, accessed 1 July 2008).
18. Suhrcke M, Rocco L, McKee M. Health: a vital investment for economic development
in eastern Europe and central Asia. Copenhagen, World Health Organization Regional
Offi ce for Europe, European Observatory on Health Systems and Policies (http://
www.euro.who.int/observatory/Publications/20070618_1, accessed May 2008).
19. Collier P. The bottom billion: why the poorest countries are failing and what can be
done about it. Oxford and New York NY, Oxford University Press, 2007.
20. Grindle MS. The good government imperative: human resources, organizations, and
institutions. In: Grindle MS, ed. Getting good government: capacity building in the
public sectors of developing countries. Boston MA, Harvard University Press, 1997
(Harvard Studies in International Development:3–28).
21. Hilderbrand ME, Grindle MS. Building sustainable capacity in the public sector: what
can be done? In: Grindle MS, ed. Getting good government: capacity building in the
public sectors of developing countries. Boston MA, Harvard University Press, 1997
(Harvard Studies in International Development:31–61).
22. Goldsbrough D. Does the IMF constrain health spending in poor countries? Evidence
and an agenda for action. Washington DC, Center for Global Development, 2007.
23. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health
issues? Health Policy and Planning, 2008, 23:95–100.
24. Bill and Melinda Gates Foundation and McKinsey and Company. Global health
partnerships: assessing country consequences. Paper presented at: Third High-
Level Forum on the Health MDGs, Paris, 14–15 November 2005 (http://www.
hlfhealthmdgs.org/documents/GatesGHPNov2005.pdf).
25. Stein E et al, eds. The politics of policies: economic and social progress in Latin
America. Inter-American Development Bank, David Rockefeller Center for Latin
American Studies and Harvard University. Washington DC, Inter-American
Development Bank, 2006.
26. Moran M. Governing the health care state: a comparative study of the United
Kingdom, the United States and Germany. Manchester, Manchester University Press,
1999.
27. Saltman RB, Busse R. Balancing regulation and entrepreneurialism in Europe’s
health sector: theory and practice. In: Saltman RB, Busse R, Mossialos E, eds.
Regulating entrepreneurial behaviour in European health care systems. Milton
Keynes, Open University Press for European Observatory on Health Systems and
Policies, 2002:3–52.
28. McDaniel A. Managing health care organizations: where professionalism meets
complexity science. Health Care Management Review, 2000, 25:1.
29. World values surveys database. World Values Surveys, 2007 (V120, V121; http://
www.worldvaluessurvey.com, accessed 15 October 2007).
30. Inglehart R, Welzel C. Modernization, cultural change and democracy: the human
development sequence. Cambridge, Cambridge University Press, 2005.
31. Lopes C, Theisohn T. Ownership, leadership, and transformation: can we do better for
capacity development? London, Earthscan, 2003.
32. Wasi P. The triangle that moves the mountain. Bangkok, Health Systems Research
Institute, 2000.
33. McKee M, Figueras J. Setting priorities: can Britain learn from Sweden? British
Medical Journal, 1996, 312:691–694.
The World Health Report 2008 Primary Health Care – Now More Than Ever
96
34. Ammar W. Health system and reform in Lebanon. World Health Organization Regional
Offi ce for the Eastern Mediterranean and Ministry of Health of Lebanon. Beirut,
Entreprise universitaire d’Etudes et de Publications, 2003.
35. Stewart J, Kringas P. Change management – strategy and values. Six case studies
from the Australian Public Sector. Canberra, University of Canberra, Centre for
Research in Public Sector Management (http://www.dmt.canberra.edu.au/crpsm/
research/pdf/stewartkringas.pdf).
36. Chalmers I. From optimism to disillusion about commitment to transparency in
the medico-industrial complex. Journal of the Royal Society of Medicine, 2006,
99:337–341.
37. Romanow RJ. Building on values. The future of health care in Canada – fi nal report.
Saskatoon, Commission on the Future of Health Care in Canada, 2002.
38. Escorel S, Arruda de Bloch R. As conferências Nacionais de Saúde na Cobnstrução
do SUS. In: Trinidade Lima N et al, eds. Saúde e democracia: história e perpsectivas
do SUS. Rio de Janeiro, Editora Fiocruz, 2005:83–120.
39. Jongudomsuk P. Achieving universal coverage of health care in Thailand through the
30 Baht scheme. Paper presented at: SEAMIC Conference 2001 FY, Chiang Mai,
Thailand, 14–17 January 2002.
40. Galichet B et al. Country initiatives to lift health system constraints: lessons from 49
GAVI–HSS proposals. Geneva, World Health Organization, Department for Health
System Governance and Service Delivery, 2008.
41. The state of health in Bangladesh 2007. Health workforce in Bangladesh: who
constitutes the healthcare system? Bangladesh Health Watch (http://sph.bracu.
ac.bd/bhw/, accessed June 2008).
42. Hemmings J, Wilkinson J. What is a public health observatory? Journal of
Epidemiology and Community Health, 2003, 57:324–326.
43. Equity gauge profi les. Global Equity Gauge Alliance, 2008 (http:www.gega.org.za,
accessed 24 April 2008).
44. De Campos FE, Hauck V. Networking collaboratively: the experience of the
observatories of human resources in Brazil. Cahiers de sociologie et de démographie
médicales, 2005, 45:173–208.
45. Ashton J. Public health observatories: the key to timely public health intelligence
in the new century. Journal of Epidemiology and Community Health, 2000,
54:724–725.
46. Intelligent health partnerships. York, Association of Public Health Observatories,
2008 (http://www.apho.org.uk/resource/item.aspx?RID=39353 accessed 10 June
2008).
47. Robinson M, Baxter H, Wilkinson J. Working together on coronary heart disease in
Northern and Yorkshire. Stockton-on-Tees, Northern and Yorkshire Public Health
Observatory, 2001.
48. Bell R et al. Perinatal and infant health: a scoping study. Stockton-on-Tees, Northern
and Yorkshire Public Health Observatory, 2001.
49. Grant S, Wilkinson J, Learmonth A. An overview of health impact assessment.
Stockton-on-Tees, Northern and Yorkshire Public Health Observatory, 2001
(Occasional Paper No. 1).
50. Bailey K et al. Towards a healthier north-east. Stockton-on-Tees, Northern and
Yorkshire Public Health Observatory, 2001.
51. Beal J, Pepper L. The dental health of fi ve-year-olds in the Northern and Yorkshire
Region. Stockton-on-Tees, Northern and Yorkshire Public Health Observatory, 2002.
52. Thailand’s health care reform project, 1996–2001: fi nal report. Bangkok, Ministry of
Health, Thailand Offi ce of Health Care Reform, 2001.
53. Tancharoensathien V, Jongudomsuk P, eds. From policy to implementation: historical
events during 2001–2004 of UC in Thailand. Bangkok, National Health Security
Offi ce, 2005.
54. Baser H, Morgan P. Capacity, change and performance. Maastricht, European Centre
for Development Policy Management, 2008.
55. Macq J et al. Quality attributes and organisational options for technical support to
health services system strengthening. Background paper commissioned for the
GAVI–HSS Task Team, Nairobi, August 2007.
56. Boffi n N, De Brouwere V. Capacity building strategies for strengthening the
stewardship function in health systems of developing countries. Results of an
international comparative study carried out in six countries. Antwerp, Institute
of Tropical Medicine, Department of Public Health, 2003 (DGOS – AIDS Impulse
Programme 97203 BVO “Human resources in developing health systems”).
57. Carrolo M, Ferrinho P, Perreira Miguel J (rapporteurs). Consultation on Strategic
Health Planning in Portugal. World Health Organization/Portugal Round Table,
Lisbon, July 2003. Lisbon, Direcção Geral da Saùde, 2004.
58. Forss K et al. Evaluation of the effectiveness of technical assistance personnel.
Report to DANIDA, FINNIDA, NORAD and SIDA, 1988.
59. Fukuda-Parr S. Capacity for development: new solutions to old problems. New York
NY, United Nations Development Programme, 2002.
60. Messian L. Renforcement des capacités et processus de changement. Réfl exions
à partir de la réforme de l’administration publique en République Démocratique du
Congo. BTC Seminar on Implementing the Paris Declaration on Aid Effectiveness,
Brussels, 2006.
61. OECD. StatExtracts [online database]. Paris, Organisation for Economic
Co-operation and Development, 2008 (http://stats.oecd.org/WBOS/Index.aspx
accessed June 2008).
62. Irwin A. Beyond the toolkits: bringing engagement into practice. In: Engaging
science: thoughts, deeds, analysis and action. London, Wellcome Trust, 2007:50–55.
63. Rowe AK et al. How can we achieve and maintain high-quality performance of health
workers in low-resource settings? Lancet, 2005, 366:1026–1035.
64. Blaise P, Kegels G. A realistic approach to the evaluation of the quality management
movement in health care systems: a comparison between European and African
contexts based on Mintzberg’s organizational models. International Journal of Health
Planning and Management, 2004, 19:337–364.
65. Lippingcott DF. Saturation training: bolstering capacity in the Indonesian Ministry of
Finance. In: Grindle MS, ed. Getting good government: capacity building in the public
sectors of developing countries. Boston MA, Harvard University Press, 1997 (Harvard
Studies in International Development:98–123).
66. Krause E. Death of the guilds. professions, states and the advance of capitalism,
1930 to the present. New Haven and London, Yale University Press, 1996.
67. World health statistics 2008. Geneva, World Health Organization, 2008.
68. Poverty Reduction Strategy Papers, their signifi cance for health: second synthesis
report. Geneva, World Health Organization, 2004 (WHO/HDP/PRSP/04.1 2004).
69. World Bank Independent Evaluation Group. Debt relief for the poorest: an evaluation
update of the HIPC Initiative. Washington DC, The World Bank, 2006 (http://www.
worldbank.org/ieg/hipc/report.html, accessed June 2008).
70. Pangu KA. Health workers’ motivation in decentralised settings: waiting for better
times? In: Ferrinho P, Van Lerberghe W, eds. Providing health care under adverse
conditions. Health personnel performance and individual coping strategies. Antwerp,
ITG Press, 2000:19–30.
71. Mutizwa-Mangiza D. The impact of health sector reform on public sector health
worker motivation in Zimbabwe. Bethesda MD, Abt Associates, 1998 (Partnerships
for Health Reform, Major Applied Research 5, Working Paper No. 4).
72. Wiscow C. The effects of reforms on the health workforce. Geneva, World Health
Organization, 2005 (background paper for The World Health Report 2006).
73. Rigoli F, Dussault G. The interface between health sector reform and human
resources in health. Human Resources for Health, 2003, 1:9.
74. Road map for a health justice majority. Oakland, CA, American Environics, 2006
(http://www.americanenvironics.com/PDF/Road_Map_for_Health_Justice_
Majority_AE.pdf, accessed 1 July 2008).
75. Labra ME. Capital social y consejos de salud en Brasil. ¿Un círculo virtuoso?
Cadernos de saúde pública, 2002, 18(Suppl. 47):55, Epub 21 January 2003.


The starkly different social, economic and health
realities faced by countries must inform the way
forward for primary health care. This chapter discusses
the implications for the way universal
coverage, primary care, public policy and
leadership reforms are operationalized.
It shows how expanding health systems
offer opportunities for PHC reform in
virtually every country. Despite the need
for contextual specifi city, there are crosscutting
elements in the reforms, common
to all countries, which provide a basis for
globally shared learning and understanding about how PHC
reforms can be advanced more systematically everywhere.
Chapter 6
Adapting reforms to
country context 100
High-expenditure
health economies 101
Rapid-growth
health economies 103
Low-expenditure, lowgrowth
health economies 105
Mobilizing the
drivers of reform 108
The way
forward
99
The World Health Report 2008 Primary Health Care – Now More Than Ever
100
Adapting reforms to country context
Although insuffi ciently acknowledged, the PHC
movement has been a critical success in that it
has contributed to the recognition of the social
value of health systems, which has now taken
hold in most countries in the world. This change
of mindset has created a radically different
health-policy landscape.
Present-day health systems are a patchwork of
components, many of which may be far removed
from the goals set out 30 years ago. These same
health systems are converging. Driven by the
demographic, fi nancial and social pressures of
modernization, they increasingly share the aims
of improved health equity, people-centred care,
and a better protection of the health of their
populations.
However, that does not mean that health systems
across the world will change overnight.
Reorienting a health system is a long-term
process, if only because of the long time lag to
restructure the workforce1 and because of the
enormous inertia stemming from misaligned
fi nancial incentives and inadequate payment
systems2. Given the countervailing forces and
vested interests that drive health systems away
from PHC values, reform requires a clear vision
for the future. Many countries have understood
this and are developing their strategic vision of
public policies for health with a perspective of
10 to 20 years.
These visions are often couched in technical
terms and are highly vulnerable to electoral
cycles. Nevertheless, they are also increasingly
driven by what people expect their health
authorities to do: secure their health and improve
access to care, protect them against catastrophic
expenditure and fi nancial exploitation, and guarantee
an equitable distribution of resources3,4.
As shown throughout this Report, the pressure
that stems from these value-based expectations,
if used resolutely, can ensure that the vision is
not defl ected and safeguard it from capture by
short-term vested interests or changes in political
leadership.
The protection this offers is greatly reinforced
by early implementation. The possibilities to start
effecting change as of now exist in virtually all
countries: the growth of the health sector provides
fi nancial leverage to do so, and globalization
is offering some unprecedented opportunities
to make use of that leverage.
This does not in any way diminish the need to
recognize the widely divergent contexts in which
countries fi nd themselves today: the nature of the
health challenges they face and their wider socioeconomic
reality; and the degree of adaptation to
challenges, the level of development and speed at
which their health systems expand.
Opportunity for change is largely related to
the fl ow of new resources into the health sector.
Across the world, expenditure on health is growing:
between 1995 and 2005, it almost doubled
from I$ 2.6 to I$ 5.1 trillion. The rate of growth
is accelerating: between 2000 and 2005, the total
amount spent on health in the world increased by
I$ 330 billion on average each year, against an
average of I$ 197 billion in each of the fi ve previous
years. Health expenditure is growing faster
than GDP and faster than population growth. The
net result is that, with some exceptions, health
spending per capita grows at a rate of more than
5% per year throughout the world.
This common trend in the growth in health
expenditure masks a greater than 300-fold variation
across countries in per capita expenditure,
which ranges from less than I$ 20 per capita
to well over I$ 6 000. These disparities stratify
countries into three categories: high-expenditure
health economies, rapid-growth health economies,
and low-expenditure, low-growth health
economies.
The high-expenditure health economies, not
surprisingly, are those of the nearly 1 billion
people living in high-income countries. In 2005,
these countries spent on average I$ 3752 per
capita on health, I$ 1563 per capita more than
in 1995: a growth rate of 5.5% per year.
At the other extreme is a group of low-expenditure,
low-growth health economies: low-income
countries in Africa and South- and South-East
Asia, as well as fragile states. They total 2.6 billion
inhabitants who spent a mere I$ 103 per
capita on health in 2005, against I$ 58 in 1995.
In relative terms, these countries have seen their
health expenditure per capita grow at roughly the
101
Chapter 6. The way forward
same rate as high-expenditure countries: 5.8%
each year since 1995, but, in absolute terms, the
growth has been disappointingly low.
In between those two groups are the other
low- and middle-income countries, those with
rapid-growth health economies. The 2.9 billion
inhabitants in these countries spent an average
of I$ 413 per capita in 2005, more that double the
I$ 189 per capita that they spent in 1995. Health
expenditure in these countries has been growing
at a rate of 8.1% per year.
These groups differ not only in the rate and
size of their growth in health expenditure. A
breakdown according to the source of growth
reveals strikingly different patterns (Figure 6.1).
In the low-expenditure, low-growth health
economies, out-of-pocket payments account for
the largest share of the growth, while in rapidgrowth
and high-expenditure health economies,
increased government expenditure and prepayment
mechanisms dominate. Where growth
in health expenditure is through pre-payment
mechanisms, there is greater opportunity to support
PHC reforms: collectively pooled monies are
more readily re-allocated towards interventions
that provide a larger health return on investment
than out-of-pocket payments. Conversely, countries
where growth is primarily through out-ofpocket
expenditures have less leverage to support
PHC reforms. Alarmingly, it is in countries where
expenditure is the lowest and the burden of disease
highest that there is a real lack of opportunities
for harnessing the growth of their health
sector for PHC reforms.
The following sections outline broad categories
of contexts that can shape responses for PHC
reforms.
High-expenditure health economies
This group of countries funds almost 90% of its
growth in health expenditure – an extra I$ 200
per capita per year in recent years − through
increased government and private pre-payment
funds. Expanding or changing the offer of services
in these countries is less constrained by fi nances
than by the relative lack of human resources to
meet rising and changing demand. Their health
systems are built around a strong and prestigious
tertiary care sector that is important to the heavyweights
of the pharmaceutical and medical supply
industries2. Out-of-pocket payments, though still
signifi cant at 15% of total expenditure, have been
dwarfed by more progressive collective means of
fi nancing. The third-party payment institutions
have, thus, become central actors while the longstanding
autonomy of the health professionals is
waning. Efforts to control costs, improve quality
and access to disadvantaged groups have given
rise to a widening public debate on which users
and special interest groups have increasing infl uence.
Nevertheless, the state carries more weight
in the health sector of these countries than ever
before, with increasingly sophisticated regulatory
tools and institutions.
Despite worries over their long-term sustainability,
the solidarity mechanisms that fi nance
these health systems enjoy considerable social
consensus. The secular trend towards extension
of coverage to all citizens, and, often reluctantly,
to non-citizen residents as well, continues. In the
state of Massachusetts, the United States, for
example, the 2006 health insurance bill aims
at 99% coverage by 2010. At the same time, it
is becoming increasingly clear that universal
Yearly growth in per capita health expenditure (percentage)
0
Low-expenditure,
low-growth
health economies
Figure 6.1 Contribution of general government, private pre-paid and private
out-of-pocket expenditure to the yearly growth in total health
expenditure per capita, percentage, weighted averages5
100
Out-of-pocket health expenditure
Private pre-paid health expenditure
Government health expenditure
Rapid-growth
health economies
High-expenditure
health economies
60
80
20
40
The World Health Report 2008 Primary Health Care – Now More Than Ever
102
coverage schemes need to be complemented by
efforts: (i) to identify those who are excluded and
set up specifi cally tailored programmes to include
them; and (ii) to tackle the social determinants of
health inequalities through policy initiatives that
cut across a large number of sectors (Box 6.1), so
as to translate the political commitment to health
equity into concrete advances.
In many of these countries, the shift in point of
gravity from tertiary and specialized care to primary
care is well under way. Better information
and technological developments are creating
new opportunities – and a market – for moving
much of the traditionally hospital-based care into
local services staffed by primary-care teams or
even into the hands of patients themselves. This
is fuelling a change in perception of how health
services should operate. It provides support for
primary care, including self-care and home care.
Movement in this direction, however, is held up by
inertial forces stemming from the threat of downsizing
and dismantling massive tertiary-care
facilities and from demand induced by the illusion
that the extension of life through technology
is unlimited7. Technological innovation is indeed
a driver of improvement and current trends show
that it is expanding the range of services offered
by primary-care teams. Technological innovation
can, however, also be a driver of exclusion and
ineffi ciency. The marked inter-country differences
in the diffusion of medical technology are
a refl ection, not of rational evaluation, but of the
incentives to providers to adopt these technologies,
and the capacity to control that adoption2.
There are two reasons why the environment
in which this is taking place is changing.
Public c �� ontestation of the management of technology
has continued to increase for reasons of
trust, price, exclusion or unmet need.
�� Regulation increasingly depends on supranational
institutions. The European Union’s
regulatory system, for example, plays an
increasing role in the harmonization of the
technical requirements for registering new
medicines or of product licencing, offering possibilities,
among others, for more effective support
to legal provisions encouraging generic
substitution for pharmaceuticals in the private
sector8. Such mechanisms offer opportunities
to increase safety and access, and thus create
an environment in which national primary
care reforms are encouraged.
This comes at a time when the supply of professionals
willing and able to engage in primary
care is under stress. In Europe, for example, the
population of general practitioners is ageing rapidly,
and new recruits are more likely than before
to opt for part-time or low-intensity careers1.
There is pressure to give a more pivotal role to
Box 6.1 Norway’s national strategy to
reduce social inequalities in health6
Norway’s strategy to reduce health inequalities illustrates that
there is no single solution to this complex problem. Norway
has identifi ed a large number of determinants that infl uence
the health of individuals: income, social support, education,
employment, early childhood development, healthy environments
and access to health services. These complex and interrelated
determinants of health are not equally distributed in
society, and it is, therefore, not surprising that this leads to
inequities in health as well.
The Norwegian strategy attempts to address the root causes
of poor health and health inequity by infl uencing the underlying
determinants of health, and making the distribution of these
determinants more equitable from the outset. The Norwegian
strategy focuses on:
�� reducing social inequities;
�� reducing inequities in health behaviours and access to
health services;
�� targeted initiatives to improve social inclusion; and
�� cross-sectoral tools to promote a whole-of-government
approach to health.
This brings together a number of interventions that are effective
in tackling inequities, and that can be applied both within
health systems, as well as through cooperation with other
sectors. For instance, health systems are able to establish
programmes for early childhood development as well as policies
that reduce fi nancial, geographical and social barriers to
health services for those who need care the most. Working
with other sectors, such as labour and fi nance, can create
job opportunities and taxation systems that encourage more
equitable distribution and redistribution of wealth, which can
have a large impact on population health. In addition to universal
approaches, social inclusion interventions targeted at
providing better living conditions for the most disadvantaged
are also critical in reducing the gaps between the most well-off
and the least well-off members of society.
103
Chapter 6. The way forward
family physicians in primary care9. In the long
run, however, a more pluralistic approach will
be required with teams that include a variety
of professionals with the instruments to provide
coordination and continuity of care. That will
require a different, more varied and more fl exible
cadre of health workers. The sustainability
of primary-care reforms in the category of highspending
countries is questionable without: (i) a
change in paradigm of the training of health personnel;
and (ii) the necessary career, social and
fi nancial incentives to move health professionals
to what in the past have been less prestigious and
rewarding career options.
Spurred by the growing awareness of global
health threats and of the stratifi cation of health
outcomes along social fault lines, there is a
major renaissance in public health. The connections
between health and other sectors are
better understood and are bringing health to the
attention of all sectors. Research and information
systems, demand for public health training and
new discourses on public health are occupying
the centre stage of public concerns. This situation
needs to be translated into multi-pronged crosssector
strategies to address the social determinants
of health and their infl uence on priority
health challenges (Box 6.1).
Over the last decades, most countries in this
category are leading reforms through a steerand-
negotiate rather than a command-and-control
approach. This refl ects the growing public
visibility of the health-policy agenda and the need
to fi nd a balance between the different and often
irreconcilable demands of diverse constituencies.
As a result, reform efforts are usually multi-levelled,
with multiple actors. They progress incrementally:
a protracted messy process of muddling
through and hard bargaining. In England and
Wales, for example, a major primary-care reform
included an extensive public consultation through
questionnaires addressed to more than 42 000
people, while over 1 000 individuals were invited
to voice their interests and concerns in public
hearings. This involvement facilitated consensus
on a number of contentious parts of the reform,
including shifts of resources to primary care
and to underserved areas, while responsibilities
were redistributed to improve cooperation and
coordination10. Time and effort for systematic
but principled negotiation is the price to pay for
obtaining the social consensus that can overcome
entrenched resistance to reform.
Rapid-growth health economies
In rapid-growth health economies, the challenge
of engaging PHC reforms presents itself quite
differently. The growing demand that comes
with increased purchasing power is fuelling an
expansion of services at unprecedented speed.
Assuming current growth rates continue through
to 2015, per capita health expenditure will grow
by 60% in the fast-growing health economies of
the Americas compared to 2005 levels. In the
same time period, that expenditure will double
in Europe and the Middle-East and triple in East
Asia (Figure 6.2).
While the rate of growth in expenditure represents
an opportunity to engage in PHC reforms,
it also fuels patterns of health-sector development
that run counter to the vision and values
Projected total health expenditure per capita, I$, 2015
0
Low- and
middleincome
countries*,
Eastern
Mediterranean
region
Figure 6.2 Projected per capita health expenditure in 2015, rapid-growth
health economies (weighted averages)a
1200
Projected growth in out-of-pocket expenditure
Projected growth in private pre-paid expenditure
Projected growth in government expenditure
800
1000
400
600
Level of total health expenditure in 2005
1400
Low- and
middleincome
countries*,
East Asia,
Western
Pacific region
Low- and
middleincome*,
Americas
Low- and
middleincome
countries*,
European
region
All rapidgrowth
health
economies
* Without fragile states.
a Assuming the yearly growth rates for government-, private pre-paid-, and out-of-pocket
expenditure estimated from 1995−2005 data5 persist to 2015.
200
The World Health Report 2008 Primary Health Care – Now More Than Ever
104
of PHC. Beginnings count: policy choices that are
made for political or technical expediency, such
as to refrain from regulating commercial health
care, may make it more diffi cult to redirect health
systems towards PHC values at a later stage, as
powerful vested interests emerge and patterns
of supply-induced demand become entrenched11.
Biases towards highly sophisticated and specialized
infrastructures that cater to the expectations
of a wealthy minority are being further fuelled
by a new growth market in medical tourism
whereby patients from high-expenditure health
economies with high-fi xed costs are out-sourced
to these comparatively low-cost environments.
This drains the supply of professionals for primary
care, encouraging unprecedented rates of
specialization within the workforce12. In contrast
with these developments, ministries of health
in many of these countries are still organized
around specifi c disease control efforts, and are
ill-equipped to use the leverage of expanding
resources to regulate health-care delivery. The
result is all too often a two-tiered system, with
highly sophisticated and specialized health infrastructure
that caters to expectations of a wealthy
minority, in the presence of huge gaps in service
availability for a large part of the population
Reforms that emphasize universal access to
people-centred primary care can help to correct
such distortions. These reforms can take advantage
of technological innovations that facilitate
rapid, simple, reliable and low-cost access to services
that were previously inaccessible because
they were too expensive or required complex
supportive infrastructure. Such innovations
include rapid diagnostic tests for HIV and gastric
ulcers, better drugs that facilitate the shift from
institution-based to primary care-based mental
health13, and advances in surgery that either
eliminate or dramatically reduce the need for
hospitalization. Combined with the multiplication
of evidence-based guidelines, such innovations
have considerably enlarged the problem solving
capacity of primary-care teams, broadening the
role of non-physician clinicians14 and the potential
of self-care. Rapid expansion of people-centred
care is thus possible in a context where the technological
gap between close-to-client ambulatory
care and tertiary institutions is less striking
than it was 30 years ago. Chile, for example, has
doubled the uptake of primary-care services
in a period of fi ve years, along with a massive
investment in personnel and equipment ranging
from emergency dental care and laboratories to
home-based management of chronic pain. The
impact of this transformation can be amplifi ed
by targeting and empowering the large numbers
of poor and excluded in these countries and by
reforming public policies accordingly.
In the rapid-growth health economies of the
Americas and the European region less that one
third of the expected growth on current trends is
through increased out-of-pocket expenditure on
health. Two thirds are through increased government
expenditure, in combination, in the Americas,
with expanded private pre-paid expenditure
(Figure 6.2). The latter also plays a growing role
in the Far East, where, as in the Middle East,
around 40% of the growth, on current trends,
will be in out-of-pocket expenditure. Leverage
of PHC reforms will depend in part on the possibility
to regulate and infl uence private pre-paid
expenditure, and, particularly in Asia, to curb the
reliance on out-of-pocket expenditure.
In most of these countries, the level of expenditure
compared to GDP or to total government
expenditure remains low, offering fi nancial room
to further accelerate PHC reforms and underpin
them through parallel, and equally important,
moves towards universal coverage and reduced
reliance on out-of-pocket payments. In many of
these countries, public resources are allocated
on a capitation basis as are, at least, part of
pooled private pre-payment funds. This provides
opportunities to include criteria, such as
relative deprivation or unmet health needs in the
capitation formulas. This effectively transforms
resource allocation into an instrument for promoting
health equity and for introducing incentives
favouring conversion towards primary care
and healthier public policies.
Some of the largest countries in the world –
Brazil, for example – are now seizing these kinds
of opportunities on a massive scale, expanding
their primary-care networks while diminishing
their reliance on out-of-pocket payments15. Such
reforms, however, rarely come about without
pressure from the user’s side. Chile’s health policy
105
Chapter 6. The way forward
has defi ned a detailed benefi t package, well publicized
among the population as an enforceable
right. People are being informed about the kind
of services, including access to specialized care,
which they can claim from their primary-care
teams. In combination with sustained investment,
such unambiguous entitlements create a
powerful dynamic for the development of primary
care. Managed well, they have the potential to
accelerate convergence while avoiding at least
part of the distortions and ineffi ciencies that have
plagued high-income countries in earlier years.
Low-expenditure,
low-growth health economies
With 2.6 billion people and less than 5% of the
world’s health expenditure, countries in this
group suffer from an absolute under-funding of
their health sector, along with a disproportionally
high disease burden. The persistence of high
levels of maternal mortality in these countries
− they claim close to 90% of all maternal deaths
− is perhaps the clearest indication of the consequences
of the under-funding of health on the
performance of their health systems.
Worryingly, growth in health expenditure in
these countries is low and highly vulnerable to
their political and economic contexts. In fragile
states, particularly in those located in Africa,
health expenditure is not only low but barely
growing at all, and 28% of this little amount
of growth in recent years is accounted for by
external aid. Health expenditure in the other
countries of this group is growing at a stronger
average rate of 6% to 7% per year. On current
trends, by 2015, per capita health expenditure
will have more than doubled in India compared
to 2005, and increased by half elsewhere, except
in fragile states (Figure 6.3). In many countries,
this represents signifi cant leverage to engage
PHC reforms, particularly where the growth is
through increased government expenditure or, as
in Southern Africa, through other forms of prepayment.
In India, however, more than 80% of the
growth will, on current trends, be in out-of pocket
expenditure, offering much less leverage.
Countries in these regions accumulate a set of
problems that in all their diversity share many
characteristics. Whole population groups are
excluded from access to quality care: because
no services are available; because they are too
expensive, or under-funded, under-staffed and
under-equipped; or because they are fragmented
and limited to a few priority programmes. Efforts
to establish sound public policies that promote
health and deal with determinants of ill-health are
limited at best. Unregulated commercialization
of both private- and public-health care is quickly
becoming the norm for urban and, increasingly,
for rural populations − a much bigger and more
underestimated challenge to PHC’s values than
the verticalism that so worries the international
health community.
In most of these countries, the state has had,
in the past, the ambition to run the health sector
on an authoritarian basis. In today’s pluralistic
context, with a multitude of different providers,
formal and informal, public and private, only
few have succeeded in switching to more appropriate
steer-and-negotiate approaches. Instead,
as public resources stagnated and bureaucratic
mechanisms failed, laissez-faire has become the
default approach to management of the health
sector.
Projected health expenditure per capita, I$, 2015
0
Fragile
states
Figure 6.3 Projected per capita health expenditure in 2015, low-expenditure,
low-growth health economies (weighted averages)a
250
Projected growth in out-of-pocket expenditure
Projected growth in private pre-paid expenditure
Projected growth in government expenditure
150
200
50
100
Level of total health expenditure in 2005
300
South- and
South-East Asia*
India Sub-saharan
Africa*
All lowexpenditure,
low-growth
health
economies
* Without fragile states.
a Assuming the yearly growth rates for government-, private pre-paid-, and out-of-pocket
expenditure estimated from 1995−2005 data5 persist to 2015.
The World Health Report 2008 Primary Health Care – Now More Than Ever
106
This has resulted in few or feeble attempts to
regulate commercial health-care provision – not
only by the private, but also within the public
sector, which has, in many instances, adopted
the commercial practices of unregulated private
care. In such settings, government capacity often
limits the extent to which new resources can be
leveraged for improved performance. Health
authorities are, thus, left with an unfunded mandate
for steering the health sector.
Therefore, growing the resource base is a priority:
to refi nance resource-starved health systems;
to provide them with new life through PHC
reforms; and to re-invest in public leadership. Prepayment
systems must be nurtured now, discouraging
direct levies on the sick and encouraging
pooling of resources. This will make it possible to
allocate limited resources more intelligently and
explicitly than when health services are paid for
out-of-pocket. While there is no single prescription
for the type of pooling mechanism, there
are greater effi ciencies in larger pools: gradual
merging or federation of pre-payment schemes
can accelerate the build-up of regulatory capacity
and accountability mechanisms16.
In a signifi cant number of these low-expenditure,
low-growth health economies, particularly
in sub-Saharan Africa and fragile states,
the steep increase in external funds directed
towards health through bilateral channels or
through the new generation of global fi nancing
instruments has boosted the vitality of the
health sector. These external funds need to be
progressively re-channelled in ways that help
build institutional capacity towards a longer-term
goal of self-sustaining, universal coverage. In the
past, the bulk of donor assistance has targeted
short-term projects and programmes resulting in
unnecessary delays, or even detracting from the
emergence of the fi nancing institutions required
to manage universal coverage schemes. The
renewed interest among donors in supporting
national planning processes as part of the harmonization
and alignment agenda, and the consensus
that calls for universal access, represent
important opportunities for scaling up investments
in the institutional apparatus necessary for
universal coverage. While reduced catastrophic
expenditure on health care and universal access
are suffi ciently strong rationales for such change
in donor behaviour, the build-up of sustainable
national fi nancing capacities also offers an eventual
exit strategy from donor dependence.
Governments can do more to support the health
sector in these settings. Low-expenditure, lowgrowth
health economies allocate only a small
fraction of their government revenue to health.
Even in sub-Saharan African countries, which
have made progress and allocated an average of
8.8% of their government expenditure to health
in 2005, the Abuja Declaration target of 15% is
still a long way off5. Reaching that target would
increase total health expenditure in the region
by 34%. Experience of the last decade shows that
it is possible to increase government revenues
allocated to health rapidly. For example, following
rising pressure from a broad range of civil
society and political movements, India’s general
government expenditure on health – with a specifi
c focus on primary health care – is expected
to triple within the next fi ve years17. In a different
context, the Ministry of Health in Burundi
quadrupled its budget between 2005 and 2007 by
successfully applying for funds that became available
through debt reduction under the Enhanced
Heavily Indebted Poor Countries (HIPC) initiative.
On average, in the 23 countries at completion
point for the HIPC and Multilateral Debt Relief
Initiative (MDRI), the annual savings from HIPC
debt relief during the 10 years following qualifi -
cation are equivalent to 70% of public spending
on health at 2005 levels18. While only part of that
money is to be directed to health, even that can
make a considerable difference to the fi nancial
clout of public-health authorities.
Opportunities arise not only from increased
resources. The preponderance of pilot projects
is gradually being replaced by more systematic
efforts to achieve universal access, albeit often
for a single intervention or disease programme.
These high visibility programmes, developed in
relation to the MDGs, have revitalized a number
of concepts that are key to people-centred
care. Among them are the imperative of universal
access to high quality and safe care without
fi nancial penalty, and the importance of continuity
of care, and the need to understand the
social, cultural and economic context in which all
107
Chapter 6. The way forward
In Mali, the primary care network is made up of communityowned,
community-operated primary-care centres, backed up
by government-run district teams and referral units. There is a
coverage plan, negotiated with the communities, which, if they
so wish, can take the initiative to create a primary-care centre
according to a set of criteria. The commitment is important, since
the health centre will be owned and run by the community: for
example, the staff of the health centre, a three to four person
team led by a nurse or a family doctor, has to be employed (and
fi nanced) by the local community health association. The community
can make an agreement with the Ministry of Health to
obtain technical and fi nancial support from the district-health
teams, for the launch of the health centre and the supervision
and back up of its subsequent operation.
The model has proved quite popular, despite the huge effort communities
have had to put into the mobilization and organization
of these facilities: by 2007, 826 such centres were in operation
(up from 360 10 years before), set up at an average cost of
US$ 17 000. The system has proved resilient and has signifi cantly
increased the production of health care: the number of curative
care episodes managed by the health centres has been multiplied
by 2.1. The number of women followed up in antenatal care has
been multiplied by 2.7 and births attended by a health professional
by 2.5, with coverage levels as measured through Demographic
Health Surveys in 2006 standing at 70% and 49%, respectively;
DTP3 vaccination coverage in 2006 was 68%.
People obviously consider the investment worthwhile. Twice
during the last 10 years, between 2000 and 2001 and 2004
and 2005, demand and local initiative for the creation of new
centres was rising so fast that Mali’s health authorities had to
take measures to slow down the expansion of the network in order
to be able to guarantee quality standards (Figure 6.4). This suggests
that the virtuous cycle of increased demand and improved
Box 6.2 The virtuous cycle of supply of and demand for primary care
supply is functioning. Health authorities are expanding the range
of services offered and improving the quality – by encouraging the
recruitment of doctors in the rural primary-care centres − while
continuing their support to the extension of the network.
Population (millions)
1998
Figure 6.4 The progressive extension of coverage by community-owned,
community–operated health centres in Mali, 1998–2007
Not yet covered
Covered, but living more than 5 km from health care
Covered, living within 5 km of health care
2
4
6
8
10
12
0
Demand-driven
acceleration of
community
initiatives
Slowdown
to safeguard
quality
1999 2000 2001 2002 2003 2004 2005 2006 2007
Slowdown
to safeguard
quality
Demand-driven
acceleration of
community
initiatives
Source: Système national d’information sanitaire (SNIS), Cellule de Planification et de
Statistiques Ministère de la Santé Mali [National health information system (SNIS), Planning
and Statistics Unit, Ministry of Health, Mali].
men, women and families of a given community
live. Integration is becoming a reality through
approaches, such as the Integrated Management
of Adolescent and Adult Illness (IMAI) and the
community-based interventions emerging from
the Onchocerciasis Control Programme (OCP)19.
Global initiatives are loosening their grip on
disease-control mandates and are beginning
to appreciate the importance of strengthening
the system more generally, such as through
GAVI Alliance’s Health System Strengthening
window, paving the way for better alignment of
previously fragmented initiatives. Driven largely
by demand, information technologies to support
primary care, such as electronic medical records,
are spreading much faster than anticipated.
Efforts to scale up HIV treatment have helped to
expose the shortfalls in key systems inputs, such
as the supply chain management of diagnostics
and drugs, and build bridges to other sectors,
such as agriculture, given the imperative of food
security. Emerging awareness of the magnitude
of the workforce crisis is leading to ambitious
policies and programmes, including task shifting,
distance learning and the innovative deployment
of fi nancial and non-fi nancial incentives.
In this context, the challenge is no longer to do
more with less, but to harness the growth in the
The World Health Report 2008 Primary Health Care – Now More Than Ever
108
health sector to do more with more. The unmet
need in these countries is vast and making services
available is still a major issue. It requires a
progressive roll-out of health districts – whether
through government services or by contracting
NGOs, or a combination of both. Yet the complexities
of contemporary health systems, particularly,
but not only in urban areas, call for fl exible and
innovative interpretations of these organizational
strategies. In many of Africa’s capitals, for example,
public facilities of primary, and even secondary,
level have almost or completely disappeared,
and have been replaced by unregulated commercial
providers20. Creative solutions will have to
build on alliances with local authorities, civil
society and consumer organizations to use growing
funds – pooled private pre-payment, social
security contributions, funds from municipal
authorities and tax-sourced funding – to create
a primary-care offer that acts as a public safety
net, as an alternative to unregulated commercial
care, and as a signal of what trustworthy, peoplecentred
health care can look like.
What eventually matters is the experience of
patients accessing services. Trust will grow if they
are welcomed and not turned away; remembered
and not forgotten; seen by someone who knows
them well; respected in terms of their privacy
and dignity; responded to with appropriate care;
informed about tests; and provided with drugs
and not charged a fee at the point of service.
Growing trust can induce a virtuous cycle of
increased demand and improved supply (Box 6.2).
The gain in credibility that comes from instating
such a virtuous cycle is key to gaining social and
political consensus on investment in healthier
public policies across sectors. Effective food
security, education and rural-urban policies are
critical for health and health equity: the health
sector’s infl uence on these policies depends to
a large extent on its performance in providing
quality primary care.
Mobilizing the drivers of reform
Across all of the diverse national contexts in which
PHC reforms must fi nd their specifi c expression,
globalization plays a major role. It is altering the
balance between international organizations,
national governments, non-state actors, local and
regional authorities and individual citizens.
The global health landscape is not immune to
these wider changes. Over the last 30 years, the
traditional nation state and multilateral architecture
have been transformed. Civil society organizations
have mushroomed, along with the emergence
of public-private partnerships and global
advocacy communities identifi ed with specifi c
health problems. Governmental agencies work
with research consortia and consulting fi rms
as well as with non-state transnational institutions,
foundations and NGOs that operate on a
global scale. National diasporas have appeared
that command substantial resources and infl uence
with remittances – about US$ 150 billion
in 2005 – that dwarf overseas development aid.
Illicit global networks make a business out of
counterfeit drugs or toxic waste disposal, and
now have the resources that allow them to capture
and subvert the capacity of public agencies.
Power is gravitating from national governments
to international organizations and, at the same
time, to sub-national entities, including a range
of local and regional governments and non-governmental
institutions21.
This new and often chaotic complexity is challenging,
particularly to health authorities that
hesitate between ineffective and often counterproductive
command and control and deleterious
laissez-faire approaches to governance. However,
it also offers new, common opportunities
for investing in the capacity to lead and mediate
the politics of reform, by mobilizing knowledge,
the workforce and people.
Mobilizing the production of knowledge
PHC reforms can be spurred and kept on track
by institutionalizing PHC policy reviews that
mobilize organizational imagination, intelligence
and ingenuity. The know-how to conduct policy
reviews exists22, but requires more explicit articulations.
They need to refocus on monitoring such
progress with each of the four interlocking sets of
PHC reforms; on identifying, as they unfold, the
technical and political obstacles to their advancement;
and on providing the elements for course
corrections, where necessary.
109
Chapter 6. The way forward
In a globalizing world, PHC policy reviews
can take advantage of the emerging within- and
across-country collaborative networks to build
up the critical mass that can lead and implement
the necessary reforms. Indeed, for many
countries, it is not realistic to fi nd, within their
own institutions, all the technical expertise, contextual
knowledge and necessary capacity for
dispassionate analysis that PHC policy reviews
require. Open, inclusive and collaborative structures,
such as the Latin American observatory
models23, can go a long way in harnessing the
diversity of national resources. Such models also
make it possible to derive further benefi ts from
international collaboration and to overcome the
scarcities within a single nation’s capacities. Policy-
makers today are more open to lessons from
abroad than they may have been in the past, and
are using them to feed national policy dialogue
with innovative approaches and better evidence
of what works and what does not22. Embedding
national institutions in regional networks that
collaborate around PHC policy reviews makes it
possible to pool technical competencies as well as
information. Importantly, it can create regional
mechanisms to get more effective representation
in important but labour-intensive global bodies,
with less strain on scarce national resources.
More structured and intensive inter-country
collaboration around PHC policy reviews would
yield better international comparative data on
variations in the development of health systems
based on PHC, on models of good practice and on
the determinants of successful PHC reforms. Such
information is currently often either absent, hard
to compare or outdated. By building on networks
of experts and institutions from different regions,
it is possible to produce consensus-based and
validated benchmarks for assessing progress
and easier access to (inter)national sources of
information relevant to monitoring primary care.
This could make a big difference in steering PHC
reforms. Various initiatives in this direction, such
as the Primary Health Care Activity Monitor for
Europe (PHAMEU)24, a network of institutes and
organizations from 10 European Union Member
States, or the Regional Network on Equity in
Health (EQUINET)25, a network of professionals,
civil society members, policy-makers, and state
offi cials in Southern Africa, are promising steps
in that direction.
There is a huge research agenda with enormous
potential to accelerate PHC reforms that
requires more concerted attention (see Box 6.3).
Yet, currently, the share of health expenses
devoted to determining what works best – to
health services research – is less that 0.1% of
health expenditure in the United States, the country
that spends the highest proportion (5.6%) of
Box 6.3. From product development to
fi eld implementation – research makes
the link27
The WHO-based Special Programme for Research and Training
in Tropical Diseases (TDR) has been a pioneer in research to
inform policy and practice. TDR-sponsored studies were the
fi rst to broadly document the effi cacy of insecticide-treated
bednets for malaria prevention in the mid-1990s, in multicountry,
multi-centre controlled trials. Following introduction
of the drug Ivermectin for onchocerciasis, or “river blindness”,
control in the late 1980s, TDR, together with the African Programme
for Onchocerciasis Control, initiated research on how
best to get Ivermectin into mass distribution in the fi eld. What
evolved was a tested and fi ne-tuned region-wide system for
“community-directed treatment” of river blindness, described
as “one of the most triumphant public health campaigns ever
waged in the developing world.”28
Now, as the global health community moves away from vertical
disease control, operational research is facilitating the shift.
Recent TDR-supported large-scale, controlled studies involving
2.5 million people in 35 health districts in three countries have
demonstrated that the community-directed treatment methods
developed to combat river blindness can be utilized as a
platform for integrated delivery of multiple primary health-care
interventions, including, bednets, malaria treatment and other
basic health-care interventions, with signifi cant increases in
coverage. For example, more than twice as many children with
fever received appropriate antimalarial treatment, exceeding
60% coverage on average. Critical to both the funding and
execution of such research are the partnerships fostered with
countries in the region, as well as other public, civil society and
private institutions. The vision now is to make implementation
and operations research an even more important element of
global research agendas, so that new products may fi nally
begin to yield their hoped-for health impact through sounder
primary health-care system implementation. Thus, the longstanding
burden of deadly diseases, such as malaria, may be
more effectively addressed – through global, regional and
local knowledge-sharing and cooperation.
The World Health Report 2008 Primary Health Care – Now More Than Ever
110
its health expenditure on biomedical research26.
As another striking example, only US$ 2 million
out of US$ 390 million in 32 GAVI Health
System Strengthening grants were allocated to
research, despite encouragement to countries to
do so. No other I$ 5 trillion economic sector would
be happy with so little investment in research
related to its core agenda: the reduction of health
inequalities; the organization of people-centred
care; and the development of better, more effective
public policies. No other industry of that size
would be satisfi ed with so little investment in a
better understanding of what their clients expect
and how they perceive performance. No other
industry of that size would pay so little attention
to intelligence on the political context in which
it operates – the positions and strategies of key
stakeholders and partners. It is time for health
leaders to understand the value of investment
in this area.
Mobilizing the commitment of
the workforce
Each of the sets of PHC reforms emphasizes the
premium placed on human resources in health.
The expected skills and competencies constitute
an ambitious workforce programme that
requires a rethink and review of existing pedagogic
approaches. The science of health equity
and primary care has yet to fi nd its central place
in schools of public health. Pre-service education
for the health professions is already beginning
to build in shared curricular activities that
emphasize problem-solving in multi-disciplinary
teams, but they need to go further in preparing
for the skills and attitudes that PHC requires.
This includes creating opportunities for on-thejob
learning across sectors through mentoring,
coaching and continuing education. These and
other changes to the wide array of curricula and
on-the-job learning require a deliberate effort to
mobilize the responsible institutional actors both
within and across countries.
However, as we have learned in recent years,
the content of what is learned or taught, although
extremely important, is but one part of a complex
of systems that governs the performance of the
health workforce1. A set of systems issues related
to the health workforce need to be guided to a
greater degree by PHC reforms. For example,
health equity targets for underserved population
groups will remain elusive if they do not consider
how health workers can be effectively recruited
and retained to work among them. Likewise,
grand visions of care coordinated around the
person or patient are unlikely to be translated
into practice if credible career options for working
in primary-care teams are not put in place.
Similarly, incentives are critical complements in
ensuring that individuals and institutions exercise
their competencies when engaging health
in all policies.
The health workforce is critical to PHC reforms.
Signifi cant investment is needed to empower
health staff – from nurses to policy-makers –
with the wherewithal to learn, adapt, be team
players, and to combine biomedical and social
perspectives, equity sensitivity and patient centredness.
Without investing in their mobilization,
they can be an enormous source of resistance to
change, anchored to past models that are convenient,
reassuring, profi table and intellectually
comfortable. If, however, they can be made to
see and experience that primary health care
produces stimulating and gratifying work, which
is socially and economically rewarding, health
workers may not only come on board but also
become a militant vanguard. Here again, taking
advantage of the opportunities afforded by the
exchange and sharing of experience offered by
a globalizing world can speed up the necessary
transformations.
Mobilizing the participation of people
The history of the politics of PHC reforms in the
countries that have made major strides is largely
unwritten. It is clear, however, that where these
reforms have been successful, the endorsement
of PHC by the health sector and by the political
world has invariably followed on rising demand
and pressure expressed by civil society. There
are many examples of such demand. In Thailand,
the initial efforts to mobilize civil society and
politicians around an agenda of universal coverage
came from within the Ministry of Health29,30.
However, it was only when Thai reformers joined
a surge in civil society pressure to improve access
to care, did it become possible to take advantage
111
Chapter 6. The way forward
of a political opportunity and launch the reform31.
In just a few years, coverage was extended and
most of the population was covered with a publicly
funded primary-care system that benefi tincidence
analysis shows to be pro-poor32,33. In
Mali, the revitalization of PHC in the 1990s started
with an alliance between part of the Ministry of
Health and part of the donor community, which
made it possible to overcome initial resistance
and scepticism34. However, sustained extension
of coverage only came about when hundreds of
local “community health associations” federated
in a powerful pressure group to spur the Ministry
of Health and sustain political commitment35. In
western Europe, consumer organizations have
a prominent place in the discussions on health
care and public policies relating to health, as have
many other civil society organizations. Elsewhere,
such as in Chile, the initiative has come from the
political arena as part of an agenda of democratization.
In India, the National Rural Health
Mission came about as a result of strong pressure
from civil society and the political world, while, in
Bangladesh, much of the pressure for PHC comes
from quasi-public NGOs36.
There is an important lesson there: powerful
allies for PHC reform are to be found within civil
society. They can make the difference between
a well-intentioned but short-lived attempt, and
successful and sustained reform; and between
a purely technical initiative, and one that is
endorsed by the political world and enjoys social
consensus. This is not to say that public policy
should be purely demand-driven. Health authorities
have to ensure that popular expectations
and demand are balanced with need, technical
priorities and anticipated future challenges.
Health authorities committed to PHC will have
to harness the dynamics of civil society pressure
for change in a policy debate that is supported
with evidence and information, and informed by
exchange of experience with others, within and
across national boundaries.
Today, it is possible to make a stronger case
for health than in previous times. This is not only
because of intrinsic values, such as health equity,
or for the sector’s contribution to economic growth
− however valid they may be, these arguments
are not always the most effective – but on political
grounds. Health constitutes an economic sector
of growing importance in itself and a feature of
development and social cohesion. Reliable protection
against health threats and equitable access
to quality health care when needed are among
the most central demands people make on their
governments in advancing societies. Health has
become a tangible measure of how well societies
are developing and, thus, how well governments
are performing their role. This constitutes a reservoir
of potential strength for the sector, and is
a basis for obtaining a level of commitment from
society and political leadership that is commensurate
with the challenges.
Economic development and the rise of a knowledge
society make it likely, though not inevitable,
that expectations regarding health and health
systems will continue to rise – some realistic,
some not, some self-serving, others balanced
with concern for what is good for society at large.
The increasing weight of some of the key values
underlying these expectations − equity, solidarity,
the centrality of people and their wish to have
a say in what affects them and their health − is a
long-term trend. Health systems do not naturally
gravitate towards these values, hence the need for
each country to make a deliberate choice when
deciding the future of their health systems. It
is possible not to choose PHC. In the long run,
however, that option carries a huge penalty: in
forfeited health benefi ts, impoverishing costs, in
loss of trust in the health system as a whole and,
ultimately, in loss of political legitimacy. Countries
need to demonstrate their ability to transform
their health systems in line with changing
challenges as well as to rising popular expectations.
That is why we need to mobilize for PHC,
now more than ever.
The World Health Report 2008 Primary Health Care – Now More Than Ever
112
References
World Health Report 2006 – Working t 1. ogether for health. Geneva, World Health
Organization, 2006.
2. Ezekiel JE. The perfect storm of overutilization. JAMA, 2008, 299:2789−2791.
3. Halman L et al. Changing values and beliefs in 85 countries. Trends from the values
surveys from 1981 to 2004. Leiden and Boston MA, Brill, 2008 (European Values
Studies, No. 11).
4. Lübker M. Globalization and perceptions of social inequality. Geneva, International
Labour Offi ce, Policy Integration Department, 2004 (World Commission on the
Social Dimension of Globalization, Working Paper No. 32).
5. National health accounts. Geneva, World Health Organization, 2008 (http//www.
who.int/nha/country/en/index.html, accessed May 2008).
6. National strategy to reduce social inequalities in health. Paper presented to the
Storting. Oslo, Norwegian Ministry of Health and Care Services, 2007 (Report No.
20 (2006–2007); http://www.regjeringen.no/en/dep/hod/Documents/regpubl/
stmeld/2006-2007/Report-No-20-2006-2007-to-the-Storting.html?id=466505,
accessed 19 July 2008).
7. Smith G et al. Genetic epidemiology and public health: hope, hype, and future
prospects. Lancet, 2005, 366:1484–1498.
8. Moran M. Governing the health care state: a comparative study of the United
Kingdom, The United States and Germany. Manchester and New York NY,
Manchester University Press, 1999.
9. Heath I. A general practitioner for every person in the world. BMJ, 2008, 336:861.
10. Busse R, Schlette S, eds. Focus on prevention, health and aging, and health
professions. Gütersloh, Verlag Bertelsmann Stiftung, 2007 (Health Policy
Developments 7/8).
11. Rothman DJ. Beginnings count: the technological imperative in American health care.
Oxford and New York NY, Oxford University Press, 1997.
12. Human resources for health database. Geneva, World Health Organization, 2008
(http://www.who.int/topics/human_resources_health/en/index.html).
13. PHC and mental health report. Geneva, World Health Organization, 2008 (in press).
14. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries.
Lancet, 2007, 370:2158–2163.
15. World Health Statistics 2008 (http://www.who.int/whosis/en/).
16. Achieving universal health coverage: developing the health fi nancing system. Geneva,
World Health Organization, 2005 (Technical briefs for Policy-Makers No. 1; WHO/
EIP/HSF/PB/05.01).
17. National Rural Health Mission. Meeting people’s health needs in rural areas.
Framework for implementation 2005–2012. New Delhi, Government of India, Ministry
of Health and Family Welfare (http://mohfw.nic.in/NRHM/Documents/NRHM%20
-%20Framework%20for%20Implementation.pdf, accessed 4 August 2008).
18. Heavily indebted poor countries (HIPC) initiative and multilateral debt relief initiative
(MDRI) – status of implementation, 28 August 2007. Washington DC, International
Monetary Fund, 2007 (http://www.imf.org/external/np/pp/2007/eng/082807.pdf,
accessed 12 March 2008).
19. Integrated community-based interventions: 2007 progress report to STAC(30).
Geneva, United Nations Development Programme/World Bank/World Health
Organization Special Programme for Research and Training in Tropical Diseases,
2008 (TDR Business Line 11).
20. Grodos D. Le district sanitaire urbain en Afrique subsaharienne. Enjeux, pratiques et
politiques. Louvain-la-Neuve, Paris, Karthala-UCL, 2004.
21. Baser H, Morgan P. Capacity, change and performance. Maastricht, European Centre
for Development Policy Management, 2008.
22. OECD reviews of health systems − Switzerland. Paris, Organisation for Economic
Co-operation and Development/World Health Organization, 2006.
23. De Campos FE, Hauck V. Networking collaboratively: the experience of the
observatories of human resources in Brazil. Cahiers de sociologie et de démographie
médicales, 2005, 45:173–208.
24. The PHAMEU project. Utrecht, Netherlands Institute for Health Services, 2008
(http://www.phameu.eu/).
25. EQUINET Africa. Regional Network on Equity in Health in Southern Africa, Harare,
2008 (http://www.equinetafrica.org/).
26. Hamilton M III et al. Financial anatomy of biomedical research. JAMA, 2005,
294:1333−1342.
27. Community-directed interventions for major health problems in Africa: a multi-country
study: fi nal report. Geneva, UNICEF/UNDP/World Bank/World Health Organization
Special Programme for Research & Training in Tropical Diseases, 2008 (http://www.
who.int/tdr/publications/publications/pdf/cdi_report_08.pdf, accessed 26 August
2008).
28. UNESCO science report 2005. Paris, United Nations Educational, Scientifi c and
Cultural Organization, 2005.
29. Tancharoensathien V, Jongudomsuk P, eds. From policy to implementation: historical
events during 2001-2004 of UC in Thailand. Bangkok, National Health Security
Offi ce, 2005.
30. Biscaia A, Conceição C, Ferrinho P. Primary health care reforms in Portugal: equity
oriented and physician driven. Paper presented at: Organizing integrated PHC
through family practice: an intercountry comparison of policy formation processes,
Brussels, 8–9 October 2007.
31. Hughes D, Leethongdee S. Universal coverage in the land of smiles: lessons from
Thailand’s 30 Baht health reforms. Health Affairs, 2007, 26:999–1008.
32. Jongudomsuk P. From universal coverage of healthcare in Thailand to SHI in China:
what lessons can be drawn? In: International Labour Offi ce, Deutsche Gesellschaft
für Technische Zusammenarbeit (GTZ) Gmbh, World Health Organization. Extending
social protection in health: developing countries’ experiences, lessons learnt and
recommendations. Paper presented at: International Conference on Social Health
Insurance in Developing Countries, Berlin, 5–7 December 2005. Eschborn, Deutsche
Gesellschaft für Technische Zusammenarbeit (GTZ), 2007:155–157 (http://www2.
gtz.de/dokumente/bib/07-0378.pdf, accessed 19 July 2008).
33. Tangcharoensathien V et al. Universal coverage in Thailand: the respective roles of
social health insurance and tax-based fi nancing. In: International Labour Offi ce,
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) Gmbh, World
Health Organization. Extending social protection in health: developing countries’
experiences, lessons learnt and recommendations. Paper presented at: International
Conference on Social Health Insurance in Developing Countries, Berlin, 5–7
December 2005. Eschborn, Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ), 2007:121–131 (http://www2.gtz.de/dokumente/bib/07-0378.pdf, accessed
19 July 2008).
34. Maiga Z, Traore Nafo F, El Abassi A. Health sector reform in Mali, 1989–1996.
Antwerp, ITG Press, 2003.
35. Balique H, Ouattara O, Ag Iknane A. Dix ans d’expérience des centres de santé
communautaire au Mali, Santé publique, 2001, 13:35−48.
36. Chaudhury RH, Chowdhury Z. Achieving the Millennium Development Goal on
maternal mortality: Gonoshasthaya Kendra’s experience in rural Bangladesh. Dhaka,
Gonoprokashani, 2007.
Index
113
AA
boriginal populations, health inequities 32
abortion, legal access vs unsafe abortion 65
Africa
low-income countries under stress (LICUS) criteria 5
PHC replaced by unregulated commercial providers 108
see also North Africa; South Africa; sub-Saharan Africa
ageing populations 8
Agreement on Trade-Related Aspects of Intellectual Property
Rights (TRIPS) 76
Alma-Ata see Declaration of Alma-Ata on Primary Health Care
ambulatory care
generalist vs specialist 53
professionals, conventional health care 55
avian infl uenza (H5N1) 68
Ayurvedic medicine training 44
B
Bangladesh
inequalities in health/health care 10
neglect of health infrastructure 2–8
patterns of exclusion 28
quasi-public NGOs 111
resource-constrained settings 87
rural credit programmes 48
Belgium, local authorities, support of intersectoral
collaboration 35
benefi t packages, defi ning 27
Benin, inequalities in health/health care 10
birthing care
empowering users to contribute to their own health 48
professionalization 17, 28
births and deaths, unrecorded/uncounted 74
Bolivia, inequalities in health/health care 10
Bosnia and Herzegovina, inequalities in health/health care 10
Botswana, inequalities in health/health care 10
Brazil
Family Health Teams 67
human resource issues (PAHO) 88
Integrated Management of Childhood Illness (IMCI) 67
policy dialogue 86
Burkina Faso, institutional capacity for health-sector
governance 92
Burundi, Enhanced Heavily Indebted Poor Countries (HIPC)
initiative 106
C
Cambodia
inequalities in health/health care 10
progressive roll-out of rural coverage 30
Campbell Collaboration 74
Canada
policy dialogue 86
SARS leading to establishment of a national public health
agency 64
cancer screening 9
capacity for change
critical mass 90
limitations of conventional capacity building in low- and
middle-income countries 91
Caribbean, professionalization of birthing care 17
Central Asia, professionalization of birthing care 17
Central and Eastern Europe and the Commonwealth of
Independent States (CEE-CIS), disengagement from health
provision 83
cerebrovascular disease, tobacco-related 9
Chad
neglect of health infrastructure 27–8
patterns of exclusion 28
Chile
administrative structures redefi ned 93
benefi t package as an enforceable right 104–5
integrating health sector information systems 35
outreach to families in long-term poverty 33
Regime of Explicit Health Guarantees 87
targeting social protection 33
under-fi ve mortality 1975–2006 2
China
ambitious rural PHC reform 93
deregulation of health sector (1980s) 83–4
health expenditure 84
outbreak of SARS in 2003 64
re-engagement of health care 84
chronic disease, prevention in developing countries 65
chronic obstructive pulmonary disease, tobacco-related 9
civil registration 74
Cochrane Collaboration 73
Codex Alimentarius Commission (1963) 76
Columbia
inequalities in health/health care 10
patterns of exclusion 28
Primary Health Care – Now More Than Ever
114
The World Health Report 2008
commercialization of health care
alternatives to unregulated commercial services 31
consequences for quality and access to care 14
unregulated, drift to 13–14
in unregulated health systems 11, 14, 106
Commission on Social Determinants of Health (CSDH),
recommendations 69
community health workers, bypassing 16
Comoros, inequalities in health/health care 10
comprehensiveness
better vaccination coverage 49
evidence of its contribution to quality of care and better
outcomes 48
conditional cash transfers 33
continuity of care 53, 57
contraceptive prevalence, sub-Saharan Africa 3
conventional health care
ambulatory care professionals 55
switch to PHC 56
vs people-centredness 43
coordination (gatekeeping) role of ambulatory care
professionals 55
Costa Rica
bias-free framework of health systems 36
local reorganization, template for national effort 36
universal coverage scheme 25
Cote d’Ivoire
GDP 4
inequalities in health/health care 10
mother-to-child transmission (MTCT) of HIV 44–5
Cuba, maximizing society’s resources 65
D
Declaration of Alma-Ata on Primary Health Care (1978) ix, xiii,
34, 69
Democratic Republic of the Congo
health budget cuts 7
institutional capacity for health-sector governance 92
rebuilding leadership in health, post-war and economic
decline 94
robustness of PHC-led health systems 31
safari surgery 14
Demographic and Health Survey (DHS) data 34–5
developing countries, chronic disease burden 65
diasporas 108
dietary salt reduction 65
disease control programmes 16
return on investment 13
vs challenges of health systems 83
vs people-centred PHC 43
disengagement from health provision, CEE-CIS 83
documentation and assessment 74
domestic investment, re-invigorating health systems xx
drugs
counterfeit drugs 108
global expenditure 12
national medicine policies 66
product licencing 102
transnational mechanisms of access 66
WHO List of Essential Medicines 66
E
Ecuador
Equity Gauges 88
inequalities in health/health care 10
electronic health records 50
entry point to PHC 50–2, 53, 57
EQUINET (Regional Network on Equity in Health) 109
Equity Gauges, stakeholder collaboration to tackle health
inequalities 88
essential packages, defi ning 27
Ethiopia
contract staff pay 13
Health Extension Workers 67
priority preventive interventions 28
Europe
2003 heatwave 54
Primary Health Care Activity Monitor for Europe (PHAMEU)
109
Regional Network on Equity in Health (EQUINET) 109
European Union
impact assessment guidelines 75
technical requirements, registering new medicines or
product licencing 102
evidence-based medicine 43–4
FF
iji, isolated/dispersed populations 30–1
Finland, health inequities 32
food
dietary salt reduction 65
marketing to children 73
“fragile states”
increase in external funds 106
low-income countries under stress (LICUS) criteria 5
per capita health expenditure 105
fragmentation of health care 11, 12–13
causes 51
fragmented funding streams and service delivery 85
France
health inequities 32
reduction in traffi c fatalities 71
self-help organization of diabetics 48
funding see total health expenditure
115
Index
G
GDP
growth in GDP xviii
life expectancy at birth, 169 countries 4
percentage of GDP used for health (2005) 82
trends per capita and life expectancy at birth, 133
countries 5
generalist ambulatory care 53
global expenditure
medical equipment and devices 12
percentage of GDP used for health (2005) 82
pharmaceutical industry 12
global trends
city dwelling 7
life expectancy 4
that undermine health systems’ response 11–12
globalization xiii–xiv
adjusting to 76
global health interdependence 76
governments
as brokers for PHC reform 82–6
or quasi-governmental institutions, participation and
negotiation 85
grassroots advocacy 35–6
growth, and peace 6
growth market in medical tourism 104
Guinea, inequalities in health/health care 10
HH
aiti, institutional capacity for health-sector governance 92
health, feature of development and social cohesion 111
Health Action Zones, United Kingdom 36
health equity 34–5
central place of 15, 24–5
common misperceptions 34–5
“health in all policies” concept 64
health expenditure see total health expenditure
health hazards, political fall-out from 16
health inequities 15, 24, 32
Aboriginal and non-Aboriginal populations 32
catastrophic expenditure related to out-of-pocket payment
24
Equity Gauges 88
increasing the visibility 34
political proposals, organized social demand 35
see also fragmentation of health care
health systems
changing values and rising expectations 14–15
components and provision of services 66
consistent inequity 24
dangerous oversimplifi cation in resource-constrained
settings xviii
defi ning essential packages 27
diversion from primary health care core values 11
expectations for better performance xiv
failure to assess political environment 9–10
inequalities in health/health care 10, 15, 24, 32, 34–5
little anticipation and slow reactions to change 9–10
making more people-centred 16
Medisave accounts 50
mismatch between expectations and performance xv
mitigating effects of social inequities 36
moving towards universal coverage 25–7
PHC reforms necessary (4 groups) xvii
shift of focus of primary health care movement xvi
three bad trends xiv
universal coverage 25
see also primary health care (PHC) reforms; public policymaking
health-adjusted life expectancy (HALE) 6
health-care delivery
fi ve common shortcomings xv
reorganization of work schedules of rural health centres
42–3
health-sector governance, institutional capacity 92
“Healthy Islands” initiative 30
heatwave, western Europe (2003) 54
Heavily Indebted Poor Countries (HIPC) initiative 106
high spending on health, better outcomes 5
high-expenditure health economies 100, 101–3
HIV infection, mother-to-child transmission (MTCT) 44
HIV/AIDS, continuum of care approaches 68
hospital-centrism 11
opportunity cost 12
I impact assessment, European Union guidelines 75
India
National Rural Health Mission 111
per capita health expenditure 105
private sector medical-care providers 44
public expenditure on health 93
under-fi ve mortality 1975 and 2006 3
Indonesia, inequalities in health/health care 10
infl uenza, avian (H5N1) 68
information and communication technologies 51
information systems
demand for health-related information 87
instrumental to PHC reform 87
strengthening policy dialogue 86–7
transforming into instruments for PHC reform 87
injections, patient safety 44
institutions (national)
capacity for health-sector governance 92
critical mass for capacity for change 90
generation of workforce 76
Primary Health Care – Now More Than Ever
116
The World Health Report 2008
leadership capacity shortfalls 90
multi-centric development 76
productive policy dialogue 86
instruments for PHC reform, information systems 87
Integrated Management of Adolescent and Adult Illness (IMAI)
107
International Clinical Epidemiology Network 73
international environment, favourable to a renewal of PHC xx
international migration 8
interventions, scaling up 28–9
investigations, inappropriate investigations prescribed 53
invisibility, births and deaths unrecorded/uncounted 74
ischaemic heart disease, tobacco-related 9
Islamic Republic of Iran, progressive roll-out of rural coverage
28
isolated/dispersed populations 30–1
fi nancing of health care 31
JJ
apan, magnetic resonance imaging (MRI) units per capita 12
K
Kenya
Equity Gauges 88
malaria prevention 64
knowledge, production of 108
Korea, universal coverage scheme 25
L
Latin America
exclusion of 47
from needed services 32
Pan American Health Organization (PAHO) 32, 66, 88
professionalization of birthing care 17
targeting social protection 33
lead poisoning, avoidable 71
leadership capacity, shortfalls 90
leadership and effective government 81–94
“learning from the fi eld”, policy development 89–90
Lebanon
hospital-centrism vs risk reduction 11
neighbourhood environment initiatives 48
Lesotho, inequalities in health/health care 10
life expectancy at birth
in 169 countries 4
global trends 4
local action, starting point for broader structural changes 36
low- and middle-income countries 101
low-expenditure low-growth health economies 100–1, 105–8
per capita health expenditure 105
low-income countries under stress (LICUS) criteria 5
MM
adagascar
inequalities in health/health care 10
life expectancy at birth 4
under-fi ve mortality 1975 and 2006 3
malaria 109
Malawi
hospital nurses leave for better-paid NGO jobs 13
inequalities in health/health care 10
Malaysia
scaling up of priority cadres of workers 67
under-fi ve mortality 1975 and 2006 2
Mali
institutional capacity for health-sector governance 92
progressive roll-out of rural coverage 30
revitalization of PHC in the 1990s 111
virtuous cycle of supply of and demand for primary care
107
medical equipment and devices, global expenditure 12
medical tourism 104
medico-industrial complex 85–6
Mexico
active ageing programme 48
universal coverage scheme 25
Middle East, professionalization of birthing care 17
Millennium Development Goals (MDGs) xiii, 2, 106
Mongolia, under-fi ve mortality 1975 and 2006 3
Morocco
institutional capacity for health-sector governance 92
trachoma programme 71
under-fi ve mortality 1975 and 2006 3
mortality
cause-of-death statistics 74
reducing under-fi ve mortality by 80, by regions, 1975–
2006 2
shift towards noncommunicable diseases and accidents 8
Mozambique, inequalities in health/health care 10
multi-morbidity 8
mutual support associations 56
NN
airobi, under-fi ve mortality rate 7
national health information systems, policy dialogue 86–7
National Institutes of Public Health (NIPHs) 74–5
International Association of National Public Health Institutes
(IANPHI) 76
Nepal
community dynamics of women’s groups 54
GDP and life expectancy 4
inequalities in health/health care 10
New Zealand, annual pharmaceutical spending 66
Nicaragua, patterns of exclusion 28
117
Index
Niger
inequalities in health/health care 10
neglect of health infrastructure 27–8
patterns of exclusion 28
reorganization of work schedules of rural health centres 42
staff–clients in PHC, direct relationship 42
noncommunicable diseases, mortality 8
North Africa, professionalization of birthing care 17
Norway, national strategy to reduce social inequalities in
health 102
OO
ffi cial Development Aid for Health, yearly aid fl ows (2005) 91
Onchocerciasis Control Programme (OCP) 107, 109
opportunity cost, hospital-centrism 12
Osler, W, quoted 42
Ottawa Charter for Health Promotion 17
outpatient attendance 27
PP
akistan, Lady Health Workers 67
Pan American Health Organization (PAHO) 32, 66, 88
patient safety, securing better outcomes 44
patterns of exclusion from needed services 32
peace, and growth 6
people-centred primary care, universal access 104
people-centredness 16, 42–3
and community participation 85
desire for participation 18
policy dialogue 85–7
vs conventional health care 43
person-centred care
evidence of quality/better outcomes 47
and provider’s job satisfaction 46
Peru, inequalities in health/health care 10
pharmaceutical industry, global expenditure 12
Philippines, inequalities in health/health care 10
policy dialogue 85–6
innovations from the fi eld 89–90
political environment
and health hazards 16
organized social demand 35
political process, from launching reform to implementation
92–3
populations, health evidence documentation 74
Portugal
2004–2010 National Health Plan 92
key health indicators 3
under-fi ve mortality 1975–2006 2
Poverty Reduction Strategy Papers (PRSPs) 92–3
pre-payment and pooling 26–7
pre-payment systems 106
Preston curve, GDP per capita and life expectancy at birth in
169 countries 4
primary health care (PHC)
comprehensive and integrated responses 48–9
comprehensiveness and integratedness 48–9
continuity of care 49–50
dangerously oversimplifi ed in resource-constrained
settings xviii
distinctive features 43–52, 56–7
empowering users 48
experience has shifted focus xiv
governments as brokers for PHC reform 82–6
monitoring progress 56
need for multiple strategies 25
networking within the community served 55
networks, fi lling availability gap 28
organizing PHC networks 52–6
people-centredness, vs conventional health care 43
person-centred, and provider’s job satisfaction 46
political endorsement of PHC reforms 93
priority health programmes 67
progressive roll-out of PHC, vs scaling up of priority
preventive interventions 28–9
rapid response capacity 68–9
reforms, driven by demand 18–19
regular and trusted provider as entry point 50–2
responsibility for a well-identifi ed population 53–4
social values and corresponding reforms 18
staff–clients direct relationship 42
under-investment 71–2
see also health systems
primary health care (PHC) reforms
adapting to country context 100
commitment of workforce 110
four interlocking sets xvii, 114
high-expenditure health economies 101–3
low-expenditure, low-growth health economies 105–8
mobilizing the drivers of reform 108–10
participation of people 110–11
rapid-growth health economies 103–5
primary-care networks 52–6
entry point 50–2
relocation 53
primary-care providers, responsibilities 56
primary-care team, as a hub of coordination 55–6
priority preventive interventions
scaling up 28–9
vs progressive roll-out of PHC 28–30
product development 109
professionalization
ambulatory care 55
birthing care 17, 28
participation and negotiation 85
project management units 91
public funding, conditional cash transfers 33
public policy-making xix–xx, 63–75
Primary Health Care – Now More Than Ever
118
The World Health Report 2008
institutional capacity for development 74–5
opportunities for better public policies 73–4
policies in other sectors 64, 70
systems policies 64
towards health in all policies 69–70
under-investment 71–2
unpopular public policy decisions 72–3
public-health interventions 64, 67–8
essential public-health functions (30 NIPHs) 75
impact assessment guidelines (EU) 75
initiatives 68
R
rapid-growth health economies 103–5
Regional Network on Equity in Health (EQUINET) 109
research
GAVI Health System Strengthening grants 110
product development to fi eld implementation 109
Research and Training in Tropical Diseases (TDR) 109
response-to-demand approach 53–4
risk factors
developing countries chronic disease burden 65
in terms of overall disease burden 8
risk reduction
patient safety and better outcomes 44
vs hospital-centrism 11
river blindness, Onchocerciasis Control Programme (OCP) 107,
109
road-traffi c accidents 7, 8, 71
rural health centres
information and communication technologies 51
reorganization of work schedules 42
Russian Federation, GDP and health 4–5
Ss
alt, dietary reduction 65
SARS pandemic, establishment of national public health
agencies 64
scaling up, limited number of interventions 28–9
Senegal, lead poisoning 71
Seventh Futures Forum, senior health executives 72
Singapore, Medisave accounts 50
skills base, extension workers 28
social cohesion 111
social contract for health 82–3
social demand, and political environment 35
social determinants of health 69
social inequities 36
social protection schemes, Latin America 33
South Africa
Equity Gauges 88
family empowerment and parent training programmes 48
South-East Asia, professionalization of birthing care 17
South-East Asian Region (SEARO) 76
stakeholder collaboration, to tackle health inequalities 88
state and health-care system 83
absence/withdrawal from health provision 83
disengagement and its consequences 83–4
Sub-Saharan Africa
abortions, increased, in unsafe conditions 3
Abuja Declaration target of 15 106
contraceptive prevalence 3
GDP per capita 7
increase in external funds 106
professionalization of birthing care 17
Sultanate of Oman
investment in a national health service 2
under-fi ve mortality 1975 and 2006 3
systems policies, for human resources 66
T Tajikistan, under-fi ve mortality 1975 and 2006 3 Tanzania
budget allocation formulae/contract specifi cations 30
inequalities in health/health care 10
treatment plans for safe motherhood 48
targeting, social protection schemes 33
technical cooperation, Offi cial Development Aid for Health,
yearly aid fl ows (2005) 91
Thailand
30 Baht universal coverage reform 89
Decade of Health Centre Development 86
Declaration of Patients’ Rights 48
First Health Care Reform Forum (1997) 86
inappropriate investigations prescribed 53
policy dialogue 86
strengthening policy dialogue with fi eld model innovations
89
under-fi ve mortality 1975–2006 2
universal coverage scheme 25
tobacco industry, efforts to limit tobacco control 73
tobacco taxes 65
tobacco-attributable deaths 9, 71–2
total health expenditure (THE), 2000–2005 100
conditional cash transfers 33
contribution of general government, private pre-paid and
private out-of-pocket expenditure 101
countries/groups 6
projected per capita health expenditure in 2015 103
rate of growth 100
toxic waste disposal 108
trachoma programme 71
Trade-Related Aspects of Intellectual Property Rights (TRIPS)
76
traffi c accidents 7, 8, 71
119
Index
tropical diseases 109
Tunisia, institutional capacity for health-sector governance 92
Turkey
patterns of exclusion 28
retraining of nurses and physicians 67
universal coverage scheme 25
U
Uganda
allocations to districts 30
outpatient attendance 27
UNICEF/WHO Integrated Management of Childhood Illness
initiatives 46
United Kingdom
career in primary care, fi nancial competitiveness 67
Health Action Zones 36
Poor Laws Commission 34
public-health observatories in England 89
United States
Alaska, staff–clients in PHC, direct relationship 42
in favour of health equity 15
magnetic resonance imaging (MRI) units per capita 12
per capita expenditure on drugs 12
universal access, people-centred primary care 104
universal coverage schemes 25–6
best practices 26
challenges in moving towards 27–8
targeted interventions to complement 32–3
three ways of moving towards 26
unregulated commercial services 31–2
V
vaccination, comprehensiveness/coverage 49
W
women’s health
abortion, legal access vs unsafe abortion 65
birthing care, professionalization 17, 28
contraceptive prevalence, sub-Saharan Africa 3
empowering users to contribute to their own health 48
health-care response to partner violence 47
work circumstances, change and adverse health effects 70
work schedules, reorganization in rural health centres 42
workforce, critical to PHC reforms 110
World Health Organization
List of Essential Medicines 66
offi ces 113
Seventh Futures Forum of senior health executives 72
World Trade Organization (WTO), consideration of health in
trade agreements 76
ZZ
aire, health budget cuts 7
Zambia
health budget cuts 7
incentives to health workers to serve in rural areas 67
life expectancy at birth 4
under-fi ve mortality 1975 and 2006 3



Headquarters
World Health Organization
Avenue Appia 20
1211 Geneva 27, Switzerland
Telephone: (41) 22 791 21 11
Facsimile: (41) 22 791 31 11
E-mail: inf@who.int
Web site: http://www.who.int
WHO Regional Offi ce for Africa
Cité du Djoue
P.O. Box 06
Brazzaville, Congo
Telephone: (47) 241 39100
Facsimile: (47) 241 39503
E-mail: webmaster@afro.who.int
Web site: http://www.afro.who.int
WHO Regional Offi ce for the Americas/
Pan American Sanitary Bureau
525, 23rd Street N.W.
Washington, D.C. 20037, USA
Telephone: (1) 202 974 3000
Facsimile: (1) 202 974 3663
E-mail: webmaster@paho.org
Web site: http://www.paho.org
WHO Regional Offi ce for South-East Asia
World Health House
Indraprastha Estate
Mahatma Gandhi Road
New Delhi 110002, India
Telephone: (91) 112 337 0804/09/10/11
Facsimile: (91) 112 337 0197/337 9395
E-mail: registry@searo.who.int
Web site: http://www.searo.who.int
WHO Regional Offi ce for Europe
8, Scherfi gsvej
2100 Copenhagen Ø, Denmark
Telephone: (45) 39 17 17 17
Facsimile: (45) 39 17 18 18
E-mail: postmaster@euro.who.int
Web site: http://www.euro.who.int
WHO Regional Offi ce for the Eastern
Mediterranean
Abdul Razzak Al Sanhouri Street
P.O. Box 7608
Nasr City
Cairo 11371, Egypt
Telephone: (202) 670 25 35
Facsimile: (202) 670 2492/94
E-mail: webmaster@emro.who.int
Web site: http://www.emro.who.int
WHO Regional Offi ce for the
Western Pacifi c
P.O. Box 2932
Manila 1000, Philippines
Telephone: (632) 528 9991
Facsimile: (632) 521 1036 or 526 0279
E-mail: pio@wpro.who.int
Web site: http://www.wpro.who.int
International Agency for
Research on Cancer
150, cours Albert-Thomas
69372 Lyon Cédex 08, France
Telephone: (33) 472 73 84 85
Facsimile: (33) 472 73 85 75
E-mail: www@iarc.fr
Web site: http://www.iarc.fr
Offi ces of the World Health Organization
PRIMARY
HEALTH
CARE
REFORMS
As nations seek to strengthen their health systems, they are increasingly
looking to primary health care (PHC) to provide a clear and comprehensive
sense of direction. The World Health Report 2008 analyses how primary
health care reforms, that embody the principles of universal access, equity
and social justice, are an essential response to the health challenges of
a rapidly changing world and the growing expectations of countries and
their citizens for health and health care.
The Report identifi es four interlocking sets of PHC reforms that aim
to: achieve universal access and social protection, so as to improve
health equity; re-organize service delivery around people’s needs and
expectations; secure healthier communities through better public policies;
and remodel leadership for health around more effective government and
the active participation of key stakeholders.
This Report comes 30 years after the Alma-Ata Conference of 1978 on
primary health care, which agreed to tackle the “politically, socially and
economically unacceptable” health inequalities in all countries. Much has
been accomplished in this regard: if children were still dying at 1978 rates,
there would have been 16.2 million child deaths globally in 2006 instead
of the actual 9.5 million. Yet, progress in health has been deeply and
unacceptably unequal, with many disadvantaged populations increasingly
lagging behind or even losing ground.
Meanwhile, the nature of health problems is changing dramatically.
Urbanization, globalization and other factors speed the worldwide
transmission of communicable diseases, and increase the burden of
chronic disorders. Climate change and food insecurity will have major
implications for health in the years ahead thereby creating enormous
challenges for an effective and equitable response.
In the face of all this, business as usual for health systems is not a
viable option. Many systems seem to be drifting from one short-term
priority to another, increasingly fragmented and without a strong sense
of preparedness for what lies ahead.
Fortunately, the current international environment is favourable to a
renewal of PHC. Global health is receiving unprecedented attention. There
is growing interest in united action, with greater calls for comprehensive,
universal care and health in all policies. Expectations have never been
so high.
By capitalizing on this momentum, investment in primary health
care reforms can transform health systems and improve the health of
individuals, families and communities everywhere. For everyone interested
in how progress in health can be made in the 21st century, the World
Health Report 2008 is indispensable reading.Primary Health Care
Now
More
Than
Ever
The World Health Report 2008
UNIVERSAL
COVERAGE
REFORMS
SERVICE
DELIVERY
REFORMS
LEADERSHIP
REFORMS
PUBLIC
POLICY
REFORMS

Primary Health Care
Now
More
Than
Ever
The World Health Report 2008
WHO Library Cataloguing-in-Publication Data
The world health report 2008 : primary health care now more than ever.
1.World health – trends. 2.Primary health care – trends. 3.Delivery of health care. 4.Health policy.
I.World Health Organization.
ISBN 978 92 4 156373 4 (NLM classifi cation: W 84.6)
ISSN 1020-3311
© World Health Organization 2008
All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission
to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the
above address (fax: +41 22 791 4806; e-mail: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on
the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full
agreement.
The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
Information concerning this publication can be obtained from:
World Health Report
World Health Organization
1211 Geneva 27, Switzerland
E-mail: whr@who.int
Copies of this publication can be ordered from: bookorders@who.int
Design: Reda Sadki
Layout: Steve Ewart and Reda Sadki
Figures: Christophe Grangier
Printing Coordination: Pascale Broisin and Frédérique Robin-Wahlin
Printed in Switzerland
The World Health Report 2008 was produced under the overall direction of Tim Evans (Assistant Director-General) and Wim Van Lerberghe (editor-in-chief). The principal writing
team consisted of Wim Van Lerberghe, Tim Evans, Kumanan Rasanathan and Abdelhay Mechbal. Other main contributors to the drafting of the report were: Anne Andermann, David
Evans, Benedicte Galichet, Alec Irwin, Mary Kay Kindhauser, Remo Meloni, Thierry Mertens, Charles Mock, Hernan Montenegro, Denis Porignon and Dheepa Rajan. Organizational
supervision of the report was provided by Ramesh Shademani.
Contributions in the form of boxes, fi gures and data analysis came from: Alayne Adams, Jonathan Abrahams, Fiifi Amoako Johnson, Giovanni Ancona, Chris Bailey, Robert Beaglehole,
Henk Bekedam, Andre Biscaia, Paul Bossyns, Eric Buch, Andrew Cassels, Somnath Chatterji, Mario Dal Poz, Pim De Graaf, Jan De Maeseneer, Nick Drager, Varatharajan Durairaj, Joan
Dzenowagis, Dominique Egger, Ricardo Fabregas, Paulo Ferrinho, Daniel Ferrante, Christopher Fitzpatrick, Gauden Galea, Claudia Garcia Moreno, André Griekspoor, Lieve Goeman,
Miriam Hirschfeld, Ahmadreza Hosseinpoor, Justine Hsu, Chandika Indikadahena, Mie Inoue, Lori Irwin, Andre Isakov, Michel Jancloes, Miloud Kaddar, Hyppolite Kalambaye, Guy Kegels,
Meleckidzedeck Khayesi, Ilona Kickbush, Yohannes Kinfu, Tord Kjellstrom, Rüdiger Krech, Mohamed Laaziri, Colin Mathers, Zoe Matthews, Maureen Mackintosh, Di McIntyre, David
Meddings, Pierre Mercenier, Pat Neuwelt, Paolo Piva, Annie Portela, Yongyut Ponsupap, Amit Prasad, Rob Ridley, Ritu Sadana, David Sanders, Salif Samake, Gerard Schmets, Iqbal
Shah, Shaoguang Wang, Anand Sivasankara Kurup, Kenji Shibuya, Michel Thieren, Nicole Valentine, Nathalie Van de Maele, Jeanette Vega, Jeremy Veillard and Bob Woollard.
Valuable inputs in the form of contributions, peer reviews, suggestions and criticisms were received from the Regional Directors and their staff, from the Deputy Director-General,
Anarfi Asamoah Bah, and from the Assistant Directors-General.
The draft report was peer reviewed at a meeting in Montreux, Switzerland, with the following participants: Azrul Azwar, Tim Evans, Ricardo Fabrega, Sheila Campbell-Forrester,
Antonio Duran, Alec Irwin, Mohamed Ali Jaffer, Safurah Jaafar, Pongpisut Jongudomsuk, Joseph Kasonde, Kamran Lankarini, Abdelhay Mechbal, John Martin, Donald Matheson,
Jan De Maeseneer, Ravi Narayan, Sydney Saul Ndeki, Adrian Ong, Pongsadhorn Pokpermdee, Thomson Prentice, Kumanan Rasanathan, Salman Rawaf, Bijan Sadrizadeh, Hugo
Sanchez, Ramesh Shademani, Barbara Starfi eld, Than Tun Sein, Wim Van Lerberghe, Olga Zeus and Maria Hamlin Zuniga.
The report benefi ted greatly from the inputs of the following participants in a one-week workshop in Bellagio, Italy: Ahmed Abdullatif, Chris Bailey, Douglas Bettcher, John Bryant,
Tim Evans, Marie Therese Feuerstein, Abdelhay Mechbal, Thierry Mertens, Hernan Montenegro, Ronald Labonte, Socrates Litsios, Thelma Narayan, Thomson Prentice, Kumanan
Rasanathan, Myat Htoo Razak, Ramesh Shademani, Viroj Tangcharoensathien, Wim Van Lerberghe, Jeanette Vega and Jeremy Veillard.
WHO working groups provided the initial inputs into the report. These working groups, of both HQ and Regional staff included: Shelly Abdool, Ahmed Abdullatif, Shambhu Acharya,
Chris Bailey, James Bartram, Douglas Bettcher, Eric Blas, Ties Boerma, Robert Bos, Marie-Charlotte Boueseau, Gui Carrin, Venkatraman Chandra-Mouli, Yves Chartier, Alessandro
Colombo, Carlos Corvalan, Bernadette Daelmans, Denis Daumerie, Tarun Dua, Joan Dzenowagis, David Evans, Tim Evans, Bob Fryatt, Michelle Funk, Chad Gardner, Giuliano Gargioni,
Gulin Gedik, Sandy Gove, Kersten Gutschmidt, Alex Kalache, Alim Khan, Ilona Kickbusch, Yunkap Kwankam, Richard Laing, Ornella Lincetto, Daniel Lopez-Acuna, Viviana Mangiaterra,
Colin Mathers, Michael Mbizvo, Abdelhay Mechbal, Kamini Mendis, Shanthi Mendis, Susan Mercado, Charles Mock, Hernan Montenegro, Catherine Mulholland, Peju Olukoya, Annie
Portela, Thomson Prentice, Annette Pruss-Ustun, Kumanan Rasanathan, Myat Htoo Razak, Lina Tucker Reinders, Elil Renganathan, Gojka Roglic, Michael Ryan, Shekhar Saxena,
Robert Scherpbier, Ramesh Shademani, Kenji Shibuya, Sameen Siddiqi, Orielle Solar, Francisco Songane, Claudia Stein, Kwok-Cho Tang, Andreas Ullrich, Mukund Uplekar, Wim Van
Lerberghe, Jeanette Vega, Jeremy Veillard, Eugenio Villar, Diana Weil and Juliana Yartey.
The editorial production team was led by Thomson Prentice, managing editor. The report was edited by Diana Hopkins, assisted by Barbara Campanini. Gaël Kernen assisted on
graphics and produced the web site version and other electronic media. Lina Tucker Reinders provided editorial advice. The index was prepared by June Morrison.
Administrative support in the preparation of the report was provided by Saba Amdeselassie, Maryse Coutty, Melodie Fadriquela, Evelyne Omukubi and Christine Perry.
Photo credits: Director-General’s photograph: WHO (p. viii); introduction and overview: WHO/Marco Kokic (p. x); chapters 1–6: Alayne Adams (p. 1); WHO/Christopher Black (p. 23);
WHO/Karen Robinson (p. 41); International Federation of Red Cross and Red Crescent Societies/John Haskew (p. 63); Alayne Adams (p. 81); WHO/Thomas Moran (p. 99).
iii
Contents
The World Health Report 2008 Primary Health Care – Now More Than Ever
Message from the Director-General viii
Introduction and Overview xi
Responding to the challenges of a changing world xii
Growing expectations for better performance xiii
From the packages of the past to the reforms of the future xiv
Four sets of PHC reforms xvi
Seizing opportunities xviii
Chapter 1. The challenges of a changing world 1
Unequal growth, unequal outcomes 2
Longer lives and better health, but not everywhere 2
Growth and stagnation 4
Adapting to new health challenges 7
A globalized, urbanized and ageing world 7
Little anticipation and slow reactions 9
Trends that undermine the health systems’ response 11
Hospital-centrism: health systems built around hospitals and specialists 11
Fragmentation: health systems built around priority programmes 12
Health systems left to drift towards unregulated commercialization 13
Changing values and rising expectations 14
Health equity 15
Care that puts people fi rst 16
Securing the health of communities 16
Reliable, responsive health authorities 17
Participation 18
PHC reforms: driven by demand 18
Chapter 2. Advancing and sustaining universal coverage 23
The central place of health equity in PHC 24
Moving towards universal coverage 25
Challenges in moving towards universal coverage 27
Rolling out primary-care networks to fi ll the availability gap 28
Overcoming the isolation of dispersed populations 30
Providing alternatives to unregulated commercial services 31
Targeted interventions to complement universal coverage mechanisms 32
Mobilizing for health equity 34
Increasing the visibility of health inequities 34
Creating space for civil society participation and empowerment 35
Primary Health Care – Now More Than Ever
iv
The World Health Report 2008
Chapter 3. Primary care: putting people fi rst 41
Good care is about people 42
The distinctive features of primary care 43
Effectiveness and safety are not just technical matters 43
Understanding people: person-centred care 46
Comprehensive and integrated responses 48
Continuity of care 49
A regular and trusted provider as entry point 50
Organizing primary-care networks 52
Bringing care closer to the people 53
Responsibility for a well-identifi ed population 53
The primary-care team as a hub of coordination 55
Monitoring progress 56
Chapter 4. Public policies for the public’s health 63
The importance of effective public policies for health 64
System policies that are aligned with PHC goals 66
Public-health policies 67
Aligning priority health programmes with PHC 67
Countrywide public-health initiatives 68
Rapid response capacity 68
Towards health in all policies 69
Understanding the under-investment 71
Opportunities for better public policies 73
Better information and evidence 73
A changing institutional landscape 74
Equitable and effi cient global health action 76
Chapter 5. Leadership and effective government 81
Governments as brokers for PHC reform 82
Mediating the social contract for health 82
Disengagement and its consequences 83
Participation and negotiation 85
Effective policy dialogue 86
Information systems to strengthen policy dialogue 86
Strengthening policy dialogue with innovations from the fi eld 89
Building a critical mass of capacity for change 90
Managing the political process: from launching reform to implementing it 92
Chapter 6. The way forward 99
Adapting reforms to country context 100
High-expenditure health economics 101
Rapid-growth health economies 103
Low-expenditure, low-growth health economies 105
Mobilizing the drivers of reform 108
Mobilizing the production of knowledge 108
Mobilizing the commitment of the workforce 110
Mobilizing the participation of people 110
v
Contents
Figure 1. The PHC reforms necessary to refocus health systems
towards health for all
xvi
Figure 1.1 Selected best performing countries in reducing underfi
ve mortality by at least 80%, by regions, 1975–2006
2
Figure 1.2 Factors explaining mortality reduction in Portugal,
1960–2008
3
Figure 1.3 Variable progress in reducing under-fi ve mortality,
1975 and 2006, in selected countries with similar rates in 1975
3
Figure 1.4 GDP per capita and life expectancy at birth in 169
countries, 1975 and 2005
4
Figure 1.5 Trends in GDP per capita and life expectancy at birth
in 133 countries grouped by the 1975 GDP, 1975−2005
5
Figure 1.6 Countries grouped according to their total health
expenditure in 2005 (international $)
6
Figure 1.7 Africa’s children are at more risk of dying from traffi c
accidents than European children: child road-traffi c deaths per
100 000 population
7
Figure 1.8 The shift towards noncommunicable diseases and
accidents as causes of death
8
Figure 1.9 Within-country inequalities in health and health care 10
Figure 1.10 How health systems are diverted from PHC core
values
11
Figure 1.11 Percentage of the population citing health as their
main concern before other issues, such as fi nancial problems,
housing or crime
15
Figure 1.12 The professionalization of birthing care: percentage
of births assisted by professional and other carers in selected
areas, 2000 and 2005 with projections to 2015
17
Figure 1.13 The social values that drive PHC and the
corresponding sets of reforms
18
Figure 2.1 Catastrophic expenditure related to out-of-pocket
payment at the point of service
24
Figure 2.2 Three ways of moving towards universal coverage 26
Figure 2.3 Impact of abolishing user fees on outpatient
attendance in Kisoro district, Uganda: outpatient attendance
1998–2002
27
Figure 2.4 Different patterns of exclusion: massive deprivation
in some countries, marginalization of the poor in others. Births
attended by medically trained personnel (percentage), by income
group
28
Figure 2.5 Under-fi ve mortality in rural and urban areas, the
Islamic Republic of Iran, 1980–2000
29
Figure 2.6 Improving health-care outputs in the midst of
disaster: Rutshuru, the Democratic Republic of the Congo,
1985–2004
31
Figure 3.1 The effect on uptake of contraception of the
reorganization of work schedules of rural health centres in Niger
42
Figure 3.2 Lost opportunities for prevention of mother-to-child
transmission of HIV (MTCT) in Côte d’Ivoire: only a tiny fraction of
the expected transmissions are actually prevented
45
Figure 3.3 More comprehensive health centres have better
vaccination coverage
49
Figure 3.4 Inappropriate investigations prescribed for simulated
patients presenting with a minor stomach complaint in Thailand
53
Figure 3.5 Primary care as a hub of coordination: networking
within the community served and with outside partners
55
Figure 4.1 Deaths attributable to unsafe abortion per 100 000
live births, by legal grounds for abortions
65
Figure 4.2 Annual pharmaceutical spending and number
of prescriptions dispensed in New Zealand since the
Pharmaceutical Management Agency was convened in 1993
66
Figure 4.3 Percentage of births and deaths recorded in countries
with complete civil registration systems, by WHO region,
1975–2004
74
Figure 4.4 Essential public-health functions that 30 national
public-health institutions view as being part of their portfolio
75
Figure 5.1 Percentage of GDP used for health, 2005 82
Figure 5.2 Health expenditure in China: withdrawal of the State
in the 1980s and 1990s and recent re-engagement
84
Figure 5.3 Transforming information systems into instruments
for PHC reform
87
Figure 5.4 Mutual reinforcement between innovation in the fi eld
and policy development in the health reform process
89
Figure 5.5 A growing market: technical cooperation as part of
Offi cial Development Aid for Health. Yearly aid fl ows in 2005,
defl ator adjusted
91
Figure 5.6 Re-emerging national leadership in health: the shift
in donor funding towards integrated health systems support, and
its impact on the Democratic Republic of the Congo’s 2004 PHC
strategy
94
Figure 6.1 Contribution of general government, private pre-paid
and private out-of-pocket expenditure to the yearly growth
in total health expenditure per capita, percentage, weighted
averages
101
Figure 6.2 Projected per capita health expenditure in 2015,
rapid-growth health economies (weighted averages)
103
Figure 6.3 Projected per capita health expenditure in 2015, low
expenditure, low-growth health economies (weighted averages)
105
Figure 6.4 The progressive extension of coverage by communityowned,
community–operated health centres in Mali, 1998–2007
107
List of Figures
Primary Health Care – Now More Than Ever
vi
The World Health Report 2008
Box 1 Five common shortcomings of health-care delivery xiv
Box 2 What has been considered primary care in well-resourced
contexts has been dangerously oversimplifi ed in resourceconstrained
settings
xvii
Box 1.1 Economic development and investment choices in health
care: the improvement of key health indicators in Portugal
3
Box 1.2 Higher spending on health is associated with better
outcomes, but with large differences between countries
6
Box 1.3 As information improves, the multiple dimensions of
growing health inequality are becoming more apparent
10
Box 1.4 Medical equipment and pharmaceutical industries are
major economic forces
12
Box 1.5 Health is among the top personal concerns 15
Box 2.1 Best practices in moving towards universal coverage 26
Box 2.2 Defi ning “essential packages”: what needs to be done to
go beyond a paper exercise?
27
Box 2.3 Closing the urban-rural gap through progressive
expansion of PHC coverage in rural areas in the Islamic Republic
of Iran
29
Box 2.4 The robustness of PHC-led health systems: 20 years of
expanding performance in Rutshuru, the Democratic Republic of
the Congo
31
Box 2.5 Targeting social protection in Chile 33
Box 2.6 Social policy in the city of Ghent, Belgium: how local
authorities can support intersectoral collaboration between
health and welfare organizations
35
Box 3.1 Towards a science and culture of improvement: evidence
to promote patient safety and better outcomes
44
Box 3.2 When supplier-induced and consumer-driven demand
determine medical advice: ambulatory care in India
44
Box 3.3 The health-care response to partner violence against
women
47
Box 3.4 Empowering users to contribute to their own health 48
Box 3.5 Using information and communication technologies to
improve access, quality and effi ciency in primary care
51
Box 4.1 Rallying society’s resources for health in Cuba 65
Box 4.2 Recommendations of the Commission on Social
Determinants of Health
69
Box 4.3 How to make unpopular public policy decisions 72
Box 4.4 The scandal of invisibility: where births and deaths are
not counted
74
Box 4.5 European Union impact assessment guidelines 75
Box 5.1 From withdrawal to re-engagement in China 84
Box 5.2 Steering national directions with the help of policy
dialogue: experience from three countries
86
Box 5.3 Equity Gauges: stakeholder collaboration to tackle health
inequalities
88
Box 5.4 Limitations of conventional capacity building in low- and
middle-income countries
91
Box 5.5 Rebuilding leadership in health in the aftermath of war
and economic collapse
94
Box 6.1 Norway’s national strategy to reduce social inequalities
in health
102
Box 6.2 The virtuous cycle of supply of and demand for primary
care
107
Box 6.3. From product development to fi eld implementation −
research makes the link
109
List of Boxes
vii
Contents
Table 1 How experience has shifted the focus of the PHC
movement
xv
Table 3.1 Aspects of care that distinguish conventional health
care from people-centred primary care
43
Table 3.2 Person-centredness: evidence of its contribution to
quality of care and better outcomes
47
Table 3.3 Comprehensiveness: evidence of its contribution to
quality of care and better outcomes
48
Table 3.4 Continuity of care: evidence of its contribution to
quality of care and better outcomes
50
Table 3.5 Regular entry point: evidence of its contribution to
quality of care and better outcomes
52
Table 4.1 Adverse health effects of changing work
circumstances
70
Table 5.1 Roles and functions of public-health observatories in
England
89
Table 5.2 Signifi cant factors in improving institutional capacity
for health-sector governance in six countries
92
List of Tables
Primary Health Care – Now More Than Ever
viii
The World Health Report 2008
Director-General’s
Message
When I took offi ce in 2007, I made
clear my commitment to direct
WHO’s attention towards primary
health care. More important than
my own conviction, this refl ects
the widespread and growing
demand for primary health
care from Member States. This
demand in turn displays a
growing appetite among policymakers
for knowledge related to
how health systems can become
more equitable, inclusive and fair.
It also
refl ects, more fundamentally, a
shift towards the need for more comprehensive
thinking about the performance
of the health system as a whole.
This
year marks both the 60th birthday
of WHO and the 30th anniversary of
the Declaration of Alma-Ata on Primary
Health Care in 1978. While our global health context has changed remarkably over six decades, the
values that lie at the core of the WHO Constitution and those that informed the Alma-Ata Declaration
have been tested and remain true. Yet, despite enormous progress in health globally, our collective failures
to deliver in line with these values are painfully obvious and deserve our greatest attention.
We see a mother suffering complications of labour without access to qualifi ed support, a child
missing out on essential vaccinations, an inner-city slum dweller living in squalor. We see the absence
of protection for pedestrians alongside traffi c-laden roads and highways, and the impoverishment
arising from direct payment for care because of a lack of health insurance. These and many other
everyday realities of life personify the unacceptable and avoidable shortfalls in the performance of
our health systems.
In moving forward, it is important to learn from the past and, in looking back, it is clear that we
can do better in the future. Thus, this World Health Report revisits the ambitious vision of primary
health care as a set of values and principles for guiding the development of health systems. The Report
represents an important opportunity to draw on the lessons of the past, consider the challenges that
Wh
cle
W
m
tow
hensive
h
day W
ix
Director-General’s Message
lie ahead, and identify major avenues for health
systems to narrow the intolerable gaps between
aspiration and implementation.
These avenues are defi ned in the Report as
four sets of reforms that refl ect a convergence
between the values of primary health care, the
expectations of citizens and the common health
performance challenges that cut across all contexts.
They include:
universal c �� overage 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;
�� service delivery reforms that re-organize
health services 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;
�� public policy reforms that secure healthier
communities, by integrating public health
actions with primary care, by pursuing healthy
public policies across sectors and by strengthening
national and transnational public health
interventions; and
�� leadership 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 indicated
by the complexity of contemporary health
systems.
While universally applicable, these reforms
do not constitute a blueprint or a manifesto for
action. The details required to give them life in
each country must be driven by specifi c conditions
and contexts, drawing on the best available
evidence. Nevertheless, there are no reasons why
any country − rich or poor − should wait to begin
moving forward with these reforms. As the last
three decades have demonstrated, substantial
progress is possible.
Doing better in the next 30 years means that
we need to invest now in our ability to bring
actual performance in line with our aspirations,
expectations and the rapidly changing realities of
our interdependent health world. United by the
common challenge of primary health care, the
time is ripe, now more than ever, to foster joint
learning and sharing across nations to chart the
most direct course towards health for all.
Dr Margaret Chan
Director-General
World Health Organization

Introduction
and Overview
Why a renewal of primary health care (PHC), and why
now, more than ever? The immediate answer is the
palpable demand for it from Member States – not just
from health professionals, but from the
political arena as well.
Globalization is putting the social
cohesion of many countries under stress,
and health systems, as key constituents
of the architecture of contemporary
societies, are clearly not performing as
well as they could and as they should.
People are increasingly impatient with
the inability of health services to deliver levels of national
coverage that meet stated demands and changing needs,
and with their failure to provide services in ways that
correspond to their expectations. Few would disagree that
health systems need to respond better – and faster – to the
challenges of a changing world. PHC can do that.
Responding to the
challenges of a
changing world
xii
Growing expectations
for better performance xiii
From the packages of
the past to the
reforms of the future
xiv
Four sets of PHC reforms xvi
Seizing opportunities xviii
xi
Primary Health Care – Now More Than Ever
xii
The World Health Report 2008
There is today a recognition that populations are
left behind and a sense of lost opportunities that
are reminiscent of what gave rise, thirty years
ago, to Alma-Ata’s paradigm shift in thinking
about health. The Alma-Ata Conference
mobilized a “Primary Health Care movement”
of professionals and institutions, governments
and civil society organizations, researchers and
grassroots organizations that undertook to tackle
the “politically, socially and economically unacceptable”
1 health inequalities in all countries.
The Declaration of Alma-Ata was clear about the
values pursued: social justice and the right to
better health for all, participation and solidarity1.
There was a sense that progress towards these
values required fundamental changes in the way
health-care systems operated and harnessed the
potential of other sectors.
The translation of these values into tangible
reforms has been uneven. Nevertheless, today,
health equity enjoys increased prominence in
the discourse of political leaders and ministries
of health2, as well as of local government structures,
professional organizations and civil society
organizations.
The PHC values to achieve health for all
require health systems that “Put people at the
centre of health care”3. What people consider
desirable ways of living as individuals and what
they expect for their societies – i.e. what people
value – constitute important parameters for
governing the health sector. PHC has remained
the benchmark for most countries’ discourse on
health precisely because the PHC movement tried
to provide rational, evidence-based and anticipatory
responses to health needs and to these
social expectations4,5,6,7. Achieving this requires
trade-offs that must start by taking into account
citizens’ “expectations about health and health
care” and ensuring “that [their] voice and choice
decisively infl uence the way in which health services
are designed and operate”8. A recent PHC
review echoes this perspective as the “right to
the highest attainable level of health”, “maximizing
equity and solidarity” while being guided
by “responsiveness to people’s needs”4. Moving
towards health for all requires that health systems
respond to the challenges of a changing
world and growing expectations for better performance.
This involves substantial reorientation
and reform of the ways health systems operate
in society today: those reforms constitute the
agenda of the renewal of PHC.
Responding to the challenges of a
changing world
On the whole, people are healthier, wealthier and
live longer today than 30 years ago. 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 deaths9. This
difference of 6.7 million is equivalent to 18 329
children’s lives being saved every day. The once
revolutionary notion of essential drugs has
become commonplace. There have been signifi -
cant improvements in access to water, sanitation
and antenatal care.
This shows that progress is possible. It can
also be accelerated. There have never been more
resources available for health than now. The global
health economy is growing faster than gross
domestic product (GDP), having increased its
share from 8% to 8.6% of the world’s GDP between
2000 and 2005. In absolute terms, adjusted for
infl ation, this represents a 35% growth in the
world’s expenditure on health over a fi ve-year
period. Knowledge and understanding of health
are growing rapidly. The accelerated technological
revolution is multiplying the potential
for improving health and transforming health
literacy in a better-educated and modernizing
global society. A global stewardship is emerging:
from intensifi ed exchanges between countries,
often in recognition of shared threats, challenges
or opportunities; from growing solidarity; and
from the global commitment to eliminate poverty
exemplifi ed in the Millennium Development Goals
(MDGs).
However, there are other trends that must
not be ignored. First, the substantial progress
in health over recent decades has been deeply
unequal, with convergence towards improved
health in a large part of the world, but at the same
time, with a considerable number of countries
increasingly lagging behind or losing ground.
Furthermore, there is now ample documentation
– not available 30 years ago – of considerable
and often growing health inequalities within
countries.
xiii
Introduction and Overview
Second, the nature of health problems is changing
in ways that were only partially anticipated,
and at a rate that was wholly unexpected. Ageing
and the effects of ill-managed urbanization and
globalization accelerate worldwide transmission
of communicable diseases, and increase
the burden of chronic and noncommunicable
disorders. The growing reality that many individuals
present with complex symptoms and
multiple illnesses challenges service delivery
to develop more integrated and comprehensive
case management. A complex web of interrelated
factors is at work, involving gradual but longterm
increases in income and population, climate
change, challenges to food security, and social
tensions, all with defi nite, but largely unpredictable,
implications for health in the years ahead.
Third, health systems are not insulated from
the rapid pace of change and transformation
that is an essential part of today’s globalization.
Economic and political crises challenge
state and institutional roles to ensure access,
delivery and fi nancing. Unregulated commercialization
is accompanied by a blurring of the
boundaries between public and private actors,
while the negotiation of entitlement and rights
is increasingly politicized. The information age
has transformed the relations between citizens,
professionals and politicians.
In many regards, the responses of the health
sector to the changing world have been inadequate
and naïve. Inadequate, insofar as they
not only fail to anticipate, but also to respond
appropriately: too often with too little, too late
or too much in the wrong place. Naïve insofar as
a system’s failure requires a system’s solution –
not a temporary remedy. Problems with human
resources for public health and health care,
fi nance, infrastructure or information systems
invariably extend beyond the narrowly defi ned
health sector, beyond a single level of policy purview
and, increasingly, across borders: this raises
the benchmark in terms of working effectively
across government and stakeholders.
While the health sector remains massively
under-resourced in far too many countries,
the resource base for health has been growing
consistently over the last decade. The opportunities
this growth offers for inducing structural
changes and making health systems more effective
and equitable are often missed. Global and,
increasingly, national policy formulation processes
have focused on single issues, with various
constituencies competing for scarce resources,
while scant attention is given to the underlying
constraints that hold up health systems development
in national contexts. Rather than improving
their response capacity and anticipating new
challenges, health systems seem to be drifting
from one short-term priority to another, increasingly
fragmented and without a clear sense of
direction.
Today, it is clear that left to their own devices,
health systems do not gravitate naturally towards
the goals of health for all through primary health
care as articulated in the Declaration of Alma-
Ata. Health systems are developing in directions
that contribute little to equity and social justice
and fail to get the best health outcomes for their
money. Three particularly worrisome trends can
be characterized as follows:
health systems that focus �� disproportionately on
a narrow offer of specialized curative care;
�� health systems where a command-and-control
approach to disease control, focused on shortterm
results, is fragmenting service delivery;
�� health systems where a hands-off or laissezfaire
approach to governance has allowed
unregulated commercialization of health to
fl ourish.
These trends fl y in the face of a comprehensive
and balanced response to health needs. In a number
of countries, the resulting inequitable access,
impoverishing costs, and erosion of trust in health
care constitute a threat to social stability.
Growing expectations for better
performance
The support for a renewal of PHC stems from the
growing realization among health policy-makers
that it can provide a stronger sense of direction
and unity in the current context of fragmentation
of health systems, and an alternative to the
assorted quick fi xes currently touted as cures
for the health sector’s ills. There is also a growing
realization that conventional health-care
Primary Health Care – Now More Than Ever
xiv
The World Health Report 2008
delivery, through different mechanisms and for
different reasons, is not only less effective than
it could be, but suffers from a set of ubiquitous
shortcomings and contradictions that are summarized
in Box 1.
The mismatch between expectations and
performance is a cause of concern for health
authorities. Given the growing economic weight
and social signifi cance of the health sector, it
is also an increasing cause for concern among
politicians: it is telling that health-care issues
were, on average, mentioned more than 28 times
in each of the recent primary election debates in
the United States22. Business as usual for health
systems is not a viable option. If these shortfalls
in performance are to be redressed, the health
problems of today and tomorrow will require
stronger collective management and accountability
guided by a clearer sense of overall direction
and purpose.
Indeed, this is what people expect to happen.
As societies modernize, people demand more
from their health systems, for themselves and
their families, as well as for the society in which
they live. Thus, there is increasingly popular
support for better health equity and an end to
exclusion; for health services that are centred
on people’s needs and expectations; for health
security for the communities in which they live;
and for a say in what affects their health and that
of their communities23.
These expectations resonate with the values
that were at the core of the Declaration of Alma-
Ata. They explain the current demand for a better
alignment of health systems with these values
and provide today’s PHC movement with reinvigorated
social and political backing for its attempts
to reform health systems.
From the packages of the past to
the reforms of the future
Rising expectations and broad support for the
vision set forth in Alma-Ata’s values have not
always easily translated into effective transformation
of health systems. There have been circumstances
and trends from beyond the health
sector – structural adjustment, for example –
over which the PHC movement had little infl uence
or control. Furthermore, all too often, the
PHC movement has oversimplifi ed its message,
resulting in one-size-fi ts-all recipes, ill-adapted
to different contexts and problems24. As a result,
national and global health authorities have at
times seen PHC not as a set of reforms, as was
intended, but as one health-care delivery programme
among many, providing poor care for
poor people. Table 1 looks at different dimensions
of early attempts at implementing PHC and
contrasts this with current approaches. Inherent
in this evolution is recognition that providing a
sense of direction to health systems requires a
set of specifi c and context-sensitive reforms that
respond to the health challenges of today and
prepare for those of tomorrow.
Box 1 Five common shortcomings of
health-care delivery
Inverse care. People with the most means – whose needs for
health care are often less – consume the most care, whereas
those with the least means and greatest health problems consume
the least10. Public spending on health services most
often benefi ts the rich more than the poor11 in high- and lowincome
countries alike12,13.
Impoverishing care. Wherever people lack social protection
and payment for care is largely out-of-pocket at the point of
service, they can be confronted with catastrophic expenses.
Over 100 million people annually fall into poverty because they
have to pay for health care14.
Fragmented and fragmenting care. The excessive specialization
of health-care providers and the narrow focus of many
disease control programmes discourage a holistic approach
to the individuals and the families they deal with and do not
appreciate the need for continuity in care15. Health services
for poor and marginalized groups are often highly fragmented
and severely under-resourced16, while development aid often
adds to the fragmentation17.
Unsafe care. Poor system design that is unable to ensure safety
and hygiene standards leads to high rates of hospital-acquired
infections, along with medication errors and other avoidable
adverse effects that are an underestimated cause of death
and ill-health18.
Misdirected care. Resource allocation clusters around curative
services at great cost, neglecting the potential of primary
prevention and health promotion to prevent up to 70% of the
disease burden19,20. At the same time, the health sector lacks
the expertise to mitigate the adverse effects on health from
other sectors and make the most of what these other sectors
can contribute to health21.
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
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):
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;
�� 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;
�� reforms that secure healthier communities, by
integrating public health actions with primary
care and by pursuing healthy public policies
across sectors – public policy reforms;
�� 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
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:
primary care provides a place to which people can bring a wide range of health problems – it is not a �� cceptable that in low-income
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;
�� 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 ailments;
�� 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;
�� 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.
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
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,
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
Primary health care: report of the International Conference 1. 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. Report on the review of primary care in the African Region. Brazzaville, World Health
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. The Ljubljana Charter on Reforming Health Care, 1996. Copenhagen, World Health
Organization Regional Offi ce for Europe, 1996.
9. World Health Statistics 2008. Geneva, World Health Organization, 2008.
10. Hart T. The inverse care law. Lancet, 1971, 1:405–412.
11. World development report 2004: making services work for poor people. Washington
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. The World Health Report 2002 – Reducing risks, promoting healthy life. Geneva,
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. Primary care. America’s health in a new era. Washington DC, National Academy
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.


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
Social, demographic
transformations fed by
and ageing populations,
magnitude that was not
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
describ
re
a
sha
t
cha
he
a
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
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.
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 sub-
Saharan 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
The World Health Report 2008
4
Primary Health Care – Now More Than Ever
in the world where access to qualifi ed providers
at childbirth is not progressing18.
Mirroring the overall trends in child survival,
global trends in life expectancy point
to a rise throughout the world of almost eight
years between 1950 and 1978, and seven more
years since: a refl ection of the growth in average
income per capita. As with child survival, widening
income inequality (income increases faster
in high-income than in low-income countries)
is refl ected in increasing disparities between
the least and most healthy19. Between the mid-
1970s and 2005, the difference in life expectancy
between high-income countries and countries in
sub-Saharan Africa, or fragile states, has widened
by 3.8 and 2.1 years, respectively.
The unmistakable relation between health and
wealth, summarized in the classic Preston curve
(Figure 1.4), needs to be qualifi ed20.
Firstly, the Preston curve continues to shift12.
An income per capita of I$ 1000 in 1975 was
associated with a life expectancy of 48.8 years.
In 2005, it was almost four years higher for the
same income. This suggests that improvements
in nutrition, education21, health technologies22,
the institutional capacity to obtain and use
information, and in society’s ability to translate
this knowledge into effective health and social
action23, allow for greater production of health
for the same level of wealth.
Secondly, there is considerable variation in
achievement across countries with the same
income, particularly among poorer countries. For
example, life expectancy in Côte d’Ivoire (GDP I$
1465) is nearly 17 years lower than in Nepal (GDP
I$ 1379), and between Madagascar and Zambia,
the difference is 18 years. The presence of high
performers in each income band shows that
the actual level of income per capita at a given
moment is not the absolute rate limiting factor
the average curve seems to imply.
Growth and stagnation
Over the last 30 years the relation between economic
growth and life expectancy at birth has
shown three distinct patterns (Figure 1.5).
In 1978, about two thirds of the world’s population
lived in countries that went on to experience
increases in life expectancy at birth and considerable
economic growth. The most impressive relative
gains were in a number of low-income countries
in Asia (including India), Latin America and
northern Africa, totalling 1.1 billion inhabitants
30 years ago and nearly 2 billion today. These
countries increased life expectancy at birth by
12 years, while GDP per capita was multiplied by
a factor of 2.6. High-income countries and countries
with a GDP between I$ 3000 and I$ 10 000
in 1975 also saw substantial economic growth
and increased life expectancy.
In other parts of the world, GDP growth was
not accompanied by similar gains in life expectancy.
The Russian Federation and Newly Independent
States increased average GDP per capita
substantially, but, with the widespread poverty
that accompanied the transition from the former
Soviet Union, women’s life expectancy stagnated
from the late 1980s and men’s plummeted, particularly
for those lacking education and job
security24,25. After a period of technological and
organizational stagnation, the health system collapsed12.
Public expenditure on health declined
in the 1990s to levels that made running a basic
system virtually impossible in several countries.
Unhealthy lifestyles, combined with the disintegration
of public health programmes, and the
unregulated commercialization of clinical services
combined with the elimination of safety
nets has offset any gains from the increase in
average GDP26. China had already increased its
Figure 1.4 GDP per capita and life expectancy at birth in 169 countriesa,
1975 and 2005
Life expectancy at birth (years)
GDP per capita, constant 2000 international $
a Only outlying countries are named.
35
85
0
Namibia
5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000
South Africa
Botswana
Swaziland
75
65
55
45
2005
1975
5
Chapter 1. The challenges of a changing world
life expectancy substantially in the period before
1980 to levels far above that of other low-income
countries in the 1970s, despite the 1961–1963
famine and the 1966–1976 Cultural Revolution.
The contribution of rural primary care and
urban health insurance to this has been well
documented27,28. With the economic reforms of
the early 1980s, however, average GDP per capita
increased spectacularly, but access to care and
social protection deteriorated, particularly in
rural areas. This slowed down improvements to
a modest rate, suggesting that only the improved
living conditions associated with the spectacular
economic growth avoided a regression of average
life expectancy29.
Finally, there is a set of low-income countries,
representing roughly 10% of the world’s
population, where both GDP and life expectancy
stagnated30. These are the countries that are
considered as “fragile states” according to the
“low-income countries under stress” (LICUS)
criteria for 2003–200631. As much as 66% of the
population in these countries is in Africa. Poor
governance and extended internal confl icts are
common among these countries, which all face
similar hurdles: weak security, fractured societal
relations, corruption, breakdown in the rule
of law, and lack of mechanisms for generating
legitimate power and authority32. They have a
huge backlog of investment needs and limited
government resources to meet them. Half of
them experienced negative GDP growth during
the period 1995–2004 (all the others remained
below the average growth of low-income countries),
while their external debt was above average33.
These countries were among those with
the lowest life expectancy at birth in 1975 and
have experienced minimal increases since then.
The other low-income African countries share
many of the characteristics and circumstances
of the fragile states – in fact many of them have
suffered protracted periods of confl ict over the
last 30 years that would have classifi ed them as
fragile states had the LICUS classifi cation existed
at that time. Their economic growth has been
very limited, as has been their life-expectancy
gain, not least because of the presence, in this
group, of a number of southern African countries
that are disproportionally confronted by the HIV/
AIDS pandemic. On average, the latter have seen
some economic growth since 1975, but a marked
reversal in terms of life expectancy.
What has been strikingly common to fragile
states and sub-Saharan African countries for
Life expectancy (years)
0
Figure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975–2005*
50
45
Chinah
55
60
65
70
75
80
1000 2000 3000 4000 5000 6000 7000 8000 9000 10 000
Middle-income
countriesb
Russian Federation
and NISg
Low-income African countriesf
Low-income
coutriesd
Indiac
Fragile statese
20 000 25 000 30 000
a 27 countries, 766 million (M) inhabitants in 1975, 953 M in 2005.
b 43 countries, 587 M inhabitants in 1975, 986 M in 2005 .
c India, 621 M inhabitants in 1975, 1 103 M in 2005.
d 17 Low-income countries, non-African, fragile states excluded, 471 M inhabitants in 1975, 872 M in 2005.
e 20 Fragile states, 169 M inhabitants in 1975, 374 M in 2005.
f 13 Low-income African countries, fragile states excluded, 71 M inhabitants in 1975, 872 M in 2005.
g Russian Federation and 10 Newly Independent States (NIS), 186 M inhabitants in 1985, 204 M in 2005.
h China, 928 M inhabitants in 1975, 1 316 M in 2005.
High-income countriesa
* No data for 1975 for the Newly Independant States. No historical data for the remaining countries.
Sources: Life expectancy, 1975, 1985: UN World Population Prospects 2006; 1995, 2005: WHO, 9 November 2008 (draft); China: 3rd, 4th and 5th National Population censuses, 1981, 1990 and 2000. GPD: 200737.
The World Health Report 2008
6
Primary Health Care – Now More Than Ever
much of the last three decades, and differentiates
them from the others that started out with less
than I$ 3000 per capita in 1975, is the combination
of stagnating economic growth, political instability
and lack of progress in life expectancy. They
accumulate characteristics that hamper improvement
of health. Education, particularly of females,
develops more slowly, as does access to modern
communications and knowledge-intensive work
that broadens people’s intellectual resources elsewhere.
People are more exposed and more vulnerable
to environmental and other health threats
that, in today’s globalized world, include lifestyle
threats, such as smoking, obesity and urban violence.
They lack the material security required to
invest in their own health and their governments
lack the necessary resources and/or commitment
to public investment. They are at much greater risk
of war and civil confl ict than richer countries30.
Without growth, peace is considerably more diffi
cult and without peace, growth stagnates: on
average, a civil war reduces a country’s growth
by around 2.3% per year for a typical duration of
seven years, leaving it 15% poorer34.
The impact of the combination of stagnation
and confl icts cannot be overstated. Confl icts are a
direct source of considerable excessive suffering,
disease and mortality. In the Democratic Republic
of the Congo, for example, the 1998–2004 confl ict
caused an excess mortality of 450 000 deaths
per year35. Any strategy to close the health gaps
between countries – and to correct inequalities
within countries – has to give consideration to
the creation of an environment of peace, stability
and prosperity that allows for investment in the
health sector.
A history of poor economic growth is also a
history of stagnating resources for health. What
In many countries, the total amount spent on health is insuffi cient
to fi nance access for all to even a very limited package of essential
health care39. This is bound to make a difference to health and
survival. Figure 1.6 shows that Kenya has a health-adjusted life
expectancy (HALE) of 44.4 years, the median for countries that
currently spend less than I$ 100 per capita on health. This is 27
years less than Germany, the median for countries that spend
more than I$ 2500 per capita. Every I$ 100
per capita spent on heath corresponds to a
1.1-year gain in HALE.
However, this masks large differences in
outcomes at comparable levels of spending.
There are up to fi ve years difference in HALE
between countries that spend more than
I$ 2500 per capita per year on health. The
spread is wider at lower expenditure levels,
even within rather narrow spending bands.
Inhabitants of Moldova, for example, enjoy 24
more HALE years than those of Haiti, yet they
are both among the 28 countries that spend I$
250–500 per capita on health. These gaps can
even be wider if one also considers countries
that are heavily affected by HIV/AIDS. Lesotho
spends more on health than Jamaica, yet its
people have a HALE that is 34 years shorter.
In contrast, the differences in HALE between
the countries with the best outcomes in each
Box 1.2 Higher spending on health is associated with better outcomes, but with large
differences between countries
spending band are comparatively small. Tajikistan, for example,
has a HALE that is 4.3 years less than that of Sweden – less than
the difference between Sweden and the United States. These differences
suggest that how, for what and for whom money is spent
matters considerably. Particularly in countries where the envelope
for health is very small, every dollar that is allocated sub-optimally
seems to make a disproportionate difference.
Figure 1.6 Countries grouped according to their total health expenditure
in 2005 (international $)38,40
HALE (years)
Total health expenditure (no. of countries)
20
80
70
50
30
THE < I$ 100
(30)
40
60
Tajikistan
Sierra Leone
THE I$ 100–250
(28)
Moldova
Haiti
Lesotho
THE I$ 250–500
(30)
Panama
Swaziland
THE I$ 500–1000
(23)
Finland
Botswana
THE I$ 1000–2500
(16)
Japan
THE > I$ 2500
(15)
Germany
Phillippines
Gabon
Colombia
Iran
United Kingdom /
New Zealand
Hungary
Sweden
USA
Kenya
Saint Vincent
and the
Grenadines
Highest
Median
Lowest
Outliers
7
Chapter 1. The challenges of a changing world
happened in sub-Saharan Africa during the years
following Alma-Ata exemplifi es this predicament.
After adjusting for infl ation, GDP per capita in
sub-Saharan Africa fell in most years from 1980–
199436, leaving little room to expand access to
health care or transform health systems. By the
early 1980s, for example, the medicines budget
in the Democratic Republic of the Congo, then
Zaïre, was reduced to zero and government disbursements
to health districts dropped below
US$ 0.1 per inhabitant; Zambia’s public sector
health budget was cut by two thirds; and funds
available for operating expenses and salaries for
the expanding government workforce dropped by
up to 70% in countries such as Cameroon, Ghana,
Sudan and the United Republic of Tanzania36. For
health authorities in this part of the world, the
1980s and 1990s were a time of managing shrinking
government budgets and disinvestment. For
the people, this period of fi scal contraction was
a time of crippling out-of-pocket payments for
under-funded and inadequate health services.
In much of the world, the health sector is often
massively under-funded. In 2005, 45 countries spent
less than I$ 100 per capita on health, including
external assistance38. In contrast, 16 high-income
countries spent more than I$ 3000 per capita. Lowincome
countries generally allocate a smaller proportion
of their GDP to health than high-income
countries, while their GDP is smaller to start with
and they have higher disease burdens.
Higher health expenditure is associated with
better health outcomes, but sensitive to policy
choices and context (Box 1.2): where money is
scarce, the effects of errors, by omission and by
commission, are amplifi ed. Where expenditure
increases rapidly, however, this offers perspectives
for transforming and adapting health systems
which are much more limited in a context
of stagnation.
Adapting to new health challenges
A globalized, urbanized and ageing world
The world has changed over the last 30 years:
few would have imagined that children in Africa
would now be at far more risk of dying from traffi
c accidents than in either the high- or the lowand
middle-income countries of the European
region (Figure 1.7).
Many of the changes that affect health were
already under way in 1978, but they have accelerated
and will continue to do so.
Thirty years ago, some 38% of the world’s
population lived in cities; in 2008, it is more than
50%, 3.3 billion people. By 2030, almost 5 billion
people will live in urban areas. Most of the
growth will be in the smaller cities of developing
countries and metropolises of unprecedented size
and complexity in southern and eastern Asia42.
Although on average health indicators in
cities score better than in rural areas, the
enormous social and economic stratification
within urban areas results in signifi cant health
inequities43,44,45,46. In the high-income area of Nairobi,
the under-fi ve mortality rate is below 15
per thousand, but in the Emabakasi slum of the
same city the rate is 254 per thousand47. These
and other similar examples lead to the more
general observation that within developing countries,
the best local governance can help produce
75 years or more of life expectancy; with poor
urban governance, life expectancy can be as low
as 35 years48. One third of the urban population
today – over one billion people – lives in slums: in
places that lack durable housing, suffi cient living
area, access to clean water and sanitation, and
secure tenure49. Slums are prone to fi re, fl oods
and landslides; their inhabitants are disproportionately
exposed to pollution, accidents, workplace
hazards and urban violence. Loss of social
Figure 1.7 Africa’s children are at more risk of dying from traffic accidents than
European children: child road-traffic deaths per 100 000 population41
0
50
30
20
10
40
0–4 5–9 10–14 15–19
Africa Europe, low- and middle-income countries Europe, high-income countries
The World Health Report 2008
8
Primary Health Care – Now More Than Ever
cohesion and globalization of unhealthy lifestyles
contribute to an environment that is decidedly
unfavourable for health.
These cities are where many of the world’s
nearly 200 million international migrants are
found50. They constitute at least 20% of the population
in 41 countries, 31% of which have less
than a million inhabitants. Excluding migrants
from access to care is the equivalent of denying
all the inhabitants of a country similar to Brazil
their rights to health. Some of the countries that
have made very signifi cant strides towards ensuring
access to care for their citizens fail to offer
the same rights to other residents. As migration
continues to gain momentum, the entitlements of
non-citizen residents and the ability of the healthcare
system to deal with growing linguistic and
cultural diversity in equitable and effective ways
are no longer marginal issues.
This mobile and urbanized world is ageing fast
and will continue to do so. By 2050, the world will
count 2 billion people over the age of 60, around
85% of whom will be living in today’s developing
countries, mostly in urban areas. Contrary to
today’s rich countries, low- and middle-income
countries are ageing fast before having become
rich, adding to the challenge.
Urbanization, ageing and globalized lifestyle
changes combine to make chronic and noncommunicable
diseases – including depression, diabetes,
cardiovascular disease and cancers – and
injuries increasingly important causes of morbidity
and mortality (Figure 1.8)51. There is a striking
shift in distribution of death and disease from
younger to older ages and from infectious, perinatal
and maternal causes to noncommunicable
diseases. Traffi c accident rates will increase;
tobacco-related deaths will overtake HIV/AIDSrelated
deaths. Even in Africa, where the population
remains younger, smoking, elevated blood
pressure and cholesterol are among the top 10 risk
factors in terms of overall disease burden52. In
the last few decades, much of the lack of progress
and virtually all reversals in life expectancy were
associated with adult health crises, such as in the
Russian Federation or southern Africa. Improved
health in the future will increasingly be a question
of better adult health.
Ageing has drawn attention to an issue that is
of particular relevance to the organization of service
delivery: the increasing frequency of multimorbidity.
In the industrialized world, as many
as 25% of 65–69 year olds and 50% of 80–84 year
olds are affected by two or more chronic health
conditions simultaneously. In socially deprived
populations, children and younger adults are
also likely to be affected53,54,55. The frequency of
multi-morbidity in low-income countries is less
well described except in the context of the HIV/
AIDS epidemic, malnutrition or malaria, but it is
probably greatly underestimated56,57. As diseases
of poverty are inter-related, sharing causes that
Cerebrovascular diseases
Ischaemic heart diseases
Cancers
Figure 1.8 The shift towards noncommunicable diseases and accidents as causes of death*
Perinatal causes
Acute respiratory infections
Diarrhoeal diseases
Malaria
HIV/AIDS
Tuberculosis
* Selected causes.
Deaths (millions)
0
2004
35
30
25
20
15
10
5
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2018 2020 2022 2024 2026 2028 2030
Road-traffic accidents
9
Chapter 1. The challenges of a changing world
are multiple and act together to produce greater
disability and ill health, multi-morbidity is
probably more rather than less frequent in poor
countries. Addressing co-morbidity – including
mental health problems, addictions and violence
– emphasizes the importance of dealing
with the person as a whole. This is as important
in developing countries as in the industrialized
world58.
It is insuffi ciently appreciated that the shift to
chronic diseases or adult health has to come on
top of an unfi nished agenda related to communicable
diseases, and maternal, newborn and child
health. Efforts directed at the latter, especially
in the poorest countries where coverage is still
insuffi cient, will have to expand12. But all health
systems, including those in the poorest countries,
will also have to deal with the expanding need and
demand for care for chronic and noncommunicable
diseases: this is not possible without much more
attention being paid to establishing a continuum
of comprehensive care than is the case today. It
is equally impossible without much more attention
being paid to addressing the pervasive health
inequalities within each country (Box 1.3).
Little anticipation and slow reactions
Over the past few decades, health authorities have
shown little evidence of their ability to anticipate
such changes, prepare for them or even adapt to
them when they have become an everyday reality.
This is worrying because the rate of change
is accelerating. Globalization, urbanization and
ageing will be compounded by the health effects of
other global phenomena, such as climate change,
the impact of which is expected to be greatest
among the most vulnerable communities living
in the poorest countries. Precisely how these will
affect health in the coming years is more diffi cult
to predict, but rapid changes in disease burden,
growing health inequalities and disruption of
social cohesion and health sector resilience are
to be expected. The current food crisis has shown
how unprepared health authorities often are for
changes in the broader environment, even after
other sectors have been sounding the alarm bell
for quite some time. All too often, the accelerated
pace and the global scale of the changes in the
challenges to health is in contrast with the sluggish
response of national health systems.
Even for well-known and documented trends,
such as those resulting from the demographic and
epidemiologic transitions, the level of response
often remains inadequate64. Data from WHO’s
World Health Surveys, covering 18 low-income
countries, show low coverage of the treatment of
asthma, arthritis, angina, diabetes and depression,
and of the screening for cervical and breast
cancer: less than 15% in the lowest income quintile
and less than 25% in the highest65. Public-health
interventions to remove the major risk factors of
disease are often neglected, even when they are
particularly cost effective: they have the potential
to reduce premature deaths by 47% and increase
global healthy life expectancy by 9.3 years64,66.
For example, premature tobacco-attributable
deaths from ischaemic heart disease, cerebrovascular
disease, chronic obstructive pulmonary
disease and other diseases are projected to rise
from 5.4 million in 2004 to 8.3 million in 2030,
almost 10% of all deaths worldwide67, with more
than 80% in developing countries12. Yet, two out
of every three countries are still without, or only
have minimal, tobacco control policies12.
With a few exceptions – the SARS epidemic, for
example – the health sector has often been slow
in dealing with new or previously underestimated
health challenges. For example, awareness of the
emerging health threats posed by climate change
and environmental hazards dates back at least to
the 1990 Earth Summit68, but only in recent years
have these begun to be translated into plans and
strategies69,70.
Health authorities have also often failed to
assess, in a timely way, the signifi cance of changes
in their political environment that affect the sector’s
response capacity. Global and national policy
environments have often taken health issues into
consideration, initiating hasty and disruptive
interventions, such as structural adjustment,
decentralization, blueprint poverty reduction
strategies, insensitive trade policies, new tax
regimes, fi scal policies and the withdrawal of
the state. Health authorities have a poor track
record in infl uencing such developments, and
have been ineffective in leveraging the economic
weight of the health sector. Many of the critical
systems issues affecting health require skills
and competencies that are not found within the
medical/public health establishment. The failure
The World Health Report 2008
10
Primary Health Care – Now More Than Ever
Box 1.3 As information improves, the multiple dimensions of growing health inequality are
becoming more apparent
In recent years, the extent of within-country disparities in vulnerability, access to care and health outcomes has been described in much
greater detail (Figure 1.9)59. Better information shows that health inequalities tend to increase, thereby highlighting how inadequate
and 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 and
consequences of health inequity.
0
20
40
60
80
100
Figure 1.9 Within-country inequalities in health and health care
Per capita household spending on health
as percentage of total household spending,
by income group
0
Côte d’Ivoire
1988
1
2
3
4
5
6
Ghana
1992
Madagascar
1993–4
Lowest quintile Quintile 2 Quintile 3 Quintile 4 Highest quintile
Mean time (minutes) taken to
reach an ambulatory health facility,
by income group
0
Bosnia and Herzegovina
2003–4
Comoros
2003–4
Ecuador
2003–4
10
20
30
40
50
Women using malaria prophylaxis (%),
by income group
Lowest quintile Quintile 2 Quintile 3 Quintile 4 Highest quintile
Full basic immunization coverage (%),
by income group
Guinea
2005
Malawi
2004
Niger
2006
Tanzania
2004
0
20
40
60
80
100
Bangladesh
2004
Colombia
2005
Indonesia
2002–3
Mozambique
2003
0
20
40
60
80
100
Neonatal mortality rate,
by education of mother
No education Primary education Secondary or higher education
Bolivia
2003
Colombia
2005
Lesotho
2003
Nepal
2006
Philippines
2003
0
20
40
60
80
100
Births attended by health professional (%),
by education of mother
Benin
2001
Bolivia
2003
Botswana
1998
Cambodia
2005
Peru
2000
Sources: (60, 61, 62, 63).
11
Chapter 1. The challenges of a changing world
to recognize the need for expertise from beyond
traditional health disciplines has condemned the
health sector to unusually high levels of systems
incompetence and ineffi ciency which society can
ill afford.
Trends that undermine the health
systems’ response
Without strong policies and leadership, health
systems do not spontaneously gravitate towards
PHC values or effi ciently respond to evolving
health challenges. As most health leaders know,
health systems are subject to powerful forces and
infl uences that often override rational priority
setting or policy formation, thereby pulling health
systems away from their intended directions71.
Characteristic trends that shape conventional
health systems today include (Figure 1.10):
a disproportionate focus on s �� pecialist, tertiary
care, often referred to as “hospital-centrism”;
�� fragmentation, as a result of the multiplication
of programmes and projects; and
�� the pervasive commercialization of health care
in unregulated health systems.
With their focus on cost containment and
deregulation, many of the health-sector reforms
of the 1980s and 1990s have reinforced these
trends. High-income countries have often been
able to regulate to contain some of the adverse
consequences of these trends. However, in
countries where under-funding compounds
limited regulatory capacity, they have had more
damaging effects.
Hospital-centrism: health systems built around
hospitals and specialists
For much of the 20th century, hospitals, with
their technology and sub-specialists, have gained
a pivotal role in most health systems throughout
the world72,73. Today, the disproportionate focus
on hospitals and sub-specialization has become
a major source of ineffi ciency and inequality, and
one that has proved remarkably resilient. Health
authorities may voice their concern more insistently
than they used to, but sub-specialization
continues to prevail74. For example, in Member
countries of the Organisation of Economic Cooperation
and Development (OECD), the 35%
growth in the number of doctors in the last 15
years was driven by rising numbers of specialists
(up by nearly 50% between 1990 and 2005
– compared with only a 20% increase in general
practitioners)75. In Thailand, less than 20% of
doctors were specialists 30 years ago; by 2003
they represented 70%76.
The forces driving this growth include professional
traditions and interests as well as the
considerable economic weight of the health industry
– technology and pharmaceuticals (Box 1.4).
Obviously, well functioning specialized tertiary
care responds to a real demand (albeit, at least in
part, induced): it is necessary, at the very least,
for the political credibility of the health system.
However, the experience of industrialized countries
has shown that a disproportionate focus on
specialist, tertiary care provides poor value for
money72. Hospital-centrism carries a considerable
cost in terms of unnecessary medicalization and
iatrogenesis77, and compromises the human and
social dimensions of health73,78. It also carries an
opportunity cost: Lebanon, for example, counts
more cardiac surgery units per inhabitant than
Germany, but lacks programmes aimed at reducing
the risk factors for cardiovascular disease79.
Ineffi cient ways of dealing with health problems
are thus crowding out more effective, effi cient –
and more equitable80 – ways of organizing health
care and improving health81.
Since the 1980s, a majority of OECD countries
has been trying to decrease reliance on hospitals,
Figure 1.10 How health systems are diverted from PHC core values
Commercialization
Hospital-centrism
Fragmentation
PHC Reform
PHC Reform
Current trends
Health equity
Universal access to
people-centred care
Healthy communities
Health
systems
The World Health Report 2008
12
Primary Health Care – Now More Than Ever
specialists and technologies, and keep costs
under control. They have done this by introducing
supply-side measures including reduction of
hospital beds, substitution of hospitalization by
home care, rationing of medical equipment, and
a multitude of fi nancial incentives and disincentives
to promote micro-level effi ciency. The results
of these efforts have been mixed, but the evolving
technology is accelerating the shift from specialized
hospital to primary care. In many highincome
countries (but not all), the PHC efforts
of the 1980s and 1990s have been able to reach
Box 1.4 Medical equipment and
pharmaceutical industries are major
economic forces
Global expenditure on medical equipment and devices has
grown from US$ 145 billion in 1998 to US$ 220 billion in 2006:
the United States accounts for 39% of the total, the European
Union for 27%, and Japan for 16%90. The industry employs
more than 411 400 workers in the United States alone, occupying
nearly one third of all the country’s bioscience jobs91. In
2006, the United States, the European Union and Japan spent
US$ 287, US$ 250 and US$ 273 per capita, respectively, on
medical equipment. In the rest of the world, the average of
such expenditure is in the order of US$ 6 per capita, and
in sub-Saharan Africa – a market with much potential for
expansion – it is US$ 2.5 per capita. The annual growth rate
of the equipment market is over 10% a year92.
The pharmaceutical industry weighs even more heavily in the
global economy, with global pharmaceutical sales expected
to expand to US$ 735–745 billion in 2008, with a growth rate
of 6–7%93. Here, too, the United States is the world’s largest
market, accounting for around 48% of the world total: per
capita expenditure on drugs was US$ 1141 in 2005, twice
the level of Canada, Germany or the United Kingdom, and 10
times that of Mexico94.
Specialized and hospital care is vital to these industries, which
depend on pre-payment and risk pooling for sustainable funding
of their expansion. While this market grows everywhere,
there are large differences from country to country. For
example, Japan and the United States have 5–8 times more
magnetic resonance imaging (MRI) units per million inhabitants
than Canada and the Netherlands. For computerized
tomography (CT) scanners, the differences are even more
pronounced: Japan had 92.6 per million in 2002, the Netherlands
5.8 in 200595. These differences show that the market
can be infl uenced, principally by using appropriate payment
and reimbursement incentives and by careful consideration
of the organization of regulatory control96.
a better balance between specialized curative
care, fi rst contact care and health promotion81.
Over the last 30 years, this has contributed to
signifi cant improvements in health outcomes81,82.
More recently, middle-income countries, such as
Chile with its Atención Primaria de Salud (Primary
Health Care)83, Brazil with its family health
initiative and Thailand under its universal coverage
scheme84 have shifted the balance between
specialized hospital and primary care in the
same way85. The initial results are encouraging:
improvement of outcome indicators86 combined
with a marked improvement in patient satisfaction87.
In each of these cases, the shift took place
as part of a move towards universal coverage,
with expanded citizen’s rights to access and social
protection. These processes are very similar to
what occurred in Malaysia and Portugal: right
to access, social protection, and a better balance
between reliance on hospitals and on generalist
primary care, including prevention and health
promotion6.
Industrialized countries are, 50 years later,
trying to reduce their reliance on hospitals,
having realized the opportunity cost of hospitalcentrism
in terms of effectiveness and equity.
Yet, many low- and middle-income countries
are creating the same distortions. The pressure
from consumer demand, the medical professions
and the medico-industrial complex88 is such that
private and public health resources fl ow disproportionately
towards specialized hospital care
at the expense of investment in primary care.
National health authorities have often lacked the
fi nancial and political clout to curb this trend and
achieve a better balance. Donors have also used
their infl uence more towards setting up disease
control programmes than towards reforms that
would make primary care the hub of the health
system89.
Fragmentation: health systems built around
priority programmes
While urban health by and large revolves around
hospitals, the rural poor are increasingly confronted
with the progressive fragmentation of
their health services, as “selective” or “vertical”
approaches focus on individual disease control
programmes and projects. Originally considered
13
Chapter 1. The challenges of a changing world
as an interim strategy to achieve equitable health
outcomes, they sprang from a concern for the
slow expansion of access to health care in a context
of persistent severe excess mortality and
morbidity for which cost-effective interventions
exist97. A focus on programmes and projects is
particularly attractive to an international community
concerned with getting a visible return
on investment. It is well adapted to commandand-
control management: a way of working that
also appeals to traditional ministries of health.
With little tradition of collaboration with other
stakeholders and participation of the public, and
with poor capacity for regulation, programmatic
approaches have been a natural channel for developing
governmental action in severely resourceconstrained
and donor-dependent countries. They
have had the merit of focusing on health care in
severely resource-constrained circumstances,
with welcome attention to reaching the poorest
and those most deprived of services.
Many have hoped that single-disease control
initiatives would maximize return on investment
and somehow strengthen health systems
as interventions were delivered to large numbers
of people, or would be the entry point to start
building health systems where none existed.
Often the opposite has proved true. The limited
sustainability of a narrow focus on disease control,
and the distortions it causes in weak and
under-funded health systems have been criticized
extensively in recent years98. Short-term
advances have been short-lived and have fragmented
health services to a degree that is now of
major concern to health authorities. With parallel
chains of command and funding mechanisms,
duplicated supervision and training schemes,
and multiplied transaction costs, they have led to
situations where programmes compete for scarce
resources, staff and donor attention, while the
structural problems of health systems – funding,
payment and human resources − are hardly
addressed. The discrepancy in salaries between
regular public sector jobs and better-funded
programmes and projects has exacerbated the
human resource crisis in fragile health systems.
In Ethiopia, contract staff hired to help implement
programmes were paid three times more
than regular government employees99, while in
Malawi, a hospital saw 88 nurses leave for better
paid nongovernmental organization (NGO) programmes
in an 18-month period100.
Eventually, service delivery ends up dealing
only with the diseases for which a (funded) programme
exists – overlooking people who have the
misfortune not to fi t in with current programme
priorities. It is diffi cult to maintain the people’s
trust if they are considered as mere programme
targets: services then lack social sustainability.
This is not just a problem for the population. It
puts health workers in the unenviable position of
having to turn down people with “the wrong kind
of problem” – something that fi ts ill with the selfimage
of professionalism and caring many cherish.
Health authorities may at fi rst be seduced by
the straightforwardness of programme funding
and management, yet once programmes multiply
and fragmentation becomes unmanageable and
unsustainable, the merits of more integrated
approaches are much more evident. The re-integration
of programmes once they have been well
established is no easy task.
Health systems left to drift towards
unregulated commercialization
In many, if not most low- and middle-income
countries, under-resourcing and fragmentation
of health services has accelerated the development
of commercialized health care, defi ned here
as the unregulated fee-for-service sale of health
care, regardless of whether or not it is supplied
by public, private or NGO providers.
Commercialization of health care has reached
previously unheard of proportions in countries
that, by choice or due to a lack of capacity, fail to
regulate the health sector. Originally limited to
an urban phenomenon, small-scale unregulated
fee-for-service health care offered by a multitude of
different independent providers now dominates the
health-care landscape from sub-Saharan Africa to
the transitional economies in Asia or Europe.
Commercialization often cuts across the
public-private divide101. Health-care delivery in
many governmental and even in traditionally
not-for-profi t NGO facilities has been de facto
commercialized, as informal payment systems
and cost-recovery systems have shifted the cost
of services to users in an attempt to compensate
The World Health Report 2008
14
Primary Health Care – Now More Than Ever
for the chronic under-funding of the public
health sector and the fi scal stringency of structural
adjustment102,103. In these same countries,
moonlighting civil servants make up a considerable
part of the unregulated commercial sector104,
while others resort to under-the-counter
payments105,106,107. The public-private debate of the
last decades has, thus, largely missed the point:
for the people, the real issue is not whether their
health-care provider is a public employee or a
private entrepreneur, nor whether health facilities
are publicly or privately owned. Rather, it is
whether or not health services are reduced to a
commodity that can be bought and sold on a feefor-
service basis without regulation or consumer
protection108.
Commercialization has consequences for quality
as well as for access to care. The reasons are
straightforward: the provider has the knowledge;
the patient has little or none. The provider has
an interest in selling what is most profi table,
but not necessarily what is best for the patient.
Without effective systems of checks and balances,
the results can be read in consumer organization
reports or newspaper articles that express
outrage at the breach of the implicit contract of
trust between caregiver and client109. Those who
cannot afford care are excluded; those who can
may not get the care they need, often get care they
do not need, and invariably pay too much.
Unregulated commercialized health systems
are highly ineffi cient and costly110: they exacerbate
inequality111, and they provide poor quality
and, at times, dangerous care that is bad for
health (in the Democratic Republic of the Congo,
for example, “la chirurgie safari” (safari surgery)
refers to a common practice of health workers
moonlighting by performing appendectomies
or other surgical interventions at the patients’
homes, often for crippling fees).
Thus, commercialization of health care is an
important contributor to the erosion of trust
in health services and in the ability of health
authorities to protect the public111. This is what
makes it a matter of concern for politicians and,
much more than was the case 30 years ago, one
of the main reasons for increasing support for
reforms that would bring health systems more
in line not only with current health challenges,
but also with people’s expectations.
Changing values
and rising expectations
The reason why health systems are organized
around hospitals or are commercialized is largely
because they are supply-driven and also correspond
to demand: genuine as well as supplyinduced.
Health systems are also a refl ection
of a globalizing consumer culture. Yet, at the
same time, there are indications that people are
aware that such health systems do not provide
an adequate response to need and demand, and
that they are driven by interests and goals that
are disconnected from people’s expectations. As
societies modernize and become more affl uent
and knowledgeable, what people consider to be
desirable ways of living as individuals and as
members of societies, i.e. what people value,
changes112. People tend to regard health services
more as a commodity today, but they also have
other, rising expectations regarding health and
health care. People care more about health as
an integral part of how they and their families
go about their everyday lives than is commonly
thought (Box 1.5)113. They expect their families
and communities to be protected from risks and
dangers to health. They want health care that
deals with people as individuals with rights and
not as mere targets for programmes or benefi ciaries
of charity. They are willing to respect health
professionals but want to be respected in turn,
in a climate of mutual trust 114.
People also have expectations about the way
their society deals with health and health care.
They aspire to greater health equity and solidarity
and are increasingly intolerant of social exclusion
– even if individually they may be reluctant to
act on these values115. They expect health authorities
– whether in government or other bodies –
to do more to protect their right to health. The
social values surveys that have been conducted
since the 1980s show increasing convergence
in this regard between the values of developing
countries and of more affl uent societies, where
protection of health and access to care is often
taken for granted112,115,116. Increasing prosperity,
access to knowledge and social connectivity are
associated with rising expectations. People want
to have more say about what happens in their
workplace, in the communities in which they live
and also in important government decisions that
15
Chapter 1. The challenges of a changing world
affect their lives117. The desire for better care and
protection of health, for less health inequity and
for participation in decisions that affect health
is more widespread and more intense now than
it was 30 years ago. Therefore, much more is
expected of health authorities today.
Health equity
Equity, whether in health, wealth or power is
rarely, if ever, fully achieved. Some societies are
more egalitarian than others, but on the whole
the world is “unequal”. Value surveys, however,
clearly demonstrate that people care about these
inequalities – considering a substantial proportion
to be unfair “inequities” that can and should
be avoided. Data going back to the early 1980s
show that people increasingly disagree with the
way in which income is distributed and believe
that a “just society” should work to correct
these imbalances120,121,122,123. This gives policymakers
less leeway to ignore the social dimensions
of their policies than they might have had
previously120,124.
People are often unaware of the full scope of
health inequalities. Most Swedish citizens, for
example, were probably unaware that the difference
in life expectancy between 20-year-old
men from the highest and lowest socioeconomic
groups was 3.97 years in 1997: a gap that had
widened by 88% compared to 1980125. However,
while people’s knowledge on these topics may be
partial, research shows that people regard social
gradients in health as profoundly unjust126. Intolerance
to inequality in health and to the exclusion
of population groups from health benefi ts and
social protection mirrors or exceeds intolerance
to inequality in income. In most societies, there is
wide consensus that everybody should be able to
take care of their health and to receive treatment
when ill or injured – without being bankrupted
and pushed into poverty127.
As societies become wealthier, popular support
for equitable access to health care and social
protection to meet basic health and social needs
gains stronger ground. Social surveys show that,
in the European region, 93% of the populations
support comprehensive health coverage117. In the
United States, long reputed for its reluctance to
adopt a national health insurance system, more
than 80% of the population is in favour of it115,
while basic care for all continues to be a widely
distributed, intensely held, social goal128. The
attitudes in lower income countries are less well
known, but extrapolating from their views on
income inequality, it is reasonable to assume
that increasing prosperity is coupled with rising
concern for health equity – even if consensus
about how this should be achieved may be as
contentious as in richer countries.
Box 1.5 Health is among the top
personal concerns
When people are asked to name the most important problems
that they and their families are currently facing, fi nancial worries
often come out on top, with health a close second118. In
one country out of two, personal illness, health-care costs,
poor quality care or other health issues are the top personal
concerns of over one third of the population surveyed
(Figure 1.11). It is, therefore, not surprising that a breakdown
of the health-care system – or even the hint of a breakdown
– can lead to popular discontent that threatens the ambitions
of the politicians seen to be responsible119.
Figure 1.11 Percentage of the population citing health as their main concern
before other issues, such as financial problems, housing or crime118
Poland
Ukraine
Russian Federation
Bulgaria
Germany
Italy
Sweden
Israel
Turkey
Spain
Czech Republic
France
Slovakia
United Kingdom
Mexico
Chile
Canada
Peru
Argentina
Brazil
United States
Venezuela
Bolivia
Republic of Korea
China
Japan
Malaysia
Bangladesh
India
Indonesia
Morocco
Pakistan
Egypt
Lebanon
Kuwait
Jordan
Occupied Palestinian Territory
Uganda
Mali
United Republic of Tanzania
Côte d’Ivoire
Senegal
Nigeria
Ghana
South Africa
Kenya
Ethiopia
0 10 20 30 40 50 60 70
The World Health Report 2008
16
Primary Health Care – Now More Than Ever
Care that puts people fi rst
People obviously want effective health care
when they are sick or injured. They want it to
come from providers with the integrity to act
in their best interests, equi tably and honestly,
with knowledge and compe tence. The demand
for competence is not trivial: it fuels the health
economy with steadily increased demand for
professional care (doctors, nurses and other
non-physician clinicians who play an increasing
role in both industrialized and developing
countries)129. For example, throughout the world,
women are switching from the use of traditional
birth attendants to midwives, doctors and obstetricians
(Figure 1.12)130.
The PHC movement has underestimated the
speed with which the transition in demand from
traditional caregivers to professional care would
bypass initial attempts to rapidly expand access
to health care by relying on non-professional
“community health workers”, with their added
value of cultural competence. Where strategies
for extending PHC coverage proposed lay workers
as an alternative rather than as a complement to
professionals, the care provided has often been
perceived to be poor131. This has pushed people
towards commercial care, which they, rightly or
wrongly, perceived to be more competent, while
attention was diverted from the challenge of more
effectively incorporating professionals under the
umbrella of PHC.
Proponents of PHC were right about the importance
of cultural and relational competence,
which was to be the key comparative advantage of
community health workers. Citizens in the developing
world, like those in rich countries, are not
looking for technical competence alone: they also
want health-care providers to be understanding,
respectful and trustworthy132. They want health
care to be organized around their needs, respectful
of their beliefs and sensitive to their particular
situation in life. They do not want to be taken
advantage of by unscrupulous providers, nor do
they want to be considered mere targets for disease
control programmes (they may never have
liked that, but they are now certainly becoming
more vocal about it). In poor and rich countries,
people want more from health care than interventions.
Increasingly, there is recognition that the
resolution of health problems should take into
account the socio-cultural context of the families
and communities where they occur133.
Much public and private health care today is
organized around what providers consider to be
effective and convenient, often with little attention
to or understanding of what is important
for their clients134. Things do not have to be that
way. As experience – particularly from industrialized
countries – has shown, health services
can be made more people-centred. This makes
them more effective and also provides a more
rewarding working environment135. Regrettably,
developing countries have often put less emphasis
on making services more people-centred, as if
this were less relevant in resource-constrained
circumstances. However, neglecting people’s
needs and expectations is a recipe for disconnecting
health services from the communities they
serve. People-centredness is not a luxury, it is a
necessity, also for services catering to the poor.
Only people-centred services will minimize social
exclusion and avoid leaving people at the mercy of
unregulated commercialized health care, where
the illusion of a more responsive environment
carries a hefty price in terms of fi nancial expense
and iatrogenesis.
Securing the health of communities
People do not think about health only in terms of
sickness or injury, but also in terms of what they
perceive as endangering their health and that of
their community118. Whereas cultural and political
explanations for health hazards vary widely,
there is a general and growing tendency to hold
the authorities responsible for offering protection
against, or rapidly responding to such dangers136.
This is an essential part of the social contract
that gives legitimacy to the state. Politicians in
rich as well as poor countries increasingly ignore
their duty to protect people from health hazards
at their peril: witness the political fall-out of the
poor management of the hurricane Katrina disaster
in the United States in 2005, or of the 2008
garbage disposal crisis in Naples, Italy.
Access to information about health hazards in
our globalizing world is increasing. Knowledge
is spreading beyond the community of health
professionals and scientifi c experts. Concerns
about health hazards are no longer limited to
the traditional public health agenda of improving
17
Chapter 1. The challenges of a changing world
the quality of drinking water and sanitation to
prevent and control infectious diseases. In the
wake of the 1986 Ottawa Charter for Health
Promotion137, a much wider array of issues constitute
the health promotion agenda, including
food safety and environmental hazards as well as
collective lifestyles, and the social environment
that affects health and quality of life138. In recent
years, it has been complemented by growing concerns
for a health hazard that used to enjoy little
visibility, but is increasingly the object of media
coverage: the risks to the safety of patients139.
Reliable, responsive health authorities
During the 20th century, health has progressively
been incorporated as a public good guaranteed
by government entitlement. There may be disagreement
as to how broadly to defi ne the welfare
state and the collective goods that go with it140,141,
but, in modernizing states, the social and political
responsibility entrusted to health authorities
– not just ministries of health, but also local
governmental structures, professional organizations
and civil society organizations with a quasigovernmental
role – is expanding.
Circumstances or short-term political expediency
may at times tempt governments to withdraw
from their social responsibilities for fi nancing
and regulating the health sector, or from service
delivery and essential public health functions.
Predictably, this creates more problems than it
solves. Whether by choice or because of external
pressure, the withdrawal of the state that
occurred in the 1980s and 1990s in China and the
former Soviet Union, as well as in a considerable
number of low-income countries, has had visible
and worrisome consequences for health and for
the functioning of health services. Signifi cantly,
it has created social tensions that affected the
legitimacy of political leadership119.
In many parts of the world, there is considerable
skepticism about the way and the extent to
which health authorities assume their responsibilities
for health. Surveys show a trend of
diminishing trust in public institutions as guarantors
of the equity, honesty and integrity of the
health sector123,142,143. Nevertheless, on the whole,
people expect their health authorities to work
for the common good, to do this well and with
foresight144. There is a multiplication of scoring
Figure 1.12 The professionalization of birthing care: percentage of births assisted
by professional and other carers in selected areas, 2000 and 2005
with projections to 2015a
Percentage of births
a Source: Pooled data from 88 DHS surveys 1995–2006, linear projection to 2015.
Lay person
0
100
Sub-Saharan
Africa
60
40
20
2000 2005 2015
South and South-East
Asia
2000 2005 2015
Middle East, North Africa
and Central Asia
2000 2005 2015
Latin America and
the Caribbean
2000 2005 2015
80
Traditional birth
attendant
Other health
professional
Doctor
The World Health Report 2008
18
Primary Health Care – Now More Than Ever
cards, rankings and other league tables of public
action used either at the national or global level141,
while consumer organizations are addressing
health sector problems111, and national and
global civil society watchdog organizations are
emerging146,147,148,149. These recent trends attest to
prevailing doubts about how well health authorities
are able to provide stewardship for the health
system, as well as to the rising expectations for
them to do even better.
Participation
At the same time, however, surveys show that, as
societies modernize, people increasingly want to
“have a say” in “important decisions that affect
their lives”123,112, which would include issues such
as resource allocation and the organization and
regulation of care. Experience from countries as
diverse as Chile, Sweden and Thailand shows,
however, that people are more concerned with
having guarantees for fair and transparent processes
than with the actual technicalities of priority
setting150,151. In other words, an optimum
response to aspirations for a bigger say in health
policy matters would be evidence of a structured
and functional system of checks and balances.
This would include relevant stakeholders and
would guarantee that the policy agenda could
not be hijacked by particular interest groups152.
PHC reforms:
driven by demand
The core values articulated by the PHC movement
three decades ago are, thus, more powerfully
present in many settings now than at the time
of Alma-Ata. They are not just there in the form
of moral convictions espoused by an intellectual
vanguard. Increasingly, they exist as concrete
social expectations felt and asserted by broad
groups of ordinary citizens within modernizing
societies. Thirty years ago, the values of equity,
people-centredness, community participation and
self-determination embraced by the PHC movement
were considered radical by many. Today,
these values have become widely shared social
expectations for health that increasingly pervade
many of the world’s societies – though the language
people use to express these expectations
may differ from that of Alma-Ata.
This evolution from formal ethical principles
to generalized social expectations fundamentally
alters the political dynamics around health systems
change. It opens fresh opportunities for generating
social and political momentum to move
health systems in the directions people want them
to go, and that are summarized in Figure 1.13.
It moves the debate from a purely technical discussion
on the relative effi ciency of various ways
of “treating” health problems to include political
considerations on the social goals that defi ne
the direction in which to steer health systems.
The subsequent chapters outline a set of reforms
aimed at aligning specialist-based, fragmented
and commercialized health systems with these
rising social expectations. These PHC reforms
aim to channel society’s resources towards more
equity and an end to exclusion; towards health
services that revolve around people’s needs and
expectations; and towards public policies that
secure the health of communities. Across these
reforms is the imperative of engaging citizens and
other stakeholders: recognizing that vested interests
that tend to pull health systems in different
directions raises the premium on leadership and
vision and on sustained learning to do better.
Figure 1.13 The social values that drive PHC
and the corresponding sets of reforms
Health equity
Solidarity
Social inclusion
People-centred care
Health authorities that
can be relied on
Communities where
health is promoted
and protected
Universal coverage reforms
Chapter 2
Service delivery reforms
Chapter 3
Leadership reforms
Chapter 5
Public policy reforms
Chapter 4
19
Chapter 1. The challenges of a changing world
References
Smith R. Oman: leaping a 1. cross the centuries. British Medical Journal, 1988,
297:540–544.
2. Sultanate of Oman: second primary health care review mission. Geneva, World Health
Organization, 2006.
3. Primary health care performance. Muscat, Sultanate of Oman. Directorate General of
Health Affairs, Department of Primary Health Care, 2006.
4. Infante A. The post military government reforms to the Chilean health system. A case
study commissioned by the Health Systems Knowledge Network. Paper presented in
the Health Services Knowledge Network Meeting, London, October 2006. Geneva,
World Health Organization, Commission on the Social Determinants of Health, 2007.
5. Pathmanathan I, Dhairiam S. Malaysia: moving from infectious to chronic diseases.
In: Tarimo E, ed. Achieving health for all by the year 2000: midway reports of country
experiences. Geneva, World Health Organization, 1990.
6. Biscaia A et al. Cuidados de saúde primários em Portugal: reformar para novos
sucessos. Lisbon, Padrões Culturais Editora, 2006.
7. Pongsupap Y. Introducing a human dimension to Thai health care: the case for family
practice. Brussels, Vrije Universiteit Brussel Press, 2007.
8. Barros P, Simões J. Portugal: health system review. Geneva, World Health
Organization Regional Offi ce for Europe on behalf of the European Observatory of
Health Systems and Policies, 2007 (Health Systems in Transition No. 9; http://www.
euro.who.int/Document/E90670.pdf, accessed 1 July 2008).
9. Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health care systems in
transition: Portugal. Copenhagen, World Health Organization Regional Offi ce for
Europe on behalf of the European Observatory on Health Systems and Policies,
2004 (Health Care Systems in Transition No. 1; http://www.euro.who.int/document/
e82937.pdf, accessed 1 July 2008).
10. Ferrinho P, Bugalho M, Miguel JP. eds. For better health in Europe, Vol. 1. Lisbon,
Fundação Merck Sharp & Dohme, 2004.
11. Biscaia A et al. Cuidados de saúde primários portugueses e a mortalidade vulnerável
às intervenções dos serviços de saúde – o caso português [Portuguese primary
health care and health services intervention in mortality amenable to health service
intervention. Geneva, World Health Organization 2008 (unpublished background
paper for the World Health Report 2008 − Primary health care: now more than ever,
Geneva, World Health Organization, 2008).
12. World Health Statistics 2008. Geneva, World Health Organization, 2008.
13. Murray CJL et al. Can we achieve Millennium Development Goal 4? New analysis
of country trends and forecasts of under-5 mortality to 2015. Lancet 2007,
370:1040–1054.
14. The Millennium Development Goals report 2007. New York, United Nations, 2007
(http://www.un.org/millenniumgoals/pdf/mdg2007.pdf, accessed 1 July 2008).
15. Levels and trends of contraceptive use as assessed in 2002. New York, United
Nations, Department of Economic and Social Affairs, Population Division, 2004
(Sales No. E.04.XIII.9).
16. World contraceptive use 2007, wall chart. New York, United Nations, Department of
Economic and Social Affairs, Population Division, 2008 (Sales No. E.08.XIII.6).
17. Sedgh G et al. Induced abortion: estimated rates and trends worldwide. Lancet,
2007, 370:1338–1345.
18. Koblinsky M et al. Going to scale with professional skilled care. Lancet, 2006,
368:1377–1386.
19. Goesling B, Ferebaugh G. The trend in international health inequality. Population and
Development Review, 2004, 30:131−146.
20. Preston S. The changing relation between mortality and level of economic
development. Population Studies, 1975, 29:231–248.
21. The state of the world’s children 2008. Paris, United Nations Children’s Fund, 2008.
22. Cutler DM, Deaton A, Lleras-Muney A. The determinants of mortality. Cambridge,
MA, National Bureau of Economic Research, 2006 (NBER Working Paper No. 11963).
23. Deaton A. Global patterns of income and health: facts, interpretations, and policies,
WIDER Annual Lecture, Helsinki, September 29th, 2006. Princeton NJ, Princeton
University Press, 2006.
24. Field M, Shkolnikov V. Russia: socioeconomic dimensions of the gender gap in
mortality. In: Evans et al. Challenging inequities in health: from ethics to action. New
York, Oxford University Press 2001.
25. WHO mortality database: tables [online database]. Geneva, World Health
Organization, 2007 (http://www.who.int/healthinfo/morttables/en/index.html,
accessed 1 July 2008).
26. Suhrcke M, Rocco L, McKee M. Health: a vital investment for economic development
in eastern Europe and central Asia. European Observatory on Health Systems and
Policies, 2008 (http://www.euro.who.int/observatory/Publications/20070618_1,
accessed 1 July 2008).
27. Banister J, Zhang X. China, economic development and mortality decline. World
Development, 2005, 33:21−41.
28. Banister J, Hill K. Mortality in China, 1964-2000. Population studies, 2004,
58:55−75.
29. Gu D et al. Decomposing changes in life expectancy at birth by age, sex and
residence from 1929 to 2000 in China. Paper present at the American Population
Association 2007 annual meeting, New York, 29-31 March 2007 (unpublished).
30. Milanovic B. Why did the poorest countries fail to catch up? Washington DC, Carnegie
Endowment for International Peace, 2005 (Carnegie Paper No. 62).
31. Carvalho S. Engaging with fragile states: an IEG review of World Bank support to
low-income countries under stress. Appendix B: LICUS, fi scal 2003-06. Washington
DC, The World Bank, 2006 (http://www.worldbank.org/ieg/licus/docs/appendix_b.
pdf, accessed 1 July 2008).
32. Carvalho S. Engaging with fragile states: an IEG review of World Bank support
to low-income countries under stress. Chapter 3: Operational utility of the LICUS
identifi cation, classifi cation, and aid-allocation system. Washington DC, The World
Bank, 2006 (http://www.worldbank.org/ieg/licus/docs/licus_chap3.pdf, accessed
1 July 2008).
33. Ikpe, E. Challenging the discourse on fragile states. Confl ict, Security and
Development, 2007, 77:84–124.
34. Collier P. The bottom billion: why the poorest countries are failing and what can be
done about it. New York, Oxford University Press, 2007.
35. Coghlan B et al. Mortality in the Democratic Republic of Congo: a nationwide survey.
Lancet, 2006, 367:44–51.
36. World development indicators 2007. Washington DC, The World Bank, 2007 (http://
go.worldbank.org/3JU2HA60D0, accessed 1 July 2008).
37. Van Lerberghe W, De Brouwere V. Etat de santé et santé de l’Etat en Afrique
subsaharienne [State of health and health of the state in sub-Saharan Africa],
Afrique Contemporaine, 2000, 135:175–190.
38. National health accounts country information for 2002–2005. Geneva, World Health
Organization, 2008 (http://www.who.int/nha/country/en, accessed 2 July 2008).
39. Xu K et al. Protecting households from catastrophic health expenditures, Health
Affairs, 2007, 26:972−983.
40. The World Health Report 2004 − Changing history: overview. Annex table 4: healthy
life expectancy in WHO Member States, estimates for 2002. Geneva, World Health
Organization, 2004 (http://www.who.int/whr/2004/annex/topic/en/annex_4_
en.pdf, accessed 2 July 2008).
41. WHO global burden of disease estimates: 2004 update. Geneva, World Health
Organization, 2008 (http://www.who.int/healthinfo/bodestimates/en/index.html,
accessed 2 July 2008).
42. State of world population 2007. Unleashing the potential of urban growth. New York,
United Nations Population Fund, 2007.
43. Vlahov D et al. Urban as a determinant of health. Journal of Urban Health, 2007,
84(Suppl. 1):16–26.
44. Montgomery M, Hewett, PC. Urban poverty and health in developing countries:
household and neighborhood effects demography. New York, The Population Council,
2004 (Policy Research Division Working paper No. 184; http://www.popcouncil.org/
pdfs/wp/184.pdf, accessed 1 July 2008).
45. Satterthwaite D. Coping with rapid urban growth. London, Royal Institution of
Chartered Surveyors, 2002 (RICS Leading Edge Series; POPLINE Document No.
180006).
46. Garenne M, Gakusi E. Health transitions in sub-Saharan Africa: overview of mortality
trends in children under 5 years old (1950–2000). Bulletin of the World Health
Organization, 2006, 84:470–478.
47. Population and health dynamics in Nairobi’s informal settlements. Nairobi, African
Population and Health Research Center Inc., 2002.
48. Report of the knowledge network on urban settlement. Geneva, World Health
Organization, Commission on Social Determinants of Health, 2008.
49. State of world population 2007. Unleashing the potential of urban growth. New York,
United Nations Population Fund, 2007.
50. International Migration Report 2006. 2006. New York, United Nations, Department
of Economic and Social Affairs, 2006.
51. Abegunde D et al. The burden and costs of chronic diseases in low-income and
middle-income countries. Lancet, 2007, 370:1929–1938.
52. The World Health Report 2002 − Reducing risks, promoting health life. Geneva, World
Health Organization, 2002.
53. Amaducci L, Scarlato G, Candalese L. Italian longitudinal study on ageing. ILSA
resource data book. Rome, Consiglio Nazionale per le Ricerche, 1996.
The World Health Report 2008
20
Primary Health Care – Now More Than Ever
54. Marengoni A. Prevalence and impact of chronic diseases and multimorbidity in the
ageing population: a clinical and epidemiological approach. Stockholm, Karolinska
Institutet, 2008.
55. McWhinney I. The essence of general practice. In: Lakhani M, ed. A celebration of
general practice. London, Royal College of General Practitioners, 2003.
56. Kazembe LN, Namangale JJ. A Bayesian multinomial model to analyse spatial
patterns of childhood co-morbidity in Malawi. European Journal of Epidemiology,
2007, 22:545−556.
57. Gwer S, Newton CR, Berkley JA. Over-diagnosis and co-morbidity of severe malaria
in African children: a guide for clinicians. American Journal of Tropical Medicine and
Hygiene. 2007 77(Suppl. 6):6–13.
58. Starfi eld B et al. Comorbidity: implications for the importance of primary care in
‘case’ management. Annals of Family Medicine, 2003, 1:814.
59. Gwatkin D et al. Socio-economic differences in health nutrition and population.
Washington DC, The World Bank, 2000 (Health Nutrition and Population Discussion
Paper).
60. Castro-Leal F et al. Public spending on health care in Africa: do the poor benefi t?
Bulletin of the World Health Organization, 2000, 78:66−74.
61. World Health Surveys. Geneva, World Health Organization, 2008.
62. STATcompiler [online database]. Calverton MD, Demographic Health Surveys, 2008
(http://www.statcompiler.com/, accessed 22 July 2008).
63. Davidson R et al. Country report on HNP and poverty − socio-economic differences in
health, nutrition, and population within developing countries: an overview. Produced
by the World Bank in collaboration with the government of the Netherlands and the
Swedish International Development Cooperation Agency. Washington DC, The World
Bank, 2007.
64. Strong K et al. Preventing chronic diseases: how many lives can we save?
Lancet, 366:1578–1582.
65. World health survey: internal calculations. Geneva, World Health Organization, 2008
(unpublished).
66. Ezzati M et al. Comparative risk assessment collaborating group. Estimates of global
and regional potential health gains from reducing multiple major risk factors. Lancet,
2003, 362:271−280.
67. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva,
World Health Organization, 2008.
68. Bettcher DW, Sapirie S, Goon EH. Essential public health functions: results of the
international Delphi study, World Health Stat Q, 1998, 51:44−54.
69. The World Health Report 2007 − A safer future, global public health security in the
21st century. Geneva, World Health Organization, 2007.
70. Rockenschaub G, Pukkila J, Profi li M. Towards health security. A discussion paper
on recent health crises in the WHO European Region. Copenhagen, World Health
Organization Regional Offi ce for Europe, 2007.
71. Moran M. Governing the health care state. A comparative study of the United
Kingdom, the United States and Germany. Manchester, Manchester University Press,
1999.
72. Starfi eld B. Primary care. Balancing health needs, services and technology. New
York, Oxford University Press, 1998.
73. Pongsupap Y. Introducing a human dimension to Thai health care: the case for family
practice. Brussels, Vrije Universiteit Brussel Press, 2007.
74. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005:
trends in primary care specialties. Journal of the American Medical Association,
2005, 294:1075–1082.
75. OECD Health Data 2007. SourceOECD [online database]. Paris, Organisation for
Economic Co-operation and Development, 18 July 2007 (http://www.oecd.org/doc
ument/10/0,3343,en_2649_37407_38976778_1_1_1_37407,00.html, accessed
1 July 2008).
76. Jindawatthana A, Jongudomsul P. Human resources for health and universal health
care coverage. Thailand’s experience. Journal for Human Resources for Health
(forthcoming).
77. The Research Priority Setting Working Group of the WHO World Alliance for Patient
Safety. Summary of the evidence on patient safety. Implications for research. Geneva,
World Health Organization, 2008.
78. Liamputtong P. Giving birth in the hospital: childbirth experiences of Thai women in
northern Thailand. Health Care for Women International, 2004, 25:454–480.
79. Ammar W. Health system and reform in Lebanon. Beirut, World Health Organization
Regional Offi ce for the Eastern Mediterranean, 2003.
80. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in
health: Levelling up part 1. Copenhagen, World Health Organization Regional Offi ce
for Europe, 2006. (Studies on Social and Economic Determinants of Population
Health No. 2; http://www.euro.who.int/document/e89383.pdf, accessed 15 July
2008).
81. Starfi eld B, Shi L. Policy relevant determinants of health: an international
perspective. Health Policy, 2002, 60:201–218.
82. Schoen C et al. 2006 US health system performance: a national scorecard. Health
Affairs, 20 September 2006 (Web Exclusive, w457–w475).
83. Gobierno de Chile. Ministerio de Salud. Orientaciones para la programación en
red. Santiago, Subsecretaria de Redes Asistenciales, Division de Gestion de Red
Asistencial, 2006.
84. Suraratdecha C, Saithanu S, Tangcharoensathien V. Is universal coverage a solution
for disparities in health care? Findings from three low-income provinces of Thailand.
Health Policy, 73:272–284.
85. Tangcharoensathien V et al. Knowledge-based changes to the Thai health system.
Bulletin of the World Health Organization, 2004, 82:750–756.
86. Macinko J et al. Going to scale with community-based primary care: an analysis of
the family health program and infant mortality in Brazil, 1999–2004. Social Science
& Medicine, 2007, 65:2070–2080.
87. Pongsupap Y, Boonyapaisarnchoaroen T, Van Lerberghe W. The perception of
patients using primary care units in comparison with conventional public hospital
outpatient departments and “prime mover family practices”: an exit survey. Journal
of Health Science, 2005, 14:475–483.
88. Relman AS. The new medical-industrial complex. New England Journal of Medicine,
1980, 303:963−970.
89. Aid effectiveness and health. Making health systems work. Geneva, World Health
Organization, 2007 (Working Paper 9; WHO/HSS/healthsystems/2007.2).
90. Lifestyle and health. EurActiv, 2006 (http://www.euractiv.com/en/health/medicaldevices/
article-117519, accessed 1 July2008).
91. Medical Device Statistics, PharmaMedDevice’s Bulletin, 2006 (http://www.
pharmameddevice.com/App/homepage.cfm?appname=100485&linkid=23294&mo
duleid=3162#Medical_Device, accessed 1 July 2008).
92. Medical technology industry at a glance. Washington DC, Advanced Medical
Technology Association, 2004 (http://www.advamed.org/NR/rdonlyres/0A261055-
827C-4CC6-80B6-CC2D8FA04A33/0/ChartbookSept2004.pdf, accessed 15 July
2008).
93. Press room: IMS health predicts 5 to 6 percent growth for global
pharmaceutical market in 2008, according to annual forecast. IMS Intelligence
Applied, 1 November 2007 (http://www.imshealth.com/ims/portal/front/
articleC/0,2777,6599_3665_82713022,00.html, accessed 1 July 2008).
94. Danzon PM, Furukawa MF. International prices and availability of pharmaceuticals in
2005. Health Affairs, 2005, 27:221–233.
95. Health at a glance 2007: OECD indicators. Paris, Organisation for Economic
Co-operation and Development, 2007.
96. Moran M. Governing the health care state. A comparative study of the United
Kingdom, the United States and Germany. Manchester, Manchester University Press,
1999.
97. Walsh JA, Warren KS. Selective primary health care: an interim strategy for
disease control in developing countries. New England Journal of Medicine, 1979,
301:967–974.
98. Buse K, Harmer AM. Seven habits of highly effective global public–private health
partnerships: Practice and potential, Social Science & Medicine, 2007, 64:259−271.
99. Stillman K, Bennet S. System wide effects of the Global Fund interim fi ndings
from three country studies. Washington DC, United States Agency for Aid and
Development, 2005.
100. Malawi Ministry of Health and The World Bank. Human resources and fi nancing in
the health sector in Malawi. Washington DC, World Bank, 2004.
101. Giusti D, Criel B, de Béthune X. Viewpoint: public versus private health care delivery:
beyond slogans. Health Policy and Planning, 1997, 12:193–198.
102. Périn I, Attaran A. Trading ideology for dialogue: an opportunity to fi x international
aid for health. Lancet, 2003, 362:1216–1219.
103. Creese AL. User charges for health care: a review of recent experience. Geneva,
World Health Organization, 1990 (Strengthening Health Systems Paper No. 1).
104. Macq J et al. Managing health services in developing countries: between the ethics
of the civil servant and the need for moonlighting. Human Resources for Health
Development Journal, 2001, 5:17−24.
105. Delcheva E, Balabanova D, McKee M. Under-the-counter payments for health care:
evidence from Bulgaria. Health Policy, 1997, 42:89–100.
106. João Schwalbach et al. Good Samaritan or exploiter of illness? Coping strategies of
Mozambican health care providers. In: Ferrinho P, Van Lerberghe W. eds. Providing
health care under adverse conditions. Health personnel performance and individual
coping strategies. Antwerp, ITGPress, 2000.
107. Ferrinho P et al. Pilfering for survival: how health workers use access to drugs as a
coping strategy. Human Resources for Health, 2004, 2:4.
108. McIntyre D et al. Commercialisation and extreme inequality in health: the
policy challenges in South Africa. Journal of International Development, 2006,
18:435–446.
109. Sakboon M et al. Case studies in litigation between patients and doctors. Bangkok,
The Foundation of Consumer Protection, 1999.
21
Chapter 1. The challenges of a changing world
110. Ammar, W. Health system and reform in Lebanon. Beirut, World Health Organization
Regional Offi ce for the Eastern Mediterranean, 2003.
111. Macintosh M. Planning and market regulation: strengths, weaknesses and
interactions in the provision of less inequitable and better quality health care. Geneva,
World Health Organization, Health Systems Knowledge Network, Commission on the
Social Determinants of Health, 2007.
112. Inglehart R, Welzel C. Modernization, cultural change and democracy: the human
development sequence. Cambridge, Cambridge University Press, 2005.
113. Kickbush I. Innovation in health policy: responding to the health society. Gaceta
Sanitaria, 2007, 21:338−342.
114. Anand S. The concern for equity in health. Journal of Epidemiology and Community
Health, 2002, 56:485–487.
115. Road map for a health justice majority. Oakland, CA, American Environics, 2006
(http://www.americanenvironics.com/PDF/Road_Map_for_Health_Justice_
Majority_AE.pdf, accessed 1 July 2008).
116. Welzel I. A human development view on value change trends (1981–2006). World
Value Surveys, 2007 (http://www.worldvaluessurvey.org/, accessed on 1 July 2008).
117. World values surveys database. Madrid, World Value Surveys, 2008 (http://www.
worldvaluessurvey.com, accessed 2 July 2008).
118. A global look at public perceptions of health problems, priorities and donors: the
Kaiser/Pew global health survey. Kaiser Family Foundation, December 2007 (http://
www.kff.org/kaiserpolls/upload/7716.pdf , accessed 1 July 2008).
119. Blumenthal D, Hsiao W. Privatization and its discontents – the evolving Chinese
health care system. New England Journal of Medicine, 2005, 353:1165–1170.
120. Lübker M. Globalization and perceptions of social inequality. International Labour
Review, 2004, 143:191.
121. Taylor, B, Thomson, K. Understanding change in social attitudes. Aldershot, England,
Dartmouth Publishing, 1996.
122. Gajdos T, Lhommeau B. L’attitude à l’égard des inegalités en France à la lumière du
système de prélèvement socio-fi scal. Mai 1999 (http://thibault.gajdos.free.fr/pdf/
cserc.pdf, accessed 2 July 2008).
123. Halman L et al. Changing values and beliefs in 85 countries. Trends from the values
surveys from 1981 to 2004. Leiden and Boston, Brill, 2008 (European values studies
11; http://www.worldvaluessurvey.org/, accessed 2 July 2008).
124. De Maeseneer J et al. Primary health care as a strategy for achieving equitable care:
a literature review commissioned by the Health Systems Knowledge Network. Geneva,
World Health Organization, Commission on the Social Determinants of Health, 2007.
125. Burstrôm K, Johannesson M, Didericksen E. Increasing socio-economic inequalities
in life expectancy and QALYs in Sweden 1980-1997. Health Economics, 2005,
14:831–850.
126. Marmot M. Achieving health equity: from root causes to fair outcomes. Lancet,
2007, 370:1153–1163.
127. Health care: the stories we tell. Framing review. Oakland CA, American Environics,
2006 (http.www.americanenvironics.com, accessed 2 July 2008).
128. Garland M, Oliver J. Oregon health values survey 2004. Tualatin, Oregon Health
Decisions, 2004.
129. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries.
Lancet, 2007, 370:2158–2163.
130. Koblinsky M et al. Going to scale with professional skilled care. Lancet, 2006,
368:1377–1386.
131. Lehmann U, Sanders D. Community health workers: what do we know about them?
The state of the evidence on programmes, activities, costs and impact on health
outcomes of using community health workers. Geneva, World Health Organization,
Department of Human Resources for Health, Evidence and Information for Policy,
2007.
132. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as
constraints to referral by isolated nurses in rural Niger. Human Resources for Health,
2004, 2:1–8.
133. Cheragi-Sohi S et al. What are the key attributes of primary care for patients?
Building a conceptual map of patient preferences. Health Expect, 2006, 9:275−284.
134. Pongsupap Y, Van Lerberghe W. Choosing between public and private or between
hospital and primary care? Responsiveness, patient-centredness and prescribing
patterns in outpatient consultations in Bangkok. Tropical Medicine & International
Health, 2006, 11:81–89.
135. Allen J et al. The European defi nition of general practice/family practice. Ljubljana,
European Society of General Practice/Family Medicine, 2002 (http://www.
globalfamilydoctor.com/publications/Euro_Def.pdf/, accessed 21 July 2008).
136. Gostin LO. Public health law in a new century. Part I: law as a tool to advance
the community’s health. Journal of the American Medical Association, 2000,
283:2837−2841.
137. Canadian Public Health Association and Welfare Canada and the World Health
Organization. Ottawa Charter for Health Promotion. First International Conference on
Health Promotion, Ottawa, 17–21 November 1986. Geneva, Department of Human
Resources for Health, World Health Organization, 1986 (WHO/HPR/HEP/95.1; http://
www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf, accessed 2 July 2008).
138. Kickbusch I. The contribution of the World Health Organization to a new public
health and health promotion. American Journal of Public Health, 2003, 93:3.
139. Jaffré Y, Olivier de Sardan JP. Une médecine inhospitalière. Paris, APAD-Karthala
(Hommes et sociétés), 2003.
140. Blank RH. The price of life: the future of American health care. New York, Colombia
University Press, 1997.
141. Weissert C, Weissert W. Governing health: the politics of health policy. Baltimore MD,
Johns Hopkins University Press, 2006.
142. Millenson ML. How the US news media made patient safety a priority. BMJ, 2002.
324:1044.
143. Davies H. Falling public trust in health services: Implications for accountability.
Journal of Health Services Research and Policy, 1999, 4:193–194.
144. Gilson L. Trust and the development of health care as a social institution. Social
Science and Medicine, 2003, 56:1453–1468.
145. Nutley S, Smith PC. League tables for performance improvement in health care.
Journal of Health Services & Research Policy, 1998, 3:50−57.
146. Allsop J, Baggott R, Jones K. Health consumer groups and the national policy
process. In: Henderson S, Petersen AR, eds. Consuming health: the commodifi cation
of health care, London, Routledge, 2002.
147. Rao H. Caveat emptor: the construction of non-profi t consumer watchdog
organizations. American Journal of Sociology, 1998, 103:912–961.
148. Larkin M. Public health watchdog embraces the web. Lancet, 2000,
356:1283–1283.
149. Lee K. Globalisation and the need for a strong public health response. The European
Journal of Public Health, 1999 9:249–250.
150. McKee M, Figueras J. Set ting priorities: can Britain learn from Sweden? British
Medical Journal, 1996, 312:691–694.
151. Daniels N. Accountability for reasonableness. Establishing a fair process for priority
setting is easier than agreeing on principles. BMJ, 2000, 321:1300–1301.
152. Martin D. Fairness, accountability for reasonableness, and the views of priority
setting decision-makers. Health Policy, 2002, 61:279–290.

Advancing and sustaining
universal coverage
People expect their health systems to be
equitable. The roots of health inequities
lie in social conditions outside the health system’s
direct control. These root causes have to be tackled
through intersectoral and cross-government action.
At the same time, the health sector can take
signifi cant actions to advance
health equity internally. The basis
for this is the set of reforms that
aim at moving towards universal
coverage, i.e. towards universal
access to health services with
social health protection.
Chapter 2
The central place of
health equity in PHC 24
Moving towards
universal coverage 25
Challenges in moving
towards universal coverage 27
Targeted interventions
to complement universal
coverage mechanisms
32
Mobilizing for health equity 34
23
The World Health Report 2008 Primary Health Care – Now More Than Ever
24
The central place of
health equity in PHC
“If you get sick, you have to choose: you either
go without treatment or you lose the farm.”1
Nearly a century ago, the unforgiving reality of
life in rural Canada prompted Matthew Anderson
(1882–1974) to launch a tax-based health insurance
scheme that eventually led to countrywide
adoption of universal health care across Canada
in 1965. Unfortunately, equally shocking lose-lose
situations abound today across the world. More
than 30 years after the clarion call of Alma-Ata
for greater equity in health, most of the world’s
health-care systems continue to rely on the most
inequitable method for fi nancing health-care services:
out-of-pocket payments by the sick or their
families at the point of service. For 5.6 billion
people in low- and middle-income countries, over
half of all health-care expenditure is through outof-
pocket payments. This deprives many families
of needed care because they cannot afford it. Also,
more than 100 million people around the world
are pushed into poverty each year because of
catastrophic health-care expenditures2. There is
a wealth of evidence demonstrating that fi nancial
protection is better, and catastrophic expenditure
less frequent, in those countries in which there
is more pre-payment for health care and less
out-of-pocket payment. Conversely, catastrophic
expenditure is more frequent when health care
has to be paid for out-of-pocket at the point of
service (Figure 2.1).
While equity marks one of PHC’s boldest features,
it is one of the areas where results have
been most uneven and where the premium for
more effective reforms is perhaps the greatest.
Out-of-pocket payments for health care are but
one of the sources of health inequity. Deeply
unequal opportunities for health combined with
endemic inequalities in health care provision
lead to pervasive inequities in health outcomes3.
Growing awareness of these regressive patterns
is causing increasing intolerance of the whole
spectrum of unnecessary, avoidable and unfair
differences in health4.
The extent of health inequities is documented
in much more detail today. They stem from
social stratifi cation and political inequalities
that lie outside the boundaries of the health system.
Income and social status matter, as do the
neighbourhoods where people live, their employment
conditions and factors, such as personal
behaviour, race and stress5. Health inequities
also fi nd their roots in the way health systems
exclude people, such as inequities in availability,
access, quality and burden of payment, and even
in the way clinical practice is conducted6. Left to
their own devices, health systems do not move
towards greater equity. Most health services –
hospitals in particular, but also fi rst-level care
– are consistently inequitable providing more
and higher quality services to the well-off than
to the poor, who are in greater need7,8,9,10. Differences
in vulnerability and exposure combine
with inequalities in health care to lead to unequal
health outcomes; the latter further contribute to
the social stratifi cation that led to the inequalities
in the fi rst place. People are rarely indifferent to
this cycle of inequalities, making their concerns
as relevant to politicians as they are to healthsystem
managers.
It takes a wide range of interventions to tackle
the social determinants of health and make health
systems contribute to more health equity11. These
interventions reach well beyond the traditional
realm of health-service policies, relying on the
mobilization of stakeholders and constituencies
outside the health sector12. They include13:
reduction of social stratifi �� cation, e.g. by reducing
income inequality through taxes and subsidized
public services, providing jobs with
Households with catastrophic expenditure (%)
0
0
Figure 2.1 Catastrophic expenditure related to out-of-pocket payment
at the point of service1
Out-of-pocket payment as percentage of total health expenditure
10
10 20 30 40 50 60 70 80 90 100
OECD countries Other countries
5
25
Chapter 2. Advancing and sustaining universal coverage
adequate pay, using labour intensive growth
strategies, promoting equal opportunities for
women and making free education available,
etc.;
reduction of vulnerabilities, �� e.g. by providing
social security for the unemployed or disabled,
developing social networks at community level,
introducing social inclusion policies and policies
that protect mothers while working or
studying, offering cash benefi ts or transfers,
providing free healthy lunches at school,
etc.;
�� protection, particularly of the disadvantaged,
against exposure to health hazards, e.g. by
introducing safety regulations for the physical
and social environment, providing safe water
and sanitation, promoting healthy lifestyles,
establishing healthy housing policies, etc.);
�� mitigation of the consequences of unequal
health outcomes that contribute to further
social stratifi cation, e.g. by protecting the sick
from unfair dismissal from their jobs.
The need for such multiple strategies could
discourage some health leaders who might feel
that health inequality is a societal problem over
which they have little infl uence. Yet, they do
have a responsibility to address health inequality.
The policy choices they make for the health
sector defi ne the extent to which health systems
exacerbate or mitigate health inequalities and
their capacity to mobilize around the equity
agenda within government and civil society.
These choices also play a key part in society’s
response to citizens’ aspirations for more equity
and solidarity. The question, therefore, is not
if, but how health leaders can more effectively
pursue strategies that will build greater equity
in the provision of health services.
Moving towards universal coverage
The fundamental step a country can take to promote
health equity is to move towards universal
coverage: universal access to the full range of
personal and non-personal health services they
need, with social health protection. Whether the
arrangements for universal coverage are taxbased
or are organized through social health
insurance, or a mix of both, the principles are
the same: pooling pre-paid contributions collected
on the basis of ability to pay, and using
these funds to ensure that services are available,
accessible and produce quality care for those who
need them, without exposing them to the risk of
catastrophic expenditures14,15,16. Universal coverage
is not, by itself, suffi cient to ensure health
for all and health equity – inequalities persist in
countries with universal or near-universal coverage
– but it provides the necessary foundation9.
While universal coverage is fundamental to
building health equity, it has rarely been the object
of an easy social consensus. Indeed, in countries
where universal coverage has been achieved or
embraced as a political goal, the idea has often
met with strong initial resistance, for example,
from associations of medical professionals concerned
about the impact of government-managed
health insurance schemes on their incomes and
working conditions, or from fi nancial experts
determined to rein in public spending. As with
other entitlements that are now taken for granted
in almost all high-income countries, universal
health coverage has generally been struggled for
and won by social movements, not spontaneously
bestowed by political leaders. There is now widespread
consensus that providing such coverage is
simply part of the package of core obligations that
any legitimate government must fulfi l vis-à-vis its
citizens. In itself, this is a political achievement
that shapes the modernization of society.
Industrialized countries, particularly in
Europe, began to put social health protection
schemes in place in the late 19th century, moving
towards universalism in the second half of
the 20th century. The opportunity now exists for
low- and middle-income countries to implement
comparable approaches. Costa Rica, Mexico,
the Rebublic of Korea, Thailand and Turkey are
among the countries that have already introduced
ambitious universal coverage schemes, moving
signifi cantly faster than industrialized countries
did in the past. Other countries are weighing similar
options14. The technical challenge of moving
towards universal coverage is to expand coverage
in three ways (Figure 2.2).
The breadth of coverage – the proportion of
the population that enjoys social health protection
– must expand progressively to encompass
The World Health Report 2008 Primary Health Care – Now More Than Ever
26
the uninsured, i.e. the population groups that
lack access to services and/or social protection
against the fi nancial consequences of taking up
health care. Expanding the breadth of coverage
is a complex process of progressive expansion
and merging of coverage models (Box 2.1). During
this process, care must be taken to ensure
safety nets for the poorest and most vulnerable
until they also are covered. It may take years to
cover the entire population but, as recent experience
from a number of middle-income countries
shows, it is possible to move much faster than
was the case for industrialized countries during
the 20th century.
Meanwhile, the depth of coverage must also
grow, expanding the range of essential services
that are necessary to address people’s health
needs effectively, taking into account demand and
expectations, and the resources society is willing
and able to allocate to health. The determination
of the corresponding “essential package” of benefi
ts can play a key role here, provided the process
is conducted appropriately (Box 2.2).
The third dimension, the height of coverage,
i.e. the portion of health-care costs covered
through pooling and pre-payment mechanisms
must also rise, diminishing reliance on out-ofpocket
co-payments at the point of service delivery.
In the 1980s and 1990s, many countries
introduced user fees in an effort to infuse new
resources into struggling services, often in a
context of disengagement of the state and dwindling
public resources for health. Most undertook
these measures without anticipating the extent
of the damage they would do. In many settings,
dramatic declines in service use ensued, particularly
among vulnerable groups20, while the
frequency of catastrophic expenditure increased.
Some countries have since reconsidered their
position and have started phasing out user fees
and replacing the lost income from pooled funds
(government subsidies or contracts, insurance
Box 2.1 Best practices in moving towards universal coverage
Emphasize pre-payment from the start. It may take many years before access to health services and fi nancial protection against the
costs involved in their use are available for all: it took Japan and the United Kingdom 36 years14. The road may seem discouragingly long,
particularly for the poorest countries, where health-care networks are sparsely developed, fi nancial protection schemes embryonic and
the health sector highly dependent on external funds. Particularly in these countries, however, it is crucial to move towards pre-payment
systems from a very early stage and to resist the temptation to rely on user fees. Setting up and maintaining appropriate mechanisms
for pre-payment builds the institutional capacity to manage the fi nancing of the system along with the extension of service supply that
is usually lacking in such contexts.
Coordinate funding sources. In order to organize universal coverage, it is necessary to consider all sources of funding in a country:
public, private, external and domestic. In low-income countries, it is particularly important that international funding be channelled
through nascent pre-payment and pooling schemes and institutions rather than through project or programme funding. Routing funds in
this way has two purposes. It makes external funding more stable and predictable and helps build the institutional capacity to develop
and extend supply, access and fi nancial protection in a balanced way.
Combine schemes to build towards full coverage. Many countries with limited resources and administrative capacity have experimented
with a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes, as a
way to foster pre-payment and pooling in preparation for the move towards more comprehensive national systems18. Such schemes are
no substitute for universal coverage although they can become building blocks of the universal system18. Realizing universal coverage
means coordinating or combining these schemes progressively into a coherent whole that ensures coverage to all population groups15
and builds bridges with broader social protection programmes19.
Figure 2.2 Three ways of moving towards universal coverage17
Height:
what
proportion
of the costs
is covered?
Depth:
which benefits
Breadth: who is insured? are covered?
Include
other
services
Extend to
uninsured
Reduce
cost sharing
Public expenditure
on health
Total health expenditure
27
Chapter 2. Advancing and sustaining universal coverage
or pre-payment schemes)21. This has resulted
in substantial increases in the use of services,
especially by the poor20. In Uganda, for example,
service use increased suddenly and dramatically
and the increase was sustained after the elimination
of user fees (Figure 2.3)22,23.
Pre-payment and pooling institutionalizes
solidarity between the rich and the less well-off,
and between the healthy and the sick. It lifts barriers
to the uptake of services and reduces the
risk that people will incur catastrophic expenses
when they are sick. Finally, it provides the means
to re-invest in the availability, range and quality
of services.
Challenges in moving
towards universal coverage
All universal coverage reforms have to fi nd compromises
between the speed with which they
increase coverage and the breadth, depth and
height of coverage. However, the way countries
devise their strategies and focus their reforms
very much depends on their specifi c national
contexts.
In some countries, a very large part of the population
lives in extremely deprived areas, with
an absent or dysfunctional health-care infrastructure.
These are countries of mass exclusion
typically brought to mind when one talks
about “scaling up”: the poor and remote rural
areas where health-care networks have not been
deployed yet or where, after years of neglect, the
health infrastructure continues to exist in name
only. Such patterns occur in low-income countries
Box 2.2 Defi ning “essential packages”:
what needs to be done to go beyond a paper exercise?
In recent years, many low- and midde-income countries (55 out of a sample of 69 reviewed in 2007) have gone through exercises to
defi ne the package of benefi ts they feel should be available to all their citizens. This has been one of the key strategies in improving the
effectiveness of health systems and the equitable distribution of resources. It is supposed to make priority setting, rationing of care,
and trade-offs between breadth and depth of coverage explicit.
On the whole, attempts to rationalize service delivery by defi ning packages have not been particularly successful24. In most cases, their
scope has been limited to maternal and child health care, and to health problems considered as global health priorities. The lack of
attention, for example, to chronic and noncommunicable diseases confi rms the under-valuation of the demographic and epidemiological
transitions and the lack of consideration for perceived needs and demand. The packages rarely give guidance on the division of tasks
and responsibilities, or on the defi ning features of primary care, such as comprehensiveness, continuity or person-centredness.
A more sophisticated approach is required to make the defi nition of benefi t packages more relevant. The way Chile has provided a
detailed specifi cation of the health rights of its citizens25 suggests a number of principles of good practice.
The exercise should not be limited to a set of predefi ned priorities: it should look at demand as well �� as at the full range of health
needs.
�� It should specify what should be provided at primary and secondary levels.
�� The implementation of the package should be costed so that political decision-makers are aware of what will not be included if
health care remains under-funded.
�� There have to be institutionalized mechanisms for evidence-based review of the package of benefi ts.
�� People need to be informed about the benefi ts they can claim, with mechanisms of mediation when claims are being denied. Chile
went to great lengths to ensure that the package of benefi ts corresponds to people’s expectations, with studies, surveys and systems
to capture the complaints and misgivings of users26.
Outpatients per month
1998
Figure 2.3 Impact of abolishing user fees on outpatient attendance in
Kisoro district, Uganda: outpatient attendance 1998–200223
10 000
0
20 000
30 000
User fees abolished
1999 2000 2001 2002
The World Health Report 2008 Primary Health Care – Now More Than Ever
28
such as Bangladesh, Chad and Niger (Figure 2.4),
and are common in confl ict and post-confl ict
areas where health workers have departed and
the health infrastructure has been destroyed and
needs to be rebuilt from scratch.
In other parts of the world, the challenge is
in providing health support to widely dispersed
populations, for example, in small island states,
remote desert or mountainous regions, and
among nomadic and some indigenous populations.
Ensuring access to quality care in these
settings entails grappling with the diseconomies
of scale connected with small, scattered populations;
logistical constraints on referral; diffi culties
linked to limited infrastructure and communications
capacities; and, in some cases, more specifi c
technical complications, such as maintaining
patient records for nomadic groups.
A different challenge is extending coverage in
settings where inequalities do not result from the
lack of available health infrastructure, but from
the way health care is organized, regulated and,
above all, paid for by offi cial or under-the-counter
user charges. These are situations where underutilization
of available services is concentrated
among the poor, whereas users are exposed to
the risks of catastrophic expenditure. Such patterns
of exclusion occur in countries such as
Colombia, Nicaragua and Turkey (Figure 2.4). It
is particularly striking in the many urban areas
of low- and middle-income countries where a
plethora of assorted, unregulated, commercial
health-care providers charge users prohibitive
fees while providing inadequate services.
Ways of tackling the situations described in
this section are elaborated below.
Rolling out primary-care networks to
fi ll the availability gap
In areas where no health services are available
for large population groups, or where such services
are grossly inadequate or fragmented, the
basic health-care infrastructure needs to be built
or rebuilt, often from the ground up. These areas
are always severely resource-constrained and
frequently affected by confl icts or complex emergencies,
while the scale of under-servicing, also
in other sectors, engenders logistical diffi culties
and problems in deploying health professionals.
Health planners in these settings face a fundamental
strategic dilemma: whether to prioritize a
massive scale-up of a limited set of interventions
to the entire population or a progressive roll-out
of more comprehensive primary-care systems on
a district-by-district basis.
Some would advocate, in the name of speed
and equity, an approach in which a restricted
number of priority programmes is rolled out
simultaneously to all the inhabitants in the
deprived areas. This allows for task shifting to
low-skilled personnel, lay workers and volunteers
and, consequently, rapid extension of coverage.
It is still central to what the global community
often prescribes for the rural areas of the poorest
countries28, and quite a number of countries
have chosen this option over the last 30 years.
Ethiopia, for example, is currently deploying
30 000 health extension workers to provide massive
numbers of people with a limited package
of priority preventive interventions. The poor
skills base is often well recognized as a limiting
factor29, but Ethiopia’s extension workers are
no longer as low skilled as they once were, and
currently benefi t from a year of post-Grade 10
training. Nevertheless, skill limitations reinforce
the focus on a limited number of effective but
simple interventions.
Scaling up a limited number of interventions
has the advantage of rapidly covering the entire
population and focusing resources on what is
known to be cost effective. The downside is that
Quintille 1
(lowest)
Figure 2.4 Different patterns of exclusion: massive deprivation in some
countries, marginalization of the poor in others. Births attended by medically
trained personnel (percentage), by income group27
100
80
60
40
20
0
Quintille 2 Quintille 3 Quintille 4 Quintille 5
(highest)
Turkey (1998)
Colombia (2005)
Nigaragua (2001)
Niger (1998)
Chad (2004)
Bangladesh (2004)
29
Chapter 2. Advancing and sustaining universal coverage
when people experience health problems, they
want them to be dealt with, whether or not they
fi t nicely within the programmatic priorities that
are being proposed. Ignoring this dimension of
demand too much opens the door to “drug peddlers”,
“injectors” and other types of providers,
who can capitalize on commercial opportunities
arising from unmet health needs. They offer
patients an appealing alternative, but one that is
often exploitative and harmful. Compared with
a situation of utter lack of health action, there
is an indisputable benefi t in scaling up even a
very limited package of interventions and the
possibility of relying on low-skilled staff makes
it an attractive option. However, upgrading often
proves more diffi cult than initially envisaged30
and, in the meantime, valuable time, resources
and credibility are lost which might have allowed
for investment in a more ambitious, but also
more sustainable and effective primary-care
infrastructure.
The alternative is a progressive roll-out of
primary care, district-by-district, of a network
of health centres with the necessary hospital
support. Such a response obviously includes the
priority interventions, but integrated in a comprehensive
primary-care package. The extension
platform is the primary-care centre: a professionalized
infrastructure where the interface with the
community is organized, with a problem solving
capacity and modular expansion of the range of
activities. The Islamic Republic of Iran’s progressive
roll-out of rural coverage is an impressive
example of this model. As one of the fathers of
the country’s PHC strategy put it: “Since it was
impossible to launch the project in all provinces
at the same time, we decided to focus on a single
province each year” (Box 2.3).
The limiting factors for a progressive roll-out
of primary-care networks are the lack of a stable
cadre of mid-level staff with the leadership
qualities to organize health districts and with the
ability to maintain, over the years, the constant
effort required to build sustainable results for the
entire population. Where the roll-out has been
conducted as an administrative exercise, it has
led to disappointment: many health districts exist
in name only. But where impatience and pressure
for short-term visibility has been managed
Box 2.3 Closing the urban-rural gap through
progressive expansion of PHC coverage in rural
areas in the Islamic Republic of Iran31
In the 1970s, the Iranian Government’s policies emphasized prevention
as a long-term investment, allocation of resources to rural and
under-privileged areas, and prioritizing ambulatory care over hospitalization.
A network of district teams to manage and oversee almost 2500
village-based rural health centres was established. These centres are
staffed by a team that includes a general practitioner, midwife, nurse and
several health technicians. Each of the rural health centres oversees 1–5
smaller points of care known as “health houses”. With 17 000 of these
health houses, over 90% of the rural population has access to health
care. In remote rural areas, these health houses are staffed by Behvarz
(multi-purpose health workers) who are selected by the community,
receive between 12 and 18 months training and are then recruited by
the Government. The district teams provide training based on problemsolving,
as well as ongoing supervision and support.
The Government deployed this strategy progressively, extending coverage
to one province at a time. Over the years, the PHC network has grown
and is now able to provide services to over 24 million people in rural
villages and small cities by bringing the points of care closer to where
people live and work, as well as by training the necessary auxiliary health
staff to provide family planning, preventive care services, and essential
curative care for the majority of health problems. Rural health service
utilization rates are now the same as in urban areas. The progressive
roll-out of this system has helped to reduce the urban-rural gap in child
mortality (Figure 2.5).
Mortality per 1000 children under five
1980
Figure 2.5 Under-five mortality in rural and urban areas, the Islamic Republic
of Iran, 1980–200032
80
Urban
60
40
20
0
Rural
1985 1990 1995 2000
adequately, a blend of response to need and
demand, and participation of the population and
key actors has made it possible to build robust
primary-care networks, even in very diffi cult and
resource-constrained settings of confl ict, and
post-confl ict environments (Box 2.4).
The World Health Report 2008 Primary Health Care – Now More Than Ever
30
The distinction between rapid deployment of
priority interventions and progressive roll-out of
primary-care networks is, in practice, often not
as straightforward as described above. However,
for all the convergence, trying to balance speed
and sustainability is a real political dilemma30.
Mali, among others, has shown that, given the
choice, people willingly opt for progressive rollout,
making community health centres – whose
infrastructure is owned and personnel employed
by the local community – the basis of functional
health districts.
Crucially, concern for equity should not be
translated into a “lowest common denominator”
approach: equal access for all to a set of largely
unsatisfactory services. Quality and sustainability
are important, particularly since nowadays
the multitude of varied and dynamic governmental,
not-for-profi t and for-profi t private providers
of various kinds are in dire need of alignment.
Progressive roll-out of health services provides
the opportunity to establish welcome leadership
coherence in health-care provision at district level.
Typical large-scale examples of this approach
in developing countries are the contracting out
of district health services in Cambodia, or the
incorporation of missionary “designated district
hospitals” in East Africa. Nevertheless, there is
no getting away from the need for massive and
sustained investment to expand and maintain
health districts in the long term and from the
fact that this represents a considerable challenge
in a context of sluggish economic growth and
stagnating health expenditure.
Extending health-care networks to underserved
areas depends on public initiative and
incentives. One way to accelerate the extension
of coverage is to adjust budget allocation formulae
(or contract specifi cations) to refl ect the
extra efforts required to contact hard-to-reach
populations. Several countries have taken steps in
this direction. In January 2004, for example, the
United Republic of Tanzania adopted a revised
formula for the allocation of basket funds to districts
that includes population size and underfi
ve mortality as a proxy for disease burden and
poverty level, while adjusting for the differential
costs of providing health services in rural and
low-density areas. Similarly, allocations to districts
under Uganda’s PHC budget factor in the
districts’ Human Development Index and levels
of external health funding, in addition to population
size. Supplements are paid to districts with
diffi cult security situations or lacking a district
hospital20. In Chile, budgets are allocated on a
capitation basis but, as part of the PHC reforms,
these were adjusted using municipal human
development indices and a factor to refl ect the
isolation of underserved areas.
Overcoming the isolation of
dispersed populations
Although providing access to services for dispersed
populations is often a daunting logistical
challenge, some countries have dealt with
it by developing creative approaches. Devising
mechanisms to share innovative experiences and
results has clearly been a key step, for example,
through the “Healthy Islands” initiative, launched
at the meeting of Ministers and Heads of Health
in Yanuca, Fiji, in 199534. The initiative brings
together health policy-makers and practitioners
to address challenges to islanders’ health and
well-being from an explicitly multi-sectoral perspective,
with a focus on expanding coverage of
curative health-care services, but also reinforcing
promotive strategies and cross-sectoral action on
the determinants of health and health equity.
Through the Healthy Islands initiative and
related experiences, a number of principles have
emerged as crucial to the advancement of universal
coverage in these settings. The fi rst concerns
collaboration in organizing infrastructure that
maximizes scales of effi ciency. An isolated community
may be unable to afford key inputs to
expand coverage, which includes infrastructure,
technologies and human resources (particularly
the training of personnel). However, when communities
join forces, they can secure such inputs
at manageable costs35. A second strategic focus is
on “mobile resources” or those that can overcome
distance and geographical obstacles effi ciently
and affordably. Depending on the setting, this
strategic focus may include transportation, radio
communications, and other information and communications
technologies. Telecommunications
31
Chapter 2. Advancing and sustaining universal coverage
Rutshuru is a health district in the east of the country. It has a
network of health centres, a referral hospital and a district management
team where community participation has been fostered
for years through local committees. Rutshuru has experienced
severe stress over the years, testing the robustness of the district
health system.
Over the last 30 years, the economy of the country has gone
into a sharp decline. GDP dropped from US$ 300 per capita in
the 1980s to below US$ 100 at the end of the 1990s. Massive
impoverishment was made worse as the State retreated from the
health sector. This was compounded by an interruption of overseas
development aid in the early 1990s. In that context, Rutshuru
suffered inter-ethnic strife, a massive infl ux of refugees and two
successive wars. This complex of disasters severely affected the
working conditions of health professionals and access to health
services for the 200 000 people living in the district.
Nevertheless, instead of
collapsing, PHC services
continued their expansion
over the years. The
number of health centres
and their output increased
(Figure 2.6), and quality
of care improved for
acute cases (case-fatality
rate after caesarean section
dropped from 7% to
less than 3%) as well as
for chronic patients (at
least 60% of tuberculosis
patients were treated
successfully). With no
more than 70 nurses and
three medical doctors at
a time, and in the midst
of war and havoc, the
Box 2.4 The robustness of PHC-led health systems: 20 years of expanding performance in
Rutshuru, the Democratic Republic of the Congo
health centres and the district hospital took care of more than
1 500 000 disease episodes in 20 years, immunized more than
100 000 infants, provided midwifery care to 70 000 women and
carried out 8 000 surgical procedures. This shows that, even in
disastrous circumstances, a robust district health system can
improve health-care outputs.
These results were achieved with modest means. Out-of-pocket
payments amounted to US$ 0.5 per capita per year. Nongovernmental
organizations subsidized the district with an average of US$
1.5 per capita per year. The Government’s contribution was virtually
nil during most of these 20 years. The continuity of the work
under extremely diffi cult circumstances can be explained by team
work and collegial decision-making, unrelenting efforts to build up
and maintain a critical mass of dedicated human resources, and
limited but constant nongovernmental support, which provided a
minimum of resources for health facilities and gave the district
management team the opportunity to maintain contact with the
outside world.
Three lessons can be learnt
from this experience. In
the long run, PHC-led
health districts are an
organizational model that
has the robustness to
resist extremely adverse
conditions. Maintaining
minimal fi nancial support
and supervision to such
districts can yield very
significant results, while
empowering and retaining
national health professionals.
Local health services
have a considerable
potential for coping with
crises33.
1985
Figure 2.6 Improving health-care outputs in the midst of disaster:
Rutshuru, the Democratic Republic of the Congo, 1985–200433
100
70
50
20
0
External aid
90 interrupted
80
60
40
30
10
1990 1995 2000
Refugee
crisis
First
War
Second
War
Coverage DPT3 vaccination (%)
Birth attended by medically
trained personnel (%)
New cases curative care
per 100 inhabitants per year
can enable less skilled frontline health-centre
staff to be advised and guided by experts at a
distance in real time36. Finally, the fi nancing
of health care for dispersed populations poses
specifi c challenges, which often require larger
per capita expenditure compared to more clustered
populations. In countries whose territories
include both high-density and low-density populations,
it is expected that dispersed populations
will receive some subsidy of care. After all, equity
does not come without solidarity.
Providing alternatives to
unregulated commercial services
In urban and periurban contexts, health services
are physically within reach of the poor and other
vulnerable populations. The presence of multiple
health-care providers does not mean, however,
that these groups are protected from diseases,
nor that they can get quality care when they need
it: the more privileged tend to get better access to
the best services, public and private, easily coming
out on top in a de facto competition for scarce
The World Health Report 2008 Primary Health Care – Now More Than Ever
32
resources. In the urban and increasingly in the
rural areas of many low- and middle-income
countries – from India and Viet Nam to sub-
Saharan Africa – much health care for the poor
is provided by small-scale, largely unregulated
and often unlicenced providers, both commercial
and not-for-profi t. Often, they work alongside
dysfunctional public services and capture
an overwhelmingly large part of the health-care
market, while the health promotion and prevention
agenda is totally ignored. Vested interests
make the promotion of universal coverage paradoxically
more diffi cult in these circumstances
than in areas where the challenge is to build
health-care delivery networks from scratch.
These contexts often combine problems of fi nancial
exploitation, bad quality and unsafe care, and
exclusion from needed services37,38,39,40,41,42,43,44,45.46.
The Pan American Health Organization (PAHO)
has estimated that 47% of Latin America’s population
is excluded from needed services47. This
may be for broader reasons of poverty, ethnicity
or gender, or because the resources of the
health system are not correctly targeted. It may
be because there are no adequate systems to protect
people against catastrophic expenditure or
from fi nancial exploitation by unscrupulous or
insensitive providers. It may have to do with the
way people, rightly or wrongly, perceive health
services: lack of trust, the expectation of ill-treatment
or discrimination, uncertainty about the
cost-of-care, or the anticipation that the cost will
be unaffordable or catastrophic. Services may
also be untimely, ineffective, unresponsive or
plain discriminatory, providing poorer patients
with inferior treatment48,49,21. As a result, health
outcomes vary considerably by social class, even
in well-regulated and well-funded health-care
systems.
In addressing these patterns of exclusion
within the health-care sector, the starting point
is to create or strengthen networks of accessible
quality primary-care services that rely on pooled
pre-payment or public resources for their funding.
Whether these networks are expanded by
contracting commercial or not-for-profi t providers,
or by revitalizing dysfunctional public facilities
is not the critical issue. The point is to ensure
that they offer care of an acceptable standard. A
critical mass of primary-care centres that provide
an essential package of quality services free-ofcharge,
provides an important alternative to substandard,
exploitative commercial care. Furthermore,
peer pressure and consumer demand can
help to create an environment in which regulation
of the commercial sector becomes possible.
More active involvement of municipal authorities
in pre-payment and pooling schemes to improve
the supply of quality care is probably one of the
avenues to follow, particularly where ministries
of health with budgetary constraints also have to
extend services to underserved rural areas.
Targeted interventions to
complement universal coverage
mechanisms
Rising average national income, a growing supply
of health-care providers and accelerated progress
towards universal coverage are, unfortunately, not
suffi cient to eliminate health inequities. Socially
determined health differences among population
groups persist in high-income countries with
robust, universal health-care and social-service
systems, such as Finland and France11,50. Health
inequalities do not just exist between the poor and
the non-poor, but across the entire socioeconomic
gradient. There are circumstances where other
forms of exclusion are of prime concern, including
the exclusion of adolescents, ethnic groups,
drug users and those affected by stigmatizing
diseases51. In Australia, Canada and New Zealand,
among others, health equity gaps between
Aboriginal and non-Aboriginal populations have
emerged as national political issues52,53,54. In other
settings, inequalities in women’s access to health
care merit attention55. In the United States, for
example, declines in female life expectancy of up
to fi ve years in over 1000 counties point to differential
exposure and clustering of risks to health
even as the country’s economy and health sector
continues to grow56. For a variety of reasons,
some groups within these societies are either not
reached or insuffi ciently reached by opportunities
for health or services and continue to experience
health outcomes systematically inferior to those
of more advantaged groups.
33
Chapter 2. Advancing and sustaining universal coverage
Thus, it is necessary to embed universal coverage
in wider social protection schemes and to
complement it with specially designed, targeted
forms of outreach to vulnerable and excluded
groups57. Established health-care networks often
do not make all possible efforts to ensure that
everyone in their target population has access
to the full range of health benefi ts they need, as
this requires extra efforts, such as home visits,
outreach services, specialized language and
cultural facilitation, evening consultations, etc.
These may, however, mitigate the effect of social
stratifi cation and inequalities in the uptake of
services58. They may also offer the opportunity
to construct comprehensive support packages to
foster social inclusion of historically marginalized
populations, in collaboration with other government
sectors and with affected communities.
Chile’s Chile Solidario (Chilean Solidarity) model
of outreach to families in long-term poverty is one
example (Box 2.5)59. Such targeted measures may
include subsidizing people – not services – to take
up specifi c health services, for example, through
vouchers60,61 for maternal care as in India and
Yemen, for bednets as in the United Republic of
Tanzania62,63, for contraceptive uptake by adolescents64
or care for the elderly uninsured as in
the United States65. Conditional cash transfers,
where the benefi ciary is not only enabled, but
compelled to take up services is another model,
which has been introduced in several countries in
Latin America. A recent systematic review of six
such programmes suggests that conditional cash
transfers can be effective in increasing the use of
preventive services and improving nutritional and
anthropometric outcomes, sometimes improving
health status66. However, their overall effect on
health status remains less clear and so does their
comparative advantage over traditional, unconditional,
income maintenance, through universal
entitlements, social insurance or – less-effective
– means-tested social assistance.
Targeted measures are not substitutes for the
long-term drive towards universal coverage. They
can be useful and necessary complements, but
without simultaneous institutionalization of the
fi nancing models and system structures that support
universal coverage, targeted approaches are
unlikely to overcome the inequalities generated
by socioeconomic stratifi cation and exclusion.
This is all the more important since systematic
evaluation of methods to target the excluded is
scarce and marred by the limited number of
documented experiences and a bias towards
reporting preferentially on successful pilots67. If
anything defi nite can be said today, it is that the
strategies for reaching the unreached will have
to be multiple and contextualized, and that no
single targeting measure will suffi ce to correct
health inequalities effectively, certainly not in the
absence of a universal coverage policy.
Box 2.5 Targeting social protection in Chile59
Established by law, the Chilean social protection programme (Chile Solidario) involves three main components to improve conditions for
people living in extreme poverty: direct psycho-social support, fi nancial support and priority access to social programmes. The direct
psycho-social support component involves families in extreme poverty being identifi ed according to pre-defi ned criteria and invited to
enter into an agreement with a designated social worker. The social worker assists them to build individual and family capacities that
help them to strengthen their links with social networks and to gain access to the social benefi ts to which they are entitled. In addition
to psycho-social support, there is also fi nancial support in terms of cash transfers and pensions, as well as subsidies for raising
families or covering water and sanitation costs. Finally, the social protection programme also provides preferential access to pre-school
programmes, adult literacy courses, employment programmes and preventive health visits for women and children.
This social protection programme complements a multisectoral effort targeting all children aged 0–18 years (Chile Crece Contigo – Chile
Grows with You). The aim is to promote early childhood development through pre-school education programmes, preventive health
checks, improved parental leave and increased child benefi ts. Better access to child-care services is also included as is enforcing the
right of working mothers to nurse their babies, which is designed to stimulate women’s insertion into the employment market.
The World Health Report 2008 Primary Health Care – Now More Than Ever
34
Mobilizing for health equity
Health systems are invariably inequitable. More
and higher quality services gravitate to the
well-off who need them less than the poor and
marginalized8. The universal coverage reforms
required to move towards greater equity demand
the enduring commitment of the highest political
levels of society. Two levers may be especially
important in accelerating action on health equity
and maintaining momentum over time. The fi rst
is raising the visibility of health inequities in public
awareness and policy debates: the history of
progress in the health of populations is intimately
linked to the measurement of health inequalities.
It was the observation of excess mortality among
the working class that informed the “Great Sanitary
Awakening” reforms of the Poor Laws Commission
in the United Kingdom in the 1830s68. The
second is the creation of space for civil society
participation in shaping the PHC reforms that are
to advance health equity: the history of progress
in universal coverage is intimately linked to that
of social movements.
Increasing the visibility of
health inequities
With the economic optimism of the 1960s and
1970s (and the expansion of social insurance in
industrialized countries), poverty ceased being
a priority issue for many policy-makers. It took
Alma-Ata to put equity back on the political
agenda. The lack of systematic measurement and
monitoring to translate this agenda into concrete
challenges has long been a major constraint in
advancing the PHC agenda. In recent years,
income-related and other health inequalities have
been studied in greater depth. The introduction of
composite asset indices has made it possible to reanalyze
demographic and health surveys from an
equity viewpoint69. This has generated a wealth
of documentary evidence on socioeconomic differentials
in health outcomes and access to care.
It took this acceleration of the measurement of
poverty and inequalities, particularly since the
mid-1990s, to bring fi rst poverty and then, more
generally, the challenge of persisting inequalities
to the centre of the health policy debate.
Measurement of health inequities is paramount
when confronting the common misperceptions
that strongly infl uence health policy
debates70,71.
Simple population averages �� are suffi cient to
assess progress – they are not.
�� Health systems designed for universal access
are equitable – they are a necessary, but not
a suffi cient condition.
�� In poor countries, everybody is equally poor
and equally unhealthy – all societies are
stratifi ed.
�� The main concern is between countries’ differences
– inequalities within countries matter
most to people.
�� Well-intended reforms to improve effi ciency
will ultimately benefi t everybody – they often
have unintended inequitable consequences.
Measurement mat ters for a variety of
reasons2.
�� It is important to know the extent and understand
the nature of health inequalities and
exclusion in a given society, so as to be able
to share that information and translate it into
objectives for change.
�� It is equally important, for the same reasons,
to identify and understand the determinants
of health inequality not only in general terms,
but also within each specifi c national context.
Health authorities must be informed of the
extent to which current or planned health
policies contribute to inequalities, so as to be
able to correct them.
�� Progress with reforms designed to reduce
health inequalities, i.e. progress in moving
towards universal coverage, needs to be monitored,
so as to steer and correct these reforms
as they unfold.
Despite policy-makers’ long-held commitment to
the value of equity in health, its defi nition and
measurement represent a more recent public
health science. Unless health information systems
collect data using standardized social stratifi ers,
such as socioeconomic status, gender, ethnicity
and geographical area, it is diffi cult to identify
and locate inequalities and, unless their magnitude
and nature are uncovered, it is unlikely
that they will be adequately addressed72. The
now widely available analyses of Demographic
and Health Survey (DHS) data by asset quintiles
35
Chapter 2. Advancing and sustaining universal coverage
have made a major difference in the awareness
of policy-makers about health equity problems
in their countries. There are also examples of
how domestic capacities and capabilities can be
strengthened to better understand and manage
equity problems. For example, Chile has recently
embarked on integrating health sector information
systems in order to have more comprehensive
information on determinants and to improve
the ability to disaggregate information according
to socioeconomic groups. Indonesia has added
health modules to household expenditure and
demographic surveys. Building in capabilities,
across administrative database systems, to link
health and socioeconomic data through unique
identifi ers (national insurance numbers or census
geo-codes) is key to socioeconomic stratifi cation
and provides information that is usually inaccessible.
However, this is more than a technical
challenge. Measuring health systems’ progress
towards equity requires an explicit deliberative
process to identify what constitutes a fair distribution
of health against shortfalls and gaps that
can be measured73. It relies on the development
of institutional collaboration between multiple
stakeholders to ensure that measurement and
monitoring translates into concrete political proposals
for better equity and solidarity.
Creating space for civil society
participation and empowerment
Knowledge about health inequalities can only
be translated into political proposals if there is
organized social demand. Demand from the communities
that bear the burden of existing inequities
and other concerned groups in civil society
are among the most powerful motors driving
universal coverage reforms and efforts to reach
the unreached and the excluded.
The amount of grassroots advocacy to improve
the health and welfare of populations in need has
grown enormously in the last 30 years, mostly
within countries, but also globally. There are
now thousands of groups around the world, large
and small, local and global, calling for action to
improve the health of particularly deprived social
groups or those suffering from specifi c health
conditions. These groups, which were virtually
non-existent in the days of the Alma-Ata,
constitute a powerful voice of collective action.
Box 2.6 Social policy in the city of
Ghent, Belgium: how local authorities
can support intersectoral collaboration
between health and welfare
organizations76
In 2004, a regional government decree in Flanders, Belgium,
institutionalized the direct participation of local stakeholders
and citizens in intersectoral collaboration on social rights. This
now applies at the level of cities and villages in the region. In
one of these cities, Ghent, some 450 local actors of the health
and welfare sector have been clustered in 11 thematic forums:
legal help; support and security of minors; services for young
people and adolescents; child care; ethnic cultural minorities;
people with a handicap; the elderly; housing; work and employment;
people living on a “critical income”; and health.
The local authorities facilitate and support the collaboration
of the various organizations and sectors, for example, through
the collection and monitoring of data, information and communication,
access to services, and efforts to make services
more pro-active. They are also responsible for networking
between all the sectors with a view to improving coordination.
They pick up the signals, bottlenecks, proposals and plans,
and are responsible for channelling them, if appropriate, to
the province, region, federal state or the European Union for
translation into relevant political decisions and legislation.
A steering committee reports directly to the city council and
integrates the work of the 11 forums. The support of the administration
and a permanent working party is critical for the
sustainability and quality of the work in the different groups.
Participation of all stakeholders is particularly prominent in
the health forum: it includes local hospitals, family physicians,
primary-care services, pharmacists, mental health facilities,
self-help groups, home care, health promotion agencies,
academia sector, psychiatric home care, and community
health centres.
This complex web of collaboration is showing results. Intersectoral
coordination contributes to a more effi cient local social
policy. For the period 2008–2013, four priority themes have
been identifi ed in a bottom-up process: sustainable housing,
access to health care, reduced thresholds to social rights, and
optimization of growth and development. The yearly action plan
operationalizes the policy through improvement projects in
areas that include fi nancial access to health care, educational
support, care for the homeless, and affordable and fl exible
child care. Among the concrete realizations is the creation
of Ghent’s “social house”, a network of service entry points
situated in the different neighbourhoods of the city, where
delivery of primary care is organized with special attention
to the most vulnerable groups of people. The participating
organizations report that the creation of the sectoral forums,
in conjunction with the organization of intersectoral cooperation,
has signifi cantly improved the way social determinants
of health are tackled in the city.
The World Health Report 2008 Primary Health Care – Now More Than Ever
36
The mobilization of groups and communities
to address what they consider to be their most
important health problems and health-related
inequalities is a necessary complement to the
more technocratic and top-down approach to
assessing social inequalities and determining
priorities for action.
Many of these groups have become capable
lobbyists, for example, by gaining access to HIV/
AIDS treatment, abolishing user fees and promoting
universal coverage. However, these achievements
should not mask the contributions that the
direct engagement of affected communities and
civil society organizations can have in eliminating
sources of exclusion within local health services.
Costa Rica’s “bias-free framework” is one
example among many. It has been used successfully
to foster dialogue with and among members
of vulnerable communities by uncovering local
practices of exclusion and barriers to access not
readily perceived by providers and by spurring
action to address the underlying causes of illhealth.
Concrete results, such as the reorganization
of a maternity hospital around the people’s
needs and expectations can transcend the local
dimension, as was the case in Costa Rica when
local reorganization was used as a template for
a national effort74.
However, there is much the health system itself
can do to mitigate the effects of social inequities
and promote fairer access to health services at
local level. Social participation in health action
becomes a reality at the local level and, at times,
it is there that intersectoral action most effectively
engages the material and social factors that shape
people’s health prospects, widening or reducing
health equity gaps. One such example is the
Health Action Zones in the United Kingdom, which
were partner-based entities whose mission was to
improve the well-being of disadvantaged groups.
Another example is the work of the municipality
of Barcelona, in Spain, where a set of interventions,
including the reform of primary care, was
followed by health improvements in a number of
disadvantaged groups, showing that local governments
can help reduce health inequities75.
Local action can also be the starting point for
broader structural changes, if it feeds into relevant
political decisions and legislation (Box 2.6).
Local health services have a critical role to play
in this regard, as it is at this level that universal
coverage and service delivery reforms meet. Primary
care is the way of organizing health-care
delivery that is best geared not only to improving
health equity, but also to meeting people’s other
basic needs and expectations.
37
Chapter 2. Advancing and sustaining universal coverage
References
Houston S. Matt Anderson’s 1939 health plan: how effective a 1. nd how economical?
Saskatchewan History, 2005, 57:4–14
2. Xu K et al. Protecting households from catastrophic health spending,
Health Affairs,
2007, 26:972–983.
3. A conceptual framework for action on the social determinants of health; discussion
paper for the Commission on Social Determinants for Health. Geneva, World
Health Organization, 2007 (http://www.who.int/social_determinants/resources/
csdh_framework_action_05_07.pdf, accessed 19 July 2008)
4. Whitehead M, Dahlgren G. Concepts and principles for tackling social inequities in
health: levelling up part 1. Copenhagen, World Health Organization Regional Offi ce
for Europe, 2006 (Studies on Social and Economic Determinants of Population
Health No. 2; http://www.euro.who.int/document/e89383.pdf, accessed 15 July
2008).
5. Adler N, Stewart J. Reaching for a healthier life. Facts on socioeconomic status and
health in the US. Chicago, JD and CT MacArthur Foundation Research Network on
Socioeconomic Status and Health, 2007.
6. Dans A et al. Assessing equity in clinical practice guidelines. Journal of Clinical
Epidemiology, 2007, 60:540–546.
7. Hart JT. The inverse care law. Lancet, 1971, 1:405–412.
8. Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable.
Lancet, 2004, 364:1273–1280.
9. Gilson L, McIntyre D. Post-apartheid challenges: household access and use of care.
International Journal of Health Services, 2007, 37:673–691.
10. 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.
11. Mackenbach JP et al. Strategies to reduce socioeconomic inequalities in health.
In: Mackenbach JP, Bakker M, eds. Reducing inequalities in health: a European
perspective. London, Routledge, 2002.
12. Report No. 20 (2006-2007): National strategy to reduce social inequalities in health.
Paper presented to the Storting. Oslo, Norwegian Ministry of Health and Care
Services, 2007 (http://www.regjeringen.no/en/dep/hod/Documents/regpubl/
stmeld/2006-2007/Report-No-20-2006-2007-to-the-Storting.html?id=466505,
accessed 19 July 2008).
13. Diderichsen F, Hallqvist J. Social inequalities in health: some methodological
considerations for the study of social position and social context. In: Arve-Parès B,
ed. Inequality in health – a Swedish perspective. Stockholm, Swedish Council for
Social Research, 1998.
14. International Labour Offi ce, Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ) Gmbh and World Health Organization. Extending social protection in health:
developing countries, experiences, lessons learnt and recommendations. International
Conference on Social Health Insurance in Developing Countries, Berlin, 5–7
December 2005. Eschborn, Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ) Gmbh, 2007 (http://www2.gtz.de/dokumente/bib/07-0378.pdf, accessed 19
July 2008).
15. Achieving universal health coverage: developing the health fi nancing system.
Geneva, World Health Organization, Department of Health Systems Financing, 2005
(Technical Briefs for Policy Makers No. 1).
16. The World Health Report 2000 – Health systems: improving performance. Geneva,
World Health Organization, 2000.
17. Busse R, Schlette S, eds. Focus on prevention, health and aging and health
professions. Gütersloh, Verlag Bertelsmann Stiftung, 2007 (Health Policy
Developments 7/8).
18. Carrin G, Waelkens MP, Criel B. Community-based health insurance in developing
countries: a study of its contribution to the performance of health fi nancing systems.
Tropical Medicine and International Health, 2005, 10:799–811.
19. Jacobs B et al. Bridging community-based health insurance and social protection
for health care – a step in the direction of universal coverage? Tropical Medicine and
International Health, 2008, 13:140–143.
20. Reclaiming the resources for health. A regional analysis of equity in health in East and
Southern Africa. Kampala, Regional Network on Equity in Health in Southern Africa
(EQUINET), 2007.
21. Gilson L. The lessons of user fee experience in Africa. Health Policy and Planning,
1997, 12:273–285.
22. Ke X et al. The elimination of user fees in Uganda: impact on utilization and
catastrophic health expenditures. Geneva, World Health Organization, Department
of Health System Financing, Evidence, Information and Policy Cluster, 2005
(Discussion Paper No. 4).
23. Hutton G. Charting the path to the World Bank’s “No blanket policy on user fees”.
A look over the past 25 years at the shifting support for user fees in health and
education, and refl ections on the future. London, Department for International
Development (DFID) Health Resource Systems Resource Centre, 2004 (http:www.
dfi dhealthrc.org/publications/health_sector_fi nancing/04hut01.pdf, accessed 19
July 2008).
24. Tarimo E. Essential health service packages: uses, abuse and future directions.
Current concerns. Geneva, World Health Organization, 1997 (ARA Paper No. 15;
WHO/ARA/CC/97.7).
25. Republica de Chile. Ley 19.966. Projecto de ley: título I del régimen general de
garantías en salud. Santiago, Ministerio de Salud, 2008 (http://webhosting.redsalud.
gov.cl/minsal/archivos/guiasges/leyauge.pdf accessed 19 July 2008).
26. Moccero D. Delivering cost-effi cient public services in health care, education and
housing in Chile. Paris, Organisation for Economic Co-operation and Development,
2008 (Economics Department Working Papers No. 606).
27. Gwatkin DR et al. Socio-economic differences in health, nutrition, and population
within developing countries. An overview. Washington DC, The World Bank, Human
Development Network, Health, Population and Nutrition, and Population Family,
2007 (POPLINE Document Number: 324740).
28. Conway MD, Gupta S, Khajavi K. Addressing Africa’s health workforce crisis. The
Mckinsey Quarterly, November 2007.
29. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as
constraints to referral by isolated nurses in rural Niger. Human Resources for Health,
2004, 2:1.
30. Maiga Z, Traoré Nafo F, El Abassi A. La Réforme du secteur santé au Mali, 1989-
1996. Studies in Health Services Organisation & Policy, 1999, 12:1–132.
31. Abolhassani F. Primary health care in the Islamic Republic of Iran. Teheran, Teheran
University of Medical Sciences, Health Network Development Centre (unpublished).
32. Naghavi M. Demographic and health surveys in Iran, 2008 (personal communication).
33. Porignon D et al. How robust are district health systems? Coping with crisis and
disasters in Rutshuru, Democratic Republic of Congo. Tropical Medicine and
International Health, 1998, 3:559–565.
34. Gauden GI, Powis B, Tamplin SA. Healthy Islands in the Western Pacifi c –
international settings development. Health Promotion International, 2000,
15:169–178.
35. The World Health Report 2006: Working together for health. Geneva, World Health
Organization, 2006.
36. Bossyns P et al. Unaffordable or cost-effective? Introducing an emergency referral
system in rural Niger. Tropical Medicine & International Health, 2005, 10:879–887.
37. Tibandebage P, Mackintosh M. The market shaping of charges, trust and abuse:
health care transactions in Tanzania. Social Science and Medicine, 2005,
61:1385–1395.
38. Segall, M et al. Health care seeking by the poor in transitional economies: the case
of Vietnam. Brighton, Institute of Development Studies, 2000 (IDS Research Reports
No. 43).
39. Baru RV. Private health care in India: social characteristics and trends. New Delhi,
Sage Publications, 1998.
40. Tu NTH, Huong NTL, Diep NB. Globalisation and its effects on health care and
occupational health in Viet Nam. Geneva, United Nations Research Institute for Social
Development, 2003 (http://www.unrisd.org, accessed 19 July 2008).
41. Narayana K. The role of the state in the privatisation and corporatisation of medical
care in Andhra Pradesh, India. In: Sen K, ed. Restructuring health services: changing
contexts and comparative perspectives. London and New Jersey, Zed Books, 2003.
42. Bennett S, McPake B, Mills A. The public/private mix debate in health care. In:
Bennett S, McPake B, Mills A, eds. Private health providers in developing countries.
Serving the public interest? London and New Jersey, Zed Books, 1997.
43. Ogunbekun I, Ogunbekun A, Orobaton N. Private health care in Nigeria: walking the
tightrope. Health Policy and Planning, 1999, 14:174–181.
44. Mills A, Bennett S, Russell S. The challenge of health sector reform: what must
governments do? Basingstoke, Palgrave Macmillan, 2001.
45. The unbearable cost of illness: poverty, ill health and access to healthcare - evidence
from Lindi Rural District, Tanzania, London, Save the Children, 2001.
46. Ferrinho P, Bugalho AM, Van Lerberghe W. Is there a case for privatising
reproductive health? Patchy evidence and much wishful thinking. Studies in Health
Services Organisation & Policy, 2001, 17:343–370.
47. Pan American Health Organization and Swedish International Development Agency.
Exclusion in health in Latin America and the Caribbean. Washington DC, Pan
American Health Organization, 2003 (Extension of Social Protection in Health Series
No. 1).
The World Health Report 2008 Primary Health Care – Now More Than Ever
38
48. Jaffré Y, Olivier de Sardan J-P, eds. Une médecine inhospitalière. Les diffi ciles relations
entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest. Paris, Karthala,
2003.
49. Schellenberg JA et al. Inequalities among the very poor: health care for children in
rural southern Tanzania. Ifakara, Ifakara Health Research and Development Centre,
2002.
50. Oliver A, ed. Health care priority setting: implications for health inequalities.
Proceedings from a meeting of the Health Equity Network. London, The Nuffi eld
Trust, 2003.
51. Overcoming obstacles to health: report from the Robert Wood Johnson Foundation to
the Commission to Build a Healthier America. Princeton NJ, Robert Wood Johnson
Foundation, 2008.
52. Franks A. Self-determination background paper. Aboriginal health promotion project.
Lismore NSW, Northern Rivers Area Health Service, Division of Population Health,
Health Promotion Unit, 2001 (http://www.ncahs.nsw.gov.au/docs/echidna/ABpaper.
pdf, accessed 19 July 2008).
53. Gathering strength – Canada’s Aboriginal action plan: a progress report. Ottawa,
Ministry of Indian Affairs and Northern Development, 2000.
54. King A, Turia T. He korowai orange – Maori Health Strategy. Wellington, Ministry of
Health of New Zealand, 2002.
55. Cecile MT et al. Gender perspectives and quality of care: towards appropriate and
adequate health care for women. Social Science & Medicine, 1996, 43:707–720.
56. Murray C, Kulkarni S, Ezzati M. Eight Americas: new perspectives on U.S. health
disparities. American Journal of Preventive Medicine, 2005, 29:4–10.
57. Paterson I, Judge K. Equality of access to healthcare. In: Mackenbach JP, Bakker
M, eds. Reducing inequalities in health: a European perspective. London, Routledge,
2002.
58. Doblin L, Leake BD. Ambulatory health services provided to low-income and
homeless adult patients in a major community health center. Journal of General
Internal Medicine, 1996 11:156–162.
59. Frenz P. Innovative practices for intersectoral action on health: a case study of four
programs for social equity. Chilean case study prepared for the CSDH. Santiago,
Ministry of Health, Division of Health Planning, Social Determinants of Health
Initiative, 2007.
60. Emanuel EJ, Fuchs VR. Health care vouchers – a proposal for universal coverage.
New England Journal of Medicine, 2005, 352:1255–1260.
61. Morris S et al. Monetary incentives in primary health care and effects on use
and coverage of preventive health care interventions in rural Honduras: cluster
randomised trial. Lancet, 2004, 364:2030–2037.
62. Armstrong JRM et al. KINET: a social marketing programme of treated nets and net
treatment for malaria control in Tanzania, with evaluation of child health and longterm
survival. Transactions of the Royal Society of Tropical Medicine and Hygiene,
1999, 93:225–231.
63. Adiel K et al. Targeted subsidy for malaria control with treated nets using a discount
voucher system in Tanzania. Health Policy and Planning, 2003, 18:163–171.
64. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health
services and impact on sexual behavior. Family Planning Perspectives, 1991,
23:6–16.
65. Meng H et al. Effect of a consumer-directed voucher and a disease-managementhealth-
promotion nurse intervention on home care use. The Gerontologist, 2005,
45:167–176.
66. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake
of health interventions in low- and middle-income countries. A systematic review.
Journal of the American Medical Association, 2007, 298:1900–1910.
67. Gwatkin DR, Wagstaff A, Yazbeck A, eds. Reaching the poor with health, nutrition
and population services. What works, what doesn’t and why. Washington DC, The
World Bank, 2005.
68. Sretzer, S. The importance of social intervention in Britain’s mortality decline,
c.1850–1914: a reinterpretation of the role of public health. Society for the Social
History of Medicine, 1988, 1:1–41.
69. Gwatkin DR. 10 best resources on ... health equity. Health Policy and Planning, 2007,
22:348–351.
70. Burström B. Increasing inequalities in health care utilisation across income groups
in Sweden during the 1990s? Health Policy, 2002, 62:117–129.
71. Whitehead M et al. As the health divide widens in Sweden and Britain, what’s
happening to access to care? British Medical Journal, 1997, 315:1006–1009.
72. Nolen LB et al. Strengthening health information systems to address health equity
challenges, Bulletin of the World Health Organization, 2005, 83:597–603.
73. Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can lowincome
countries escape the medical poverty trap. Lancet, 2001, 358:833–836.
74. Burke MA, Eichler M. The BIAS FREE framework: a practical tool for identifying
and eliminating social biases in health research. Geneva, Global Forum for Health
Research, 2006 (http://www.globalforumhealth.org/Site/002__What%20we%20
do/005__Publications/010__BIAS%20FREE.php, accessed 19 July 2008).
75. Benach J, Borell C, Daponte A. Spain. In: Mackenbach JP, Bakker M, eds. Reducing
inequalities in health: a European perspective. London, Routledge, 2002.
76. Balthazar T, Versnick G. Lokaal sociaal beleidsplan, Gent. Strategisch meerjarenplan
2008-2013. Gent, Lokaal Sociaal Beleid, 2008 (http://www.lokaalsociaalbeleidgent.
be/documenten/publicaties%20LSB-Gent/LSB-plan%20Gent.pdf, accessed 23
July 2008).


Primary care
Putting people fi rst
This chapter describes how primary care brings
promotion and prevention, cure and care together in
a safe, effective and socially productive way at the interface
between the population and the health
system. In short, what needs to be done to
achieve this is “to put people fi rst”: to give
balanced consideration to health and wellbeing
as well as to the values and capacities
of the population and the health workers1.
The chapter starts by describing features of
health care that, along with effectiveness and safety, are essential
in ensuring improved health and social outcomes.
l
Chapter 3
Good care is about people 42
The distinctive features of
primary care 43
Organizing
primary-care networks 52
Monitoring progress 56
41
The World Health Report 2008 Primary Health Care – Now More Than Ever
42
These features are person-centredness, comprehensiveness
and integration, and continuity of
care, with a regular point of entry into the health
system, so that it becomes possible to build an
enduring relationship of trust between people
and their health-care providers. The chapter
then defi nes what this implies for the organization
of health-care delivery: the necessary
switch from specialized to generalist ambulatory
care, with responsibility for a defi ned population
and the ability to coordinate support from
hospitals, specialized services and civil society
organizations.
Good care is about people
Biomedical science is, and should be, at the heart
of modern medicine. Yet, as William Osler, one of
its founders, pointed out, “it is much more important
to know what sort of patient has a disease
than what sort of disease a patient has”2. Insuffi
cient recognition of the human dimension in
health and of the need to tailor the health service’s
response to the specifi city of each community and
individual situation represent major shortcomings
in contemporary health care, resulting not
only in inequity and poor social outcomes, but
also diminishing the health outcome returns on
the investment in health services.
Putting people fi rst, the focus of service delivery
reforms is not a trivial principle. It can require
signifi cant – even if often simple – departures
from business as usual. The reorganization of
a medical centre in Alaska in the United States,
accommodating 45 000 patient contacts per year,
illustrates how far-reaching the effects can be.
The centre functioned to no great satisfaction of
either staff or clients until it decided to establish
a direct relationship between each individual
and family in the community and a specifi c staff
member3. The staff were then in a position to
know “their” patients’ medical history and understand
their personal and family situation. People
were in a position to get to know and trust their
health-care provider: they no longer had to deal
with an institution but with their personal caregiver.
Complaints about compartmentalized and
fragmented services abated4. Emergency room
visits were reduced by approximately 50% and
referrals to specialty care by 30%; waiting times
shortened signifi cantly. With fewer “rebound”
visits for unresolved health problems, the workload
actually decreased and staff job satisfaction
improved. Most importantly, people felt that
they were being listened to and respected – a key
aspect of what people value about health care5,6. A
slow bureaucratic system was thus transformed
into one that is customer-responsive, customerowned
and customer-driven4.
In a very different setting, the health centres
of Ouallam, a rural district in Niger, implemented
an equally straightforward reorganization of
their way of working in order to put people fi rst.
Rather than the traditional morning curative care
consultation and specialized afternoon clinics
(growth monitoring, family planning, etc.), the
full range of services was offered at all times,
while the nurses were instructed to engage in an
active dialogue with their patients. For example,
they no longer waited for women to ask for contraceptives,
but informed them, at every contact,
about the range of services available. Within a few
months, the very low uptake of family planning,
previously attributed to cultural constraints, was
a thing of the past (Figure 3.1)7.
People’s experiences of care provided by the
health system are determined fi rst and foremost
by the way they are treated when they experience
a problem and look for help: by the responsiveness
of the health-worker interface between population
Women attending the health centre (%)
Source: 7
60
0
80
Year before reorganization
Figure 3.1 The effect on uptake of contraception of the reorganization
of work schedules of rural health centres in Niger
40
20
Year after reorganization
100
Informed Interested Contraception started
43
Chapter 3. Primary care: putting people fi rst
and health services. People value some freedom
in choosing a health provider because they want
one they can trust and who will attend to them
promptly and in an adequate environment, with
respect and confi dentiality8.
Health-care delivery can be made more effective
by making it more considerate and convenient,
as in Ouallam district. However, primary
care is about more than shortening waiting
times, adapting opening hours or getting staff
to be more polite. Health workers have to care
for people throughout the course of their lives,
as individuals and as members of a family and a
community whose health must be protected and
enhanced9, and not merely as body parts with
symptoms or disorders that require treating10.
The service delivery reforms advocated by the
PHC movement aim to put people at the centre of
health care, so as to make services more effective,
effi cient and equitable. Health services that
do this start from a close and direct relationship
between individuals and communities and their
caregivers. This, then, provides the basis for person-
centredness, continuity, comprehensiveness
and integration, which constitute the distinctive
features of primary care. Table 3.1 summarizes
the differences between primary care and care
provided in conventional settings, such as in
clinics or hospital outpatient departments, or
through the disease control programmes that
shape many health services in resource-limited
settings. The section that follows reviews these
defi ning features of primary care, and describes
how they contribute to better health and social
outcomes.
The distinctive features of
primary care
Effectiveness and safety are not just
technical matters
Health care should be effective and safe. Professionals
as well as the general public often
over-rate the performance of their health services.
The emergence of evidence-based medicine
in the 1980s has helped to bring the power
and discipline of scientifi c evidence to healthcare
decision-making11, while still taking into
consideration patient values and preferences12.
Over the last decade, several hundred reviews of
Table 3.1 Aspects of care that distinguish conventional health care from people-centred primary care
Conventional ambulatory
medical care in clinics or
outpatient departments Disease control programmes People-centred primary care
Focus on illness and cure Focus on priority diseases Focus on health needs
Relationship limited to the moment of
consultation
Relationship limited to programme
implementation
Enduring personal relationship
Episodic curative care Programme-defi ned disease control
interventions
Comprehensive, continuous and personcentred
care
Responsibility limited to effective
and safe advice to the patient at the
moment of consultation
Responsibility for disease-control
targets among the target population
Responsibility for the health of all in
the community along the life cycle;
responsibility for tackling determinants
of ill-health
Users are consumers of the care they
purchase
Population groups are targets of
disease-control interventions
People are partners in managing their
own health and that of their community
The World Health Report 2008 Primary Health Care – Now More Than Ever
44
effectiveness have been conducted13, which have
led to better information on the choices available
to health practitioners when caring for their
patients.
Evidence-based medicine, however, cannot
in itself ensure that health care is effective and
safe. Growing awareness of the multiple ways in
which care may be compromised is contributing
to a gradual rise in standards of quality and
safety (Box 3.1). Thus far, however, such efforts
have concentrated disproportionately on hospital
and specialist care, mainly in high- and middleincome
countries. The effectiveness and safety of
generalist ambulatory care, where most interactions
between people and health services take
place, has been given much less attention14. This
is a particularly important issue in the unregulated
commercial settings of many developing
countries where people often get poor value for
money (Box 3.2)15.
Technical and safety parameters are not the
only determinants of the outcomes of health care.
The disappointingly low success rate in preventing
mother-to-child transmission (MTCT) of HIV
in a study in the Côte d’Ivoire (Figure 3.2) illustrates
that other features of the organization of
health care are equally critical – good drugs are
Box 3.1 Towards a science and culture
of improvement: evidence to promote
patient safety and better outcomes
The outcome of health care results from the balance between
the added value of treatment or intervention, and the harm it
causes to the patient16. Until recently, the extent of such harm
has been underestimated. In industrialized countries, approximately
1 in 10 patients suffers harm caused by avoidable
adverse events while receiving care17: up to 98 000 deaths per
year are caused by such events in the United States alone18.
Multiple factors contribute to this situation19, ranging from
systemic faults to problems of competence, social pressure on
patients to undergo risky procedures, to incorrect technology
usage20. For example, almost 40% of the 16 billion injections
administered worldwide each year are given with syringes
and needles that are reused without sterilization14. Each year,
unsafe injections thus cause 1.3 million deaths and almost 26
million years of life lost, mainly because of transmission of
hepatitis B and C, and HIV21.
Especially disquieting is the paucity of information on the
extent and determinants of unsafe care in low- and middleincome
countries. With unregulated commercialization of care,
weaker quality control and health resource limitations, healthcare
users in low-income countries may well be even more
exposed to the risk of unintended patient harm than patients in
high-income countries. The World Alliance for Patient Safety22,
among others, advocates making patients safer through systemic
interventions and a change in organizational culture
rather than through the denunciation of individual health-care
practitioners or administrators23.
Box 3.2 When supplier-induced and
consumer-driven demand determine
medical advice: ambulatory care in India
“Ms. S is a typical patient who lives in urban Delhi. There
are over 70 private-sector medical care providers within a
15-minute walk from her house (and virtually any household
in her city). She chooses the private clinic run by Dr. SM and
his wife. Above the clinic a prominent sign says “Ms. MM,
Gold Medalist, MBBS”, suggesting that the clinic is staffed by
a highly profi cient doctor (an MBBS is the basic degree for a
medical doctor as in the British 2 system). As it turns out, Ms.
MM is rarely at the clinic. We were told that she sometimes
comes at 4 a.m. to avoid the long lines that form if people know
she is there. We later discover that she has “franchised” her
name to a number of different clinics. Therefore, Ms. S sees
Dr. SM and his wife, both of whom were trained in traditional
Ayurvedic medicine through a six-month long-distance course.
The doctor and his wife sit at a small table surrounded, on one
side, by a large number of bottles full of pills, and on the other,
a bench with patients on them, which extends into the street.
Ms. S sits at the end of this bench. Dr. SM and his wife are the
most popular medical care providers in the neighbourhood,
with more than 200 patients every day. The doctor spends an
average of 3.5 minutes with each patient, asks 3.2 questions,
and performs an average of 2.5 examinations. Following the
diagnosis, the doctor takes two or three different pills, crushes
them using a mortar and pestle, and makes small paper packets
from the resulting powder which he gives to Ms. S and
asks her to take for two or three days. These medicines usually
include one antibiotic and one analgesic and anti-infl ammatory
drug. Dr. SM tells us that he constantly faces unrealistic patient
expectations, both because of the high volume of patients and
their demands for treatments that even Dr. SM knows are
inappropriate. Dr. SM and his wife seem highly motivated to
provide care to their patients and even with a very crowded
consultation room they spend more time with their patients
than a public sector doctor would. However, they are not bound
by their knowledge […] and instead deliver health care like
the crushed pills in a paper packet, which will result in more
patients willing to pay more for their services”24.
45
Chapter 3. Primary care: putting people fi rst
not enough. How services deal with people is also
vitally important. Surveys in Australia, Canada,
Germany, New Zealand, the United Kingdom and
the United States show that a high number of
patients report safety risks, poor care coordination
and defi ciencies in care for chronic conditions25.
Communication is often inadequate and
lacking in information on treatment schedules.
Nearly one in every two patients feels that doctors
only rarely or never asked their opinion about
treatment. Patients may consult different providers
for related or even for the same conditions
which, given the lack of coordination among these
providers, results in duplication and contradictions25.
This situation is similar to that reported
in other countries, such as Ethiopia26, Pakistan27
and Zimbabwe28.
There has, however, been progress in recent
years. In high-income countries, confrontation
with chronic disease, mental health problems,
multi-morbidity and the social dimension of disease
has focused attention on the need for more
comprehensive and person-centred approaches
and continuity of care. This resulted not only
from client pressure, but also from professionals
who realized the critical importance of such
Figure 3.2 Lost opportunities for prevention of mother-to-child transmission of HIV (MTCT) in
Côte d’Ivoire29: only a tiny fraction of the expected transmissions are
actually prevented
450 failures to prevent transmission
Did not attend
antenatal care
Lack of
coverage:
77 lost
462 mother-to-child
transmissions of HIV
(expected among 11 582
pregnant women)
Mother
attends
antenatal
care
HIV testing
offered
Did not
accept
test
Bad
communication:
107 lost
Counselling
recommends
treatment
12 mother-to-child
transmissions
successfully
prevented
Were not
counselled
Lack of
follow-up:
153 lost
Consent
obtained
Did not
agree to
be treated
Bad
communication:
50 lost
Treatment
offered
Did not get
the treatment
Access to
drugs: 40 lost
Treatment
taken
Treatment
ineffective
23 lost
Treatment
effective
The World Health Report 2008 Primary Health Care – Now More Than Ever
46
features of care in achieving better outcomes for
their patients. Many health professionals have
begun to appreciate the limitations of narrow
clinical approaches, for example, to cardiovascular
disease. As a result there has been a welcome
blurring of the traditional boundaries between
curative care, preventive medicine and health
promotion.
In low-income countries, this evolution is also
visible. In recent years, many of the programmes
targeting infectious disease priorities have given
careful consideration to comprehensiveness,
continuity and patient-centredness. Maternal
and child health services have often been at the
forefront of these attempts, organizing a continuum
of care and a comprehensive approach.
This process has been consolidated through the
joint UNICEF/WHO Integrated Management of
Childhood Illness initiatives30. Their experience
with programmes such as the WHO’s Extended
Programme for Immunization has put health professionals
in many developing countries a step
ahead compared to their high-income country
colleagues, as they more readily see themselves
responsible not just for patients, but also for
population coverage. More recently, HIV/AIDS
programmes have drawn the attention of providers
and policy-makers to the importance of
counselling, continuity of care, the complementarity
of prevention, treatment and palliation and
critically, to the value of empathy and listening
to patients.
Understanding people:
person-centred care
When people are sick they are a great deal less
concerned about managerial considerations of
productivity, health targets, cost-effectiveness
and rational organization than about their own
predicament. Each individual has his or her own
way of experiencing and coping with health problems
within their specifi c life circumstances31.
Health workers have to be able to handle that
diversity. For health workers at the interface
between the population and the health services,
the challenge is much more complicated than for
a specialized referral service: managing a welldefi
ned disease is a relatively straightforward
technical challenge. Dealing with health problems,
however, is complicated as people need to
be understood holistically: their physical, emotional
and social concerns, their past and their
future, and the realities of the world in which they
live. Failure to deal with the whole person in their
specifi c familial and community contexts misses
out on important aspects of health that do not
immediately fi t into disease categories. Partner
violence against women (Box 3.3), for example,
can be detected, prevented or mitigated by health
services that are suffi ciently close to the communities
they serve and by health workers who
know the people in their community.
People want to know that their health worker
understands them, their suffering and the constraints
they face. Unfortunately, many providers
neglect this aspect of the therapeutic relation,
particularly when they are dealing with
disadvantaged groups. In many health services,
responsiveness and person-centredness are
treated as luxury goods to be handed out only
to a selected few.
Over the last 30 years, a considerable body
of research evidence has shown that personcentredness
is not only important to relieve
the patient’s anxiety but also to improve the
provider’s job satisfaction50. The response to
a health problem is more likely to be effective
if the provider understands its various dimensions51.
For a start, simply asking patients how
they feel about their illness, how it affects their
lives, rather than focusing only on the disease,
results in measurably increased trust and compliance52
that allows patient and provider to
fi nd a common ground on clinical management,
and facilitates the integration of prevention and
health promotion in the therapeutic response50,51.
Thus, person-centredness becomes the “clinical
method of participatory democracy”53, measurably
improving the quality of care, the success of
treatment and the quality of life of those benefi ting
from such care (Table 3.2).
In practice, clinicians rarely address their
patients’ concerns, beliefs and understanding
of illness, and seldom share problem management
options with them58. They limit themselves
to simple technical prescriptions, ignoring the
complex human dimensions that are critical to
the appropriateness and effectiveness of the care
they provide59.
47
Chapter 3. Primary care: putting people fi rst
Thus, technical advice on lifestyle, treatment
schedule or referral all too often neglects
not only the constraints of the environment in
which people live, but also their potential for selfhelp
in dealing with a host of health problems
ranging from diarrhoeal disease60 to diabetes
management61. Yet, neither the nurse in Niger’s
rural health centre nor the general practitioner
in Belgium can, for example, refer a patient to
hospital without negotiating62,63: along with medical
criteria, they have to take into account the
patient’s values, the family’s values, and their
lifestyle and life perspective64.
Few health providers have been trained for
person-centred care. Lack of proper preparation
is compounded by cross-cultural confl icts, social
stratifi cation, discrimination and stigma63. As a
consequence, the considerable potential of people
to contribute to their own health through lifestyle,
behaviour and self-care, and by adapting
Table 3.2 Person-centredness: evidence of its
contribution to quality of care and better outcomes
Improved treatment intensity and quality of life − Ferrer
(2005)54
Better understanding of the psychological aspects of a
patient's problems − Gulbrandsen (1997)55
Improved satisfaction with communication −
Jaturapatporn (2007)56
Improved patient confi dence regarding sensitive
problems − Kovess-Masféty (2007)57
Increased trust and treatment compliance − Fiscella
(2004)52
Better integration of preventive and promotive care −
Mead (1982)50
Box 3.3 The health-care response to partner violence against women
Intimate partner violence has numerous well-documented consequences for women’s health (and for the health of their children), including
injuries, chronic pain syndromes, unintended and unwanted pregnancies, pregnancy complications, sexually transmitted infections and
a wide range of mental health problems32,33,34,35,36,37. Women suffering from violence are frequent health-care users 38,39.
Health workers are, therefore, well placed to identify and provide care to the victims of violence, including referral for psychosocial,
legal and other support. Their interventions can reduce the impact of violence on a woman’s health and well-being, and that of her
children, and can also help prevent further violence.
Research has shown that most women think health-care providers should ask about violence40. While they do not expect them to solve
their problem, they would like to be listened to and treated in a non-judgemental way and get the support they need to take control over
their decisions. Health-care providers often fi nd it diffi cult to ask women about violence. They lack the time and the training and skills
to do it properly, and are reluctant to be involved in judicial proceedings.
The most effective approach for health providers to use when responding to violence is still a matter of debate41. They are generally
advised to ask all women about intimate partner abuse as a routine part of any health assessment, usually referred to as “screening”
or routine enquiry42. Several reviews found that this technique increased the rate of identifi cation of women experiencing violence in
antenatal and primary-care clinics, but there was little evidence that this was sustained40, or was effective in terms of health outcomes43.
Among women who have stayed in shelters, there is evidence that those who received a specifi c counselling and advocacy service
reported a lower rate of re-abuse and an improved quality of life44. Similarly, among women experiencing violence during pregnancy,
those who received “empowerment counselling” reported improved functioning and less psychological and non-severe physical abuse,
and had lower postnatal depression scores45.
While there is still no consensus on the most effective strategy, there is growing agreement that health services should aim to identify
and support women experiencing violence46, and that health-care providers should be well educated about these issues, as they are
essential in building capacity and skills. Health-care providers should, as a minimum, be informed about violence against women, its
prevalence and impact on health, when to suspect it and how to best respond. Clearly, there are technical dimensions to this. For example,
in the case of sexual assault, providers need to be able to provide the necessary treatment and care, including provision of emergency
contraception and prophylaxis for sexually transmitted infections, including HIV where relevant, as well as psychosocial support. There
are other dimensions too: health workers need to be able to document any injuries as completely and carefully as possible47,48,49 and
they need to know how to work with communities – in particular with men and boys – on changing attitudes and practices related to
gender inequality and violence.
The World Health Report 2008 Primary Health Care – Now More Than Ever
48
professional advice optimally to their life circumstances
is underutilized. There are numerous,
albeit often missed, opportunities to empower
people to participate in decisions that affect
their own health and that of their families (Box
3.4). They require health-care providers who
can relate to people and assist them in making
informed choices. The current payment systems
and incentives in community health-care delivery
often work against establishing this type of
dialogue65. Confl icts of interest between provider
and patient, particularly in unregulated commercial
settings, are a major disincentive to personcentred
care. Commercial providers may be more
courteous and client-friendly than in the average
health centre, but this is no substitute for personcentredness.
Comprehensive and integrated responses
The diversity of health needs and challenges that
people face does not fi t neatly into the discrete
diagnostic categories of textbook promotive, preventive,
curative or rehabilitative care78,79. They
call for the mobilization of a comprehensive range
of resources that may include health promotion
and prevention interventions as well as diagnosis
and treatment or referral, chronic or long-term
home care, and, in some models, social services80.
It is at the entry point of the system, where people
fi rst present their problem, that the need for a
comprehensive and integrated offer of care is
most critical.
Comprehensiveness makes managerial and
operational sense and adds value (Table 3.3).
People take up services more readily if they know
a comprehensive spectrum of care is on offer.
Moreover, it maximizes opportunities for preventive
care and health promotion while reducing
unnecessary reliance on specialized or hospital
care81. Specialization has its comforts, but the
fragmentation it induces is often visibly counterproductive
and ineffi cient: it makes no sense to
monitor the growth of children and neglect the
health of their mothers (and vice versa), or to treat
someone’s tuberculosis without considering their
HIV status or whether they smoke.
Table 3.3 Comprehensiveness: evidence of its
contribution to quality of care and better outcomes
Better health outcomes − Forrest (1996)82, Chande
(1996)83, Starfi eld (1998)84
Increased uptake of disease-focused preventive care
(e.g. blood pressure screen, mammograms, pap smears)
− Bindman (1996)85
Fewer patients admitted for preventable complications of
chronic conditions − Shea (1992)86
Box 3.4 Empowering users to contribute to their own health
Families can be empowered to make choices that are relevant to their health. Birth and emergency plans66, for example, are based on
a joint examination between the expectant mother and health staff − well before the birth − of her expectations regarding childbirth.
Issues discussed include where the birth will take place, and how support for care of the home and any other children will be organized
while the woman is giving birth. The discussion can cover planning for expenses, arrangements for transport and medical supplies, as
well as identifi cation of a compatible blood donor in case of haemorrhage. Such birth plans are being implemented in countries as diverse
as Egypt, Guatemala, Indonesia, the Netherlands and the United Republic of Tanzania. They constitute one example of how people can
participate in decisions relating to their health in a way that empowers them67. Empowerment strategies can improve health and social
outcomes through several pathways; the condition for success is that they are embedded in local contexts and based on a strong and
direct relationship between people and their health workers68. The strategies can relate to a variety of areas, as shown below:
developing household capacities to stay healthy, make healthy decisions and respond to emergencies �� − France’s self-help organization
of diabetics69, South Africa’s family empowerment and parent training programmes70, the United Republic of Tanzania’s negotiated
treatment plans for safe motherhood71, and Mexico’s active ageing programme72;
�� increasing citizens’ awareness of their rights, needs and potential problems − Chile’s information on entitlements73 and Thailand’s
Declaration of Patients’ Rights74;
�� strengthening linkages for social support within communities and with the health system − support and advice to family caregivers
dealing with dementia in developing country settings75, Bangladesh’s rural credit programmes and their impact on care-seeking
behaviour76, and Lebanon’s neighbourhood environment initiatives77.
49
Chapter 3. Primary care: putting people fi rst
That does not mean that entry-point health
workers should solve all the health problems
that are presented there, nor that all health programmes
always need to be delivered through
a single integrated service-delivery point. Nevertheless,
the primary-care team has to be able
to respond to the bulk of health problems in the
community. When it cannot do so, it has to be
able to mobilize other resources, by referring or
by calling for support from specialists, hospitals,
specialized diagnostic and treatment centres,
public-health programmes, long-term care services,
home-care or social services, or self-help
and other community organizations. This cannot
mean giving up responsibility: the primary-care
team remains responsible for helping people to
navigate this complex environment.
Comprehensive and integrated care for the
bulk of the assorted health problems in the community
is more effi cient than relying on separate
services for selected problems, partly because it
leads to a better knowledge of the population and
builds greater trust. One activity reinforces the
other. Health services that offer a comprehensive
range of services increase the uptake and coverage
of, for example, preventive programmes, such
as cancer screening or vaccination (Figure 3.3).
They prevent complications and improve health
outcomes.
Comprehesive services also facilitate early
detection and prevention of problems, even in the
absence of explicit demand. There are individuals
and groups who could benefi t from care even if
they express no explicit spontaneous demand, as
in the case of women attending the health centres
in Ouallam district, Niger, or people with undiagnosed
high blood pressure or depression. Early
detection of disease, preventive care to reduce
the incidence of poor health, health promotion
to reduce risky behaviour, and addressing social
and other determinants of health all require the
health service to take the initiative. For many
problems, local health workers are the only ones
who are in a position to effectively address problems
in the community: they are the only ones,
for example, in a position to assist parents with
care in early childhood development, itself an
important determinant of later health, well-being
and productivity87. Such interventions require
proactive health teams offering a comprehensive
range of services. They depend on a close and
trusting relationship between the health services
and the communities they serve, and, thus, on
health workers who know the people in their
community88.
Continuity of care
Understanding people and the context in which
they live is not only important in order to provide
a comprehensive, person-centred response,
it also conditions continuity of care. Providers
often behave as if their responsibility starts when
a patient walks in and ends when they leave the
premises. Care should not, however, be limited to
the moment a patient consults nor be confi ned to
the four walls of the consultation room. Concern
for outcomes mandates a consistent and coherent
approach to the management of the patient’s problem,
until the problem is resolved or the risk that
justifi ed follow-up has disappeared. Continuity
of care is an important determinant of effectiveness,
whether for chronic disease management,
reproductive health, mental health or for making
sure children grow up healthily (Table 3.4).
Figure 3.3 More comprehensive health centres have better
vaccination coveragea,b
DPT3 vaccination coverage (%)
Facility performance score
0
20% health centres
with lowest overall
performance
a Total 1227 health centres, covering a population of 16 million people.
b Vaccination coverage was not included in the assessment of overall health-centre
performance across a range of services.
20
40
60
80
100
120
Quintile 2 Quintile 3 Quintile 4 20% health centres
with highest overall
performance
c Includes vaccination of children not belonging to target population.
Democratic Republic of the Congo
(380 health centres, 2004)
Madagascar (534 health centres, 2006)
Weighted average of coverage
in each country quintile
Rwanda (313 health centres, 1999)
c
The World Health Report 2008 Primary Health Care – Now More Than Ever
50
capitation or by fee-for-episode, out-of-pocket
fee-for-service payment is a common deterrent,
not only to access, but also to continuity of care107.
In Singapore, for example, patients were formerly
not allowed to use their health savings account
(Medisave) for outpatient treatment, resulting
in patient delays and lack of treatment compliance
for the chronically ill. This had become so
problematic that regulations were changed. Hospitals
are now encouraged to transfer patients
with diabetes, high blood pressure, lipid disorder
and stroke to registered general practitioners,
with Medisave accounts covering ambulatory
care108.
Other barriers to continuity include treatment
schedules requiring frequent clinic attendance
that carry a heavy cost in time, travel expenses
or lost wages. They may be ill-understood and
patient motivation may be lacking. Patients may
get lost in the complicated institutional environment
of referral hospitals or social services. Such
problems need to be anticipated and recognized
at an early stage. The effort required from health
workers is not negligible: negotiating the modalities
of the treatment schedule with the patients
so as to maximize the chances that it can be
completed; keeping registries of clients with
chronic conditions; and creating communication
channels through home visits, liaison with community
workers, telephonic reminders and text
messages to re-establish interrupted continuity.
These mundane tasks often make the difference
between a successful outcome and a treatment
failure, but are rarely rewarded. They are much
easier to implement when patient and caregiver
have clearly identifi ed how and by whom followup
will be organized.
A regular and trusted provider as
entry point
Comprehensiveness, continuity and person-centredness
are critical to better health outcomes.
They all depend on a stable, long-term, personal
relat ionship (a feature also cal led
“longitudinality”84) between the population and
the professionals who are their entry point to the
health system.
Most ambulatory care in conventional settings
is not organized to build such relationships. The
Table 3.4 Continuity of care: evidence of its
contribution to quality of care and better outcomes
Lower all-cause mortality − Shi (2003)90, Franks
(1998)91, Villalbi (1999)92, PAHO (2005)93
Better access to care − Weinick (2000)94, Forrest
(1998)95
Less re-hospitalization − Weinberger (1996)96
Fewer consultations with specialists − Woodward
(2004)97
Less use of emergency services − Gill (2000)98
Better detection of adverse effects of medical
interventions − Rothwell (2005)99, Kravitz (2004)100
Continuity of care depends on ensuring continuity
of information as people get older, when
they move from one residence to another, or when
different professionals interact with one particular
individual or household. Access to medical
records and discharge summaries, electronic,
conventional or client-held, improves the choice
of the course of treatment and of coordination
of care. In Canada, for example, one in seven
people attending an emergency department had
medical information missing that was very likely
to result in patient harm101. Missing information
is a common cause of delayed care and uptake
of unnecessary services102. In the United States,
it is associated with 15.6% of all reported errors
in ambulatory care103. Today’s information and
communication technologies, albeit underutilized,
gives unprecedented possibilities to
improve the circulation of medical information
at an affordable cost104, thus enhancing continuity,
safety and learning (Box 3.5). Moreover, it is
no longer the exclusive privilege of high-resource
environments, as the Open Medical Record System
demonstrates: electronic health records
developed through communities of practice and
open-source software are facilitating continuity
and quality of care for patients with HIV/AIDS in
many low-income countries105.
Better patient records are necessary but not
suffi cient. Health services need to make active
efforts to minimize the numerous obstacles to
continuity of care. Compared to payment by
51
Chapter 3. Primary care: putting people fi rst
busy, anonymous and technical environment of
hospital outpatient departments, with their many
specialists and sub-specialists, produce mechanical
interactions between nameless individuals
and an institution – not people-centred care.
Smaller clinics are less anonymous, but the care
they provide is often more akin to a commercial
or administrative transaction that starts and
ends with the consultation than to a responsive
problem-solving exercise. In this regard, private
clinics do not perform differently than public
health centres64. In the rural areas of low-income
countries, governmental health centres are usually
designed to work in close relationship with
the community they serve. The reality is often
different. Earmarking of resources and staff for
selected programmes is increasingly leading to
fragmentation109, while the lack of funds, the
pauperization of the health staff and rampant
commercialization makes building such relationships
diffi cult110. There are many examples to the
contrary, but the relationship between providers
and their clients, particularly the poorer ones, is
often not conducive to building relationships of
understanding, empathy and trust62.
Building enduring relationships requires time.
Studies indicate that it takes two to fi ve years
before its full potential is achieved84 but, as the
Alaska health centre mentioned at the beginning
of this chapter shows, it drastically changes the
way care is being provided. Access to the same
team of health-care providers over time fosters
the development of a relationship of trust
between the individual and their health-care provider97,111,112.
Health professionals are more likely
to respect and understand patients they know
Box 3.5 Using information and communication technologies to improve access, quality and
effi ciency in primary care
Information and communication technologies enable people in remote and underserved areas to have access to services and expertise
otherwise unavailable to them, especially in countries with uneven distribution or chronic shortages of physicians, nurses and health
technicians or where access to facilities and expert advice requires travel over long distances. In such contexts, the goal of improved
access to health care has stimulated the adoption of technology for remote diagnosis, monitoring and consultation. Experience in Chile
of immediate transmission of electrocardiograms in cases of suspected myocardial infarction is a noteworthy example: examination
is carried out in an ambulatory setting and the data are sent to a national centre where specialists confi rm the diagnosis via fax or
e-mail. This technology-facilitated consultation with experts allows rapid response and appropriate treatment where previously it
was unavailable. The Internet is a key factor in its success, as is the telephone connectivity that has been made available to all health
facilities in the country.
A further benefi t of using information and communication technologies in primary-care services is the improved quality of care. Healthcare
providers are not only striving to deliver more effective care, they are also striving to deliver safer care. Tools, such as electronic
health records, computerized prescribing systems and clinical decision aids, support practitioners in providing safer care in a range
of settings. For example, in a village in western Kenya, electronic health records integrated with laboratory, drug procurement and
reporting systems have drastically reduced clerical labour and errors, and have improved follow-up care.
As the costs of delivering health care continue to rise, information and communication technologies provide new avenues for personalized,
citizen-centred and home-centred care. Towards this end, there has been signifi cant investment in research and development of
consumer-friendly applications. In Cape Town, South Africa, an “on cue compliance service” takes the names and mobile telephone
numbers of patients with tuberculosis (supplied by a clinic) and enters them into a database. Every half an hour, the on cue server
reads the database and sends personalized SMS messages to the patients, reminding them to take their medication. The technology
is low-cost and robust. Cure and completion rates are similar to those of patients receiving clinic-based DOTS, but at lower cost to
both clinic and patient, and in a way that interferes much less with everyday life than the visits to the clinic106. In the same concept of
supporting lifestyles linked to primary care, network devices have become a key element of an innovative community programme in
the Netherlands, where monitoring and communication devices are built into smart apartments for senior citizens. This system reduces
clinic visits and facilitates living independently with chronic diseases that require frequent checks and adjustment of medications.
Many clinicians who want to promote health and prevent illness are placing high hopes in the Internet as the place to go for health advice
to complement or replace the need to seek the advice of a health professional. New applications, services and access to information
have permanently altered the relationships between consumers and health professionals, putting knowledge directly into people’s
own hands.
The World Health Report 2008 Primary Health Care – Now More Than Ever
52
well, which creates more positive interaction and
better communication113. They can more readily
understand and anticipate obstacles to continuity
of care, follow up on the progress and assess how
the experience of illness or disability is affecting
the individual’s daily life. More mindful of
the circumstances in which people live, they can
tailor care to the specifi c needs of the person and
recognize health problems at earlier stages.
This is not merely a question of building trust
and patient satisfaction, however important these
may be114,115. It is worthwhile because it leads to
better quality and better outcomes (Table 3.5).
People who use the same source of care for most
of their health-care needs tend to comply better
with advice given, rely less on emergency services,
require less hospitalization and are more
satisfi ed with care98 116,117,118. Providers save consultation
time, reduce the use of laboratory tests
and costs95,119,120, and increase uptake of preventive
care121. Motivation improves through the
social recognition built up by such relationships.
Still, even dedicated health professionals will not
seize all these opportunities spontaneously122,123.
The interface between the population and their
health services needs to be designed in a way that
not only makes this possible, but also the most
likely course of action.
Organizing primary-care networks
A health service that provides entry point ambulatory
care for health- and health-related problems
should, thus, offer a comprehensive range
of integrated diagnostic, curative, rehabilitative
and palliative services. In contrast to most conventional
health-care delivery models, the offer
of services should include prevention and promotion
as well as efforts to tackle determinants of
ill-health locally. A direct and enduring relationship
between the provider and the people in the
community served is essential to be able to take
into account the personal and social context of
patients and their families, ensuring continuity
of care over time as well as across services.
In order for conventional health services to
be transformed into primary care, i.e. to ensure
that these distinctive features get due prominence,
they must reorganized. A precondition
is to ensure that they become directly and permanently
accessible, without undue reliance on
out-of-pocket payments and with social protection
offered by universal coverage schemes. But
another set of arrangements is critical for the
transformation of conventional care – ambulatory-
and institution-based, generalist and
specialist – into local networks of primary-care
centres135,136,137,138,139,140 :
bringing care closer �� to people, in settings in
close proximity and direct relationship with
the community, relocating the entry point to
the health system from hospitals and specialists
to close-to-client generalist primary-care
centres;
�� giving primary-care providers the responsibility
for the health of a defi ned population, in its
entirety: the sick and the healthy, those who
choose to consult the services and those who
choose not to do so;
�� strengthening primary-care providers’ role as
coordinators of the inputs of other levels of
care by giving them administrative authority
and purchasing power.
Table 3.5 Regular entry point: evidence of its
contribution to quality of care and better outcomes
Increased satisfaction with services − Weiss (1996)116,
Rosenblatt (1998)117, Freeman (1997)124, Miller (2000)125
Better compliance and lower hospitalization rate − Weiss
(1996)116, Rosenblatt (1998)117, Freeman (1997)124,
Mainous (1998)126
Less use of specialists and emergency services −
Starfi eld (1998)82, Parchman (1994)127, Hurley (1989)128,
Martin (1989)129, Gadomski (1998)130
Fewer consultations with specialists − Hurley (1989)128,
Martin (1989)129
More effi cient use of resources − Forrest (1996)82,
Forrest (1998)95, Hjortdahl (1991)131, Roos (1998)132
Better understanding of the psychological aspects of a
patient's problem − Gulbrandsen (1997)55
Better uptake of preventive care by adolescents − Ryan
(2001)133
Protection against over-treatment − Schoen (2007)134
53
Chapter 3. Primary care: putting people fi rst
Bringing care closer to the people
A fi rst step is to relocate the entry point to the
health system from specialized clinics, hospital
outpatient departments and emergency services,
to generalist ambulatory care in close-to-client
settings. Evidence has been accumulating that
this transfer carries measurable benefi ts in terms
of relief from suffering, prevention of illness and
death, and improved health equity. These fi ndings
hold true in both national and cross-national
studies, even if all of the distinguishing features
of primary care are not fully realized31.
Generalist ambulatory care is more likely or
as likely to identify common life-threatening
conditions as specialist care141,142. Generalists
adhere to clinical practice guidelines to the same
extent as specialists143, although they are slower
to adopt them144,145. They prescribe fewer invasive
interventions146,147,148,149, fewer and shorter
hospitalizations127,133,149 and have a greater focus
on preventive care133,150. This results in lower
overall health-care costs82 for similar health
outcomes146,151,152,153,154,155 and greater patient
satisfaction125,150,156. Evidence from comparisons
between high-income countries shows that higher
proportions of generalist professionals working
in ambulatory settings are associated with
lower overall costs and higher quality rankings157.
Conversely, countries that increase reliance on
specialists have stagnating or declining health
outcomes when measured at the population
level, while fragmentation of care exacerbates
user dissatisfaction and contributes to a growing
divide between health and social services157,158,159.
Information on low- and middle-income countries
is harder to obtain160, but there are indications
that patterns are similar. Some studies estimate
that in Latin America and the Caribbean more
reliance on generalist care could avoid one out of
two hospital admissions161. In Thailand, generalist
ambulatory care outside a hospital context
has been shown to be more patient-centred and
responsive as well as cheaper and less inclined
to over-medicalization162 (Figure 3.4).
The relocation of the entry point into the system
from specialist hospital to generalist ambulatory
care creates the conditions for more comprehensiveness,
continuity and person-centredness.
This amplifi es the benefi ts of the relocation. It
is particularly the case when services are organized
as a dense network of small, close-to-client
service delivery points. This makes it easier to
have teams that are small enough to know their
communities and be known by them, and stable
enough to establish an enduring relationship.
These teams require relational and organizational
capacities as much as the technical competencies
to solve the bulk of health problems
locally.
Responsibility for a well-identifi ed
population
In conventional ambulatory care, the provider
assumes responsibility for the person attending
the consultation for the duration of the consultation
and, in the best of circumstances, that
responsibility extends to ensuring continuity of
care. This passive, response-to-demand approach
fails to help a considerable number of people who
could benefi t from care. There are people who,
for various reasons, are, or feel, excluded from
access to services and do not take up care even
when they are in need. There are people who suffer
illness but delay seeking care. Others present
risk factors and could benefi t from screening or
prevention programmes (e.g. for cervical cancer
or for childhood obesity), but are left out because
they do not consult: preventive services that are
limited to service users often leave out those
most in need163. A passive, response-to-demand
Patients for whom inappropriate investigations were prescribed (%)
0
Public health centre,
general practitioner
(US $ 5.7)b
Figure 3.4 Inappropriate investigations prescribed for simulated patients
presenting with a minor stomach complaint, Thailanda,b,162
a Observation made in 2000, before introduction of Thailand’s universal coverage scheme.
b Cost to the patient, including doctor’s fees, drugs, laboratory and technical investigations.
20
40
60
Private hospital,
outpatient
department (US $ 43.7)b
Public hospital,
outpatient department
(US $15.2)b
Private clinic,
specialist
(US $ 16.4)b
Private clinic,
general practitioner
(US $ 11.1)b
Biopsy
X-ray
Gastroscopy
Gastroscopy + X-ray
The World Health Report 2008 Primary Health Care – Now More Than Ever
54
approach has a second untoward consequence: it
lacks the ambition to deal with local determinants
of ill-health – whether social, environmental or
work-related. All this represents lost opportunities
for generating health: providers that only
assume responsibility for their customers concentrate
on repairing rather than on maintaining
and promoting health.
The alternative is to entrust each primary-care
team with the explicit responsibility for a welldefi
ned community or population. They can then
be held accountable, through administrative measures
or contractual arrangements, for providing
comprehensive, continuous and person-centred
care to that population, and for mobilizing a
comprehensive range of support services – from
promotive through to palliative. The simplest
way of assigning responsibility is to identify the
community served on the basis of geographical
criteria – the classic approach in rural areas. The
simplicity of geographical assignment, however,
is deceptive. It follows an administrative, public
sector logic that often has problems adapting to
the emergence of a multitude of other providers.
Furthermore, administrative geography may not
coincide with sociological reality, especially in
urban areas. People move around and may work
in a different area than where they live, making
the health unit closest to home actually an inconvenient
source of care. More importantly, people
value choice and may resent an administrative
assignment to a particular health unit. Some
countries fi nd geographical criteria of proximity
the most appropriate to defi ne who fi ts in the
population of responsibility, others rely on active
registration or patient lists. The important point
is not how but whether the population is well
identifi ed and mechanisms exist to ensure that
nobody is left out.
Once such explicit comprehensive responsibilities
for the health of a well-identifi ed and defi ned
population are assigned, with the related fi nancial
and administrative accountability mechanisms,
the rules change.
The primary-care �� team has to broaden the
portfolio of care it offers, developing activities
and programmes that can improve outcomes,
but which they might otherwise neglect164. This
sets the stage for investment in prevention and
promotion activities, and for venturing into
areas that are often overlooked, such as health
in schools and in the workplace. It forces the
primary-care team to reach out to and work
with organizations and individuals within the
community: volunteers and community health
workers who act as the liaison with patients or
animate grassroots community groups, social
workers, self-help groups, etc.
�� It forces the team to move out of the four walls
of their consultation room and reach out to
the people in the community. This can bring
signifi cant health benefi ts. For example, largescale
programmes, based on home-visits and
community animation, have been shown to be
effective in reducing risk factors for neonatal
mortality and actual mortality rates. In the
United States, such programmes have reduced
neonatal mortality by 60% in some settings165.
Part of the benefi t is due to better uptake of
effective care by people who would otherwise
remain deprived. In Nepal, for example, the
community dynamics of women’s groups led
to the better uptake of care, with neonatal and
maternal mortality lower than in control communities
by 29% and 80%, respectively166.
�� It forces the team to take targeted initiatives,
in collaboration with other sectors, to reach
the excluded and the unreached and tackle
broader determinants of ill-health. As Chapter
2 has shown, this is a necessary complement to
establishing universal coverage and one where
local health services play a vital role. The 2003
heatwave in western Europe, for example,
highlighted the importance of reaching out to
the isolated elderly and the dramatic consequences
of failing to do so: an excess mortality
of more than 50 000 people167.
For people and communities, formal links with
an identifi able source of care enhance the likelihood
that long-term relationships will develop;
that services are encouraged to pay more attention
to the defi ning features of primary care; and
that lines of communication are more intelligible.
At the same time, coordination linkages can be
formalized with other levels of care – specialists,
hospitals or other technical services – and with
social services.
55
Chapter 3. Primary care: putting people fi rst
The primary-care team as a hub
of coordination
Primary-care teams cannot ensure comprehensive
responsibility for their population without
support from specialized services, organizations
and institutions that are based outside the community
served. In resource-constrained circumstances,
these sources of support will typically
be concentrated in a “fi rst referral level district
hospital”. Indeed, the classic image of a healthcare
system based on PHC is that of a pyramid
with the district hospital at the top and a set of
(public) health centres that refer to the higher
authority.
In conventional settings, ambulatory care professionals
have little say in how hospitals and
specialized services contribute – or fail to contribute
– to the health of their patients, and feel
little inclination to reach out to other institutions
and stakeholders that are relevant to the health
of the local community. This changes if they are
entrusted with responsibility for a defi ned population
and are recognized as the regular point of
entry for that population. As health-care networks
expand, the health-care landscape becomes far
more crowded and pluralistic. More resources
allow for diversifi cation: the range of specialized
services that comes within reach may include
emergency services, specialists, diagnostic
infrastructure, dialysis centres, cancer screening,
environmental technicians, long-term care
institutions, pharmacies, etc. This represents
new opportunities, provided the primary-care
teams can assist their community in making the
best use of that potential, which is particularly
critical to public health, mental health and longterm
care168.
The coordination (or gatekeeping) role this
entails effectively transforms the primary-care
pyramid into a network, where the relations
between the primary-care team and the other
institutions and services are no longer based only
on top-down hierarchy and bottom-up referral,
but on cooperation and coordination (Figure 3.5).
The primary-care team then becomes the mediator
between the community and the other levels
Surgery
Maternity
Figure 3.5 Primary care as a hub of coordination: networking within the community served
and with outside partners173,174
Environmental
health lab
Training Training centre
support
Cancer
screening
centre
Women’s
shelter
Alcoholics
anonymous
Community
mental
health unit
Emergency
department
Specialized care Hospital
Diagnostic services
TB
control
centre
Diabetes clinic
CT
Scan
Cytology
lab
Diagnostic support
Self-help
group
Liaison
community
health worker
Other
Other
Social
services
Specialized NGOs
prevention services
Community
Primary-care team:
continuous,
comprehensive,
person-centred care
Pap smears
Waste disposal
inspection
Mammography
Gender
violence
Alcoholism
Hernia
Placenta
praevia
Traffic
accident
Consultant
Referral for support
multi-drug resistance
Referral for
complications
The World Health Report 2008 Primary Health Care – Now More Than Ever
56
of the health system, helping people navigate the
maze of health services and mobilizing the support
of other facilities by referring patients or
calling on the support of specialized services.
This coordination and mediation role also
extends to collaboration with other types of
organizations, often nongovernmental. These
can provide signifi cant support to local primary
care. They can help ensure that people know what
they are entitled to and have the information to
avoid substandard providers169,170. Independent
ombudsman structures or consumer organizations
can help users handle complaints. Most
importantly, there is a wealth of self-help and
mutual support associations for diabet ics, people
living with handicaps and chronic diseases that
can help people to help themselves171. In the
United States alone, more than fi ve million people
belong to mutual help groups while, in recent
years, civil society organizations dealing with
health and health-related issues, from self-help
to patient’s rights, have been mushrooming in
many low- and middle-income countries. These
groups do much more than just inform patients.
They help people take charge of their own situation,
improve their health, cope better with illhealth,
increase self-confi dence and diminish
over-medicalization172. Primary-care teams can
only be strengthened by reinforcing their linkages
with such groups.
Where primary-care teams are in a position
to take on this coordinator role, their work
becomes more rewarding and attractive, while
the overall effects on health are positive. Reliance
on specialists and hospitalization is reduced by
fi ltering out unnecessary uptake, whereas patient
delay is reduced for those who do need referral
care, the duration of their hospitalization is
shortened, and post-hospitalization follow-up is
improved83,128,129.
The coordination function provides the institutional
framework for mobilizing across sectors to
secure the health of local communities. It is not an
optional extra but an essential part of the remit of
primary-care teams. This has policy implications:
coordination will remain wishful thinking unless
the primary-care team has some form of either
administrative or fi nancial leverage. Coordination
also depends on the different institutions’
recognition of the key role of the primary-care
teams. Current professional education systems,
career structure and remuneration mechanisms
most often give signals to the contrary. Reversing
these well-entrenched disincentives to primary
care requires strong leadership.
Monitoring progress
The switch from conventional to primary care is
a complex process that cannot be captured in a
single, universal metric. Only in recent years has
it been possible to start disentangling the effects
of the various features that defi ne primary care.
In part, this is because the identifi cation of the
features that make the difference between primary
care and conventional health-care delivery
has taken years of trial and error, and the instruments
to measure them have not been generalized.
This is because these features are never all
put into place as a single package of reforms, but
are the result of a gradual shaping and transformation
of the health system. Yet, for all this
complexity, it is possible to measure progress, as
a complement to the follow-up required for measuring
progress towards universal coverage.
The fi rst dimension to consider is the extent
to which the organizational measures required
to switch to primary care are being put into
place.
Is the predominant t �� ype of fi rst-contact provider
being shifted from specialists and hospitals
to generalist primary-care teams in close
proximity to where the people live?
�� Are primary-care providers being made
responsible for the health of all the members of
a well-identifi ed population: those who attend
health services and those who do not?
�� Are primary-care providers being empowered
to coordinate the various inputs of specialized,
hospital and social services, by strengthening
their administrative authority and purchasing
power?
The second dimension to consider is the extent
to which the distinctive features of primary care
are gaining prominence.
�� Person-centredness: is there evidence of
improvement, as shown by direct observation
and user surveys?
57
Chapter 3. Primary care: putting people fi rst
Comprehensiveness: i �� s the portfolio of primary-
care services expanding and becoming
more comprehensive, reaching the full essential
benefi ts package, from promotion through
to palliation, for all age groups?
�� Continuity: is information for individuals being
recorded over the life-course, and transferred
between levels of care in cases of referral and
to a primary-care unit elsewhere when people
relocate?
�� Regular entry point: are measures taken to
ensure that providers know their clients and
vice versa?
This should provide the guidance to policy-makers
as to the progress they are making with the transformation
of health-care delivery. However, they
do not immediately make it possible to attribute
References
1. People at the centre of health care: harmonizing mind and body, people and systems.
New Delhi, World Health Organization Regional Offi ce for South-East Asia, Manila,
World Health Organization Regional Offi ce for the Western Pacifi c, 2007.
2. Osler W. Aequanimitas. Philadelphia PA, Blakiston, 1904.
3. Eby D. Primary care at the Alaska Native Medical Centre: a fully deployed “new
model” of primary care. International Journal of Circumpolar Health, 2007,
66(Suppl. 1):4−13.
4. Eby D. Integrated primary care. International Journal of Circumpolar Health, 1998,
57(Suppl. 1):665−667.
5. Gottlieb K, Sylvester I, Eby D. Transforming your practice: what matters most. Family
Practice Management, 2008, 15:32−38.
6. Kerssens JJ et al. Comparison of patient evaluations of health care quality in relation
to WHO measures of achievement in 12 European countries. Bulletin of the World
Health Organization, 2004 82:106−114.
7. Bossyns P, Miye M, Van Lerberghe W. Supply-level measures to increase uptake of
family planning services in Niger: the effectiveness of improving responsiveness.
Tropical Medicine and International Health, 2002, 7:383−390.
8. The World Health Report 2000 − Health systems: improving performance. Geneva,
World Health Organization, 2000.
9. Mercer SW, Cawston PG, Bikker AP. Quality in general practice consultations: a
qualitative study of the views of patients living in an area of high socio-economic
deprivation in Scotland. BMC Family Practice, 2007, 8:22.
10. Scherger JE. What patients want. Journal of Family Practice, 2001, 50:137.
11. Sackett DL et al. Evidence based medicine: what it is and what it isn’t. British
Medical Journal, 1996, 312:71–72.
12. Guyatt G, Cook D, Haynes B. Evidence based medicine has come a long way: The
second decade will be as exciting as the fi rst. BMJ, 2004, 329:990−991.
13. Cochrane database of systematic reviews. The Cochrane Library, 2008 (http://www.
cochrane.org, accessed 27 July 2008).
14. Iha A, ed. Summary of the evidence on patient safety: implications for research.
Geneva, World Health Organization, The Research Priority Setting Working Group of
the World Alliance for Patient Safety, 2008.
15. Smith GD, Mertens T. What’s said and what’s done: the reality of sexually
transmitted disease consultations. Public Health, 2004, 118:96–103.
16. Berwick DM. The science of improvement. JAMA, 2008, 299:1182–1184.
17. Donaldson L, Philip P. Patient safety: a global priority. Bulletin of the World Health
Organization, 2004, 82:892−893
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 Health
Care in America, Institute of Medicine, 1999.
19. Reason J. Human error: models and management. BMJ, 2000, 320:768−770.
20. Kripalani S et al. Defi cits in communication and information transfer between
hospital-based and primary care physicians: implications for patient safety and
continuity of care. JAMA, 2007, 297:831−841.
21. Miller MA, Pisani E. The cost of unsafe injections. Bulletin of the World Health
Organization, 1999, 77:808–811.
22. The purpose of a world alliance. Geneva, World Health Organization, World Alliance
for Patient Safety, 2008 (http://www.who.int/patientsafety/worldalliance/alliance/
en/, accessed 28 July 2008).
23. Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA
2008, 299:445−447.
24. Das J, Hammer JS, Kenneth LL. The quality of medical advice in low-income
countries. Washington DC, The World Bank, 2008 (World Bank Policy Research
Working Paper No. 4501; http://ssrn.com/abstract=1089272, accessed 28 Jul
2008).
25. Schoen C et al. Taking the pulse of health care systems: experiences of patients with
health problems in six countries. Health Affairs, 2005 (web exclusive W 5-5 0 9 DOI
10.1377/hlthaff.W5.509).
26. Mekbib TA, Teferi B. Caesarean section and foetal outcome at Yekatit 12 hospital,
Addis Abba, Ethiopia, 1987-1992. Ethiopian Medical Journal, 1994, 32:173−179.
27. Siddiqi S et al. The effectiveness of patient referral in Pakistan. Health Policy and
Planning, 2001, 16:193−198.
28. Sanders D et al. Zimbabwe’s hospital referral system: does it work? Health Policy
and Planning, 1998, 13:359−370.
29. Data reported at World Aids Day Meeting, Antwerp, Belgium, 2000.
30. The World Health Report 2005 − Make every mother and child count. Geneva, World
Health Organization, 2005.
31. Starfi eld B, Shi L, Macinko J. Contributions of primary care to health systems and
health. The Milbank Quarterly, 2005, 83:457−502.
32. Heise L, Garcia-Moreno C. Intimate partner violence. In: Krug EG et al, eds. World
report on violence and health. Geneva, World Health Organization, 2002.
33. Ellsberg M et al. Intimate partner violence and women’s physical and mental health
in the WHO multi-country study on women’s health and domestic violence: an
observational study. Lancet, 2008, 371:1165−1172.
health and social outcomes to specifi c aspects of
the reform efforts. In order to do so, the monitoring
of the reform effort needs to be complemented
with a much more vigorous research agenda. It is
revealing that the Cochrane Review on strategies
for integrating primary-health services in lowand
middle-income countries could identify only
one valid study that took the user’s perspective
into account160. There has been a welcome surge
of research on primary care in high-income countries
and, more recently, in the middle-income
countries that have launched major PHC reforms.
Nevertheless, it is remarkable that an industry
that currently mobilizes 8.6% of the world’s GDP
invests so little in research on two of its most
effective and cost-effective strategies: primary
care and the public policies that underpin and
complement it.
The World Health Report 2008 Primary Health Care – Now More Than Ever
58
Campbell JC. Health consequences of intimate 34. partner violence. Lancet, 2002,
359:1331−1336.
35. Edleson JL. Children’s witnessing of domestic violence. Journal of Interpersonal
Violence, 1996, 14: 839–870.
36. Dube SR et al. Exposure to abuse, neglect, and household dysfunction among adults
who witnessed intimate partner violence as children: implications for health and
social services. Violence and Victims, 2002, 17: 3–17.
37. Åsling-Monemi K et al. Violence against women increases the risk of infant and
child mortality: a case-referent study in Nicaragua. Bulletin of the World Health
Organization, 2003, 81:10−18.
38. Bonomi A et al. Intimate partner violence and women’s physical, mental and social
functioning. American Journal of Preventive Medicine, 2006, 30:458-466.
39. National Centre for Injury Prevention and Control. Costs of intimate partner violence
against women in the United States. Atlanta GA, Centres for Disease Control and
Prevention, 2003.
40. Ramsay J et al. Should health professionals screen women for domestic violence?
Systematic review. BMJ, 2002, 325:314−318.
41. Nelson HD et al. Screening women and elderly adults for family and intimate partner
violence: a review of the evidence for the U.S. Preventive Services Task force.
Annals of Internal Medicine, 2004, 140:387−403.
42. Garcia-Moreno C. Dilemmas and opportunities for an appropriate health-service
response to violence against women. Lancet, 2002, 359:1509−1514.
43. Wathan NC, MacMillan HL. Interventions for violence against women. Scientifi c
review. JAMA, 2003, 289:589−600.
44. Sullivan CM, Bybee DI. Reducing violence using community-based advocacy for
women with abusive partners. Journal of Consulting and Clinical Psychology, 1999,
67:43−53.
45. Tiwari A et al. A randomized controlled trial of empowerment training for
Chinese abused pregnant women in Hong Kong. British Journal of Obstetrics and
Gynaecology, 2005, 112:1249−1256.
46. Taket A et al. Routinely asking women about domestic violence in health settings.
BMJ, 2003, 327:673−676.
47. MacDonald R. Time to talk about rape. BMJ, 2000, 321:1034−1035.
48. Basile KC, Hertz FM, Back SE. Intimate partner and sexual violence victimization
instruments for use in healthcare settings. 2008. Atlanta GA, Centers for Disease
Control and Prevention, 2008.
49. Guidelines for the medico-legal care of victims of sexual violence. Geneva, World
Health Organization, 2003.
50. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the
empirical literature. Social Science and Medicine, 51:1087−1110.
51. Stewart M. Towards a global defi nition of patient centred care. BMJ, 2001,
322:444−445.
52. Fiscella K et al. Patient trust: is it related to patient-centred behavior of primary care
physicians? Medical Care, 2004, 42:1049−1055.
53. Marincowitz GJO, Fehrsen GS. Caring, learning, improving quality and doing
research: Different faces of the same process. Paper presented at: 11th South
African Family Practice Congress, Sun City, South Africa, August 1998.
54. Ferrer RL, Hambidge SJ, Maly RC. The essential role of generalists in health care
systems. Annals of Internal Medicine, 2005, 142:691−699.
55. Gulbrandsen P, Hjortdahl P, Fugelli P. General practitioners’ knowledge of their
patients’ psychosocial problems: multipractice questionnaire survey. British Medical
Journal, 1997, 314:1014–1018.
56. Jaturapatporn D, Dellow A. Does family medicine training in Thailand affect patient
satisfaction with primary care doctors? BMC Family Practice, 2007, 8:14.
57. Kovess-Masféty V et al. What makes people decide who to turn to when faced with
a mental health problem? Results from a French survey. BMC Public Health, 2007,
7:188.
58. Bergeson D. A systems approach to patient-centred care. JAMA, 2006, 296:23.
59. Kravitz RL et al. Recall of recommendations and adherence to advice among
patients with chronic medical conditions. Archives of Internal Medicine, 1993,
153:1869−1878.
60. Werner D et al. Questioning the solution: the politics of primary health care and child
survival, with an in-depth critique of oral rehydration therapy. Palo Alto CA, Health
Wrights, 1997.
61. Norris et al. Increasing diabetes self-management education in community settings.
A systematic review. American Journal of Preventive Medicine, 2002, 22:39−66.
62. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as
constraints to referral by isolated nurses in rural Niger. Human Resources for Health,
2004, 2:1.
63. Willems S et al. Socio-economic status of the patient and doctor-patient
communication: does it make a difference. Patient Eucation and Counseling, 2005,
56:139−146.
64. Pongsupap Y. Introducing a human dimension to Thai health care: the case for family
practice. Brussels, Vrije Universiteit Brussel Press. 2007.
65. Renewing primary health care in the Americas. A Position paper of the Pan American
Health Organization. Washington DC, Pan American Health Organization, 2007.
66. Penny Simkin, PT. Birth plans: after 25 years, women still want to be heard.
Birth, 34:49–51.
67. Portela A, Santarelli C. Empowerment of women, men, families and communities:
true partners for improving maternal and newborn health. British Medical Bulletin,
2003, 67:59−72.
68. Wallerstein N. What is the evidence on effectiveness of empowerment to improve
health? Copenhagen, World Health Organization Regional Offi ce for Europe 2006
(Health Evidence Network report; (http://www.euro.who.int/Document/E88086.pdf,
accessed 21-11-07).
69. Diabète-France.com − portail du diabète et des diabetiques en France, 2008 (http://
www.diabete-france.com, accessed 30 July 2008).
70. Barlow J, Cohen E, Stewart-Brown SSB. Parent training for improving maternal
psychosocial health. Cochrane Database of Systematic Reviews,2003,
(4):CD002020.
71. Ahluwalia I. An evaluation of a community-based approach to safe motherhood in
northwestern Tanzania. International Journal of Gynecology and Obstetrics, 2003,
82:231.
72. De la Luz Martínez-Maldonado M, Correa-Muñoz E, Mendoza-Núñez VM. Program
of active aging in a rural Mexican community: a qualitative approach. BMC Public
Health, 2007, 7:276 (DOI:10.1186/1471-2458-7-276).
73. Frenz P. Innovative practices for intersectoral action on health: a case study of four
programs for social equity. Chilean case study prepared for the CSDH. Santiago,
Ministry of Health, Division of Health Planning, Social Determinants of Health
Initiative, 2007.
74. Paetthayasapaa. Kam Prakard Sitti Pu Paui, 2003? (http://www.tmc.or.th/,
accessed 30 July 2008).
75. Prince M, Livingston G, Katona C. Mental health care for the elderly in low-income
countries: a health systems approach. World Psychiatry, 2007, 6:5−13.
76. Nanda P. Women’s participation in rural credit programmes in Bangladesh and their
demand for formal health care: is there a positive impact? Health Economics, 1999,
8:415−428.
77. Nakkash R et al. The development of a feasible community-specifi c cardiovascular
disease prevention program: triangulation of methods and sources. Health Education
and Behaviour, 2003, 30:723−739.
78. Stange KC. The paradox of the parts and the whole in understanding and improving
general practice. International Journal for Quality in Health Care, 2002, 14:267−268.
79. Gill JM. The structure of primary care: framing a big picture. Family Medicine, 2004,
36:65−68.
80. Pan-Canadian Primary Health Care Indicator Development Project. Pan-Canadian
primary health care indicators, Report 1, Volume 1. Ottawa, Canadian Institute for
Health Information 2008 (http:www.cihi.ca).
81. Bindman AB et al. Primary care and receipt of preventive services. Journal of
General Internal Medicine, 1996, 11:269−276.
82. Forrest CB, Starfi eld B. The effect of fi rst-contact care with primary care clinicians
on ambulatory health care expenditures. Journal of Family Practice, 1996,
43:40–48.
83. Chande VT, Kinane JM. Role of the primary care provider in expediting children
with acute appendicitis. Achives of Pediatrics and Adolescent Medicine, 1996,
150:703−706.
84. Starfi eld B. Primary care: balancing health needs, services, and technology. New
York, Oxford University Press 1998.
85. Bindman AB et al. Primary care and receipt of preventive services. Journal of
General Internal Medicine, 1996, 11:269–276.
86. Shea S et al. Predisposing factors for severe, uncontrolled hypertension in an innercity
minority population. New England Journal of Medicine, 1992, 327:776–781.
87. Galobardes B, Lynch JW, Davey Smith G. Is the association between childhood
socioeconomic circumstances and cause-specifi c mortality established? Update
of a systematic review. Journal of Epidemiology and Community Health, 2008,
62:387−390.
88. Guide to clinical preventive services, 2007. Rockville MD, Agency for Healthcare
Research and Quality, 2007 (AHRQ Publication No. 07-05100; http://www.ahrq.gov/
clinic/pocketgd.htm).
89. Porignon D et al. Comprehensive is effective: vaccination coverage and health system
performance in Sub-Saharan Africa, 2008 (forthcoming).
90. Shi L et al. The relationship between primary care, income inequality, and mortality
in the United States, 1980–1995. Journal of the American Board of Family Practice,
2003, 16:412–422.
91. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians.
Health care expenditures and mortality experience. Journal of Family Practice, 1998,
47:105–109.
92. Villalbi JR et al. An evaluation of the impact of primary care reform on health.
Atenci´on Primaria, 1999, 24:468–474.
59
Chapter 3. Primary care: putting people fi rst
93. Regional core health data initiative. Washington DC, Pan American Health
Organization, 2005 (http://www.paho.org/English/SHA/coredata/tabulator/
newTabulator.htm).
94. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care.
American Journal of Public Health, 2000, 90:1771–1774.
95. Forrest CB, Starfi eld B. Entry into primary care and continuity: the effects of access.
American Journal of Public Health, 1998, 88:1330–1336.
96. Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care
reduce hospital readmissions? For The Veterans Affairs Cooperative Study Group on
Primary Care and Hospital Readmission. New England Journal of Medicine, 1996,
334:1441–1447.
97. Woodward CA et al. What is important to continuity in home care? Perspectives of
key stakeholders. Social Science and Medicine, 2004, 58:177–192.
98. Gill JM, Mainous AGI, Nsereko M. The effect of continuity of care on emergency
department use. Archives of Family Medicine, 2000, 9:333−338.
99. Rothwell P. Subgroup analysis in randomised controlled trials: importance,
indications, and interpretation, Lancet, 2005, 365:176−186.
100. Kravitz RL, Duan N, Braslow J. Evidence-based medicine, heterogeneity of
treatment effects, and the trouble with averages. The Milbank Quarterly, 2004,
82:661–687.
101. Stiell A. et al. Prevalence of information gaps in the emergency department and
the effect on patient outcomes. Canadian Medical Association Journal, 2003,
169:1023−1028.
102. Smith PC et al. Missing clinical information during primary care visits. JAMA, 2005,
293:565−571.
103. Elder NC, Vonder Meulen MB, Cassedy A. The identifi cation of medical errors
by family physicians during outpatient visits. Annals of Family Medicine, 2004,
2:125−129.
104. Elwyn G. Safety from numbers: identifying drug related morbidity using electronic
records in primary care. Quality and Safety in Health Care, 2004, 13:170−171.
105. Open Medical Records System (OpenMRS) [online database]. Cape Town, South
African Medical Research Council, 2008 (http://openmrs.org/wiki/OpenMRS,
accessed 29 July 2008).
106. Hüsler J, Peters T. Evaluation of the On Cue Compliance Service pilot: testing
the use of SMS reminders in the treatment of tuberculosis in Cape Town, South
Africa. Prepared for the City of Cape Town Health Directorate and the International
Development Research Council (IDRC). Cape Town, Bridges Organization, 2005.
107. Smith-Rohrberg Maru D et al. Poor follow-up rates at a self-pay northern Indian
tertiary AIDS clinic. International Journal for Equity in Health, 2007, 6:14.
108. Busse R, Schlette S, eds. Focus on prevention, health and aging, and health
professions. Gütersloh, Verlag Bertelsmann Stiftung, 2007 (Health policy
developments 7/8).
109. James Pfeiffer International. NGOs and primary health care in Mozambique:
the need for a new model of collaboration. Social Science and Medicine, 2003,
56:725–738.
110. Jaffré Y, Olivier de Sardan J-P. Une médecine inhospitalière. Les diffi ciles relations
entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest. Paris, Karthala,
2003.
111. Naithani S, Gulliford M, Morgan M. Patients’ perceptions and experiences of
“continuity of care” in diabetes. Health Expectations, 2006, 9:118−129.
112. Schoenbaum SC. The medical home: a practical way to improve care and cut costs.
Medscape Journal of Medicine , 2007, 9:28.
113. Beach MC. Are physicians’ attitudes of respect accurately perceived by patients
and associated with more positive communication behaviors? Patient Education and
Counselling, 2006, 62:347−354 (Epub 2006 Jul 21).
114. Farmer JE et al. Comprehensive primary care for children with special health care
needs in rural areas. Pediatrics, 2005, 116:649−656.
115. Pongsupap Y, Van Lerberghe W. Patient experience with self-styled family practices
and conventional primary care in Thailand. Asia Pacifi c Family Medicine Journal,
2006, Vol 5.
116. Weiss LJ, Blustein J. Faithful patients: the effect of long term physician–patient
relationships on the costs and use of health care by older Americans. American
Journal of Public Health, 1996, 86:1742–1747.
117. Rosenblatt RL et al. The generalist role of specialty physicians: is there a hidden
system of primary care? JAMA,1998, 279:1364−1370.
118. Kempe A et al. Quality of care and use of the medical home in a state-funded
capitated primary care plan for low-income children. Pediatrics, 2000,
105:1020−1028.
119. Raddish MS et al. Continuity of care: is it cost effective? American Journal of
Managed Care, 1999, 5:727−734.
120. De Maeseneer JM et al. Provider continuity in family medicine: does it make a
difference for total health care costs? Annals of Family Medicine, 2003, 1:131−133.
121. Saver B. Financing and organization fi ndings brief. Academy for Research and Health
Care Policy, 2002, 5:1−2.
122. Tudiver F, Herbert C, Goel V. Why don’t family physicians follow clinical practice
guidelines for cancer screening? Canadian Medical Association Journal, 1998,
159:797−798.
123. Oxman AD et al. No magic bullets: a systematic review of 102 trials of interventions
to improve professional practice. Canadian Medical Association Journal, 1995,
153:1423−1431.
124. Freeman G, Hjortdahl P. What future for continuity of care in general practice? British
Medical Journal, 1997, 314: 1870−1873.
125. Miller MR et al. Parental preferences for primary and specialty care collaboration
in the management of teenagers with congenital heart disease. Pediatrics, 2000,
106:264−269.
126. Mainous AG III, Gill JM. The importance of continuity of care in the likelihood of
future hospitalization: is site of care equivalent to a primary clinician? American
Journal of Public Health, 1998, 88:1539−1541.
127. Parchman ML, Culler SD. Primary care physicians and avoidable hospitalizations.
Journal of Family Practice, 1994, 39:123−128.
128. Hurley RE, Freund DA, Taylor DE. Emergency room use and primary care case
management: evidence from four medicaid demonstration programs. American
Journal of Public Health, 1989, 79: 834−836.
129. Martin DP et al. Effect of a gatekeeper plan on health services use and charges: a
randomized trial. American Journal of Public Health, 1989, 79:1628–1632.
130. Gadomski A, Jenkins P, Nichols M. Impact of a Medicaid Primary Care Provider
and Preventive Care on pediatric hospitalization. Pediatrics, 1998, 101:E1 (http://
pediatrics.aappublications.org/cgi/reprint/101/3/e1, accessed 29 July 2008).
131. Hjortdahl P, Borchgrevink CF. Continuity of care: infl uence of general practitioners’
knowledge about their patients on use of resources in consultations. British Medical
Journal, 1991, 303:1181–1184.
132. Roos NP, Carriere KC, Friesen D. Factors infl uencing the frequency of visits by
hypertensive patients to primary care physicians in Winnipeg. Canadian Medical
Association Journal, 1998, 159:777–783.
133. Ryan S et al. The effects of regular source of care and health need on medical care
use among rural adolescents. Archives of Pediatric and Adolescent Medicine, 2001,
155:184–190.
134. Schoen C et al. Towards higher-performance health systems: adults’ health care
experiences in seven countries, 2007. Health Affairs, 2007, 26:w717−w734.
135. Saltman R, Rico A, Boerma W, eds. Primary 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).
136. Nutting PA. Population-based family practice: the next challenge of primary care.
Journal of Family Practice, 1987, 24:83−88.
137. Strategies for population health: investing in the health of Canadians. Ottawa, Health
Canada, Advisory Committee on Population Health, 1994.
138. Lasker R. Medicine and public health: the power of collaboration. New York, New
York Academy of Medicine, 1997.
139. Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: historical
perspective. Journal of the American Board of Family Practice, 2001,14:54−563.
140. Improving health for New Zealanders by investing in primary health care. Wellington,
National Health Committee, 2000.
141. Provenzale D et al. Gastroenterologist specialist care and care provided by
generalists − an evaluation of effectiveness and effi ciency. American Journal of
Gastroenterology, 2003, 98:21-8.
142. Smetana GW et al. A comparison of outcomes resulting from generalist vs specialist
care for a single discrete medical condition: a systematic review and methodologic
critique. Archives of Internal Medicine, 2007, 167:10−20.
143. Beck CA et al. Discharge prescriptions following admission for acute myocardial
infarction at tertiary care and community hospitals in Quebec. Canadian Journal of
Cardiology, 2001, 17:33−40.
144. Fendrick AM, Hirth RA, Chernew ME. Differences between generalist and specialist
physicians regarding Helicobacter pylori and peptic ulcer disease. American Journal
of Gastroenterology, 1996, 91:1544−1548.
145. Zoorob RJ et al. Practice patterns for peptic ulcer disease: are family physicians
testing for H. pylori? Helicobacter, 1999, 4:243−248.
146. Rose JH et al. Generalists and oncologists show similar care practices and outcomes
for hospitalized late-stage cancer patients. For SUPPORT Investigators (Study to
Understand Prognoses and Preferences for Outcomes and Risks for Treatment).
Medical Care, 2000, 38:1103−1118.
147. Krikke EH, Bell NR. Relation of family physician or specialist care to obstetric
interventions and outcomes in patients at low risk: a western Canadian cohort study.
Canadian Medical Association Journal, 1989, 140:637−643.
148. MacDonald SE, Voaklander K, Birtwhistle RV. A comparison of family physicians’ and
obstetricians’ intrapartum management of low-risk pregnancies. Journal of Family
Practice, 1993, 37:457-462.
149. Abyad A, Homsi R. A comparison of pregnancy care delivered by family physicians
versus obstetricians in Lebanon. Family Medicine, 1993 25:465−470.
The World Health Report 2008 Primary Health Care – Now More Than Ever
60
150. Grunfeld E et al. Comparison of breast cancer patient satisfaction with follow-up
in primary care versus specialist care: results from a randomized controlled trial.
British Journal of General Practice, 1999, 49:705−710.
151. Grunfeld E et al. Randomized trial of long-term follow-up for early-stage breast
cancer: a comparison of family physician versus specialist care. Journal of Clinical
Oncology, 2006, 24:848−855.
152. Scott IA et al. An Australian comparison of specialist care of acute myocardial
infarction. International Journal for Quality in Health Care, 2003, 15:155−161..
153. Regueiro CR et al. A comparison of generalist and pulmonologist care for patients
hospitalized with severe chronic obstructive pulmonary disease: resource intensity,
hospital costs, and survival. For SUPPORT Investigators (Study to Understand
Prognoses and Preferences for Outcomes and Risks of Treatment). American Journal
of Medicine, 1998, 105:366−372.
154. McAlister FA et al. The effect of specialist care within the fi rst year on subsequent
outcomes in 24,232 adults with new-onset diabetes mellitus: population-based
cohort study. Quality and Safety in Health Care, 2007, 16:6−11.
155. Greenfi eld S et al. Outcomes of patients with hypertension and non-insulin
dependent diabetes mellitus treated by different systems and specialties. Results
from the medical outcomes study. Journal of the American Medical Association,
1995, 274:1436−1444.
156. Pongsupap Y, Boonyapaisarnchoaroen T, Van Lerberghe W. The perception of
patients using primary care units in comparison with conventional public hospital
outpatient departments and “prime mover family practices”: an exit survey. Journal
of Health Science, 2005, 14:3.
157. Baicker K, Chandra A. Medicare spending, the physician workforce, and
benefi ciaries’ quality of care. Health Affairs, 2004 (Suppl. web exclusive:
W4-184−197).
158. Shi, L. Primary care, specialty care, and life chances. International Journal of Health
Services, 1994, 24:431−458.
159. Baicker K et al. Who you are and where you live: how race and geography affect
the treatment of Medicare benefi ciaries. Health Affairs, 2004 (web exclusive:
VAR33−V44).
160. Briggs CJ, Garner P. Strategies for integrating primary health services in middle
and low-income countries at the point of delivery. Cochrane Database of Systematic
Reviews, 2006, (3):CD003318.
161. Estudo regional sobre assistencia hospitalar e ambulatorial especializada na America
Latina e Caribe. Washington DC, Pan American Health Organization, Unidad de
Organización de Servicios de Salud, Area de Tecnología y Prestación de Servicios
de Salud, 2004.
162. Pongsupap Y, Van Lerberghe W. Choosing between public and private or between
hospital and primary care? Responsiveness, patient-centredness and prescribing
patterns in outpatient consultations in Bangkok. Tropical Medicine and International
Health, 2006, 11:81−89.
163. Guide to clinical preventive services, 2007. Rockville MD, Agency for Healthcare
Research and Quality, 2007 (AHRQ Publication No. 07-05100; http://www.ahrq.gov/
clinic/pocketgd.htm).
164. Margolis PA et al. From concept to application: the impact of a community-wide
intervention to improve the delivery of preventive services to children. Pediatrics,
2001, 108:E42.
165. Donovan EF et al. Intensive home visiting is associated with decreased risk of infant
death. Pediatrics, 2007, 119:1145−1151.
166. Manandhar D et al. Effect of a participatory intervention with women’s groups on
birth outcomes in Nepal: cluster-randomised controlled trial. Lancet, 364:970−979.
167. Rockenschaub G, Pukkila J, Profi li MC, eds. Towards health security. A discussion
paper on recent health crises in the WHO European Region. Copenhagen, World
Health Organization Regional Offi ce for Europe, 2007
168. Primary care. America’s health in a new era. Washington DC, National Academy
Press Institute of Medicine, 1996.
169. Tableau d’honneur des 50 meilleurs hôpitaux de France. Palmarès des Hôpitaux.
Le Point, 2008 (http://hopitaux.lepoint.fr/tableau-honneur.php, accessed 29 July
2008).
170. Davidson BN, Sofaer S, Gertler P. Consumer information and biased selection in the
demand for coverage supplementing Medicare. Social Science and Medicine, 1992,
34:1023−1034.
171. Davison KP, Pennebaker JW, Dickerson SS. Who talks? The social psychology of
illness support groups. American Psychology, 2000, 55:205−217.
172. Segal SP, Redman D, Silverman C. Measuring clients’ satisfaction with self-help
agencies. Psychiatric Services, 51:1148−1152.
173. Adapted from Wollast E, Mercenier P. Pour une régionalisation des soins. In: Groupe
d'Etude pour une Réforme de la Médecine. Pour une politique de la santé. Bruxelles,
Editions Vie Ouvrière/La Revue Nouvelle, 1971.
174. Criel B, De Brouwere V, Dugas S. Integration of vertical programmes in multi-function
health services. Antwerp, ITGPress, 1997 (Studies in Health Services Organization
and Policy 3).


Public policies
for the public’s health
Public policies in the health sector, together with
those in other sectors, have a huge potential to
secure the health of communities. They represent an important
complement to universal coverage and
service delivery reforms. Unfortunately,
in most societies, this potential is largely
untapped and failures to effectively
engage other sectors are widespread.
Looking ahead at the diverse range of
challenges associated with the growing
importance of ageing, urbanization and
the social determinants of health, there
is, without question, a need for a greater
capacity to seize this potential. That is why a drive for better
public policies – the theme of this chapter – forms a third
pillar supporting the move towards PHC, along with universal
coverage and primary care.
Chapter 4
The importance of effective
public policies for health 64
System policies that are
aligned with PHC goals 66
Public-health policies 67
Towards health
in all policies 69
Understanding the
under-investment 71
Opportunities for
better public policies 73
63
The World Health Report 2008
64
Primary Health Care – Now More Than Ever
The chapter reviews the policies that must be in
place. These are:
systems policies �� – the arrangements that are
needed across health systems’ building blocks
to support universal coverage and effective
service delivery;
�� public-health policies – the specifi c actions
needed to address priority health problems
through cross-cutting prevention and health
promotion; and
�� policies in other sectors – contributions to
health that can be made through intersectoral
collaboration.
The chapter explains how these different public
policies can be strengthened and aligned with
the goals pursued by PHC.
The importance of effective public
policies for health
People want to live in communities and environments
which secure and promote their health1.
Primary care, with universal access and social
protection represent key responses to these
expectations. People also expect their governments
to put into place an array of public policies
that span local through to supra-national level
arrangements, without which primary care and
universal coverage lose much of their impact and
meaning. These include the policies required to
make health systems function properly; to organize
public-health actions of major benefi t to all;
and, beyond the health sector, the policies that
can contribute to health and a sense of security,
while ensuring that issues, such as urbanization,
climate change, gender discrimination or social
stratifi cation are properly addressed.
A fi rst group of critical public policies are
the health systems policies (related to essential
drugs, technology, quality control, human
resources, accreditation, etc.) on which primary
care and universal coverage reforms depend.
Without functional supply and logistics systems,
for example, a primary-care network cannot
function properly: in Kenya, for example, children
are now much better protected against malaria
as a result of local services providing them with
insecticide-treated bednets2. This has only been
possible because the work of primary care was
supported by a national initiative with strong
political commitment, social marketing and
national support for supply and logistics.
Effective public-health policies that address
priority health problems are a second group without
which primary care and universal coverage
reforms would be hindered. These encompass the
technical policies and programmes that provide
guidance to primary-care teams on how to deal
with priority health problems. They also encompass
the classical public-health interventions,
from public hygiene and disease prevention to
health promotion. Some interventions, such as
the fortifi cation of salt with iodine, are only feasible
at the regional, national or, increasingly at
supra-national level. This may be because it is
only at those levels that there is the necessary
authority to decide upon such policies, or because
it is more effi cient to develop and implement
such policies on a scale that is beyond the local
dimensions of primary-care action. Finally, public
policies encompass the rapid response capacity,
in command-and-control mode, to deal with
acute threats to the public’s health, particularly
epidemics and catastrophes. The latter is of the
utmost political importance, because failures
profoundly affect the public’s trust in its health
authorities. The lack of preparedness and uncoordinated
responses of both the Canadian and
the Chinese health systems to the outbreak of
SARS in 2003, led to public outcries and eventually
to the establishment of a national public
health agency in Canada. In China, a similar lack
of preparedness and transparency led to a crisis
in confi dence – a lesson learned in time for subsequent
events3,4.
The third set of policies that is of critical concern
is known as “health in all policies”, which is
based on the recognition that population health
can be improved through policies that are mainly
controlled by sectors other than health5. The
health content of school curricula, industry’s
policy towards gender equality, or the safety
of food and consumer goods are all issues that
can profoundly infl uence or even determine the
health of entire communities, and that can cut
across national boundaries. It is not possible to
address such issues without intensive intersectoral
collaboration that gives due weight to health
in all policies.
65
Chapter 4. Public policies for the public’s health
Better public policies can make a difference
in very different ways. They can mobilize the
whole of society around health issues, as in Cuba
(Box 4.1). They can provide a legal and social environment
that is more or less favourable to health
outcomes. The degree of legal access to abortion,
for example, co-determines the frequency
and related mortality of unsafe abortion6. In
South Africa, a change in legislation increased
women’s access to a broad range of options for
the prevention and treatment of unwanted pregnancy,
resulting in a 91% drop in abortion-related
deaths7. Public policies can anticipate future
problems. In Bangladesh, for example, the death
toll due to high intensity cyclones and fl ooding
was 240 000 people in 1970. With emergency preparedness
and multisectoral risk reduction programmes,
the death toll of comparable or more
severe storms was reduced to 138 000 people in
1991 and 4500 people in 20078,9,10 .
In the 23 developing countries that comprise
80% of the global chronic disease burden, 8.5
million lives could be saved in a decade by a 15%
dietary salt reduction through manufacturers
voluntarily reducing salt content in processed
foods and a sustained mass-media campaign
encouraging dietary change. Implementation of
four measures from the Framework Convention
on Tobacco Control (increased tobacco taxes;
smoke-free workplaces; convention-compliant
packaging, labelling and awareness campaigns
about health risks; and a comprehensive advertising,
promotion, and sponsorship ban) could
save a further 5.5 million lives in a decade11. As is
often the case when considering social, economic
and political determinants of ill-health, improvements
are dependent on a fruitful collaboration
between the health sector and a variety of other
sectors.
Figure 4.1 Deaths attributable to unsafe abortion per 100 000 live births,
by legal grounds for abortiona,12,13
200
To save
the
women’s
life only,
or no grounds
> 200
150
100
50
0
Also to
preserve
health
Also in
cases
of rape
or
incest
Also in
cases
of fetal
impairment
Also for
economic
or
social
reasons
Also on request
aEvery dot represents one country.
Box 4.1 Rallying society’s resources for
health in Cuba14,15,16
In Cuba, average life expectancy at birth is the second highest
in the Americas: in 2006, it was 78 years, and only 7.1 per
1000 children died before the age of fi ve. Educational indicators
for young children are among the best in Latin America.
Cuba has achieved these results despite signifi cant economic
diffi culties – even today, GDP per capita is only I$ 4500. Cuba’s
success in ensuring child welfare refl ects its commitment to
national public-health action and intersectoral action.
The development of human resources for health has been a
national priority. Cuba has a higher proportion of doctors in
the population than any other country. Training for primary
care gives specifi c attention to the social determinants of
health. They work in multidisciplinary teams in comprehensive
primary-care facilities, where they are accountable for the
health of a geographically defi ned population providing both
curative and preventive services. They work in close contact
with their communities, social services and schools, reviewing
the health of all children twice a year with the teachers.
They also work with organizations such as the Federation of
Cuban Women (FMC) and political structures. These contacts
provide them with the means to act on the social determinants
of health within their communities.
Cuban national policy has also prioritized investing in early
child development. There are three non-compulsory preschool
education programmes, which together are taken up
by almost 100% of children under six years of age. In these
programmes, screening for developmental disorders facilitates
early intervention. Children who are identifi ed with special
needs, and their families, receive individual attention through
multidisciplinary teams that contain both health and educational
specialists. National policy in Cuba has not succumbed
to a false choice between investing in the medical workforce
and acting on the social determinants of health. Instead, it has
promoted intersectoral cooperation to improve health through
a strong preventive approach. In support of this policy, a large
workforce has been trained to be competent in clinical care,
working as an active part of the community it serves.
The World Health Report 2008
66
Primary Health Care – Now More Than Ever
System policies that are
aligned with PHC goals
There is growing awareness that when parts of
the health system malfunction, or are misaligned,
the overall performance suffers. Referred to variously
as “core functions”17 or “building blocks”18,
the components of health systems include infrastructure,
human resources, information, technologies
and fi nancing – all with consequences
for the provision of services. These components
are not aligned naturally or simply with the
intended direction of PHC reforms that promote
primary care and universal coverage: to obtain
that alignment requires deliberate and comprehensive
policy arrangements.
Experience in promoting essential medicines
has shed light on both the opportunities and
obstacles to effective systems policies for PHC.
Since the WHO List of Essential Medicines was
established in 1977, it has become a primary
stimulus to the development of national medicines
policies. Over 75% of the 193 WHO Member
States now claim to have a national list of essential
medicines, and over 100 countries have developed
a national medicine policy. Surveys reveal
that these policies have been effective in making
lower cost and safer medicines available and
more rationally used19,20. This particular policy
has been successfully designed to support PHC,
and it offers lessons on how to handle cross-cutting
challenges of scale effi ciencies and systems
co-dependence. Without such arrangements,
the health costs are enormous: nearly 30 000
children die every day from diseases that could
easily have been treated if they had had access
to essential medicines21.
Medicines policies are indicative of how effi -
ciencies in the scale of organization can be tapped.
Safety, effi cacy and quality of care have universal
properties that make them amenable to globally
agreed international standards. Adoption and
adaptation of these global standards by national
authorities is much more effi cient than each
country inventing its own standards. National
decision-making and purchasing mechanisms
can then guide rational, cost-effectiveness-based
selection of medicines and reduce costs through
bulk purchase. For example, Figure 4.2 shows
how centralized oversight of drug purchasing
and subsidization in New Zealand signifi cantly
improved access to essential medicines while
lowering the average prescription price. On a
larger scale, transnational mechanisms, such as
UNICEF’s international procurement of vaccines,
PAHO’s Revolving Fund and the Global Drug
Facility for tuberculosis treatment, afford considerable
savings as well as quality assurances
that countries on their own would be unlikely to
negotiate22,23,24,25.
A second key lesson of experience with essential
drugs policies is that a policy cannot exist
as an island and expect to be effectively implemented.
Its formulation must identify those other
systems elements, be they fi nancing, information,
infrastructure or human resources, upon which
its implementation is dependent. Procurement
mechanisms for pharmaceuticals, for example,
raise important considerations for systems fi nancing
policies: they are interdependent. Likewise,
human resources issues related to the education
of consumers as well as the training and working
conditions of providers are likely to be key
determinants of the rational use of drugs.
Systems policies for human resources have
long been a neglected area and one of the main
constraints to health systems development27. The
realization that the health MDGs are contingent
on bridging the massive health-worker shortfall
in low-income countries has brought long overdue
attention to a previously neglected area. Furthermore,
the evidence of increasing dependence on
migrant health workers to address shortages in
OECD countries underlines the fact that one country’s
policies may have a signifi cant impact on
another’s. The choices countries make – or fail to
600
500
Net expenditure (NZ$, millions)
0
1993
Figure 4.2 Annual pharmaceutical spending and number of prescriptions
dispensed in New Zealand since the Pharmaceutical Management
Agency was convened in 199326
100
400
200
300
700
Prescriptions (millions)
Average cost
per prescription:
NZ$ 24.3
30
25
0
5
20
10
15
35
Average cost
per prescription:
NZ$ 19.0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
67
Chapter 4. Public policies for the public’s health
make – can have major long-term consequences.
Human resources for health are the indispensable
input to effective implementation of primary
care and universal coverage reforms, and they
are also the personifi cation of the values that
defi ne PHC. Yet, in the absence of a deliberate
choice to guide the health workforce policy by the
PHC goals, market forces within the health-care
system will drive health workers towards greater
sub-specialization in tertiary care institutions,
if not towards migration to large cities or other
countries. PHC-based policy choices, on the other
hand, focus on making staff available for the
extension of coverage to underserved areas and
disadvantaged population groups, as with Malaysia’s
scaling up of 11 priority cadres of workers,
Ethiopia’s training of 30 000 Health Extension
Workers, Zambia’s incentives to health workers
to serve in rural areas, the 80 000 Lady Health
Workers in Pakistan, or the task shifting for the
care of HIV patients. These policies direct investments
towards the establishment of the primarycare
teams that are to be the hub of the PHCbased
health system: the 80 000 health workers
for Brazil’s 30 000 Family Health Teams or the
retraining of over 10 000 nurses and physicians
in Turkey. Furthermore, these policies require
both fi nancial and non-fi nancial incentives to
compete effectively for scarce human resources,
as in the United Kingdom, where measures have
been taken to make a career in primary care
fi nancially competitive with specialization.
The core business of ministries of health
and other public authorities is to put into place,
across the various building blocks of the health
system, the set of arrangements and mechanisms
required to meet their health goals. When a
country chooses to base its health systems on
PHC – when it starts putting into place primary
care and universal coverage reforms – its whole
arsenal of system policies needs to be aligned
behind these reforms: not just those pertaining
to service delivery models or fi nancing. It is possible
to develop system policies that do not take
account of the PHC agenda. It is also possible to
choose to align them to PHC. If a country opts
for PHC, effective implementation allows no half
measures; no health systems building block will
be left untouched.
Public-health policies
Aligning priority health programmes
with PHC
Much action in the health sector is marshalled
around specifi c high-burden diseases, such as
HIV/AIDS, or stages of the life course such as
children – so-called priority health conditions.
The health programmes that are designed around
these priorities are often comprehensive insofar
as they set norms, ensure visibility and quality
assurance, and entail a full range of entry
points to address them locally or at the level of
countries or regions. Responses to these priority
health conditions can be developed in ways that
either strengthen or undercut PHC28.
In 1999 for example, the Primary Care Department
of the Brazilian Paediatrics Society (SBP)
prepared a plan to train its members in the Integrated
Management of Childhood Illness (IMCI)
and to adapt this strategy to regional epidemiological
characteristics29. Despite conducting an
initial training course, the SBP then warned
paediatricians that IMCI was not a substitute for
traditional paediatric care and risked breaching
the basic rights of children and adolescents. In a
next step, it objected to the delegation of tasks to
the nurses, who are part of the multidisciplinary
family health teams, the backbone of Brazil’s PHC
policy. Eventually, the SBP attempted to reclaim
child and adolescent care as the exclusive domain
of paediatricians with the argument that this
ensured the best quality of care.
Experience with priority health programmes
shows that the way they are designed makes the
difference: trying to construct an entire set of
PHC reforms around the unique requirements
of a single disease leads to considerable ineffi -
ciencies. Yet, the reverse is equally true. While
AIDS has been referred to as a metaphor for all
that ails health systems and the wider society30,
the global response to the HIV pandemic can, in
many respects, also be viewed as a pathfi nder for
PHC. From the start, it has had a strong rightsbased
and social justice foundation31. Its links to
often marginalized and disadvantaged high-risk
constituencies, and concerns about stigma, have
led to concerted efforts to secure their rights and
entitlements to employment, social services and
The World Health Report 2008
68
Primary Health Care – Now More Than Ever
health care. Efforts to scale-up services to conform
to the goals of universal access have helped
to expose the critical constraints deriving from
the workforce crisis. The challenge of providing
life-long treatment in resource-constrained
settings has inspired innovations, such as more
effective deployment of scarce human resources
via “task shifting”, the use of “patient advocates”32,
and the unexpected implementation of electronic
health records. Most importantly, the adoption
of a continuum of care approaches for HIV/AIDS
from prevention to treatment to palliation has
helped to revive and reinforce core features of
primary care, such as comprehensiveness, continuity
and person-centredness32.
Countrywide public-health initiatives
While it is essential that primary-care teams
seek to improve the health of populations at local
level, this may be of limited value if national- and
global-level policy-makers fail to take initiatives
for broader, public policy measures, which are
important in changing nutrition patterns and
infl uencing the social determinants of health.
These can rarely be implemented only in the
context of local policies. Classical areas in which
beyond-local-scale public-health interventions
may be benefi cial include: altering individual
behaviours and lifestyles; controlling and preventing
disease; tackling hygiene and the broader
determinants of health; and secondary prevention,
including screening for disease33. This
includes measures such as the fortifi cation of
bread with folate, taxation of alcohol and tobacco,
and ensuring the safety of food, consumer goods
and toxic substances. Such national- and transnational-
scale public-health interventions have the
potential to save millions of lives. The successful
removal of the major risk factors of disease,
which is technically possible, would reduce premature
deaths by an estimated 47% and increase
global healthy life expectancy by an estimated 9.3
years34. However, as is the case for the priority
programmes discussed above, the corresponding
public-health policies must be designed so as to
reinforce the PHC reforms.
Not all such public-health interventions will
improve, for example, equity. Health promotion
efforts that target individual risk behaviours,
such as health education campaigns aimed at
smoking, poor nutrition and sedentary lifestyles,
have often inadvertently exacerbated inequities.
Socioeconomic differences in the uptake of onesize-
fi ts-all public-health interventions have, at
times, not only resulted in increased health inequities,
but also in victim-blaming to explain the
phenomenon35. Well-designed public-health policies
can, however, reduce inequities when they
provide health benefi ts to entire populations or
when they explicitly prioritize groups with poor
health36. The evidence base for privileging public
policies that reduce inequities is increasing, most
notably through the work of the Commission on
Social Determinants of Health (Box 4.2)37.
Rapid response capacity
While PHC reforms emphasize the importance
of participatory and deliberative engagement of
diverse stakeholders, humanitarian disasters
or disease outbreaks demand a rapid response
capacity that is crucial in dealing effectively with
the problem at hand and is an absolute imperative
in maintaining the trust of the population
in their health system. Invoking quarantines or
travel bans, rapidly sequencing the genome of
a new pathogen to inform vaccine or therapeutic
design, and mobilizing health workers and
institutions without delay can be vital. While the
advent of an “emergency” often provides the necessary
good will and fl exibility of these diverse
actors to respond, an effective response is more
likely if there have been signifi cant investments
in preparedness38.
Global efforts related to the threat of pandemic
avian inf luenza (H5N1) provide a number of
interesting insights into how policies that inform
preparedness and response could be guided by
the values of PHC related to equity, universal
coverage and primary-care reforms. In dealing
with seasonal and pandemic infl uenza, 116
national infl uenza laboratories, and fi ve international
collaborating centre laboratories share
infl uenza viruses in a system that was started by
WHO over 50 years ago. The system was implemented
to identify new pandemic virus threats
and inform the optimal annual preparation of a
seasonal infl uenza vaccine that is used primarily
by industrialized countries. With the primarily
69
Chapter 4. Public policies for the public’s health
developing country focus of human zoonotic
infections and the spectre of a global pandemic
associated with H5N1 strains of infl uenza, the
interest in infl uenza now extends to developing
countries, and the long-standing public-private
approach to infl uenza vaccine production and
virus sharing has come under intense scrutiny.
The expectation of developing countries for equitable
access to protection, including affordable
access to anti-virals and vaccines in the event of a
pandemic, is resulting in changes to national and
global capacity strengthening: from surveillance
and laboratories to capacity transfer for vaccine
formulation and production, and capacity for
stock-piling. Thus, the most equitable response
is the most effective response, and the most effective
rapid response capacity can only emerge
from the engagement of multiple stakeholders in
this global process of negotiation.
Towards health in all policies
The health of populations is not merely a product
of health sector activities – be they primary-care
action or countrywide public-health action. It is
to a large extent determined by societal and economic
factors, and hence by policies and actions
that are not within the remit of the health sector.
Changes in the workplace, for example, can have
a range of consequences for health (Table 4.1).
Confronted with these phenomena, the health
authorities may perceive the sector as powerless
to do more than try to mitigate the consequences.
It cannot, of itself, redefi ne labour relations or
unemployment arrangements. Neither can it
increase taxes on alcohol, impose technical
norms on motor vehicles or regulate rural migration
and the development of slums – although all
these measures can yield health benefi ts. Good
urban governance, for example, can lead to 75
years or more of life expectancy, against as few
as 35 years with poor governance39. Thus, it is
important for the health sector to engage with
other sectors, not just in order to obtain collaboration
on tackling pre-identifi ed priority health
problems, as is the case for well-designed publichealth
interventions, but to ensure that health is
recognized as one of the socially valued outcomes
of all policies.
Such intersectoral action was a fundamental
principle of the Alma-Ata Declaration. However,
ministries of health in many countries have struggled
to coordinate with other sectors or wield
infl uence beyond the health system for which
they are formally responsible. A major obstacle
to reaping the rewards of intersectoral action has
been the tendency, within the health sector, to see
such collaboration as “mostly symbolic in trying
to get other sectors to help [health] services”40.
Intersectoral action has often not concentrated
Box 4.2 Recommendations of the
Commission on Social Determinants of
Health37
The Commission on Social Determinants of Health (CSDH)
was a three-year effort begun in 2005 to provide evidencebased
recommendations for action on social determinants to
reduce health inequities. The Commission accumulated an
unprecedented collection of material to guide this process,
drawing from theme-based knowledge networks, civil society
experiences, country partners and departments within WHO.
The fi nal report of the CSDH contains a detailed series of
recommendations for action, organized around the following
three overarching recommendations.
1. Improve daily living conditions
Key improvements required in the well-being of girls and
women; the circumstances in which their children are born,
early child development and education for girls and boys; living
and working conditions; social protection policy; and conditions
for a fl ourishing older life.
2. Tackle the inequitable distribution of power, money and
resources
To address health inequities it is necessary to address inequities
in the way society is organized. This requires a strong
public sector that is committed, capable and adequately
fi nanced. This in turn requires strengthened governance
including stronger civil society and an accountable private
sector. Governance dedicated to pursuing equity is required
at all levels.
3. Measure and understand the problem and assess the impact
of action
It is essential to acknowledge the problem of health inequity
and ensure that it is measured – both within countries and
globally. National and global health equity surveillance systems
for routine monitoring of health inequity and the social determinants
of health are required that also evaluate the health
equity impact of policy and action. Other requirements are the
training of policy-makers and health practitioners, increased
public understanding of social determinants of health, and a
stronger social determinants focus in research.
The World Health Report 2008
70
Primary Health Care – Now More Than Ever
on improving the policies of other sectors, but
on instrumentalizing their resources: mobilizing
teachers to contribute to the distribution
of bednets, police offi cers to trace tuberculosis
treatment defaulters, or using the transport of
the department of agriculture for the emergency
evacuation of sick patients.
A “whole-of-government approach”, aiming for
“health in all policies” follows a different logic41,42.
It does not start from a specifi c health problem
and look at how other sectors can contribute to
solving them – as would be the case, for example,
for tobacco-related disease. It starts by looking
at the effects of agricultural, educational, environmental,
fi scal, housing, transport and other
policies on health. It then seeks to work with
these other sectors to ensure that, while contributing
to well-being and wealth, these policies
also contribute to health5.
Other sector’s public policies, as well as private
sector policies, can be important to health
in two ways.
Some may lead to �� adverse consequences for
health (Table 4.1). Often such adverse consequences
are identifi ed retrospectively, as in the
case of the negative health effects of air pollution
or industrial contamination. Yet, it is also
often possible to foresee them or detect them
at an early stage. Decision-makers in other
sectors may be unaware of the consequences
Table 4.1 Adverse health effects of changing work circumstances5
Adverse health effects
of unemployment
Adverse health effects of
restructuring
Adverse health effects of non-standard
work arrangements
Elevated blood pressure
Increased depression and
anxiety
Increased visits to general
practitioners
Increased symptoms of
coronary disease
Worse mental health and
greater stress
Increased psychological
morbidity and increased
medical visits
Decreased self-reported
health status and an
increase in the number of
health problems
Increase in family
problems, particularly
fi nancial hardships
Reduced job satisfaction, reduced
organizational commitment and
greater stress
Feelings of unfairness in
downsizing process
Survivors face new technologies,
work processes, new physical
and psychological exposures
(reduced autonomy, increased
work intensity, changes in
the characteristics of social
relationships, shifts in the
employment contracts and
changes in personal behaviour)
Changes in the psychological
contract and lost sense of trust
Prolonged stress with
physiological and psychological
signs
Higher rates of occupational injury and disease than
workers with full-time stable employment
High level of stress, low job satisfaction and other
negative health and well-being factors
More common in distributive and personal service
sub-sectors where people in general have lower
educational attainment and low skill levels
Low entitlement to workers’ compensation and low
level of claims by those who are covered
Increased occupational health hazards due to work
intensifi cation motivated by economic pressures
Inadequate training and poor communication caused
by institutional disorganization and inadequate
regulatory control
Inability of workers to organize their own protection
Cumulative trauma claims are diffi cult to show due
to mobility of workers
Reduced ability to improve life conditions due to
inability to obtain credit, fi nd housing, make pension
arrangements, and possibility for training
Fewer concerns for environmental issues and health
and safety at work
71
Chapter 4. Public policies for the public’s health
of the choices they are making, in which case
engagement, with due consideration for the
other sectors’ goals and objectives, may then
be the fi rst step in minimizing the adverse
health effects.
Public policies �� developed by other sectors –
education, gender equality and social inclusion
– may positively contribute to health in ways
that these other sectors are equally unaware
of. They may be further enhanced by more
purposefully pursuing these positive health
outcomes, as an integral part of the policy. For
example, a gender equality policy, developed
in its own right, may produce health benefi ts,
often to a degree that the proponents of the
policy underestimate. By collaborating to give
more formal recognition to these outcomes, the
gender equality policy itself is reinforced, and
the synergies enhance the health outcomes.
In that case, the objective of intersectoral collaboration
is to reinforce the synergies.
Failing to collaborate with other sectors is not
without its consequences. It affects the performance
of health systems and, particularly, primary
care. For example, Morocco’s trachoma
programme relied both on high levels of community
mobilization and on effective collaboration
with the ministries of education, interior and
local affairs. That collaboration has been the key
to the successful elimination of trachoma43. In
contrast, the same country’s tuberculosis control
programme failed to link up with urban development
and poverty reduction efforts and, as a
result, its performance has been disappointing44.
Both were administered by the same Ministry of
Health, by staff with similar capacities working
under similar resource constraints, but with different
strategies.
Failing to collaborate with other sectors has
another consequence, which is that avoidable illhealth
is not avoided. In the NGagne Diaw quarter
of Thiaroye-sur-Mer, Dakar, Senegal, people
make a living from the informal recycling of lead
batteries. This was of little concern to the authorities
until an unexplained cluster of child deaths
prompted an investigation. The area was found to
be contaminated with lead, and the siblings and
mothers of the dead children were found to have
extremely high concentrations of lead in their
blood. Now, major investments are required to
deal with the health and social consequences
and to decontaminate the affected area, including
people’s homes. Before the cluster of deaths
occurred, the health sector had, unfortunately,
not considered it a priority to work with other
sectors to help to avoid this situation45.
Where intersectoral collaboration is successful,
the health benefi ts can be considerable, although
deaths avoided are less readily noticed than lives
lost. For example, pressure from civil society and
professionals led to the development, in France, of
a multi-pronged, high-profi le strategy to improve
road safety as a social and political issue that had
to be confronted (and not primarily as a health
sector issue). Various sectors worked together in a
sustained effort, with high-level political endorsement,
to reduce road-traffic accidents, with
highly publicized monitoring of progress and a
reduction in fatalities of up to 21% per year46.
The health and health equity benefi ts of working
towards health in all policies have become apparent
in programmes such as “Healthy Cities and
Municipalities”, “Sustainable Cities”, and “Cities
Without Slums”, with integrated approaches that
range from engagement in budget hearings and
social accountability mechanisms to data gathering
and environmental intervention47.
In contemporary societies, health tends to
become fragmented into various sub-institutions
dealing with particular aspects of health
or health systems, while the capacity to assemble
the various aspects of public policy that jointly
determine health is underdeveloped. Even in the
well-resourced context of, for example, the European
Union, the institutional basis for doing this
remains poorly developed48. Ministries of health
have a vital role to play in creating such a basis,
which is among the key strategies for making
headway in tackling the socioeconomic determinants
of ill-health49.
Understanding the under-investment
Despite the benefi ts and low relative cost of better
public policies, their potential remains largely
underutilized across the world. One high-profi le
example is that only 5% of the world’s population
live in countries with comprehensive tobacco
The World Health Report 2008
72
Primary Health Care – Now More Than Ever
advertising, promotion and sponsorship bans,
despite their proven effi cacy in reducing health
threats, which are projected to claim one billion
lives this century50.
The health sector’s approach to improving public
policies has been singularly unsystematic and
guided by patchy evidence and muddled decisionmaking
– not least because the health community
has put so little effort into collating and
communicating these facts. For all the progress
that has been made in recent years, information
on the effectiveness of interventions to redress,
for example, health inequities is still hard to come
by and, when it is available, it is confi ned to a
privileged circle of concerned experts. A lack
of information and evidence is, thus, one of the
explanations for under-investment.
Box 4.3 How to make unpopular public policy decisions51
The Seventh Futures Forum of senior health executives organized by the World Health Organization’s Regional Offi ce for Europe in
2004 discussed the diffi culties decision-makers can have in tackling unpopular policy decisions. A popular decision is usually one that
results from broad public demand; an unpopular decision does not often respond to clearly expressed public expectations, but is made
because the minister or the chief medical offi cer knows it is the right action to bring health gains and improve quality. Thus, a potentially
unpopular decision should not seek popularity but, rather, efforts must be made to render it understandable and, therefore, acceptable.
Making decisions more popular is not an academic exercise but one that deals with actual endorsement. When a decision is likely to be
unpopular, participants in the Forum agreed that it is advisable for health executives to apply some of the following approaches.
Talk about health and quality improvement. Health is the core area of expertise and competence, and the explanations of how the
decision will improve the quality of health and health services should therefore come fi rst. Avoiding non-health arguments that are
diffi cult to promote may be useful – for instance, in the case of hospital closures, it is much better to talk about improving quality of
care than about containing costs.
Offer compensation. Explain what people will receive to balance what they will have to give up. Offer some gains in other sectors or in
other services; work to make a win-win interpretation of the coming decision by balancing good and bad news.
Be strong on implementation. If health authorities are not ready to implement the decision, they should refrain from introducing it until
they are ready to do so.
Be transparent. Explain who is taking the decision and the stakes of those involved and those who are affected. Enumerate all the
stakeholders and whether they [are] involved negatively.
Avoid one-shot decisions. Design and propose the decisions as part of an overall plan or strategy.
Ensure good timing. Before making a decision, it is essential to take enough time to prepare and develop a good plan. When the plan
is ready, the best choice may be to act quickly for implementation.
Involve all groups. Bring into the discussion both the disadvantaged groups and the ones who will benefi t from the decision. Diversify
the approach.
Do not expect mass-media support solely because the decision is the right one from the viewpoint of health gains. The mass media
cannot be expected to be always neutral or positive; they may often be brought into the debate by the opponents of the decision. Be
prepared to face problems with the press.
Be modest. Acceptability of the decision is more likely when decision-makers acknowledge in public that there is some uncertainty
about the result and they commit openly to monitoring and evaluating the outcomes. This leaves the door open for adjustments during
the process of implementation.
Be ready for quick changes. Sometimes the feelings of the public change quickly and what was perceived as opposition can turn into
acceptance.
Be ready for crisis and unexpected side-effects. Certain groups of populations can be especially affected by a decision (such as general
practitioners in the case of hospital closures). Public-health decision-makers have to cope with reactions that were not planned.
Stick to good evidence. Public acceptance may be low without being based on any objective grounds. Having good facts is a good way
to shape the debate and avoid resistance.
Use examples from other countries. Decision-makers may look at what is being done elsewhere and explain why other countries deal
with a problem differently; they can use such arguments to make decisions more acceptable in their own country.
Involve health professionals and, above all, be courageous.
73
Chapter 4. Public policies for the public’s health
The fact is, however, that even for wellinformed
political decision-makers, many public
policy issues have a huge potential for unpopularity:
whether it is reducing the number of hospital
beds, imposing seatbelts, culling poultry or
taxing alcohol, resistance is to be expected and
controversy an everyday occurrence. Other decisions
have so little visibility, e.g. measures that
ensure a safe food production chain, that they
offer little political mileage. Consensus on stern
measures may be easy to obtain at a moment
of crisis, but public opinion has a notoriously
short attention span. Politicians often pay more
attention to policies that produce benefi ts within
electoral cycles of two to four years and, therefore,
undervalue efforts where benefi ts, such as
those of environmental protection or early child
development, accrue over a time span of 20 to 40
years. If unpopularity is one intractable disincentive
to political commitment, active opposition
from well-resourced lobbies is another. An obvious
example is the tobacco industry’s efforts to
limit tobacco control. Similar opposition is seen
to the regulation of industrial waste and to the
marketing of food to children. These obstacles
to steering public policy are real and need to be
dealt with in a systematic way (Box 4.3).
Compounding these disincentives to political
commitment is the diffi culty of coordinating
operations across multiple institutions and sectors.
Many countries have limited institutional
capacity to do so and, very often, do not have
enough capable professionals to cope with the
work involved. Crisis management, short-term
planning horizons, lack of understandable
evidence, unclear intersectoral arrangements,
vested interests and inadequate modes of governing
the health sector reinforce the need for comprehensive
policy reforms to realize the potential
of public-health action. Fortunately, there are
promising opportunities to build upon.
Opportunities for better public
policies
Better information and evidence
Although there are strong indications that the
potential gains from better public policies are
enormous, the evidence base on their outcomes
and on their cost-effectiveness is surprisingly
weak52. We know much about the relationship
between certain behaviours – smoking, diet,
exercise, etc. – and health outcomes, but much
less about how to effect behavioural change in a
systematic and sustainable way at population levels.
Even in well-resourced contexts, the obstacles
are many: the time-scale in achieving outcomes;
the complexity of multifactorial disease causation
and intervention effects; the lack of data; the
methodological problems, including the diffi culties
in applying the well-accepted criteria used
in the evaluation of clinical methods; and the
different perspectives of the multiple stakeholders
involved. Infectious disease surveillance is
improving, but information on chronic diseases
and their determinants or on health inequities is
patchy and often lacks systematic focus. Even the
elementary foundations for work on population
health and the collection of statistics on births
and deaths or diseases are defi cient in many
countries (Box 4.4)53.
Over the last 30 years, however, there has been
a quantum leap in the production of evidence for
clinical medicine through collaborative efforts
such as the Cochrane Collaboration and the International
Clinical Epidemiology Network56,57. A
similar advance is possible in the production of
evidence on public policies, although such efforts
are still too tentative compared to the enormous
resources available for research in other areas
of health, e.g. diagnostic and therapeutic medical
technologies. There are, however, signs of progress
in the increasing use of systematic reviews
by policy-makers58,59.
Two tracks offer potential for signifi cantly
strengthening the knowledge base.
Speeding u �� p the organization of systematic
reviews of critical interventions and their
economic evaluation. One way of doing this
is by expanding the remit of existing health
technology assessment agencies to include
the assessment of public-health interventions
and delivery modes, since this would make use
of existing institutional capacities with ringfenced
resources. The emerging collaborative
networks, such as the Campbell Collaboration60,
can play a catalyzing role, exploiting
The World Health Report 2008
74
Primary Health Care – Now More Than Ever
the comparative advantage of scale effi ciency
and international comparisons.
Accelerating t �� he documentation and assessment
of whole-of-government approaches
using techniques that build on the initial
experience with “health impact assessment”
or “health equity impact assessment”
tools61,62,63. Although these tools are still in
development, there is growing demand from
local to supra-national policy-makers for such
analyses (Box 4.5). Evidence of their utility in
infl uencing public policies is building up64,65,66,
and they constitute a strategic way of organizing
more thoughtful cross-sector discussions.
That in itself is an inroad into one of the more
intractable aspects of the use of the available
evidence base: the clear need for more
systematic communication on the potential
health gains to be derived from better public
policies. Decision-makers, particularly in
other sectors, are insuffi ciently aware of the
health consequences of their policies, and of
the potential benefi ts that could be derived
from them. Communication beyond the realm
of the specialist is as important as the production
of evidence and requires far more effective
approaches to the dissemination of evidence
among policy-makers67. Framing population
health evidence in terms of the health impact
of policies, rather than in the classical modes
of communication among health specialists,
has the potential to change radically the type
and quality of policy dialogue.
A changing institutional landscape
Along with lack of evidence, the area where new
opportunities are appearing is in the institutional
capacity for developing public policies that are
aligned with PHC goals. Despite the reluctance,
including from donors, to commit substantial
funds to National Institutes of Public Health
(NIPHs)69, policy-makers rely heavily on them or
Civil registration is both a product of economic and social development,
and a condition for modernization. There has been little
improvement in coverage of vital registration (offi cial recording
of births and deaths) over recent decades (see Figure 4.3).
Almost 40% (48 million) of 128 million global births each year
go uncounted because of
the lack of civil53 registration
systems. The situation
is even worse for deaths
registration. Globally, two
thirds (38 million) of 57 million
annual deaths are not
registered. WHO receives
reliable cause-of-death
statistics from only 31 of
its 193 Member States.
International efforts to
improve vital statistics
infrastructure in developing
countries have been
too limited in size and
scope54. Neither, the global
health community nor the
countries have given the
development of health statistics
and civil registration
systems the same priority
Box 4.4 The scandal of invisibility: where births and deaths are not counted
as health interventions. Within the UN system, civil registration
development has no identifi able home. There are no coordination
mechanisms to tackle the problem and respond to requests
for technical support for mobilizing the necessary fi nancial and
technical resources. Establishing the infrastructure of civil registration
systems to ensure
all births and deaths are
counted requires collaboration
between different
partners in different sectors.
It needs sustained
advocacy, the nurturing
of public trust, supportive
legal frameworks,
incentives, fi nancial support,
human resources
and modernized data
management systems55.
Where it functions well,
vital statistics provide
basic information for priority
setting. The lack of
progress in the registration
of births and deaths
is a major concern for the
design and implementation
of PHC reforms.
100
Percentage of births
and deaths registered
0
Figure 4.3 Percentage of births and deaths recorded in countries with
complete civil registration systems, by WHO region, 1975–2004a
20
40
80
60
1975–84
Africa
Deaths
Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
Africa
Americas
Eastern Mediterranean
Europe
South-East Asia
Western Pacific
Births
1985–94 1995–2004
a Source: adapted from 54.
75
Chapter 4. Public policies for the public’s health
on their functional equivalents. In many countries,
NIPHs have been the primary repositories of
independent technical expertise for public health,
but also, more broadly, for public policies. Some
have a prestigious track record: the Fiocruz in
Brazil, the Instituto de Medicina Tropical “Pedro
Kouri” in Cuba, Kansanterveyslaitos in Finland,
the Centers for Disease Control and Prevention
in the United States, or the National Institute of
Hygiene and Epidemiology in Viet Nam. They
testify to the importance that countries accord
to being able to rely on such capacity69. Increasingly,
however, this capacity is unable to cope
with the multiple new demands for public policies
to protect or promote health. This is leaving
traditional national and global institutes of public
health with an oversized, under-funded mandate,
which poses problems of dispersion and diffi culties
in assembling the critical mass of diversifi ed
and specialized expertise (Figure 4.4).
In the meantime, the institutional landscape
is changing as the capacity for public policy support
is being spread over a multitude of national
and supra-national institutions. The number of
loci of expertise, often specialized in some aspect
of public policy, has increased considerably,
spanning a broad range of institutional forms
including: research centres, foundations, academic
units, independent consortia and think
tanks, projects, technical agencies and assorted
initiatives. Malaysia’s Health Promotion Foundation
Board, New Zealand’s Alcohol Advisory
Box 4.5 European Union impact assessment guidelines68
European Union guidelines suggest that the answers to the following questions can form the basis of an assessment of the impact of
proposed public-health interventions.
Public health and safety
Does the proposed option:
affect the health and safety of individuals or populations, including life expectancy, mortality and morbidity t �� hrough impacts on the
socioeconomic environment, e.g. working environment, income, education, occupation or nutrition?
�� increase or decrease the likelihood of bioterrorism?
�� increase or decrease the likelihood of health risks attributable to substances that are harmful to the natural environment?
�� affect health because of changes in the amount of noise or air, water or soil quality in populated areas?
�� affect health because of changes in energy use or waste disposal?
�� affect lifestyle-related determinants of health such as the consumption of tobacco or alcohol, or physical activity?
�� produce specifi c effects on particular risk groups (determined by age, sex, disability, social group, mobility, region, etc.)?
Access to and effects on social protection, health and educational systems
Does the proposed option:
�� have an impact on services in terms of their quality and access to them?
�� have an effect on the education and mobility of workers (health, education, etc.)?
�� affect the access of individuals to public or private education or vocational and continuing training?
�� affect the cross-border provision of services, referrals across borders and cooperation in border regions?
�� affect the fi nancing and organization of and access to social, health and education systems (including vocational training)?
�� affect universities and academic freedom or self-governance?
20 40 60 80 10
Proportion of institutions surveyed (%)
Evaluation and promotion of coverage
and access to health services
Figure 4.4 Essential public-health functions that 30 national public-health
institutions view as being part of their portfolio69
0
Quality assurance in personal and
population-based health services
Regulation and enforcement
Social participation
and citizen empowerment
Human resource development and training
Reduction of the impact
of disasters on health
Planning and management
Health promotion and prevention programmes
Evaluation and analysis of health status
Public health research
Surveillance, problem investigation,
control of risks and threats to public health
The World Health Report 2008
76
Primary Health Care – Now More Than Ever
Council and Estonia’s Health Promotion Commission
show that funding channels have diversifi ed
and may include research grants and contracts,
government subsidies, endowments, or hypothecated
taxes on tobacco and alcohol sales. This
results in a more complex and diffuse, but also
much richer, network of expertise.
There are important scale effi ciencies to be
obtained from cross-border collaboration on
a variety of public policy issues. For example,
the International Association of National Public
Health Institutes (IANPHI) helps countries to set
up strategies for institutional capacity development70.
In this context, institution building will
have to establish careful strategies for specialization
and complementarity, paying attention to the
challenge of leadership and coordination.
At the same time, this offers perspectives for
transforming the production of the highly diverse
and specialized workforce that better public policies
require. Schools of public health, community
medicine and community nursing have traditionally
been the primary institutional reservoirs for
generating that workforce. However, they produce
too few professionals who are too often focused
on disease control and classical epidemiology,
and are usually ill-prepared for a career of fl exibility,
continuous learning and coordinated
leadership.
The multi-centric institutional development
provides opportunities for a fundamental rethink
of curricula and of the institutional settings
of pre-service education, with on-the-job training
in close contact with the institutions where
the expertise is located and developed71. There
are promising signs of renewal in this regard
in the WHO South-East Asian Region (SEARO)
that should be drawn upon to stimulate similar
thinking and action elsewhere27. The increasing
cross-border exchange of experience and expertise,
combined with a global interest in improving
public policy-making capacity, is creating new
opportunities – not just in order to prepare professionals
in more adequate numbers but, above
all, professionals with a broader outlook and who
are better prepared to address complex public
heath challenges of the future.
Equitable and effi cient global
health action
In many countries, responsibilities for health and
social services are being delegated to local levels. At
the same time, fi nancial, trade, industrial and agricultural
policies are shifting to international level:
health outcomes have to be obtained locally, while
health determinants are being infl uenced at international
level. Countries increasingly align their
public policies with those of a globalized world.
This presents both opportunities and risks.
In adjusting to globalization, fragmented
policy competencies in national governance systems
are fi nding convergence. Various ministries,
including health, agriculture, fi nance, trade and
foreign affairs are now exploring together how
they can best inform pre-negotiation trade positions,
provide input during negotiations, and
weigh the costs and benefi ts of alternative policy
options on health, the economy and the future of
their people. This growing global health “interdependence”
is accompanied by a mushrooming
of activities expressed at the global level. The
challenge is, therefore, to ensure that emerging
networks of governance are adequately inclusive
of all actors and sectors, responsive to local needs
and demands, accountable, and oriented towards
social justice72. The recent emergence of a global
food crisis provides further legitimacy to an input
from the health sector into the evolving global
response. Gradually, a space is opening for the
consideration of health in the trade agreements
negotiated through the World Trade Organization
(WTO). Although implementation has proved
problematic, the fl exibilities agreed at Doha for
provision in the Agreement on Trade-Related
Aspects of Intellectual Property Rights (TRIPS)73
of compulsory licencing of pharmaceuticals are
examples of emerging global policies to protect
health.
There is a growing demand for global norms
and standards as health threats are being shifted
from areas where safety measures are being tightened
to places where they barely exist. Assembling
the required expertise and processes is complex
and expensive. Increasingly, countries are relying
on global mechanisms and collaboration74. This
trend started over 40 years ago with the creation
of the Codex Alimentarius Commission in 1963
77
Chapter 4. Public policies for the public’s health
by the Food and Agriculture Organization (FAO)
and the WHO to coordinate international food
standards and consumer protection. Another
long-standing example is the International Programme
on Chemical Safety, established in 1980
as a joint programme of the WHO, the International
Labour Organization (ILO) and the United
Nations Environment Programme (UNEP). In the
European Union, the construction of health protection
standards is shared between agencies and
applied across Europe. Given the expense and
complexity of drug safety monitoring, many countries
adapt and use the standards of the United
States Food and Drug Administration (FDA). WHO
sets global standards for tolerable levels of many
contaminants. In the meantime, countries must
either undertake these processes themselves or
ensure access to standards from other countries
or international agencies, adapted to their own
context.
The imperative for global public-health action,
thus, places further demands on the capacity and
strength of health leadership to respond to the
need to protect the health of their communities.
Local action needs to be accompanied by the
coordination of different stakeholders and sectors
within countries. It also needs to manage global
health challenges through global collaboration
and negotiation. As the next chapter shows, this
is a key responsibility of the state.
References
1. Sen A. Development as freedom. Oxford, Oxford University Press, 1999.
2. Fegan GW et al. Effect of expanded insecticide-treated bednet coverage on child
survival in rural Kenya: a longitudinal study. Lancet, 2007, 370:1035–1039.
3. Liu Y. China’s public health-care system: facing the challenges. Bulletin of the World
Health Organization, 2004, 82:532–538.
4. Kaufman JA. China’s heath care system and avian infl uenza preparedness. Journal
of Infectious Diseases, 2008, 197(Suppl. 1):S7–S13.
5. Ståhl T et al, eds. Health in all policies: prospects and potentials. Helsinki, Ministry of
Social Affairs and Health, 2006.
6. Berer M. National laws and unsafe abortion: the parameters of change. Reproductive
Health Matters, 2004, 12:1–8.
7. Grimes DA et al. Unsafe abortion: the preventable pandemic. Lancet, 2006,
368:1908–1919.
8. Sommer A, Mosley WH. East Bengal cyclone of November 1970: epidemiological
approach to disaster assessment. Lancet, 1972, 1:1029–1036.
9. Bern C et al. Risk factors for mortality in the Bangladesh cyclone of 1991. Bulletin of
the World Health Organization, 1993, 71:73–78.
10. Chowdhury AM. Personal communication, 2008.
11. Asaria P et al. Chronic disease prevention: health effects and fi nancial costs
of strategies to reduce salt intake and control tobacco use. Lancet, 2007,
370:2044–2053.
12. World abortion policies 2007. New York NY, United Nations, Department of Economic
and Social Affairs, Population Division, 2007 (ST/ESA/SER.A/264, Wallchart).
13. Unsafe abortion. Global and regional estimates of the incidence of unsafe abortion
and associated mortality in 2003, 5th ed. Geneva, World Health Organization, 2007.
14. Maternal health and early childhood development in Cuba. Ottawa, Committee on
Social Affairs, Science and Technology, 2007 (Second Report of the Subcommittee
on Population Health of the Standing Senate).
15. Evans RG. Thomas McKeown, meet Fidel Castro: physicians, population health and
the Cuban paradox. Healthcare Policy, 2008, 3:21–32.
16. Spiegel JM, Yassi A. Lessons from the margins of globalization: appreciating the
Cuban health paradox. Journal of Public Health Policy, 2004, 25:85–110.
17. The World Health Report – Health systems: improving performance. Geneva, World
Health Organization, 2000.
18. Everybody’s business – strengthening health systems to improve health outcomes.
Geneva, World Health Organization, Health Systems Services, 2007.
19. Hogerzeil HV. The concept of essential medicines: lessons for rich countries. BMJ,
2004, 329:1169–1172.
20. Measuring medicine prices, availability, affordability and price components, 2nd ed.
Geneva, Health Action International and World Health Organization, 2008 (http://
www.haiweb.org/medicineprices/, accessed 20 August 2008).
21. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every
year? Lancet, 2003, 361:2226–2234.
22. Supply annual report 2007. Copenhagen, United Nations Children’s Fund Supply
Division, 2008.
23. Tambini G et al. Regional immunization programs as a model for strengthening
cooperation among nations. Revista panamericana de salud pública, 2006,
20:54–59.
24. EPI Revolving Fund: quality vaccines at low cost. EPI Newsletter, 1997, 19:6–7.
25. Matiru R, Ryan T. The global drug facility: a unique, holistic and pioneering approach
to drug procurement and management. Bulletin of the World Health Organization,
2007, 85:348–353.
26. Annual Report. Wellington, Pharmaceutical Management Agency, 2007.
27. The World Health Report 2006 - Working together for health. Geneva, World Health
Organization, 2006.
28. Victora CG et al. Achieving universal coverage with health interventions. Lancet,
2004, 364:1555–1556.
29. Freitas do Amaral JJ et al. Multi-country evaluation of IMCI, Brazil study. Ceará,
Federal University of Ceará, ND.
30. Sontag S. AIDS and its metaphors. New York, NY, Farrar, Straus & Giroux, 1988.
31. Mann JM et al, eds. Health and human rights: a reader. New York NY, Routledge,
1999.
32. Friedman S, Mottiar S. A rewarding engagement? The treatment action campaign
and the politics of HIV/AIDS. Politics and Society, 2005, 33:511–565.
33. Ottawa Charter for Health Promotion. In: First International Conference on Health
Promotion, Ottawa, 21 November 1986. Geneva, World Health Organization,
Department of Human Resources for Health, 1986 (WHO/HPR/HEP/95.1; http://
www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf, accessed 2 July 2008).
34. Ezzati M et al. Comparative risk assessment collaborating group. Estimates of global
and regional potential health gains from reducing multiple major risk factors. Lancet,
2003, 362:271–280..
35. Friel S, Chopra M, Satcher D. Unequal weight: equity oriented policy responses to
the global obesity epidemic. BMJ, 2007, 335:1241–1243.
36. Satcher D, Higginbotham EJ. The public health approach to eliminating disparities in
health. American Journal of Public Health, 2008, 98:400–403.
The World Health Report 2008
78
Primary Health Care – Now More Than Ever
Commission on Social Determinants 37. of Health. Closing the gap in a generation:
health equity through action on the social determinants of health. Final report.
Geneva, World Health Organization, 2008.
38. The World Health Report 2007 – A safer future: global public health security in the
21st century. Geneva, World Health Organization, 2007
39. Satterthwaite D. In pursuit of a healthy urban environment. In: Marcotullkio PJ,
McGranahan G, eds. Scaling urban environmental challenges: from local to global
and back. London, Earthscan, 2007.
40. Taylor CE, Taylor HG. Scaling up community-based primary health care. In: Rohde
J, Wyon J, eds. Community-based health care: lessons from Bangladesh to Boston.
Boston, Management Sciences for Health, 2002.
41. WHO/Public Health Agency Canada Collaborative Project. Improving health equity
through intersectoral action. Geneva, World Health Organization, 2008 (in press).
42. Puska P. Health in all policies. European Journal of Public Health, 2007, 17:328.
43. Chami Y, Hammou J, Mahjour J. Lessons from the Moroccan national trachoma
control programme. Community Eye Health, 2004, 17:59.
44. Dye C et al. The decline of tuberculosis epidemics under chemotherapy: a case
study in Morocco. International Journal of Tuberculosis and Lung Disease, 2007,
11:1225–1231.
45. Senegal: outbreak of lead intoxication in Thiaroye sur Mer 20 June 2008. Geneva,
World Health Organization, 2008 (http://www.who.int/environmental_health_
emergencies/events/Senegal2008/en/index.html, accessed 21 July 2008).
46. Muhlrad N. Road safety management in France: political leadership as a path to
sustainable progress. Paper presented at: Gambit 2004 Road Safety Conference,
Gdansk, April 2004.
47. Our cities, our health, our future: acting on social determinants for health equity in
urban settings. Geneva, World Health Organization, 2007.
48. Koivusalo M. Moving health higher up the European agenda. In: Ståhl T et al, eds.
Health in all policies: prospects and potentials. Helsinki, Ministry of Social Affairs and
Health, 2006:21–40.
49. Gilson L et al. Challenging health inequity through health systems. Geneva, World
Health Organization, 2007.
50. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva,
World Health Organization, 2008.
51. Anaudova A. Seventh Futures Forum on Unpopular Decisions in Public Health.
Copenhagen, World Health Organization Regional Offi ce for Europe, 2005.
52. Allin S et al. Making decisions on public health: a review of eight countries. Geneva,
World Health Organization, European Observatory on Health Systems and Policies,
2004.
53. Setel PW et al. on behalf of the Monitoring of Vital Events (MoVE) writing group. A
scandal of invisibility: making everyone count by counting everyone. Lancet, 2007
(published online: DOI: 10.1016/S0140-6736(07)61307-5).
54. Mahapatra P et al. on behalf of the Monitoring of Vital Events (MoVE) writing group.
Civil registration systems and vital statistics: successes and missed opportunities.
Lancet, 2007 (published online: DOI: 10.1016/S0140-6736(07)61308-7).
55. AbouZahr C et al. on behalf of the Monitoring of Vital Events (MoVE) writing
group. The way forward. Lancet, 2007 (published online: DOI: 10.1016/S0140-
6736(07)61310-5).
56. Volmink J et al. AM. Research synthesis and dissemination as a bridge to knowledge
management: the Cochrane Collaboration. Bulletin of the World Health Organization,
2004, 82:778–783.
57. Halstead SB, Tugwell P, Bennett K. The International Clinical Epidemiology Network
(INCLEN): a progress report. Journal of Clinical Epidemiology, 1991, 44:579–589.
58. Waters E et al. Cochrane Collaboration. Evaluating the effectiveness of public health
interventions: the role and activities of the Cochrane Collaboration. Journal of
Epidemiology and Community Health, 2006, 60:285–289.
59. Sweet M, Moynihan R. Improving population health: the uses of systematic reviews.
New York NY, Milbank Memorial Fund, 2007.
60. Davies P, Boruch R. The Campbell Collaboration does for public policy what
Cochrane does for health. BMJ, 2001, 323:294–295.
61. An idea whose time has come: New opportunities for HIA in New Zealand public
policy and planning. Wellington, Public Health Advisory Committee, 2007.
62. Harris P et al. Health impact assessment: a practical guide. Sydney, University of
New South Wales, 2007.
63. Wismar M et al. Implementing and institutionalizing health impact assessment in
Europe. In: Ståhl T et al, eds. Health in all policies: prospects and potentials. Helsinki,
Ministry of Social Affairs and Health, 2006.
64. Blau J et al. The use of health impact assessment across Europe. In: Ståhl T et
al, eds. Health in all policies: prospects and potentials. Helsinki, Ministry of Social
Affairs and Health, 2006.
65. Dannenberg AL et al. Use of health impact assessment in the US: 27 case studies,
1999–2007. American Journal of Preventive Medicine, 2008, 34:241–256.
66. Wismar M et al, eds. The effectiveness of health impact assessment: scope
and limitations of supporting decision-making in Europe. Geneva, World Health
Organization, 2007.
67. Jewell CJ, Bero LA. Developing good taste in evidence: facilitators of and
hindrances to evidence-informed health policymaking in state government. The
Milbank Quarterly, 2008, 86:177–208.
68. Communication from the Commission on Better Regulation for Growth and Jobs in the
European Union. Brussels, European Commission, 2005 (COM (2005) 97 fi nal).
69. Binder S et al. National public health institutes: contributing to the public good.
Journal of Public Health Policy, 2008, 29:3–21.
70. Framework for the creation and development of national public health institutes.
Helsinki, International Association of National Public Health Institutes, 2007.
71. Khaleghian P, Das Gupta M. Public management and the essential public health
functions. Washington DC, The World Bank, 2004 (World Bank Policy Research
Working Paper 3220).
72. Kickbusch I. A new agenda for health. Perspectives in Health, 2004, 9:8–13.
73. World Trade Organization Declaration on the TRIPS Agreement and Public Health.
Ministerial Conference, 4th Session, Doha, 9–14 November 2001. 2001 (WT/
MIN(01)/DEC/2).
74. Wilk EA van der et al. Learning from our neighbours – cross-national inspiration
for Dutch public health polices: smoking, alcohol, overweight, depression, health
inequalities, youth screening. Bilthoven, National Institute for Public Health and the
Environment, 2008 (RIVM Rapport 270626001; http://www.rivm.nl/bibliotheek/
rapporten/270626001.pdf, accessed 30 July 2008).


Leadership and
effective government
Chapter 5
Governments as brokers for
PHC reform 82
Effective policy dialogue 86
Managing the political
process: from launching
reform to implementing it
92
The preceding chapters have described how health
systems can be transformed to deliver better health
in ways that people value: equitably, people-centred, and with
the knowledge that health authorities administer public-health
functions to secure the well-being of all
communities. These PHC reforms demand
new forms of leadership for health. This
chapter begins by clarifying why the
public sector needs to have a strong role
in leading and steering public health care
reforms, and emphasizes the fact that this
function should be exercised through collaborative models of
policy dialogue with multiple stakeholders, because this is
what people expect and because it is the most effective. It then
considers strategies to improve the effectiveness of reform
efforts and the management of the political processes that
condition them.
81
The World Health Report 2008 Primary Health Care – Now More Than Ever
82
Governments as brokers for
PHC reform
Mediating the social contract
for health
The ultimate responsibility for shaping national
health systems lies with governments. Shaping
does not suggest that governments should − or
even could – reform the entire health sector on
their own. Many different groups have a role to
play: national politicians and local governments,
the health professions, the scientifi c community,
the private sector and civil society organizations,
as well as the global health community. Nevertheless,
the responsibility for health that is entrusted
to government agencies is unique and is rooted
in principled politics as well as in widely held
expectations1.
Politically, the legitimacy of governments and
their popular support depends on their ability to
protect their citizens and play a redistributive
role. The governance of health is among the core
public policy instruments for institutionalized
protection and redistribution. In modern states,
governments are expected to protect health, to
guarantee access to health care and to safeguard
people from the impoverishment that illness can
bring. These responsibilities were progressively
extended, incorporating the correction of market
failures that characterize the health sector2.
Since the beginning of the 20th century, health
protection and health care have progressively
been incorporated as goods that are guaranteed
by governments and are central to the social
contract between the state and its citizens. The
importance of health systems as a key element
of the social contract in modernizing societies is
most acutely evident during reconstruction after
periods of war or disaster: rebuilding health services
counts among the fi rst tangible signs that
society is returning to normal3.
The legitimacy of state intervention is not
only based on social and political considerations.
There are also key economic actors – the
medical equipment industry, the pharmaceutical
industry and the professions – with an interest in
governments taking responsibility for health to
ensure a viable health market: a costly modern
health economy cannot be sustained without risk
sharing and pooling of resources. Indeed, those
countries that spend the most on health are also
those countries with the largest public fi nancing
of the health sector (Figure 5.1).
Even in the United States, its exceptionalism
stems not from lower public expenditure – at 6.9%
of GDP it is no lower than the high-income countries
average of 6.7% – but from its singularly high
additional private expenditure. The persistent
under-performance of the United States health
sector across domains of health outcomes, quality,
access, effi ciency and equity5, explains opinion
polls that show increasing consensus of the
notion of government intervention to secure more
equitable access to essential health care6,7.
A more effective public sector stewardship of
the health sector is, thus, justifi ed on the grounds
of greater effi ciency and equity. This crucial stewardship
role is often misinterpreted as a mandate
for centralized planning and complete administrative
control of the health sector. While some
types of health challenges, e.g. public-health
emergencies or disease eradication, may require
authoritative command-and-control management,
effective stewardship increasingly relies
on “mediation” to address current and future
complex health challenges. The interests of public
authorities, the health sector and the public
are closely intertwined. Over the years, this has
made all the institutions of medical care, such
as training, accreditation, payment, hospitals,
14
12
10
Percentage GDP
0
Low-income
countries,
without India
Figure 5.1 Percentage of GDP used for health, 20054
2
8
4
6
16
External resources
Out-of-pocket expenditure
Other private expenditure
General government expenditure
India Lower
middle-income
countries,
without China
China Upper
middle-income
countries,
without Brazil
Brazil High-income
countries,
without USA
USA
83
Chapter 5. Leadership and effective government
entitlements, etc., the object of intensive bargaining
on how broadly to defi ne the welfare state and
the collective goods that go with it8,9. This means
that public and quasi-public institutions have to
mediate the social contract between institutions
of medicine, health and society10. In high-income
countries today, the health-care system and the
state appear indissolubly bound together. In
low- and middle-income countries, the state has
often had a more visible role, but paradoxically,
one that was less effective in steering the health
sector, particularly when, during the 1980s and
1990s, some countries of them became severely
tested by confl icts and economic recession. This
resulted in their health systems being drawn in
directions quite different from the goals and values
pursued by the PHC movement.
Disengagement and its consequences
In many socialist and post-socialist countries
undergoing economic restructuring, the state
has withdrawn abruptly from its previously predominant
role in health. China’s deregulation of
the health sector in the 1980s, and the subsequent
steep increases in reliance on out-of-pocket
spending, is a case in point and a warning to the
rest of the world11. A spectacular deterioration of
health-care provision and social protection, particularly
in rural areas, led to a marked slowdown
in the increase in life expectancy11,12. This caused
China to re-examine its policies and reassert the
Government’s leadership role − a re-examination
that is far from over (Box 5.1)13.
A similar scenario of disengagement was
observed in many of the countries of central
and eastern Europe and the Commonwealth of
Independent States (CEE-CIS). In the early 1990s,
public expenditure on health declined to levels
that made administering a basic system virtually
impossible. This contributed to a major decline
in life expectancy17. Catastrophic health spending
became a major cause of poverty18. More recently,
funding levels have stabilized or even increased,
but signifi cant improvements in health outcomes
have not followed and socioeconomic inequalities
in health and health-care access are rising.
Evidence and trends related to these rises, as well
as increases in informal payment mechanisms
for health care, indicate that re-engagement is
still insuffi cient.
Elsewhere, but most spectacularly in lowincome
countries and fragile states, the absence
or withdrawal of the state from its responsibilities
for health refl ects broader conditions of
economic stagnation, political and social crisis
and poor governance19. In such conditions, public
leadership has often become dysfunctional and
de-institutionalized20, a weakness that is compounded
by a lack of fi nancial leverage to steer
the health sector. Global development policies
have often added to the diffi culties governments
face in assuming their responsibilities, for at
least two reasons.
�� The global development agenda of the 1980s
and 1990s was dominated by concern for the
problems created by too much state involvement21.
The structural adjustment and downsizing
recipes of these decades still constrain
the reconstruction of leadership capacity
today. Public fi nancing in the poorest countries
became unpredictable, making medium-term
commitments to the growth of the health sector
diffi cult or impossible. Health planning
based on needs became the exception rather
than the rule, since key fi scal decisions were
taken with little understanding of the potential
consequences for the health sector and health
ministries were unable to make an effective
case for prioritizing budget increases22.
�� For decades, the international community’s
health agenda – including that of WHO – has
been structured around diseases and interventions
rather than around the broader challenges
being faced by health systems. While
this agenda has certainly contributed to a
better appreciation of the burden of disease
affecting poor countries, it has also profoundly
infl uenced the structure of governmental and
quasi-governmental institutions in low- and
middle-income countries. The resulting fragmentation
of the governance of the health
sector has diverted attention from important
issues, such as the organization of primary
care, the control of the commercialization of
the health sector and human resources for
health crises.
The World Health Report 2008 Primary Health Care – Now More Than Ever
84
The untoward consequences of this trend are
most marked in aid-dependent countries because
it has shaped the way funds are channelled23.
The disproportionate investment in a limited
number of disease programmes considered as
global priorities in countries that are dependent
on external support has diverted the limited
energies of ministries of health away from their
primary role as mediator in the comprehensive
planning of primary care and the public’s health.
Box 5.1 From withdrawal to re-engagement in China
During the 1980s and 1990s, reduced Government engagement in the health sector exposed increasing numbers of Chinese households
to catastrophic expenditures for health care. As a result, millions of families in both rural and urban areas found themselves unable
to meet the costs and were effectively excluded from health care. In cities, the Government Insurance Scheme (GIS) and Labour
Insurance Scheme (LIS) had previously covered more than half of the population with either full or partial health insurance. However,
the structural weaknesses of these schemes reached critical levels under the impact of accelerating economic change in the 1990s.
The percentage of China’s urban population not covered by any health insurance or health plan rose from 27.3% in 1993 to 44.1% in
199814. By the end of the century, out-of-pocket payments made up more than 60% of health expenditure. This crisis spurred efforts
to invert the trend: pooling and pre-payment schemes were bolstered in 1998 with the introduction of Basic Medical Insurance (BMI)
for urban employees.
Financed through compulsory contributions from workers and employers, the BMI aims to replace the old GIS and LIS systems. The
BMI has aimed for breadth of coverage with a relatively modest depth of benefi ts, linked to fl exibility that can enable the development
of different types of packages according to local needs in the participating municipalities. Structurally, the BMI fund is divided into two
parts: individual savings accounts and social pooling funds. Generally speaking, the fi nancial contribution from an employee’s salary or
wages goes to his or her individual savings account, while the employer’s contribution is split between the individual savings accounts
and the social pooling fund, applying different percentages according to the age group of employees.
Financial resources under the new BMI are pooled at municipal or city level, instead of by individual enterprises, which signifi cantly
strengthens the capacity for risk sharing. Each municipal government has developed its own regulations on the use of the resources
of individual savings accounts and social pooling funds (the two structural parts of the system). The individual savings accounts cover
outpatient services, while the social pooling fund is meant to cover inpatient expenditures14.
Signifi cant diffi culties with the BMI model remain to be ironed out, in particular as regards equity. For example, studies indicate that, in
urban areas, better-off populations have been quicker to benefi t from the provisions of the BMI than households with very low incomes,
while informal sector workers remain on the margins of the scheme. Nonetheless, the BMI has made progress in expanding health
insurance coverage and access to services among China’s urban population, and is instrumental in reversing the deleterious trends of
the 1980s and 1990s and, at the same time, assigning a new, intermediary role to government institutions.
Figure 5.2 Health expenditure in China: withdrawal of the State in the 1980s and 1990s
and recent re-engagement
Percentage of total health expenditure
01965
100
80
60
20
40
Pre-paid private
expenditure
Social security
expenditure
Other general
government
expenditure
Out-of-pocket
expenditure
1978
1979
1980
1997
1998
1999
2000
2001
2002003
2004
2005
2006
1975
1970
1981982
1983
1984
1985
1986
1987
1988
1989
1990
1991992
1993
1994
1995
1996
Sources: 1965 to 197515; 1978 to 199416; 1995 to 20064.
85
Chapter 5. Leadership and effective government
As a result, multiple, fragmented funding streams
and segmented service delivery are leading to
duplication, ineffi ciencies and counterproductive
competition for resources between different
programmes. Consequently, the massive mobilization
of global solidarity has not been able to
offset a growing estrangement between country
needs and global support, and between people’s
expectations for decent care and the priorities set
by their health-sector managers. Moreover, the
growth in aid-fl ow mechanisms and new implementing
institutions has further heightened the
degree of complexity faced by weak government
bureaucracies in donor-dependent countries,
increasing transaction costs for those countries
that can least afford them24. So much effort is
required to respond to international partners’
short-term agendas that little energy is left to deal
with the multiple domestic stakeholders – professions,
civil society organizations, politicians,
and others – where, in the long run, leadership
matters most. As advocates have rightly argued
in recent years, better inter-donor coordination
is not going to solve this problem on its own:
there is also an urgent need for reinvestment in
governance capacity.
Participation and negotiation
The necessary reinvestment in governmental or
quasi-governmental institutions cannot mean
a return to command-and-control health governance.
Health systems are too complex: the
domains of the modern state and civil society are
interconnected, with constantly shifting boundaries25.
Professions play a major role in how health
is governed26, while, as mentioned in Chapter
2, social movements and quasi-governmental
autonomous institutions have become complex
and infl uential political actors27. Patients, professions,
commercial interests and other groups are
organizing themselves in order to improve their
negotiating position and to protect their interests.
Ministries of health are, also, far from homogenous:
individuals and programmes compete for
infl uence and resources, adding to the complexity
of promoting change. Effective mediation in
health must replace overly simplistic management
models of the past and embrace new mechanisms
for multi-stakeholder policy dialogue to work out
the strategic orientations for PHC reforms28.
At the core of policy dialogue is the participation
of the key stakeholders. As countries modernize,
their citizens attribute more value to social
accountability and participation. Throughout the
world, increasing prosperity, intellectual skills
and social connectivity are associated with people’s
rising aspiration to have more say29 in what
happens at their workplaces and in their communities
− hence the importance of people-centredness
and community participation − and in
important government decisions that affect their
lives − hence the importance of involving civil
society in the social debate on health policies30.
Another reason that policy dialogue is so
important is that PHC reforms require a broad
policy dialogue to put the expectations of various
stakeholders in perspective, to weigh up need,
demand and future challenges, and to resolve the
inevitable confrontations such reforms imply31.
Health authorities and ministries of health, which
have a primary role, have to bring together the
decision-making power of the political authorities,
the rationality of the scientifi c community, the
commitment of the professionals, and the values
and resources of civil society32. This is a process
that requires time and effort (Box 5.2). It would
be an illusion to expect PHC policy formation
to be wholly consensual, as there are too many
confl icting interests. However, experience shows
that the legitimacy of policy choices depends less
on total consensus than on procedural fairness
and transparency33,34,35.
Without a structured, participatory policy
dialogue, policy choices are vulnerable to appropriation
by interest groups, changes in political
personnel or donor fi ckleness. Without a social
consensus, it is also much more diffi cult to engage
effectively with stakeholders whose interests
diverge from the options taken by PHC reforms,
including other sectors that compete for society’s
resources; for the “medico-industrial complex”36,
for whom PHC reform may imply a realignment of
their industrial strategy and for vested interests,
such as those of the tobacco or alcohol industries,
where effective PHC reform constitutes a direct
threat.
The World Health Report 2008 Primary Health Care – Now More Than Ever
86
Effective policy dialogue
The institutional capacities to enable a productive
policy dialogue are not a given. They are typically
weak in countries where, by choice or by
default, laissez-faire dominates the approach to
policy formation in health. Even in countries with
mature and well-resourced health systems there
is scope, and need, for more systematic and institutionalized
approaches: negotiation between
health authorities and professional institutions
is often well established, but is much less so with
other stakeholders and usually limited to discussions
on resource allocation for service delivery.
Policy dialogue must be built. How to do that
depends very much on context and background.
Experience from countries that have been able to
accelerate PHC reforms suggests three common
elements of effective policy dialogue:
the importance of �� making information systems
instrumental to PHC reform;
�� systematically harnessing innovations; and
�� sharing lessons on what works.
Information systems to
strengthen policy dialogue
Policy dialogue on PHC reforms needs to be
informed, not just by better data, but also by
information obtained through a departure from
traditional views on the clients, the scope and
the architecture of national health information
systems (Figure 5.3).
Many national health information systems that
are used to inform policy can be characterized as
closed administrative structures through which
there is a limited fl ow of data on resource use,
services and health status. They are often only
used to a limited extent by offi cials at national
and global level when formulating policy reforms,
while little use is made of critical information that
could be extracted from other tools and sources
(census data, household expenditure or opinion
surveys, academic institutions, NGOs, health
insurance agencies, etc.), many of which are
located outside the public system or even outside
the health sector.
Box 5.2 Steering national directions with the help of policy dialogue:
experience from three countries
In Canada, a Commission examining the future of health care drew on inputs from focus group discussions and public hearings. Diverse
stakeholders and groups of the public made clear the value placed by Canadians on equitable access to high-quality care, based on
need and regardless of ability to pay. At the same time, the Commission had to ensure that this debate would be fed by evidence from
top policy experts on the realities of the country’s health system. Of critical importance was the evidence that public fi nancing of
health care not only achieves goals of equity, but also those of effi ciency, in view of the higher administrative costs associated with
private fi nancing. The discussion on values and the relevant evidence were then brought together in a policy report in 2002 that set
out the direction for a responsive, sustainable and publicly funded PHC system, considered to be “the highest expression of Canadians
caring for one another”37. The strong uptake by policy-makers of the Commission’s recommendations refl ects the robustness of the
evidence-informed analysis and public engagement.
In Brazil, the fi rst seven Conferências Nacionais de Saúde, the platform for national policy dialogue in the health sector between 1941
and 1977, had a distinctly top-down and public-sector-only fl avour, with a classic progression from national plans to programmes and
extension of the network of basic health services. The watershed came with the 8th conference in 1980: the number of participants
increased from a few hundred to 4000, from a wide range of constituencies. This and subsequent conferências pursued agendas that
were driven far more than before by values of health democracy, access, quality, humanization of care and social control. The 12th
national conference, in 2003, ushered in a third consolidation phase: 3000 delegates, 80% of them elected, and a focus on health as
a right for all and a duty of the State38.
Thailand went through similar phases. The extension of basic health care coverage by a proactive Ministry of Health, encouraged by
the lobby of the Rural Doctors Association, resulted in the 1992 launch of the Decade of Health Centre Development. After the 1994
economic crisis, ministry offi cials started mobilizing civil society and academia around the universal coverage agenda, convening a
few thousand delegates to the First Health Care Reform Forum in 1997. Liaison with the political world soon followed, with a bold move
towards universal access and social protection known as the “30 Baht policy”39. With the National Health Act of 2007, stakeholder
participation has been institutionalized through a National Health Commission that includes health professionals, civil society members
and politicians.
87
Chapter 5. Leadership and effective government
Routine data from traditional health information
systems fails to respond to the rising demand
for health-related information from a multitude
of constituencies. Citizens need easier access to
their own health records, which should inform
them about the progress being made in their
treatment plans and allow them to participate
in decisions related to their own health and that
of their families and communities. Communities
and civil society organizations need better information
to protect their members’ health, reduce
exclusion and promote equity. Health professionals
need better information to improve the quality
of their work, and to improve coordination and
integration of services. Politicians need information
on how well the health system is meeting
society’s goals and on how public money is being
used.
Information that can be used to steer change
at the policy level is quite different from the
data that most conventional health information
systems currently produce. There is a need to
monitor what the reforms are achieving across
the range of social values and the associated outcomes
that are central to PHC: equity, people-centredness,
protection of the health of communities
and participation. That means asking questions
such as:
is care comprehensive, �� integrated, continuous
and effective?
�� is access guaranteed and are people aware of
what they are entitled to?
�� are people protected against the economic
consequences of ill-health?
�� are authorities effective in ensuring protection
against exclusion from care?
�� are they effective in ensuring protection against
exploitation by commercial providers?
Such questions go well beyond what can be
answered by tracking health outcome indicators,
resource use and service output, which is what
conventional health information systems focus on.
The paradigm shift required to make information
systems instrumental to PHC reform is to refocus
on what is holding up progress in reorienting
the health system. Better identifi cation of priority
health problems and trends is important (and
vital to anticipate future challenges) but, from
a policy point of view, the crucial information is
that which allows identifi cation of the operational
and systemic constraints. In low-income countries
in particular, where planning has long been
structured along epidemiological considerations,
this can provide a new and dynamic basis for
orienting systems development40. The report by
the Bangladesh Health Watch on the state of the
country’s health workforce, for example, identifi
ed such systemic constraints and corresponding
recommendations for the consideration of health
authorities41.
The multiplication of information needs and
users implies that the way health information is
generated, shared and used also has to evolve.
This critically depends on accessibility and transparency,
for example, by making all health-related
information readily accessible via the Internet –
as in Chile, where effective communication was
considered both an outcome
and a motor of their “Regime
of Explicit Health Guarantees”.
PHC reform calls for open and
collaborative models to ensure
that all the best sources of data
are tapped and information
fl ows quickly to those who can
translate it into appropriate
action.
Open and col laborat ive
structures, such as the “Observatories”
or “Equity Gauges”
offer specifi c models of complementing
routine information
From
Figure 5.3 Transforming information systems into instruments for PHC reform
Ministry of health
Multiple users, producers and
stakeholders
Monitor routine data on:
�� morbidity
�� resource usage
�� service production
Information fl owing upwards
within the public sector
hierarchy
�� Produce intelligence to
understand challenges
�� Monitor performance towards
social objectives
�� Identify system constraints
Open knowledge networks
with multiple collaborating
institutions; transparency
essential
To
Clients
Scope
Architecture
The World Health Report 2008 Primary Health Care – Now More Than Ever
88
systems, by directly linking the production and
dissemination of intelligence on health and social
care to policy-making and to the sharing of best
practices42. They refl ect the increasing value
given to cross-agency work, health inequalities
and evidence-based policy-making. They
bring together various constituencies, such as
academia, NGOs, professional associations, corporate
providers, unions, user representatives,
governmental institutions and others, around
a shared agenda of monitoring trends, studies,
information sharing, policy development and
policy dialogue (Box 5.3).
Paradoxically, these open and fl exible confi
gurations provide continuity in settings where
administrative and policy continuity may be
affected by a rapid turnover of decision-makers.
In the Americas, there are observatories that specifi
cally focus on human resource issues in 22
countries. In Brazil, for example, the observatory
is a network of more than a dozen participating
institutions (referred to as “workstations”): university
institutes, research centres and a federal
offi ce, coordinated through a secretariat based
at the Ministry of Health and the Brasilia offi ce
of PAHO44. These networks played a key role in
setting up Brazil’s current PHC initiatives. Such
national and sub-national structures also exist
in various European countries, including France,
Italy and Portugal45. Comparatively autonomous,
such state/non-state multi-stakeholder networks
can cover a wide range of issues and be sensitive
to local agendas. In the United Kingdom, each
regional observatory takes the lead on specifi c
Box 5.3 Equity Gauges: stakeholderholder collaboration to tackle health inequalities43
Equity Gauges are partnerships of multiple stakeholders that organize active monitoring and remedial action around inequity in health
and health care. So far, they have been established in 12 countries on three continents. Some operate at a countrywide level, some
monitor a subset of districts or provinces in a country, a few operate at a regional level and others focus specifi cally on equity within a
city or municipality; nine have a national focus and three work at the municipal level (in Cape Town (South Africa), El Tambo (Ecuador)
and Nairobi (Kenya). The Equity Gauges bring together stakeholders representing a diversity of local contexts, including parliamentarians
and councillors, the media, ministries and departments of health, academic institutions, churches, traditional leaders, women’s
associations, community-based and nongovernmental organizations, local authority organizations and civic groups. Such a diversity of
stakeholders not only encourages wide social and political investment, but also supports capacity development within countries.
Equity Gauges develop an active approach to monitoring and dealing with inequity in health and health care. They move beyond a
mere description or passive monitoring of equity indicators to a set of specifi c actions designed to effect real and sustained change in
reducing unfair disparities in health and health care. This work entails an ongoing set of strategically planned and coordinated actions
that involves a range of different actors who cut across a number of different disciplines and sectors.
The Equity Gauge strategy is explicitly based on three “pillars of action”. Each one is considered to be equally important and essential
to a successful outcome and all three are developed in parallel:
research and monitoring to measure a �� nd describe inequities;
�� advocacy and public participation to promote the use of information to effect change, involving a broad range of stakeholders from
civil society working together in a movement for equity;
�� community involvement to involve poor and marginalized people as active participants in decision-making rather than passive
recipients of measures designed for their benefi t.
The Equity Gauge strategy consists, therefore, of a set of interconnected and overlapping actions – it is not, as the name might suggest,
just a set of measurements. For example, the selection of equity indicators for measurement and monitoring should take account of
the views of community groups and consider what would be useful from an advocacy perspective. In turn, the advocacy pillar relies on
reliable indicators developed by the measurement pillar and may involve community members or public fi gures.
Equity Gauges choose indicators according to the particular needs of the country as well as of the stakeholders. Emphasis is placed,
however, on generating trend data within all Gauges to enable understanding of progress over time. Indicators are measured across a
variety of dimensions of health, including health status; health-care fi nancing and resource allocation; access to health care; and quality
of health care (such as maternal and child health, communicable diseases and trauma). All indicators are disaggregated according to the
“PROGRESS” acronym that describes a broad range of socioeconomic factors often associated with inequities in health determinants:
Place of residence, Religion, Occupation, Gender, Race/ethnicity, Education, Socioeconomic status and Social networks/capital.
89
Chapter 5. Leadership and effective government
issues, such as inequalities, primary care, violence
and health, or the health of older people46.
All cover a wide range of issues of regional
relevance (Table 5.1): they thus institutionalize
the linkages between local developments and
countrywide policy-making.
Strengthening policy dialogue with
innovations from the fi eld
These links between local reality and policy-making
conditions the design and implementation of
PHC reforms. The build up to the introduction of
Thailand’s “30 Baht” universal coverage scheme
provides an example of a deliberate attempt to
infuse policy deliberations with learning from
the fi eld. Leaders of Thailand’s reform process
organized a mutually reinforcing interplay
between policy development at the central level
and “fi eld model development” in the country’s
provinces. Health workers on the periphery and
civil society organizations were given the space
to develop and test innovative approaches to care
delivery, to see how well they met both professional
standards and community expectations
(Figure 5.4). Field model development activities,
which were supported by the Ministry of Health,
were organized and managed at provincial level,
and extensively discussed and negotiated with
provincial contracts. Each province developed its
own strategies to deal with its specifi c problems.
The large amount of fl exibility given to the provinces
in deciding their own work programmes
had the advantage of promoting ownership,
fostering creativity and allowing original ideas
to come forward. It also built local capacities.
The downside to the high level of autonomy of
the provinces was a tendency to multiply initiatives,
making it diffi cult to evaluate the results to
be fed into the policy work in a systematic way.
On balance, however, the diffi culties due to the
locally-driven approach were compensated for
by the positive effects related to reform dynamics
and capacity building. By 2001, nearly half
of Thailand’s 76 provinces were experimenting
with organizational innovation, most of it around
issues of equitable access, local health-care systems
and community health52.
Thailand’s “30 Baht” universal coverage
reform was a bold political initiative to improve
health equity. Its transformation into a concrete
reality was made possible through the accumulated
experience from the fi eld and through the
alliances the fi eldwork had built between health
workers, civil society organizations and the public.
When the scheme was launched in 2001, these
provinces were ready to pilot and implement the
Table 5.1 Roles and functions of public-health
observatories in England42
Roles Functionsa
Monitoring health and
disease trends and
highlighting areas for
action
Study on the inequalities existing
in coronary heart disease, together
with recommendations for action47
Identifying gaps in
health information
Study of current information sources
and gaps on perinatal and infant
health48
Advising on methods
for health and health
inequality impact
assessment
Overview of health impact
assessment49
Drawing together
information from
different sources in
new ways to improve
health
Health profi le using housing and
employment data alongside health
data50
Carrying out projects
to highlight particular
health issues
A study of the dental health of fi veyear-
olds in the Region51
Evaluating progress
by local agencies in
improving health and
eliminating inequality
Baselines and trend data
Looking ahead to give
early warning of future
public health problems
Forum for partners to address likely
future public health issues such as
the ageing population and genetics
a Example: Northern and Yorkshire Public Health Observatory.
Figure 5.4 Mutual reinforcement between innovation in the fi eld and
policy development in the health reform process
Policy
mobilization
and development
Field model
development
a
Demonstration,
diffusion and
pressure for change
Identify opportunities
and alliances
The World Health Report 2008 Primary Health Care – Now More Than Ever
90
scheme. Furthermore, the organizational models
they had developed informed the translation of
political commitment to universal coverage into
concrete measures and regulations53.
This mutually reinforcing process of linking
policy development with learning from the fi eld
is important for several reasons:
it taps the wealth �� of latent knowledge and innovation
within the health sector;
�� bold experiments in the fi eld give front-line
workers, system leaders and the public an
inspiring glimpse of what the future might look
like in a health system shaped by PHC values.
This overcomes one of the greatest obstacles to
bold change in systems − people’s inability to
imagine that things could actually be different
and be an opportunity rather than a threat;
�� the linking of policy development with frontline
action fosters alliances and support from
within the sector, without which far-reaching
reform is not sustainable;
�� such processes engage society both locally and
at national level, generating the demand for
change that is essential in building political
commitment and maintaining the momentum
for reform.
Building a critical mass of
capacity for change
The stimulation of open, collaborative structures
that supply reforms with strategic intelligence
and harness innovation throughout the health
system requires a critical mass of committed and
experienced people and institutions. They must
not only carry out technical and organizational
tasks, but they must also be able to balance fl exibility
and coherence, adapt to new ways of working,
and build credibility and legitimacy54.
However, that critical mass of people and
institutions is often not available31. Institutions
in low-income countries that have suffered
from decades of neglect and disinvestment are
of particular concern. They are often short on
credibility and starved of resources, while key
staff may have found more rewarding working
environments with partner agencies. Poor governance
complicates matters, and is compounded
by international pressure for state minimalism
and the disproportionate infl uence of the donor
community. The conventional responses to leadership
capacity shortfalls in such settings, which
are characterized by a heavy reliance on external
technical assistance, toolkits and training, have
been disappointing (Box 5.4). They need to be
replaced by more systematic and sustainable
approaches in order to institutionalize competencies
that learn from and share experience55.
Documented evidence of how individual and
institutional policy dialogue and leadership
capacities build up over time is hard to fi nd, but
a set of extensive interviews of health sector leaders
in six countries shows that personal career
trajectories are shaped by a combination of three
decisive experiences56.
�� At some point in their careers, all had been
part of a major sectoral programme or project,
particularly in the area of basic health services.
Many of them refer to this as a formative
experience: it is where they learned about
PHC, but also where they forged a commitment
and started building critical alliances
and partnerships.
�� Many became involved in national planning
exercises, which strengthened their capacity to
generate and use information and, again, their
capacity to build alliances and partnerships.
Few had participated personally in major studies
or surveys, but those who had, found it an
opportunity to hone their skills in generating
and analyzing information.
�� All indicated the importance of cooptation and
coaching by their elders: “You have to start out
as a public health doctor and be noticed in one
of the networks that infl uence decision making
in MOH. After that your personal qualities and
learning by doing [determine whether you’ll get
to be in a position of leadership].”56
These personal histories of individual capacity
strengthening are corroborated by more in-depth
analysis of the factors that contributed to the
institutional capacities for steering the health
sector in these same countries. Table 5.2 shows
that opportunities to learn from large-scale
health-systems development programmes have
contributed most, confi rming the importance of
hands-on engagement with the problems of the
health sector in a collaborative environment.
91
Chapter 5. Leadership and effective government
Box 5.4 Limitations of conventional capacity building in low- and middle-income countries55
The development community has always tended to respond to the
consequences of institutional disinvestment in low- and middleincome
countries through its traditional arsenal of technical assistance
and expert support, toolkits and training (Figure 5.5). From
the 1980s onwards, however, it became clear that such “technical
assistance” was no longer relevant 58 and the response re-invented
itself as “project management units” concentrating on planning,
fi nancial management and monitoring.
The stronger health systems were able to benefit from the
resources and innovation that came with projects but, in others,
the picture was much more mixed. As a recurrent irritant to national
authorities, accountability to funding agencies often proved
stronger than commitment to national development: demonstrating
project results took precedence over capacity building and
long-term development59, giving disproportionate weight to project
managers at the expense of policy coherence and country leadership.
In more recent years, the wish to reinforce country ownership
– and changes in the way donors purchase technical assistance
services – paved the way for a shift from project management to
the supply of short-term expertise through external consultants.
In the 1980s and early 1990s, the expertise was essentially provided
by academic institutions and the in-house experts of bilateral
cooperation and United Nations agencies. The increased volume of
funding for technical support
contributed to shifting
the expertise market
to freelance consultants
and consultancy fi rms, so
that expertise has become
increasingly provided on a
one-time basis, by technical
experts whose understanding
of the systemic
and local political context
is necessarily limited60.
In 2006, technical cooperation
constituted 41%
of total overseas development
aid for health.
Adjusted for infl ation, its
volume tripled between
1999 and 2006, particularly
through expansion of
technical cooperation on
HIV/AIDS. Adapting to the complexities of the aid architecture,
experts and consultants now also increasingly act as intermediaries
between countries and the donor community: harmonization
has become a growth business, lack of country capacity fuelling
further disempowerment.
12 000
10 000
Millions I$ 2005
0
2002
Figure 5.5 A growing market: technical cooperation as part of Official
Development Aid for Health. Yearly aid flows in 2005,
deflator adjusted61
2000
8000
4000
6000
14 000
Other health aid
Technical cooperation HIV/AIDS
Technical cooperation health
11%
36%
2003 2004 2005 2006
20%
21%
The second mainstay response to the capacity problem has been the
multiplication of planning, management and programme toolkits.
These toolkits promise to solve technical problems encountered
by countries while aiming for self-reliance. For all their potential,
rigour and evidence base, the usefulness of toolkits in the fi eld has
often not lived up to expectations for four main reasons.
They often underestimate the complexity �� of the problems they
are supposed to deal with62.
�� They often rely on international expertise for their implementation,
thereby defeating one of their main purposes, which is
to equip countries with the ways and means to deal with their
problems themselves.
�� Some have not delivered the promised technical results63 or
led to unexpected untoward side-effects64.
�� The introduction of toolkits is largely supply driven and linked to
institutional interests, which makes it diffi cult for countries to
choose among the multitude of competing tools that are proposed.
The capacity-building prescription that completes the spectrum is
training. Sometimes, this is part of a coherent strategy: Morocco’s
Ministry of Health, for example, has applied a saturation training
approach similar to that of Indonesia’s Ministry of Finance65, sending
out large numbers of young professionals for training in order
to build up a recruitment
base of qualifi ed staff and,
eventually, a critical mass
of leaders. Such deliberate
approaches, however, are
rare. Much more common are
short “hotel” training courses
that mix technical objectives
and exchange with implicit
aims to top-up salaries and
buy political goodwill. The
prevailing scepticism about
the usefulness of such programmes
(systematic evaluation
is uncommon) contrasts
sharply with the resources
they mobilize, at a considerable
opportunity cost.
In the meantime, new markets
in education, training
and virtual learning are
developing, while actors in
low- and middle-income countries can access Internet sites on
most health systems issues and establish electronic communities
of practice. With contemporary information technology and
globalization, traditional recipes for capacity development in poor
countries are quickly becoming obsolete54.
The World Health Report 2008 Primary Health Care – Now More Than Ever
92
Especially noteworthy is the fact that the introduction
of tools was rarely identifi ed as a critical
input, and respondents did not highlight inputs
from experts and training.
The implication is that the key investment
for capacity building for PHC reforms should be
to create opportunities for learning by linking
individuals and institutions to ongoing reform
processes. A further consideration is the importance
of doing so in an environment where
exchange, within and between countries, is
facilitated. Unlike the conventional approaches
to capacity building, exchange and exposure to
the experience of others enhances self-reliance.
This is not just a recipe for under-resourced
and poorly performing countries. Portugal, for
example, has organized a broad societal debate
on its 2004−2010 National Health Plan involving
a pyramid of participation platforms from local
and regional to national level, and 108 substantial
contributions to the plan from sources ranging
from civil society and professional organizations
to local governments and academia. At three critical
moments in the process, international panels
of experts were also invited from other countries
to act as sounding boards for their policy debate:
a collaboration that was a learning exercise for
all parties57.
Managing the political process: from
launching reform to implementing it
PHC reforms change the balance of power within
the health sector and the relationship between
health and society. Success depends not only on
a credible technical vision, but also on the ability
to obtain the high-level political endorsement
and the wider commitment that is necessary to
mobilize governmental, fi nancial and other institutional
machineries.
As a technical sector, health rarely has prominence
in the hierarchy of the political arena.
Ministries of health have often had enough to
deal with simply trying to resolve the technical
challenges internal to the sector. They are
traditionally ill at ease, short of leverage and ill
equipped to make their case in the wider political
arena, particularly in low- and low-middleincome
countries.
The general lack of political infl uence limits
the ability of health authorities, and of other
stakeholders in the PHC movement, to advance
the PHC agenda, especially when it challenges
the interests of other constituencies. It explains
the frequently absent or overly cautious reactions
against the health effects of working conditions
and environmental damage, or the slow implementation
of regulations that may interfere with
the commercial interests of the food and tobacco
industry. Similarly, ambitious reform efforts are
often diluted or watered down under the infl uence
of the donor community, the pharmaceutical
and the health technology industries, or the
professional lobbies26,66.
Lack of political infl uence also has consequences
within governmental spheres. Ministries
of health are in a particularly weak position in
low- and low-middle-income countries, as is
evidenced by the fact that they can claim only
4.5% and 1.7%, respectively, of total government
expenditure (against 10% and 17.7%, respectively,
in upper-middle and high-income countries)67.
The lack of prominence of health priorities in
wider development strategies, such as the Poverty
Reduction Strategy Papers (PRSPs), is another
illustration of that weakness68. Equally, ministries
of health are often absent in discussions
about caps on social (and health) spending, which
Table 5.2 Signifi cant factors in improving institutional
capacity for health-sector governance in six countriesa,56
Factorsb
No. of countries
where factor was an
important contributor
Average score
for strength of
contribution
Sector programmes/
large-scale projects
4 7.25
Establishment of
institutions
3 6.7
National policy
debate events
3 5.6
Research, studies
and situation
analysis
4 5.1
New planning and
management tools
1 5
a Burkina Faso, the Democratic Republic of the Congo, Haiti, Mali, Morocco and Tunisia.
b
Identifi ed through document analysis and interviews with 136 key informants.
93
Chapter 5. Leadership and effective government
are dominated by debates on macroeconomic
stability, infl ation targets or sustainable debt. It
is telling that, in highly indebted countries, the
health sector’s efforts to obtain a share of the debt
relief funds have been generally slow, less than
forceful and unconvincing compared to education,
foregoing possibilities for rapid expansion
of their resource base69.
Despite these challenges, there is a growing
indication that the political will for ambitious
reforms based on PHC is taking place. India’s
health missions − “rural” and subsequently
“urban” − are accompanied by a doubling of public
expenditure on health. China is preparing an
extremely ambitious rural PHC reform that also
includes a major commitment of public resources.
The size and comprehensiveness of PHC-oriented
reforms in Brazil, Chile, Ethiopia, the Islamic
Republic of Iran, New Zealand, Thailand and
many other countries, refl ect very clearly that it
is not unrealistic to mobilize political will. Even
in extremely unfavourable circumstances, it has
proven possible to gain credibility and political
clout through pragmatic engagement with political
and economic forces (Box 5.5).
Experience across these countries shows that
political endorsement of PHC reforms critically
depends on a reform programme that is formulated
in terms that show its potential political
dividends. To do that it has to:
respond explicitly �� to rising demand as well
as to the health challenges and health system
constraints the country faces, showing that it
is not merely a technical programme, but one
rooted in concerns relevant to society;
�� specify the expected health, social and political
returns, as well as the relevant costs, in
order to demonstrate the expected political
mileage as well as its affordability;
�� be visibly based on the key constituencies’
consensus to tackle the obstacles to PHC, providing
reassurance of the reforms’ political
feasibility.
Creating the political alignment and commitment
to reform, however, is only a fi rst step.
Insuffi cient preparation of its implementation is
often the weak point. Of particular importance
is an understanding of resistance to change,
particularly from health workers70,71,72,73. While
the intuition of leadership has its merits, it is also
possible to organize more systematic exercises to
anticipate and respond to the potential reactions
of stakeholders and the public: political mapping
exercises, as in Lebanon34; marketing studies and
opinion polls, as in the United States74; public
hearings, as in Canada; or sector-wide meetings
of stakeholders, as in the Etats Généraux de la
Santé in French-speaking Africa. Delivering on
PHC reforms requires a sustained management
capacity across levels of the system, embedded
in institutions that are fi t for the purpose. In
Chile, for example, administrative structures and
competencies across the whole of the Ministry
of Health are being redefi ned in line with the
PHC reforms. Such structural changes are not
suffi cient. They need to be instigated in conjunction
with changes in the organizational culture,
from one of issuing decrees for change to a more
inclusive collaboration with a variety of stakeholders
across the levels of the health system.
That in turn requires the institutionalization of
policy-dialogue mechanisms drawing practicebased
knowledge up from the ground level to
inform overall systems governance, while reinforcing
social linkages and collaborative action
among constituencies at community level75. This
management capacity should not be assumed, it
requires active investment.
Even with effective political dialogue to gain
consensus on specifi c PHC reforms and the requisite
management for implementation across
levels of the system, many such reforms do not
have their intended impact. The best-planned and
executed policy reforms often run into unanticipated
challenges or rapidly changing contexts.
Broad experience in dealing with complex systems
behaviour suggests that signifi cant shortfalls
or shifts away from articulated goals are to
be expected. An important component to build
into the reform processes is mechanisms that
can pick up signifi cant unintended consequences
or deviations from expected performance benchmarks,
which allow for course corrections during
implementation.
Widespread evidence on inequities in health
and health care in virtually all countries is a
humbling reminder of the diffi culties confronting
The World Health Report 2008 Primary Health Care – Now More Than Ever
94
Recent developments in the Democratic Republic of the Congo
show how renewed leadership can emerge even under extremely
challenging conditions. The beginnings of the reconstruction of
the country’s health system, devastated by economic collapse
and state failure culminating in a brutal war is, above all, a story
of skilful political management.
The Democratic Republic of the Congo had seen a number of successful
experiences in PHC development at the district level during
the 1970s and early 1980s. The economic and political turmoil
from the mid-1980s onwards saw central government authority
in health disintegrate, with an extreme pauperization of the health
system and the workers within it. Health workers developed a
multiplicity of survival strategies, charging patients and capitalizing
on the many aid-funded projects, with little regard for the
consequences for the health system. Donors and international
partners lost confi dence in the district model of integrated service
delivery in the country and instead chose to back stand-alone disease
control and humanitarian aid programmes. While, between
1999 and 2002, the Ministry of Health commanded less than 0.5%
of total government expenditure, its central administration and its
Department of Planning and Studies – 15 staff in total – faced the
overwhelming task of providing guidance to some 25 bilateral and
multilateral agencies, more than 60 international and 200 national
NGOs, 53 disease control programmes (with 13 government donor
coordination committees)
and 13 provincial ministries
of health – not forgetting
health-care structures organized
by private companies and
universities.
As the intensity of civil strife
abated, a number of key
Ministry of Health staff took it
upon themselves to revitalize
and update the district model
of primary health care. Aware
of the marginal position of the
Ministry in the health sector,
they co-opted the “internal
diaspora” (former civil servants
now working for the
many international development
agencies present in the
Box 5.5 Rebuilding leadership in health in the aftermath of war and economic collapse
country) in an open structure around the Ministry. This steering
group drafted a national health systems strengthening strategy.
It included (i) a progressive roll-out of integrated services, district
by district, coordinated through regional plans and backed by a
fundamental shift in funding from programme-specifi c fl ows to
system funding; (ii) a set of protective “damage-control” measures
to halt institutional infl ation and prevent further distortion of the
system; and (iii) an explicit plan to tackle the problem of donor
fragmentation, which had reached critical proportions. In designing
the strategy, the steering group made deliberate efforts to set up
networks within the health sector itself and alliances with other
government actors and social constituencies.
The formal endorsement of the national plan by donors and civil
society sent a strong political signal of the success of this new
mode of working. The national health systems strengthening strategy
became the health component of the national poverty reduction
strategy. Donors and international partners aligned existing
projects, albeit to a variable degree, while others reshaped new
initiatives to fi t the national strategy.
Perhaps the most powerful testimony to the effective management
of this process is the change in the composition of donor
funding for health (Figure 5.6). The proportion of funds dedicated
to general systems strengthening under provincial and district
plans has increased appreciably
in relation to the level
of funding earmarked for
disease control and humanitarian
relief programmes.
The advances remain fragile,
in a context where much of
the health sector – including
its governance – needs to be
reconstructed.
Nevertheless, the national
strategy has strong roots in
fi eldwork and, in a remarkable
turnaround against high
odds, the Ministry of Health
has gained credibility with
other stakeholders and has
improved its position in renegotiating
the fi nances of the
health sector.
250
US$ millions
0
2003
Figure 5.6 Re-emerging national leadership in health: the shift in donor funding
towards integrated health systems support, and its impact on the
Democratic Republic of the Congo’s 2004 PHC strategy
300
Humanitarian aid
Vertical programmes
Support to health districts
50
100
150
200
2004 2005 2006 2007
95
Chapter 5. Leadership and effective government
PHC reforms. This chapter has emphasized that
leadership for greater equity in health must be
an effort undertaken by the whole of society and
engage all relevant stakeholders. Mediating multistakeholder
dialogues around ambitious reforms
be they for universal coverage or primary care
places a high premium on effective government.
This requires re-orienting information systems
the better to inform and evaluate reforms, building
fi eld-based innovations into the design and
redesign of reforms, and drawing on experienced
and committed individuals to manage the
direction and implementation of reforms. While
not a recipe, these elements of leadership and
effective government constitute in and of themselves
a major focus of reform for PHC. Without
reforms in leadership and effective government,
other PHC reforms are very unlikely to succeed.
While necessary, therefore, they are not suffi
cient conditions for PHC reforms to succeed.
The next chapter describes how the four sets of
PHC reforms must be adapted to vastly different
national contexts while mobilizing a common set
of drivers to advance equity in health.
References
1. Porter D. Health, civilization and the state. A history of public health from ancient to
modern times. London and New York, Routledge, 1999.
2. The World Health Report 2000 – Health systems: improving performance. Geneva,
World Health Organization, 2000.
3. Waldman R. Health programming for rebuilding states: a briefi ng paper. Arlington VA,
Partnership for Child Health Care, Basic Support for Institutionalizing Child Survival
(BASICS), 2007.
4. National health accounts. Geneva, World Health Organization (http//www.who.int/
nha/country/en/index.html, accessed May 2008).
5. Schoen C et al. US health system performance: a national scorecard. Health Affairs,
2006, 25(Web Exclusive):w457–w475.
6. Jacobs LR, Shapiro RY. Public opinion’s tilt against private enterprise. Health Affairs,
1994, 13:285–289.
7. Blendon RJ, Menson JM. Americans’ views on health policy: a fi fty year historical
perspective. Health Affairs, 2001, 20:33–46.
8. Fox DM. The medical institutions and the state. In: Bynum WF, Porter R, eds.
Companion encyclopedia of the history of medicine. London and New York,
Routledge, 1993, 50:1204–1230.
9. Blank RH. The price of life: the future of American health care. New York NY,
Colombia University Press, 1997.
10. Frenk J, Donabedian A. State intervention in health care: type, trends and
determinants. Health Policy and Planning, 1987, 2:17–31.
11. Blumenthal D, Hsiao W. Privatization and its discontents – the evolving Chinese
health care system. New England Journal of Medicine, 2005, 353:1165–1170.
12. Liu Y, Hsiao WC, Eggleston K. Equity in health and health care: the Chinese
experience. Social Science and Medicine, 1999, 49:1349–1356.
13. Bloom G, Xingyuan G. Health sector reform: lessons from China. Social Science and
Medicine, 1997, 45:351–360.
14. Tang S, Cheng X, Xu L. Urban social health insurance in China. Eschborn, Gesellschaft
für Technische Zusammenarbeit and International Labour Organization, 2007.
15. China: long-term issues and options in the health transition. Washington DC, The
World Bank, 1992.
16. China statistics 2007. Beijing, Ministry of Health, 2007 (http://moh.gov.cn/open/
statistics/year2007/p83.htm, accessed 31 May 2008).
17. WHO mortality database. Geneva, World Health Organization, 2007 (Tables; http://
www.who.int/healthinfo/morttables/en/index.html, accessed 1 July 2008).
18. Suhrcke M, Rocco L, McKee M. Health: a vital investment for economic development
in eastern Europe and central Asia. Copenhagen, World Health Organization Regional
Offi ce for Europe, European Observatory on Health Systems and Policies (http://
www.euro.who.int/observatory/Publications/20070618_1, accessed May 2008).
19. Collier P. The bottom billion: why the poorest countries are failing and what can be
done about it. Oxford and New York NY, Oxford University Press, 2007.
20. Grindle MS. The good government imperative: human resources, organizations, and
institutions. In: Grindle MS, ed. Getting good government: capacity building in the
public sectors of developing countries. Boston MA, Harvard University Press, 1997
(Harvard Studies in International Development:3–28).
21. Hilderbrand ME, Grindle MS. Building sustainable capacity in the public sector: what
can be done? In: Grindle MS, ed. Getting good government: capacity building in the
public sectors of developing countries. Boston MA, Harvard University Press, 1997
(Harvard Studies in International Development:31–61).
22. Goldsbrough D. Does the IMF constrain health spending in poor countries? Evidence
and an agenda for action. Washington DC, Center for Global Development, 2007.
23. Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other health
issues? Health Policy and Planning, 2008, 23:95–100.
24. Bill and Melinda Gates Foundation and McKinsey and Company. Global health
partnerships: assessing country consequences. Paper presented at: Third High-
Level Forum on the Health MDGs, Paris, 14–15 November 2005 (http://www.
hlfhealthmdgs.org/documents/GatesGHPNov2005.pdf).
25. Stein E et al, eds. The politics of policies: economic and social progress in Latin
America. Inter-American Development Bank, David Rockefeller Center for Latin
American Studies and Harvard University. Washington DC, Inter-American
Development Bank, 2006.
26. Moran M. Governing the health care state: a comparative study of the United
Kingdom, the United States and Germany. Manchester, Manchester University Press,
1999.
27. Saltman RB, Busse R. Balancing regulation and entrepreneurialism in Europe’s
health sector: theory and practice. In: Saltman RB, Busse R, Mossialos E, eds.
Regulating entrepreneurial behaviour in European health care systems. Milton
Keynes, Open University Press for European Observatory on Health Systems and
Policies, 2002:3–52.
28. McDaniel A. Managing health care organizations: where professionalism meets
complexity science. Health Care Management Review, 2000, 25:1.
29. World values surveys database. World Values Surveys, 2007 (V120, V121; http://
www.worldvaluessurvey.com, accessed 15 October 2007).
30. Inglehart R, Welzel C. Modernization, cultural change and democracy: the human
development sequence. Cambridge, Cambridge University Press, 2005.
31. Lopes C, Theisohn T. Ownership, leadership, and transformation: can we do better for
capacity development? London, Earthscan, 2003.
32. Wasi P. The triangle that moves the mountain. Bangkok, Health Systems Research
Institute, 2000.
33. McKee M, Figueras J. Setting priorities: can Britain learn from Sweden? British
Medical Journal, 1996, 312:691–694.
The World Health Report 2008 Primary Health Care – Now More Than Ever
96
34. Ammar W. Health system and reform in Lebanon. World Health Organization Regional
Offi ce for the Eastern Mediterranean and Ministry of Health of Lebanon. Beirut,
Entreprise universitaire d’Etudes et de Publications, 2003.
35. Stewart J, Kringas P. Change management – strategy and values. Six case studies
from the Australian Public Sector. Canberra, University of Canberra, Centre for
Research in Public Sector Management (http://www.dmt.canberra.edu.au/crpsm/
research/pdf/stewartkringas.pdf).
36. Chalmers I. From optimism to disillusion about commitment to transparency in
the medico-industrial complex. Journal of the Royal Society of Medicine, 2006,
99:337–341.
37. Romanow RJ. Building on values. The future of health care in Canada – fi nal report.
Saskatoon, Commission on the Future of Health Care in Canada, 2002.
38. Escorel S, Arruda de Bloch R. As conferências Nacionais de Saúde na Cobnstrução
do SUS. In: Trinidade Lima N et al, eds. Saúde e democracia: história e perpsectivas
do SUS. Rio de Janeiro, Editora Fiocruz, 2005:83–120.
39. Jongudomsuk P. Achieving universal coverage of health care in Thailand through the
30 Baht scheme. Paper presented at: SEAMIC Conference 2001 FY, Chiang Mai,
Thailand, 14–17 January 2002.
40. Galichet B et al. Country initiatives to lift health system constraints: lessons from 49
GAVI–HSS proposals. Geneva, World Health Organization, Department for Health
System Governance and Service Delivery, 2008.
41. The state of health in Bangladesh 2007. Health workforce in Bangladesh: who
constitutes the healthcare system? Bangladesh Health Watch (http://sph.bracu.
ac.bd/bhw/, accessed June 2008).
42. Hemmings J, Wilkinson J. What is a public health observatory? Journal of
Epidemiology and Community Health, 2003, 57:324–326.
43. Equity gauge profi les. Global Equity Gauge Alliance, 2008 (http:www.gega.org.za,
accessed 24 April 2008).
44. De Campos FE, Hauck V. Networking collaboratively: the experience of the
observatories of human resources in Brazil. Cahiers de sociologie et de démographie
médicales, 2005, 45:173–208.
45. Ashton J. Public health observatories: the key to timely public health intelligence
in the new century. Journal of Epidemiology and Community Health, 2000,
54:724–725.
46. Intelligent health partnerships. York, Association of Public Health Observatories,
2008 (http://www.apho.org.uk/resource/item.aspx?RID=39353 accessed 10 June
2008).
47. Robinson M, Baxter H, Wilkinson J. Working together on coronary heart disease in
Northern and Yorkshire. Stockton-on-Tees, Northern and Yorkshire Public Health
Observatory, 2001.
48. Bell R et al. Perinatal and infant health: a scoping study. Stockton-on-Tees, Northern
and Yorkshire Public Health Observatory, 2001.
49. Grant S, Wilkinson J, Learmonth A. An overview of health impact assessment.
Stockton-on-Tees, Northern and Yorkshire Public Health Observatory, 2001
(Occasional Paper No. 1).
50. Bailey K et al. Towards a healthier north-east. Stockton-on-Tees, Northern and
Yorkshire Public Health Observatory, 2001.
51. Beal J, Pepper L. The dental health of fi ve-year-olds in the Northern and Yorkshire
Region. Stockton-on-Tees, Northern and Yorkshire Public Health Observatory, 2002.
52. Thailand’s health care reform project, 1996–2001: fi nal report. Bangkok, Ministry of
Health, Thailand Offi ce of Health Care Reform, 2001.
53. Tancharoensathien V, Jongudomsuk P, eds. From policy to implementation: historical
events during 2001–2004 of UC in Thailand. Bangkok, National Health Security
Offi ce, 2005.
54. Baser H, Morgan P. Capacity, change and performance. Maastricht, European Centre
for Development Policy Management, 2008.
55. Macq J et al. Quality attributes and organisational options for technical support to
health services system strengthening. Background paper commissioned for the
GAVI–HSS Task Team, Nairobi, August 2007.
56. Boffi n N, De Brouwere V. Capacity building strategies for strengthening the
stewardship function in health systems of developing countries. Results of an
international comparative study carried out in six countries. Antwerp, Institute
of Tropical Medicine, Department of Public Health, 2003 (DGOS – AIDS Impulse
Programme 97203 BVO “Human resources in developing health systems”).
57. Carrolo M, Ferrinho P, Perreira Miguel J (rapporteurs). Consultation on Strategic
Health Planning in Portugal. World Health Organization/Portugal Round Table,
Lisbon, July 2003. Lisbon, Direcção Geral da Saùde, 2004.
58. Forss K et al. Evaluation of the effectiveness of technical assistance personnel.
Report to DANIDA, FINNIDA, NORAD and SIDA, 1988.
59. Fukuda-Parr S. Capacity for development: new solutions to old problems. New York
NY, United Nations Development Programme, 2002.
60. Messian L. Renforcement des capacités et processus de changement. Réfl exions
à partir de la réforme de l’administration publique en République Démocratique du
Congo. BTC Seminar on Implementing the Paris Declaration on Aid Effectiveness,
Brussels, 2006.
61. OECD. StatExtracts [online database]. Paris, Organisation for Economic
Co-operation and Development, 2008 (http://stats.oecd.org/WBOS/Index.aspx
accessed June 2008).
62. Irwin A. Beyond the toolkits: bringing engagement into practice. In: Engaging
science: thoughts, deeds, analysis and action. London, Wellcome Trust, 2007:50–55.
63. Rowe AK et al. How can we achieve and maintain high-quality performance of health
workers in low-resource settings? Lancet, 2005, 366:1026–1035.
64. Blaise P, Kegels G. A realistic approach to the evaluation of the quality management
movement in health care systems: a comparison between European and African
contexts based on Mintzberg’s organizational models. International Journal of Health
Planning and Management, 2004, 19:337–364.
65. Lippingcott DF. Saturation training: bolstering capacity in the Indonesian Ministry of
Finance. In: Grindle MS, ed. Getting good government: capacity building in the public
sectors of developing countries. Boston MA, Harvard University Press, 1997 (Harvard
Studies in International Development:98–123).
66. Krause E. Death of the guilds. professions, states and the advance of capitalism,
1930 to the present. New Haven and London, Yale University Press, 1996.
67. World health statistics 2008. Geneva, World Health Organization, 2008.
68. Poverty Reduction Strategy Papers, their signifi cance for health: second synthesis
report. Geneva, World Health Organization, 2004 (WHO/HDP/PRSP/04.1 2004).
69. World Bank Independent Evaluation Group. Debt relief for the poorest: an evaluation
update of the HIPC Initiative. Washington DC, The World Bank, 2006 (http://www.
worldbank.org/ieg/hipc/report.html, accessed June 2008).
70. Pangu KA. Health workers’ motivation in decentralised settings: waiting for better
times? In: Ferrinho P, Van Lerberghe W, eds. Providing health care under adverse
conditions. Health personnel performance and individual coping strategies. Antwerp,
ITG Press, 2000:19–30.
71. Mutizwa-Mangiza D. The impact of health sector reform on public sector health
worker motivation in Zimbabwe. Bethesda MD, Abt Associates, 1998 (Partnerships
for Health Reform, Major Applied Research 5, Working Paper No. 4).
72. Wiscow C. The effects of reforms on the health workforce. Geneva, World Health
Organization, 2005 (background paper for The World Health Report 2006).
73. Rigoli F, Dussault G. The interface between health sector reform and human
resources in health. Human Resources for Health, 2003, 1:9.
74. Road map for a health justice majority. Oakland, CA, American Environics, 2006
(http://www.americanenvironics.com/PDF/Road_Map_for_Health_Justice_
Majority_AE.pdf, accessed 1 July 2008).
75. Labra ME. Capital social y consejos de salud en Brasil. ¿Un círculo virtuoso?
Cadernos de saúde pública, 2002, 18(Suppl. 47):55, Epub 21 January 2003.


The starkly different social, economic and health
realities faced by countries must inform the way
forward for primary health care. This chapter discusses
the implications for the way universal
coverage, primary care, public policy and
leadership reforms are operationalized.
It shows how expanding health systems
offer opportunities for PHC reform in
virtually every country. Despite the need
for contextual specifi city, there are crosscutting
elements in the reforms, common
to all countries, which provide a basis for
globally shared learning and understanding about how PHC
reforms can be advanced more systematically everywhere.
Chapter 6
Adapting reforms to
country context 100
High-expenditure
health economies 101
Rapid-growth
health economies 103
Low-expenditure, lowgrowth
health economies 105
Mobilizing the
drivers of reform 108
The way
forward
99
The World Health Report 2008 Primary Health Care – Now More Than Ever
100
Adapting reforms to country context
Although insuffi ciently acknowledged, the PHC
movement has been a critical success in that it
has contributed to the recognition of the social
value of health systems, which has now taken
hold in most countries in the world. This change
of mindset has created a radically different
health-policy landscape.
Present-day health systems are a patchwork of
components, many of which may be far removed
from the goals set out 30 years ago. These same
health systems are converging. Driven by the
demographic, fi nancial and social pressures of
modernization, they increasingly share the aims
of improved health equity, people-centred care,
and a better protection of the health of their
populations.
However, that does not mean that health systems
across the world will change overnight.
Reorienting a health system is a long-term
process, if only because of the long time lag to
restructure the workforce1 and because of the
enormous inertia stemming from misaligned
fi nancial incentives and inadequate payment
systems2. Given the countervailing forces and
vested interests that drive health systems away
from PHC values, reform requires a clear vision
for the future. Many countries have understood
this and are developing their strategic vision of
public policies for health with a perspective of
10 to 20 years.
These visions are often couched in technical
terms and are highly vulnerable to electoral
cycles. Nevertheless, they are also increasingly
driven by what people expect their health
authorities to do: secure their health and improve
access to care, protect them against catastrophic
expenditure and fi nancial exploitation, and guarantee
an equitable distribution of resources3,4.
As shown throughout this Report, the pressure
that stems from these value-based expectations,
if used resolutely, can ensure that the vision is
not defl ected and safeguard it from capture by
short-term vested interests or changes in political
leadership.
The protection this offers is greatly reinforced
by early implementation. The possibilities to start
effecting change as of now exist in virtually all
countries: the growth of the health sector provides
fi nancial leverage to do so, and globalization
is offering some unprecedented opportunities
to make use of that leverage.
This does not in any way diminish the need to
recognize the widely divergent contexts in which
countries fi nd themselves today: the nature of the
health challenges they face and their wider socioeconomic
reality; and the degree of adaptation to
challenges, the level of development and speed at
which their health systems expand.
Opportunity for change is largely related to
the fl ow of new resources into the health sector.
Across the world, expenditure on health is growing:
between 1995 and 2005, it almost doubled
from I$ 2.6 to I$ 5.1 trillion. The rate of growth
is accelerating: between 2000 and 2005, the total
amount spent on health in the world increased by
I$ 330 billion on average each year, against an
average of I$ 197 billion in each of the fi ve previous
years. Health expenditure is growing faster
than GDP and faster than population growth. The
net result is that, with some exceptions, health
spending per capita grows at a rate of more than
5% per year throughout the world.
This common trend in the growth in health
expenditure masks a greater than 300-fold variation
across countries in per capita expenditure,
which ranges from less than I$ 20 per capita
to well over I$ 6 000. These disparities stratify
countries into three categories: high-expenditure
health economies, rapid-growth health economies,
and low-expenditure, low-growth health
economies.
The high-expenditure health economies, not
surprisingly, are those of the nearly 1 billion
people living in high-income countries. In 2005,
these countries spent on average I$ 3752 per
capita on health, I$ 1563 per capita more than
in 1995: a growth rate of 5.5% per year.
At the other extreme is a group of low-expenditure,
low-growth health economies: low-income
countries in Africa and South- and South-East
Asia, as well as fragile states. They total 2.6 billion
inhabitants who spent a mere I$ 103 per
capita on health in 2005, against I$ 58 in 1995.
In relative terms, these countries have seen their
health expenditure per capita grow at roughly the
101
Chapter 6. The way forward
same rate as high-expenditure countries: 5.8%
each year since 1995, but, in absolute terms, the
growth has been disappointingly low.
In between those two groups are the other
low- and middle-income countries, those with
rapid-growth health economies. The 2.9 billion
inhabitants in these countries spent an average
of I$ 413 per capita in 2005, more that double the
I$ 189 per capita that they spent in 1995. Health
expenditure in these countries has been growing
at a rate of 8.1% per year.
These groups differ not only in the rate and
size of their growth in health expenditure. A
breakdown according to the source of growth
reveals strikingly different patterns (Figure 6.1).
In the low-expenditure, low-growth health
economies, out-of-pocket payments account for
the largest share of the growth, while in rapidgrowth
and high-expenditure health economies,
increased government expenditure and prepayment
mechanisms dominate. Where growth
in health expenditure is through pre-payment
mechanisms, there is greater opportunity to support
PHC reforms: collectively pooled monies are
more readily re-allocated towards interventions
that provide a larger health return on investment
than out-of-pocket payments. Conversely, countries
where growth is primarily through out-ofpocket
expenditures have less leverage to support
PHC reforms. Alarmingly, it is in countries where
expenditure is the lowest and the burden of disease
highest that there is a real lack of opportunities
for harnessing the growth of their health
sector for PHC reforms.
The following sections outline broad categories
of contexts that can shape responses for PHC
reforms.
High-expenditure health economies
This group of countries funds almost 90% of its
growth in health expenditure – an extra I$ 200
per capita per year in recent years − through
increased government and private pre-payment
funds. Expanding or changing the offer of services
in these countries is less constrained by fi nances
than by the relative lack of human resources to
meet rising and changing demand. Their health
systems are built around a strong and prestigious
tertiary care sector that is important to the heavyweights
of the pharmaceutical and medical supply
industries2. Out-of-pocket payments, though still
signifi cant at 15% of total expenditure, have been
dwarfed by more progressive collective means of
fi nancing. The third-party payment institutions
have, thus, become central actors while the longstanding
autonomy of the health professionals is
waning. Efforts to control costs, improve quality
and access to disadvantaged groups have given
rise to a widening public debate on which users
and special interest groups have increasing infl uence.
Nevertheless, the state carries more weight
in the health sector of these countries than ever
before, with increasingly sophisticated regulatory
tools and institutions.
Despite worries over their long-term sustainability,
the solidarity mechanisms that fi nance
these health systems enjoy considerable social
consensus. The secular trend towards extension
of coverage to all citizens, and, often reluctantly,
to non-citizen residents as well, continues. In the
state of Massachusetts, the United States, for
example, the 2006 health insurance bill aims
at 99% coverage by 2010. At the same time, it
is becoming increasingly clear that universal
Yearly growth in per capita health expenditure (percentage)
0
Low-expenditure,
low-growth
health economies
Figure 6.1 Contribution of general government, private pre-paid and private
out-of-pocket expenditure to the yearly growth in total health
expenditure per capita, percentage, weighted averages5
100
Out-of-pocket health expenditure
Private pre-paid health expenditure
Government health expenditure
Rapid-growth
health economies
High-expenditure
health economies
60
80
20
40
The World Health Report 2008 Primary Health Care – Now More Than Ever
102
coverage schemes need to be complemented by
efforts: (i) to identify those who are excluded and
set up specifi cally tailored programmes to include
them; and (ii) to tackle the social determinants of
health inequalities through policy initiatives that
cut across a large number of sectors (Box 6.1), so
as to translate the political commitment to health
equity into concrete advances.
In many of these countries, the shift in point of
gravity from tertiary and specialized care to primary
care is well under way. Better information
and technological developments are creating
new opportunities – and a market – for moving
much of the traditionally hospital-based care into
local services staffed by primary-care teams or
even into the hands of patients themselves. This
is fuelling a change in perception of how health
services should operate. It provides support for
primary care, including self-care and home care.
Movement in this direction, however, is held up by
inertial forces stemming from the threat of downsizing
and dismantling massive tertiary-care
facilities and from demand induced by the illusion
that the extension of life through technology
is unlimited7. Technological innovation is indeed
a driver of improvement and current trends show
that it is expanding the range of services offered
by primary-care teams. Technological innovation
can, however, also be a driver of exclusion and
ineffi ciency. The marked inter-country differences
in the diffusion of medical technology are
a refl ection, not of rational evaluation, but of the
incentives to providers to adopt these technologies,
and the capacity to control that adoption2.
There are two reasons why the environment
in which this is taking place is changing.
Public c �� ontestation of the management of technology
has continued to increase for reasons of
trust, price, exclusion or unmet need.
�� Regulation increasingly depends on supranational
institutions. The European Union’s
regulatory system, for example, plays an
increasing role in the harmonization of the
technical requirements for registering new
medicines or of product licencing, offering possibilities,
among others, for more effective support
to legal provisions encouraging generic
substitution for pharmaceuticals in the private
sector8. Such mechanisms offer opportunities
to increase safety and access, and thus create
an environment in which national primary
care reforms are encouraged.
This comes at a time when the supply of professionals
willing and able to engage in primary
care is under stress. In Europe, for example, the
population of general practitioners is ageing rapidly,
and new recruits are more likely than before
to opt for part-time or low-intensity careers1.
There is pressure to give a more pivotal role to
Box 6.1 Norway’s national strategy to
reduce social inequalities in health6
Norway’s strategy to reduce health inequalities illustrates that
there is no single solution to this complex problem. Norway
has identifi ed a large number of determinants that infl uence
the health of individuals: income, social support, education,
employment, early childhood development, healthy environments
and access to health services. These complex and interrelated
determinants of health are not equally distributed in
society, and it is, therefore, not surprising that this leads to
inequities in health as well.
The Norwegian strategy attempts to address the root causes
of poor health and health inequity by infl uencing the underlying
determinants of health, and making the distribution of these
determinants more equitable from the outset. The Norwegian
strategy focuses on:
�� reducing social inequities;
�� reducing inequities in health behaviours and access to
health services;
�� targeted initiatives to improve social inclusion; and
�� cross-sectoral tools to promote a whole-of-government
approach to health.
This brings together a number of interventions that are effective
in tackling inequities, and that can be applied both within
health systems, as well as through cooperation with other
sectors. For instance, health systems are able to establish
programmes for early childhood development as well as policies
that reduce fi nancial, geographical and social barriers to
health services for those who need care the most. Working
with other sectors, such as labour and fi nance, can create
job opportunities and taxation systems that encourage more
equitable distribution and redistribution of wealth, which can
have a large impact on population health. In addition to universal
approaches, social inclusion interventions targeted at
providing better living conditions for the most disadvantaged
are also critical in reducing the gaps between the most well-off
and the least well-off members of society.
103
Chapter 6. The way forward
family physicians in primary care9. In the long
run, however, a more pluralistic approach will
be required with teams that include a variety
of professionals with the instruments to provide
coordination and continuity of care. That will
require a different, more varied and more fl exible
cadre of health workers. The sustainability
of primary-care reforms in the category of highspending
countries is questionable without: (i) a
change in paradigm of the training of health personnel;
and (ii) the necessary career, social and
fi nancial incentives to move health professionals
to what in the past have been less prestigious and
rewarding career options.
Spurred by the growing awareness of global
health threats and of the stratifi cation of health
outcomes along social fault lines, there is a
major renaissance in public health. The connections
between health and other sectors are
better understood and are bringing health to the
attention of all sectors. Research and information
systems, demand for public health training and
new discourses on public health are occupying
the centre stage of public concerns. This situation
needs to be translated into multi-pronged crosssector
strategies to address the social determinants
of health and their infl uence on priority
health challenges (Box 6.1).
Over the last decades, most countries in this
category are leading reforms through a steerand-
negotiate rather than a command-and-control
approach. This refl ects the growing public
visibility of the health-policy agenda and the need
to fi nd a balance between the different and often
irreconcilable demands of diverse constituencies.
As a result, reform efforts are usually multi-levelled,
with multiple actors. They progress incrementally:
a protracted messy process of muddling
through and hard bargaining. In England and
Wales, for example, a major primary-care reform
included an extensive public consultation through
questionnaires addressed to more than 42 000
people, while over 1 000 individuals were invited
to voice their interests and concerns in public
hearings. This involvement facilitated consensus
on a number of contentious parts of the reform,
including shifts of resources to primary care
and to underserved areas, while responsibilities
were redistributed to improve cooperation and
coordination10. Time and effort for systematic
but principled negotiation is the price to pay for
obtaining the social consensus that can overcome
entrenched resistance to reform.
Rapid-growth health economies
In rapid-growth health economies, the challenge
of engaging PHC reforms presents itself quite
differently. The growing demand that comes
with increased purchasing power is fuelling an
expansion of services at unprecedented speed.
Assuming current growth rates continue through
to 2015, per capita health expenditure will grow
by 60% in the fast-growing health economies of
the Americas compared to 2005 levels. In the
same time period, that expenditure will double
in Europe and the Middle-East and triple in East
Asia (Figure 6.2).
While the rate of growth in expenditure represents
an opportunity to engage in PHC reforms,
it also fuels patterns of health-sector development
that run counter to the vision and values
Projected total health expenditure per capita, I$, 2015
0
Low- and
middleincome
countries*,
Eastern
Mediterranean
region
Figure 6.2 Projected per capita health expenditure in 2015, rapid-growth
health economies (weighted averages)a
1200
Projected growth in out-of-pocket expenditure
Projected growth in private pre-paid expenditure
Projected growth in government expenditure
800
1000
400
600
Level of total health expenditure in 2005
1400
Low- and
middleincome
countries*,
East Asia,
Western
Pacific region
Low- and
middleincome*,
Americas
Low- and
middleincome
countries*,
European
region
All rapidgrowth
health
economies
* Without fragile states.
a Assuming the yearly growth rates for government-, private pre-paid-, and out-of-pocket
expenditure estimated from 1995−2005 data5 persist to 2015.
200
The World Health Report 2008 Primary Health Care – Now More Than Ever
104
of PHC. Beginnings count: policy choices that are
made for political or technical expediency, such
as to refrain from regulating commercial health
care, may make it more diffi cult to redirect health
systems towards PHC values at a later stage, as
powerful vested interests emerge and patterns
of supply-induced demand become entrenched11.
Biases towards highly sophisticated and specialized
infrastructures that cater to the expectations
of a wealthy minority are being further fuelled
by a new growth market in medical tourism
whereby patients from high-expenditure health
economies with high-fi xed costs are out-sourced
to these comparatively low-cost environments.
This drains the supply of professionals for primary
care, encouraging unprecedented rates of
specialization within the workforce12. In contrast
with these developments, ministries of health
in many of these countries are still organized
around specifi c disease control efforts, and are
ill-equipped to use the leverage of expanding
resources to regulate health-care delivery. The
result is all too often a two-tiered system, with
highly sophisticated and specialized health infrastructure
that caters to expectations of a wealthy
minority, in the presence of huge gaps in service
availability for a large part of the population
Reforms that emphasize universal access to
people-centred primary care can help to correct
such distortions. These reforms can take advantage
of technological innovations that facilitate
rapid, simple, reliable and low-cost access to services
that were previously inaccessible because
they were too expensive or required complex
supportive infrastructure. Such innovations
include rapid diagnostic tests for HIV and gastric
ulcers, better drugs that facilitate the shift from
institution-based to primary care-based mental
health13, and advances in surgery that either
eliminate or dramatically reduce the need for
hospitalization. Combined with the multiplication
of evidence-based guidelines, such innovations
have considerably enlarged the problem solving
capacity of primary-care teams, broadening the
role of non-physician clinicians14 and the potential
of self-care. Rapid expansion of people-centred
care is thus possible in a context where the technological
gap between close-to-client ambulatory
care and tertiary institutions is less striking
than it was 30 years ago. Chile, for example, has
doubled the uptake of primary-care services
in a period of fi ve years, along with a massive
investment in personnel and equipment ranging
from emergency dental care and laboratories to
home-based management of chronic pain. The
impact of this transformation can be amplifi ed
by targeting and empowering the large numbers
of poor and excluded in these countries and by
reforming public policies accordingly.
In the rapid-growth health economies of the
Americas and the European region less that one
third of the expected growth on current trends is
through increased out-of-pocket expenditure on
health. Two thirds are through increased government
expenditure, in combination, in the Americas,
with expanded private pre-paid expenditure
(Figure 6.2). The latter also plays a growing role
in the Far East, where, as in the Middle East,
around 40% of the growth, on current trends,
will be in out-of-pocket expenditure. Leverage
of PHC reforms will depend in part on the possibility
to regulate and infl uence private pre-paid
expenditure, and, particularly in Asia, to curb the
reliance on out-of-pocket expenditure.
In most of these countries, the level of expenditure
compared to GDP or to total government
expenditure remains low, offering fi nancial room
to further accelerate PHC reforms and underpin
them through parallel, and equally important,
moves towards universal coverage and reduced
reliance on out-of-pocket payments. In many of
these countries, public resources are allocated
on a capitation basis as are, at least, part of
pooled private pre-payment funds. This provides
opportunities to include criteria, such as
relative deprivation or unmet health needs in the
capitation formulas. This effectively transforms
resource allocation into an instrument for promoting
health equity and for introducing incentives
favouring conversion towards primary care
and healthier public policies.
Some of the largest countries in the world –
Brazil, for example – are now seizing these kinds
of opportunities on a massive scale, expanding
their primary-care networks while diminishing
their reliance on out-of-pocket payments15. Such
reforms, however, rarely come about without
pressure from the user’s side. Chile’s health policy
105
Chapter 6. The way forward
has defi ned a detailed benefi t package, well publicized
among the population as an enforceable
right. People are being informed about the kind
of services, including access to specialized care,
which they can claim from their primary-care
teams. In combination with sustained investment,
such unambiguous entitlements create a
powerful dynamic for the development of primary
care. Managed well, they have the potential to
accelerate convergence while avoiding at least
part of the distortions and ineffi ciencies that have
plagued high-income countries in earlier years.
Low-expenditure,
low-growth health economies
With 2.6 billion people and less than 5% of the
world’s health expenditure, countries in this
group suffer from an absolute under-funding of
their health sector, along with a disproportionally
high disease burden. The persistence of high
levels of maternal mortality in these countries
− they claim close to 90% of all maternal deaths
− is perhaps the clearest indication of the consequences
of the under-funding of health on the
performance of their health systems.
Worryingly, growth in health expenditure in
these countries is low and highly vulnerable to
their political and economic contexts. In fragile
states, particularly in those located in Africa,
health expenditure is not only low but barely
growing at all, and 28% of this little amount
of growth in recent years is accounted for by
external aid. Health expenditure in the other
countries of this group is growing at a stronger
average rate of 6% to 7% per year. On current
trends, by 2015, per capita health expenditure
will have more than doubled in India compared
to 2005, and increased by half elsewhere, except
in fragile states (Figure 6.3). In many countries,
this represents signifi cant leverage to engage
PHC reforms, particularly where the growth is
through increased government expenditure or, as
in Southern Africa, through other forms of prepayment.
In India, however, more than 80% of the
growth will, on current trends, be in out-of pocket
expenditure, offering much less leverage.
Countries in these regions accumulate a set of
problems that in all their diversity share many
characteristics. Whole population groups are
excluded from access to quality care: because
no services are available; because they are too
expensive, or under-funded, under-staffed and
under-equipped; or because they are fragmented
and limited to a few priority programmes. Efforts
to establish sound public policies that promote
health and deal with determinants of ill-health are
limited at best. Unregulated commercialization
of both private- and public-health care is quickly
becoming the norm for urban and, increasingly,
for rural populations − a much bigger and more
underestimated challenge to PHC’s values than
the verticalism that so worries the international
health community.
In most of these countries, the state has had,
in the past, the ambition to run the health sector
on an authoritarian basis. In today’s pluralistic
context, with a multitude of different providers,
formal and informal, public and private, only
few have succeeded in switching to more appropriate
steer-and-negotiate approaches. Instead,
as public resources stagnated and bureaucratic
mechanisms failed, laissez-faire has become the
default approach to management of the health
sector.
Projected health expenditure per capita, I$, 2015
0
Fragile
states
Figure 6.3 Projected per capita health expenditure in 2015, low-expenditure,
low-growth health economies (weighted averages)a
250
Projected growth in out-of-pocket expenditure
Projected growth in private pre-paid expenditure
Projected growth in government expenditure
150
200
50
100
Level of total health expenditure in 2005
300
South- and
South-East Asia*
India Sub-saharan
Africa*
All lowexpenditure,
low-growth
health
economies
* Without fragile states.
a Assuming the yearly growth rates for government-, private pre-paid-, and out-of-pocket
expenditure estimated from 1995−2005 data5 persist to 2015.
The World Health Report 2008 Primary Health Care – Now More Than Ever
106
This has resulted in few or feeble attempts to
regulate commercial health-care provision – not
only by the private, but also within the public
sector, which has, in many instances, adopted
the commercial practices of unregulated private
care. In such settings, government capacity often
limits the extent to which new resources can be
leveraged for improved performance. Health
authorities are, thus, left with an unfunded mandate
for steering the health sector.
Therefore, growing the resource base is a priority:
to refi nance resource-starved health systems;
to provide them with new life through PHC
reforms; and to re-invest in public leadership. Prepayment
systems must be nurtured now, discouraging
direct levies on the sick and encouraging
pooling of resources. This will make it possible to
allocate limited resources more intelligently and
explicitly than when health services are paid for
out-of-pocket. While there is no single prescription
for the type of pooling mechanism, there
are greater effi ciencies in larger pools: gradual
merging or federation of pre-payment schemes
can accelerate the build-up of regulatory capacity
and accountability mechanisms16.
In a signifi cant number of these low-expenditure,
low-growth health economies, particularly
in sub-Saharan Africa and fragile states,
the steep increase in external funds directed
towards health through bilateral channels or
through the new generation of global fi nancing
instruments has boosted the vitality of the
health sector. These external funds need to be
progressively re-channelled in ways that help
build institutional capacity towards a longer-term
goal of self-sustaining, universal coverage. In the
past, the bulk of donor assistance has targeted
short-term projects and programmes resulting in
unnecessary delays, or even detracting from the
emergence of the fi nancing institutions required
to manage universal coverage schemes. The
renewed interest among donors in supporting
national planning processes as part of the harmonization
and alignment agenda, and the consensus
that calls for universal access, represent
important opportunities for scaling up investments
in the institutional apparatus necessary for
universal coverage. While reduced catastrophic
expenditure on health care and universal access
are suffi ciently strong rationales for such change
in donor behaviour, the build-up of sustainable
national fi nancing capacities also offers an eventual
exit strategy from donor dependence.
Governments can do more to support the health
sector in these settings. Low-expenditure, lowgrowth
health economies allocate only a small
fraction of their government revenue to health.
Even in sub-Saharan African countries, which
have made progress and allocated an average of
8.8% of their government expenditure to health
in 2005, the Abuja Declaration target of 15% is
still a long way off5. Reaching that target would
increase total health expenditure in the region
by 34%. Experience of the last decade shows that
it is possible to increase government revenues
allocated to health rapidly. For example, following
rising pressure from a broad range of civil
society and political movements, India’s general
government expenditure on health – with a specifi
c focus on primary health care – is expected
to triple within the next fi ve years17. In a different
context, the Ministry of Health in Burundi
quadrupled its budget between 2005 and 2007 by
successfully applying for funds that became available
through debt reduction under the Enhanced
Heavily Indebted Poor Countries (HIPC) initiative.
On average, in the 23 countries at completion
point for the HIPC and Multilateral Debt Relief
Initiative (MDRI), the annual savings from HIPC
debt relief during the 10 years following qualifi -
cation are equivalent to 70% of public spending
on health at 2005 levels18. While only part of that
money is to be directed to health, even that can
make a considerable difference to the fi nancial
clout of public-health authorities.
Opportunities arise not only from increased
resources. The preponderance of pilot projects
is gradually being replaced by more systematic
efforts to achieve universal access, albeit often
for a single intervention or disease programme.
These high visibility programmes, developed in
relation to the MDGs, have revitalized a number
of concepts that are key to people-centred
care. Among them are the imperative of universal
access to high quality and safe care without
fi nancial penalty, and the importance of continuity
of care, and the need to understand the
social, cultural and economic context in which all
107
Chapter 6. The way forward
In Mali, the primary care network is made up of communityowned,
community-operated primary-care centres, backed up
by government-run district teams and referral units. There is a
coverage plan, negotiated with the communities, which, if they
so wish, can take the initiative to create a primary-care centre
according to a set of criteria. The commitment is important, since
the health centre will be owned and run by the community: for
example, the staff of the health centre, a three to four person
team led by a nurse or a family doctor, has to be employed (and
fi nanced) by the local community health association. The community
can make an agreement with the Ministry of Health to
obtain technical and fi nancial support from the district-health
teams, for the launch of the health centre and the supervision
and back up of its subsequent operation.
The model has proved quite popular, despite the huge effort communities
have had to put into the mobilization and organization
of these facilities: by 2007, 826 such centres were in operation
(up from 360 10 years before), set up at an average cost of
US$ 17 000. The system has proved resilient and has signifi cantly
increased the production of health care: the number of curative
care episodes managed by the health centres has been multiplied
by 2.1. The number of women followed up in antenatal care has
been multiplied by 2.7 and births attended by a health professional
by 2.5, with coverage levels as measured through Demographic
Health Surveys in 2006 standing at 70% and 49%, respectively;
DTP3 vaccination coverage in 2006 was 68%.
People obviously consider the investment worthwhile. Twice
during the last 10 years, between 2000 and 2001 and 2004
and 2005, demand and local initiative for the creation of new
centres was rising so fast that Mali’s health authorities had to
take measures to slow down the expansion of the network in order
to be able to guarantee quality standards (Figure 6.4). This suggests
that the virtuous cycle of increased demand and improved
Box 6.2 The virtuous cycle of supply of and demand for primary care
supply is functioning. Health authorities are expanding the range
of services offered and improving the quality – by encouraging the
recruitment of doctors in the rural primary-care centres − while
continuing their support to the extension of the network.
Population (millions)
1998
Figure 6.4 The progressive extension of coverage by community-owned,
community–operated health centres in Mali, 1998–2007
Not yet covered
Covered, but living more than 5 km from health care
Covered, living within 5 km of health care
2
4
6
8
10
12
0
Demand-driven
acceleration of
community
initiatives
Slowdown
to safeguard
quality
1999 2000 2001 2002 2003 2004 2005 2006 2007
Slowdown
to safeguard
quality
Demand-driven
acceleration of
community
initiatives
Source: Système national d’information sanitaire (SNIS), Cellule de Planification et de
Statistiques Ministère de la Santé Mali [National health information system (SNIS), Planning
and Statistics Unit, Ministry of Health, Mali].
men, women and families of a given community
live. Integration is becoming a reality through
approaches, such as the Integrated Management
of Adolescent and Adult Illness (IMAI) and the
community-based interventions emerging from
the Onchocerciasis Control Programme (OCP)19.
Global initiatives are loosening their grip on
disease-control mandates and are beginning
to appreciate the importance of strengthening
the system more generally, such as through
GAVI Alliance’s Health System Strengthening
window, paving the way for better alignment of
previously fragmented initiatives. Driven largely
by demand, information technologies to support
primary care, such as electronic medical records,
are spreading much faster than anticipated.
Efforts to scale up HIV treatment have helped to
expose the shortfalls in key systems inputs, such
as the supply chain management of diagnostics
and drugs, and build bridges to other sectors,
such as agriculture, given the imperative of food
security. Emerging awareness of the magnitude
of the workforce crisis is leading to ambitious
policies and programmes, including task shifting,
distance learning and the innovative deployment
of fi nancial and non-fi nancial incentives.
In this context, the challenge is no longer to do
more with less, but to harness the growth in the
The World Health Report 2008 Primary Health Care – Now More Than Ever
108
health sector to do more with more. The unmet
need in these countries is vast and making services
available is still a major issue. It requires a
progressive roll-out of health districts – whether
through government services or by contracting
NGOs, or a combination of both. Yet the complexities
of contemporary health systems, particularly,
but not only in urban areas, call for fl exible and
innovative interpretations of these organizational
strategies. In many of Africa’s capitals, for example,
public facilities of primary, and even secondary,
level have almost or completely disappeared,
and have been replaced by unregulated commercial
providers20. Creative solutions will have to
build on alliances with local authorities, civil
society and consumer organizations to use growing
funds – pooled private pre-payment, social
security contributions, funds from municipal
authorities and tax-sourced funding – to create
a primary-care offer that acts as a public safety
net, as an alternative to unregulated commercial
care, and as a signal of what trustworthy, peoplecentred
health care can look like.
What eventually matters is the experience of
patients accessing services. Trust will grow if they
are welcomed and not turned away; remembered
and not forgotten; seen by someone who knows
them well; respected in terms of their privacy
and dignity; responded to with appropriate care;
informed about tests; and provided with drugs
and not charged a fee at the point of service.
Growing trust can induce a virtuous cycle of
increased demand and improved supply (Box 6.2).
The gain in credibility that comes from instating
such a virtuous cycle is key to gaining social and
political consensus on investment in healthier
public policies across sectors. Effective food
security, education and rural-urban policies are
critical for health and health equity: the health
sector’s infl uence on these policies depends to
a large extent on its performance in providing
quality primary care.
Mobilizing the drivers of reform
Across all of the diverse national contexts in which
PHC reforms must fi nd their specifi c expression,
globalization plays a major role. It is altering the
balance between international organizations,
national governments, non-state actors, local and
regional authorities and individual citizens.
The global health landscape is not immune to
these wider changes. Over the last 30 years, the
traditional nation state and multilateral architecture
have been transformed. Civil society organizations
have mushroomed, along with the emergence
of public-private partnerships and global
advocacy communities identifi ed with specifi c
health problems. Governmental agencies work
with research consortia and consulting fi rms
as well as with non-state transnational institutions,
foundations and NGOs that operate on a
global scale. National diasporas have appeared
that command substantial resources and infl uence
with remittances – about US$ 150 billion
in 2005 – that dwarf overseas development aid.
Illicit global networks make a business out of
counterfeit drugs or toxic waste disposal, and
now have the resources that allow them to capture
and subvert the capacity of public agencies.
Power is gravitating from national governments
to international organizations and, at the same
time, to sub-national entities, including a range
of local and regional governments and non-governmental
institutions21.
This new and often chaotic complexity is challenging,
particularly to health authorities that
hesitate between ineffective and often counterproductive
command and control and deleterious
laissez-faire approaches to governance. However,
it also offers new, common opportunities
for investing in the capacity to lead and mediate
the politics of reform, by mobilizing knowledge,
the workforce and people.
Mobilizing the production of knowledge
PHC reforms can be spurred and kept on track
by institutionalizing PHC policy reviews that
mobilize organizational imagination, intelligence
and ingenuity. The know-how to conduct policy
reviews exists22, but requires more explicit articulations.
They need to refocus on monitoring such
progress with each of the four interlocking sets of
PHC reforms; on identifying, as they unfold, the
technical and political obstacles to their advancement;
and on providing the elements for course
corrections, where necessary.
109
Chapter 6. The way forward
In a globalizing world, PHC policy reviews
can take advantage of the emerging within- and
across-country collaborative networks to build
up the critical mass that can lead and implement
the necessary reforms. Indeed, for many
countries, it is not realistic to fi nd, within their
own institutions, all the technical expertise, contextual
knowledge and necessary capacity for
dispassionate analysis that PHC policy reviews
require. Open, inclusive and collaborative structures,
such as the Latin American observatory
models23, can go a long way in harnessing the
diversity of national resources. Such models also
make it possible to derive further benefi ts from
international collaboration and to overcome the
scarcities within a single nation’s capacities. Policy-
makers today are more open to lessons from
abroad than they may have been in the past, and
are using them to feed national policy dialogue
with innovative approaches and better evidence
of what works and what does not22. Embedding
national institutions in regional networks that
collaborate around PHC policy reviews makes it
possible to pool technical competencies as well as
information. Importantly, it can create regional
mechanisms to get more effective representation
in important but labour-intensive global bodies,
with less strain on scarce national resources.
More structured and intensive inter-country
collaboration around PHC policy reviews would
yield better international comparative data on
variations in the development of health systems
based on PHC, on models of good practice and on
the determinants of successful PHC reforms. Such
information is currently often either absent, hard
to compare or outdated. By building on networks
of experts and institutions from different regions,
it is possible to produce consensus-based and
validated benchmarks for assessing progress
and easier access to (inter)national sources of
information relevant to monitoring primary care.
This could make a big difference in steering PHC
reforms. Various initiatives in this direction, such
as the Primary Health Care Activity Monitor for
Europe (PHAMEU)24, a network of institutes and
organizations from 10 European Union Member
States, or the Regional Network on Equity in
Health (EQUINET)25, a network of professionals,
civil society members, policy-makers, and state
offi cials in Southern Africa, are promising steps
in that direction.
There is a huge research agenda with enormous
potential to accelerate PHC reforms that
requires more concerted attention (see Box 6.3).
Yet, currently, the share of health expenses
devoted to determining what works best – to
health services research – is less that 0.1% of
health expenditure in the United States, the country
that spends the highest proportion (5.6%) of
Box 6.3. From product development to
fi eld implementation – research makes
the link27
The WHO-based Special Programme for Research and Training
in Tropical Diseases (TDR) has been a pioneer in research to
inform policy and practice. TDR-sponsored studies were the
fi rst to broadly document the effi cacy of insecticide-treated
bednets for malaria prevention in the mid-1990s, in multicountry,
multi-centre controlled trials. Following introduction
of the drug Ivermectin for onchocerciasis, or “river blindness”,
control in the late 1980s, TDR, together with the African Programme
for Onchocerciasis Control, initiated research on how
best to get Ivermectin into mass distribution in the fi eld. What
evolved was a tested and fi ne-tuned region-wide system for
“community-directed treatment” of river blindness, described
as “one of the most triumphant public health campaigns ever
waged in the developing world.”28
Now, as the global health community moves away from vertical
disease control, operational research is facilitating the shift.
Recent TDR-supported large-scale, controlled studies involving
2.5 million people in 35 health districts in three countries have
demonstrated that the community-directed treatment methods
developed to combat river blindness can be utilized as a
platform for integrated delivery of multiple primary health-care
interventions, including, bednets, malaria treatment and other
basic health-care interventions, with signifi cant increases in
coverage. For example, more than twice as many children with
fever received appropriate antimalarial treatment, exceeding
60% coverage on average. Critical to both the funding and
execution of such research are the partnerships fostered with
countries in the region, as well as other public, civil society and
private institutions. The vision now is to make implementation
and operations research an even more important element of
global research agendas, so that new products may fi nally
begin to yield their hoped-for health impact through sounder
primary health-care system implementation. Thus, the longstanding
burden of deadly diseases, such as malaria, may be
more effectively addressed – through global, regional and
local knowledge-sharing and cooperation.
The World Health Report 2008 Primary Health Care – Now More Than Ever
110
its health expenditure on biomedical research26.
As another striking example, only US$ 2 million
out of US$ 390 million in 32 GAVI Health
System Strengthening grants were allocated to
research, despite encouragement to countries to
do so. No other I$ 5 trillion economic sector would
be happy with so little investment in research
related to its core agenda: the reduction of health
inequalities; the organization of people-centred
care; and the development of better, more effective
public policies. No other industry of that size
would be satisfi ed with so little investment in a
better understanding of what their clients expect
and how they perceive performance. No other
industry of that size would pay so little attention
to intelligence on the political context in which
it operates – the positions and strategies of key
stakeholders and partners. It is time for health
leaders to understand the value of investment
in this area.
Mobilizing the commitment of
the workforce
Each of the sets of PHC reforms emphasizes the
premium placed on human resources in health.
The expected skills and competencies constitute
an ambitious workforce programme that
requires a rethink and review of existing pedagogic
approaches. The science of health equity
and primary care has yet to fi nd its central place
in schools of public health. Pre-service education
for the health professions is already beginning
to build in shared curricular activities that
emphasize problem-solving in multi-disciplinary
teams, but they need to go further in preparing
for the skills and attitudes that PHC requires.
This includes creating opportunities for on-thejob
learning across sectors through mentoring,
coaching and continuing education. These and
other changes to the wide array of curricula and
on-the-job learning require a deliberate effort to
mobilize the responsible institutional actors both
within and across countries.
However, as we have learned in recent years,
the content of what is learned or taught, although
extremely important, is but one part of a complex
of systems that governs the performance of the
health workforce1. A set of systems issues related
to the health workforce need to be guided to a
greater degree by PHC reforms. For example,
health equity targets for underserved population
groups will remain elusive if they do not consider
how health workers can be effectively recruited
and retained to work among them. Likewise,
grand visions of care coordinated around the
person or patient are unlikely to be translated
into practice if credible career options for working
in primary-care teams are not put in place.
Similarly, incentives are critical complements in
ensuring that individuals and institutions exercise
their competencies when engaging health
in all policies.
The health workforce is critical to PHC reforms.
Signifi cant investment is needed to empower
health staff – from nurses to policy-makers –
with the wherewithal to learn, adapt, be team
players, and to combine biomedical and social
perspectives, equity sensitivity and patient centredness.
Without investing in their mobilization,
they can be an enormous source of resistance to
change, anchored to past models that are convenient,
reassuring, profi table and intellectually
comfortable. If, however, they can be made to
see and experience that primary health care
produces stimulating and gratifying work, which
is socially and economically rewarding, health
workers may not only come on board but also
become a militant vanguard. Here again, taking
advantage of the opportunities afforded by the
exchange and sharing of experience offered by
a globalizing world can speed up the necessary
transformations.
Mobilizing the participation of people
The history of the politics of PHC reforms in the
countries that have made major strides is largely
unwritten. It is clear, however, that where these
reforms have been successful, the endorsement
of PHC by the health sector and by the political
world has invariably followed on rising demand
and pressure expressed by civil society. There
are many examples of such demand. In Thailand,
the initial efforts to mobilize civil society and
politicians around an agenda of universal coverage
came from within the Ministry of Health29,30.
However, it was only when Thai reformers joined
a surge in civil society pressure to improve access
to care, did it become possible to take advantage
111
Chapter 6. The way forward
of a political opportunity and launch the reform31.
In just a few years, coverage was extended and
most of the population was covered with a publicly
funded primary-care system that benefi tincidence
analysis shows to be pro-poor32,33. In
Mali, the revitalization of PHC in the 1990s started
with an alliance between part of the Ministry of
Health and part of the donor community, which
made it possible to overcome initial resistance
and scepticism34. However, sustained extension
of coverage only came about when hundreds of
local “community health associations” federated
in a powerful pressure group to spur the Ministry
of Health and sustain political commitment35. In
western Europe, consumer organizations have
a prominent place in the discussions on health
care and public policies relating to health, as have
many other civil society organizations. Elsewhere,
such as in Chile, the initiative has come from the
political arena as part of an agenda of democratization.
In India, the National Rural Health
Mission came about as a result of strong pressure
from civil society and the political world, while, in
Bangladesh, much of the pressure for PHC comes
from quasi-public NGOs36.
There is an important lesson there: powerful
allies for PHC reform are to be found within civil
society. They can make the difference between
a well-intentioned but short-lived attempt, and
successful and sustained reform; and between
a purely technical initiative, and one that is
endorsed by the political world and enjoys social
consensus. This is not to say that public policy
should be purely demand-driven. Health authorities
have to ensure that popular expectations
and demand are balanced with need, technical
priorities and anticipated future challenges.
Health authorities committed to PHC will have
to harness the dynamics of civil society pressure
for change in a policy debate that is supported
with evidence and information, and informed by
exchange of experience with others, within and
across national boundaries.
Today, it is possible to make a stronger case
for health than in previous times. This is not only
because of intrinsic values, such as health equity,
or for the sector’s contribution to economic growth
− however valid they may be, these arguments
are not always the most effective – but on political
grounds. Health constitutes an economic sector
of growing importance in itself and a feature of
development and social cohesion. Reliable protection
against health threats and equitable access
to quality health care when needed are among
the most central demands people make on their
governments in advancing societies. Health has
become a tangible measure of how well societies
are developing and, thus, how well governments
are performing their role. This constitutes a reservoir
of potential strength for the sector, and is
a basis for obtaining a level of commitment from
society and political leadership that is commensurate
with the challenges.
Economic development and the rise of a knowledge
society make it likely, though not inevitable,
that expectations regarding health and health
systems will continue to rise – some realistic,
some not, some self-serving, others balanced
with concern for what is good for society at large.
The increasing weight of some of the key values
underlying these expectations − equity, solidarity,
the centrality of people and their wish to have
a say in what affects them and their health − is a
long-term trend. Health systems do not naturally
gravitate towards these values, hence the need for
each country to make a deliberate choice when
deciding the future of their health systems. It
is possible not to choose PHC. In the long run,
however, that option carries a huge penalty: in
forfeited health benefi ts, impoverishing costs, in
loss of trust in the health system as a whole and,
ultimately, in loss of political legitimacy. Countries
need to demonstrate their ability to transform
their health systems in line with changing
challenges as well as to rising popular expectations.
That is why we need to mobilize for PHC,
now more than ever.
The World Health Report 2008 Primary Health Care – Now More Than Ever
112
References
World Health Report 2006 – Working t 1. ogether for health. Geneva, World Health
Organization, 2006.
2. Ezekiel JE. The perfect storm of overutilization. JAMA, 2008, 299:2789−2791.
3. Halman L et al. Changing values and beliefs in 85 countries. Trends from the values
surveys from 1981 to 2004. Leiden and Boston MA, Brill, 2008 (European Values
Studies, No. 11).
4. Lübker M. Globalization and perceptions of social inequality. Geneva, International
Labour Offi ce, Policy Integration Department, 2004 (World Commission on the
Social Dimension of Globalization, Working Paper No. 32).
5. National health accounts. Geneva, World Health Organization, 2008 (http//www.
who.int/nha/country/en/index.html, accessed May 2008).
6. National strategy to reduce social inequalities in health. Paper presented to the
Storting. Oslo, Norwegian Ministry of Health and Care Services, 2007 (Report No.
20 (2006–2007); http://www.regjeringen.no/en/dep/hod/Documents/regpubl/
stmeld/2006-2007/Report-No-20-2006-2007-to-the-Storting.html?id=466505,
accessed 19 July 2008).
7. Smith G et al. Genetic epidemiology and public health: hope, hype, and future
prospects. Lancet, 2005, 366:1484–1498.
8. Moran M. Governing the health care state: a comparative study of the United
Kingdom, The United States and Germany. Manchester and New York NY,
Manchester University Press, 1999.
9. Heath I. A general practitioner for every person in the world. BMJ, 2008, 336:861.
10. Busse R, Schlette S, eds. Focus on prevention, health and aging, and health
professions. Gütersloh, Verlag Bertelsmann Stiftung, 2007 (Health Policy
Developments 7/8).
11. Rothman DJ. Beginnings count: the technological imperative in American health care.
Oxford and New York NY, Oxford University Press, 1997.
12. Human resources for health database. Geneva, World Health Organization, 2008
(http://www.who.int/topics/human_resources_health/en/index.html).
13. PHC and mental health report. Geneva, World Health Organization, 2008 (in press).
14. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries.
Lancet, 2007, 370:2158–2163.
15. World Health Statistics 2008 (http://www.who.int/whosis/en/).
16. Achieving universal health coverage: developing the health fi nancing system. Geneva,
World Health Organization, 2005 (Technical briefs for Policy-Makers No. 1; WHO/
EIP/HSF/PB/05.01).
17. National Rural Health Mission. Meeting people’s health needs in rural areas.
Framework for implementation 2005–2012. New Delhi, Government of India, Ministry
of Health and Family Welfare (http://mohfw.nic.in/NRHM/Documents/NRHM%20
-%20Framework%20for%20Implementation.pdf, accessed 4 August 2008).
18. Heavily indebted poor countries (HIPC) initiative and multilateral debt relief initiative
(MDRI) – status of implementation, 28 August 2007. Washington DC, International
Monetary Fund, 2007 (http://www.imf.org/external/np/pp/2007/eng/082807.pdf,
accessed 12 March 2008).
19. Integrated community-based interventions: 2007 progress report to STAC(30).
Geneva, United Nations Development Programme/World Bank/World Health
Organization Special Programme for Research and Training in Tropical Diseases,
2008 (TDR Business Line 11).
20. Grodos D. Le district sanitaire urbain en Afrique subsaharienne. Enjeux, pratiques et
politiques. Louvain-la-Neuve, Paris, Karthala-UCL, 2004.
21. Baser H, Morgan P. Capacity, change and performance. Maastricht, European Centre
for Development Policy Management, 2008.
22. OECD reviews of health systems − Switzerland. Paris, Organisation for Economic
Co-operation and Development/World Health Organization, 2006.
23. De Campos FE, Hauck V. Networking collaboratively: the experience of the
observatories of human resources in Brazil. Cahiers de sociologie et de démographie
médicales, 2005, 45:173–208.
24. The PHAMEU project. Utrecht, Netherlands Institute for Health Services, 2008
(http://www.phameu.eu/).
25. EQUINET Africa. Regional Network on Equity in Health in Southern Africa, Harare,
2008 (http://www.equinetafrica.org/).
26. Hamilton M III et al. Financial anatomy of biomedical research. JAMA, 2005,
294:1333−1342.
27. Community-directed interventions for major health problems in Africa: a multi-country
study: fi nal report. Geneva, UNICEF/UNDP/World Bank/World Health Organization
Special Programme for Research & Training in Tropical Diseases, 2008 (http://www.
who.int/tdr/publications/publications/pdf/cdi_report_08.pdf, accessed 26 August
2008).
28. UNESCO science report 2005. Paris, United Nations Educational, Scientifi c and
Cultural Organization, 2005.
29. Tancharoensathien V, Jongudomsuk P, eds. From policy to implementation: historical
events during 2001-2004 of UC in Thailand. Bangkok, National Health Security
Offi ce, 2005.
30. Biscaia A, Conceição C, Ferrinho P. Primary health care reforms in Portugal: equity
oriented and physician driven. Paper presented at: Organizing integrated PHC
through family practice: an intercountry comparison of policy formation processes,
Brussels, 8–9 October 2007.
31. Hughes D, Leethongdee S. Universal coverage in the land of smiles: lessons from
Thailand’s 30 Baht health reforms. Health Affairs, 2007, 26:999–1008.
32. Jongudomsuk P. From universal coverage of healthcare in Thailand to SHI in China:
what lessons can be drawn? In: International Labour Offi ce, Deutsche Gesellschaft
für Technische Zusammenarbeit (GTZ) Gmbh, World Health Organization. Extending
social protection in health: developing countries’ experiences, lessons learnt and
recommendations. Paper presented at: International Conference on Social Health
Insurance in Developing Countries, Berlin, 5–7 December 2005. Eschborn, Deutsche
Gesellschaft für Technische Zusammenarbeit (GTZ), 2007:155–157 (http://www2.
gtz.de/dokumente/bib/07-0378.pdf, accessed 19 July 2008).
33. Tangcharoensathien V et al. Universal coverage in Thailand: the respective roles of
social health insurance and tax-based fi nancing. In: International Labour Offi ce,
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) Gmbh, World
Health Organization. Extending social protection in health: developing countries’
experiences, lessons learnt and recommendations. Paper presented at: International
Conference on Social Health Insurance in Developing Countries, Berlin, 5–7
December 2005. Eschborn, Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ), 2007:121–131 (http://www2.gtz.de/dokumente/bib/07-0378.pdf, accessed
19 July 2008).
34. Maiga Z, Traore Nafo F, El Abassi A. Health sector reform in Mali, 1989–1996.
Antwerp, ITG Press, 2003.
35. Balique H, Ouattara O, Ag Iknane A. Dix ans d’expérience des centres de santé
communautaire au Mali, Santé publique, 2001, 13:35−48.
36. Chaudhury RH, Chowdhury Z. Achieving the Millennium Development Goal on
maternal mortality: Gonoshasthaya Kendra’s experience in rural Bangladesh. Dhaka,
Gonoprokashani, 2007.
Index
113
AA
boriginal populations, health inequities 32
abortion, legal access vs unsafe abortion 65
Africa
low-income countries under stress (LICUS) criteria 5
PHC replaced by unregulated commercial providers 108
see also North Africa; South Africa; sub-Saharan Africa
ageing populations 8
Agreement on Trade-Related Aspects of Intellectual Property
Rights (TRIPS) 76
Alma-Ata see Declaration of Alma-Ata on Primary Health Care
ambulatory care
generalist vs specialist 53
professionals, conventional health care 55
avian infl uenza (H5N1) 68
Ayurvedic medicine training 44
B
Bangladesh
inequalities in health/health care 10
neglect of health infrastructure 2–8
patterns of exclusion 28
quasi-public NGOs 111
resource-constrained settings 87
rural credit programmes 48
Belgium, local authorities, support of intersectoral
collaboration 35
benefi t packages, defi ning 27
Benin, inequalities in health/health care 10
birthing care
empowering users to contribute to their own health 48
professionalization 17, 28
births and deaths, unrecorded/uncounted 74
Bolivia, inequalities in health/health care 10
Bosnia and Herzegovina, inequalities in health/health care 10
Botswana, inequalities in health/health care 10
Brazil
Family Health Teams 67
human resource issues (PAHO) 88
Integrated Management of Childhood Illness (IMCI) 67
policy dialogue 86
Burkina Faso, institutional capacity for health-sector
governance 92
Burundi, Enhanced Heavily Indebted Poor Countries (HIPC)
initiative 106
C
Cambodia
inequalities in health/health care 10
progressive roll-out of rural coverage 30
Campbell Collaboration 74
Canada
policy dialogue 86
SARS leading to establishment of a national public health
agency 64
cancer screening 9
capacity for change
critical mass 90
limitations of conventional capacity building in low- and
middle-income countries 91
Caribbean, professionalization of birthing care 17
Central Asia, professionalization of birthing care 17
Central and Eastern Europe and the Commonwealth of
Independent States (CEE-CIS), disengagement from health
provision 83
cerebrovascular disease, tobacco-related 9
Chad
neglect of health infrastructure 27–8
patterns of exclusion 28
Chile
administrative structures redefi ned 93
benefi t package as an enforceable right 104–5
integrating health sector information systems 35
outreach to families in long-term poverty 33
Regime of Explicit Health Guarantees 87
targeting social protection 33
under-fi ve mortality 1975–2006 2
China
ambitious rural PHC reform 93
deregulation of health sector (1980s) 83–4
health expenditure 84
outbreak of SARS in 2003 64
re-engagement of health care 84
chronic disease, prevention in developing countries 65
chronic obstructive pulmonary disease, tobacco-related 9
civil registration 74
Cochrane Collaboration 73
Codex Alimentarius Commission (1963) 76
Columbia
inequalities in health/health care 10
patterns of exclusion 28
Primary Health Care – Now More Than Ever
114
The World Health Report 2008
commercialization of health care
alternatives to unregulated commercial services 31
consequences for quality and access to care 14
unregulated, drift to 13–14
in unregulated health systems 11, 14, 106
Commission on Social Determinants of Health (CSDH),
recommendations 69
community health workers, bypassing 16
Comoros, inequalities in health/health care 10
comprehensiveness
better vaccination coverage 49
evidence of its contribution to quality of care and better
outcomes 48
conditional cash transfers 33
continuity of care 53, 57
contraceptive prevalence, sub-Saharan Africa 3
conventional health care
ambulatory care professionals 55
switch to PHC 56
vs people-centredness 43
coordination (gatekeeping) role of ambulatory care
professionals 55
Costa Rica
bias-free framework of health systems 36
local reorganization, template for national effort 36
universal coverage scheme 25
Cote d’Ivoire
GDP 4
inequalities in health/health care 10
mother-to-child transmission (MTCT) of HIV 44–5
Cuba, maximizing society’s resources 65
D
Declaration of Alma-Ata on Primary Health Care (1978) ix, xiii,
34, 69
Democratic Republic of the Congo
health budget cuts 7
institutional capacity for health-sector governance 92
rebuilding leadership in health, post-war and economic
decline 94
robustness of PHC-led health systems 31
safari surgery 14
Demographic and Health Survey (DHS) data 34–5
developing countries, chronic disease burden 65
diasporas 108
dietary salt reduction 65
disease control programmes 16
return on investment 13
vs challenges of health systems 83
vs people-centred PHC 43
disengagement from health provision, CEE-CIS 83
documentation and assessment 74
domestic investment, re-invigorating health systems xx
drugs
counterfeit drugs 108
global expenditure 12
national medicine policies 66
product licencing 102
transnational mechanisms of access 66
WHO List of Essential Medicines 66
E
Ecuador
Equity Gauges 88
inequalities in health/health care 10
electronic health records 50
entry point to PHC 50–2, 53, 57
EQUINET (Regional Network on Equity in Health) 109
Equity Gauges, stakeholder collaboration to tackle health
inequalities 88
essential packages, defi ning 27
Ethiopia
contract staff pay 13
Health Extension Workers 67
priority preventive interventions 28
Europe
2003 heatwave 54
Primary Health Care Activity Monitor for Europe (PHAMEU)
109
Regional Network on Equity in Health (EQUINET) 109
European Union
impact assessment guidelines 75
technical requirements, registering new medicines or
product licencing 102
evidence-based medicine 43–4
FF
iji, isolated/dispersed populations 30–1
Finland, health inequities 32
food
dietary salt reduction 65
marketing to children 73
“fragile states”
increase in external funds 106
low-income countries under stress (LICUS) criteria 5
per capita health expenditure 105
fragmentation of health care 11, 12–13
causes 51
fragmented funding streams and service delivery 85
France
health inequities 32
reduction in traffi c fatalities 71
self-help organization of diabetics 48
funding see total health expenditure
115
Index
G
GDP
growth in GDP xviii
life expectancy at birth, 169 countries 4
percentage of GDP used for health (2005) 82
trends per capita and life expectancy at birth, 133
countries 5
generalist ambulatory care 53
global expenditure
medical equipment and devices 12
percentage of GDP used for health (2005) 82
pharmaceutical industry 12
global trends
city dwelling 7
life expectancy 4
that undermine health systems’ response 11–12
globalization xiii–xiv
adjusting to 76
global health interdependence 76
governments
as brokers for PHC reform 82–6
or quasi-governmental institutions, participation and
negotiation 85
grassroots advocacy 35–6
growth, and peace 6
growth market in medical tourism 104
Guinea, inequalities in health/health care 10
HH
aiti, institutional capacity for health-sector governance 92
health, feature of development and social cohesion 111
Health Action Zones, United Kingdom 36
health equity 34–5
central place of 15, 24–5
common misperceptions 34–5
“health in all policies” concept 64
health expenditure see total health expenditure
health hazards, political fall-out from 16
health inequities 15, 24, 32
Aboriginal and non-Aboriginal populations 32
catastrophic expenditure related to out-of-pocket payment
24
Equity Gauges 88
increasing the visibility 34
political proposals, organized social demand 35
see also fragmentation of health care
health systems
changing values and rising expectations 14–15
components and provision of services 66
consistent inequity 24
dangerous oversimplifi cation in resource-constrained
settings xviii
defi ning essential packages 27
diversion from primary health care core values 11
expectations for better performance xiv
failure to assess political environment 9–10
inequalities in health/health care 10, 15, 24, 32, 34–5
little anticipation and slow reactions to change 9–10
making more people-centred 16
Medisave accounts 50
mismatch between expectations and performance xv
mitigating effects of social inequities 36
moving towards universal coverage 25–7
PHC reforms necessary (4 groups) xvii
shift of focus of primary health care movement xvi
three bad trends xiv
universal coverage 25
see also primary health care (PHC) reforms; public policymaking
health-adjusted life expectancy (HALE) 6
health-care delivery
fi ve common shortcomings xv
reorganization of work schedules of rural health centres
42–3
health-sector governance, institutional capacity 92
“Healthy Islands” initiative 30
heatwave, western Europe (2003) 54
Heavily Indebted Poor Countries (HIPC) initiative 106
high spending on health, better outcomes 5
high-expenditure health economies 100, 101–3
HIV infection, mother-to-child transmission (MTCT) 44
HIV/AIDS, continuum of care approaches 68
hospital-centrism 11
opportunity cost 12
I impact assessment, European Union guidelines 75
India
National Rural Health Mission 111
per capita health expenditure 105
private sector medical-care providers 44
public expenditure on health 93
under-fi ve mortality 1975 and 2006 3
Indonesia, inequalities in health/health care 10
infl uenza, avian (H5N1) 68
information and communication technologies 51
information systems
demand for health-related information 87
instrumental to PHC reform 87
strengthening policy dialogue 86–7
transforming into instruments for PHC reform 87
injections, patient safety 44
institutions (national)
capacity for health-sector governance 92
critical mass for capacity for change 90
generation of workforce 76
Primary Health Care – Now More Than Ever
116
The World Health Report 2008
leadership capacity shortfalls 90
multi-centric development 76
productive policy dialogue 86
instruments for PHC reform, information systems 87
Integrated Management of Adolescent and Adult Illness (IMAI)
107
International Clinical Epidemiology Network 73
international environment, favourable to a renewal of PHC xx
international migration 8
interventions, scaling up 28–9
investigations, inappropriate investigations prescribed 53
invisibility, births and deaths unrecorded/uncounted 74
ischaemic heart disease, tobacco-related 9
Islamic Republic of Iran, progressive roll-out of rural coverage
28
isolated/dispersed populations 30–1
fi nancing of health care 31
JJ
apan, magnetic resonance imaging (MRI) units per capita 12
K
Kenya
Equity Gauges 88
malaria prevention 64
knowledge, production of 108
Korea, universal coverage scheme 25
L
Latin America
exclusion of 47
from needed services 32
Pan American Health Organization (PAHO) 32, 66, 88
professionalization of birthing care 17
targeting social protection 33
lead poisoning, avoidable 71
leadership capacity, shortfalls 90
leadership and effective government 81–94
“learning from the fi eld”, policy development 89–90
Lebanon
hospital-centrism vs risk reduction 11
neighbourhood environment initiatives 48
Lesotho, inequalities in health/health care 10
life expectancy at birth
in 169 countries 4
global trends 4
local action, starting point for broader structural changes 36
low- and middle-income countries 101
low-expenditure low-growth health economies 100–1, 105–8
per capita health expenditure 105
low-income countries under stress (LICUS) criteria 5
MM
adagascar
inequalities in health/health care 10
life expectancy at birth 4
under-fi ve mortality 1975 and 2006 3
malaria 109
Malawi
hospital nurses leave for better-paid NGO jobs 13
inequalities in health/health care 10
Malaysia
scaling up of priority cadres of workers 67
under-fi ve mortality 1975 and 2006 2
Mali
institutional capacity for health-sector governance 92
progressive roll-out of rural coverage 30
revitalization of PHC in the 1990s 111
virtuous cycle of supply of and demand for primary care
107
medical equipment and devices, global expenditure 12
medical tourism 104
medico-industrial complex 85–6
Mexico
active ageing programme 48
universal coverage scheme 25
Middle East, professionalization of birthing care 17
Millennium Development Goals (MDGs) xiii, 2, 106
Mongolia, under-fi ve mortality 1975 and 2006 3
Morocco
institutional capacity for health-sector governance 92
trachoma programme 71
under-fi ve mortality 1975 and 2006 3
mortality
cause-of-death statistics 74
reducing under-fi ve mortality by 80, by regions, 1975–
2006 2
shift towards noncommunicable diseases and accidents 8
Mozambique, inequalities in health/health care 10
multi-morbidity 8
mutual support associations 56
NN
airobi, under-fi ve mortality rate 7
national health information systems, policy dialogue 86–7
National Institutes of Public Health (NIPHs) 74–5
International Association of National Public Health Institutes
(IANPHI) 76
Nepal
community dynamics of women’s groups 54
GDP and life expectancy 4
inequalities in health/health care 10
New Zealand, annual pharmaceutical spending 66
Nicaragua, patterns of exclusion 28
117
Index
Niger
inequalities in health/health care 10
neglect of health infrastructure 27–8
patterns of exclusion 28
reorganization of work schedules of rural health centres 42
staff–clients in PHC, direct relationship 42
noncommunicable diseases, mortality 8
North Africa, professionalization of birthing care 17
Norway, national strategy to reduce social inequalities in
health 102
OO
ffi cial Development Aid for Health, yearly aid fl ows (2005) 91
Onchocerciasis Control Programme (OCP) 107, 109
opportunity cost, hospital-centrism 12
Osler, W, quoted 42
Ottawa Charter for Health Promotion 17
outpatient attendance 27
PP
akistan, Lady Health Workers 67
Pan American Health Organization (PAHO) 32, 66, 88
patient safety, securing better outcomes 44
patterns of exclusion from needed services 32
peace, and growth 6
people-centred primary care, universal access 104
people-centredness 16, 42–3
and community participation 85
desire for participation 18
policy dialogue 85–7
vs conventional health care 43
person-centred care
evidence of quality/better outcomes 47
and provider’s job satisfaction 46
Peru, inequalities in health/health care 10
pharmaceutical industry, global expenditure 12
Philippines, inequalities in health/health care 10
policy dialogue 85–6
innovations from the fi eld 89–90
political environment
and health hazards 16
organized social demand 35
political process, from launching reform to implementation
92–3
populations, health evidence documentation 74
Portugal
2004–2010 National Health Plan 92
key health indicators 3
under-fi ve mortality 1975–2006 2
Poverty Reduction Strategy Papers (PRSPs) 92–3
pre-payment and pooling 26–7
pre-payment systems 106
Preston curve, GDP per capita and life expectancy at birth in
169 countries 4
primary health care (PHC)
comprehensive and integrated responses 48–9
comprehensiveness and integratedness 48–9
continuity of care 49–50
dangerously oversimplifi ed in resource-constrained
settings xviii
distinctive features 43–52, 56–7
empowering users 48
experience has shifted focus xiv
governments as brokers for PHC reform 82–6
monitoring progress 56
need for multiple strategies 25
networking within the community served 55
networks, fi lling availability gap 28
organizing PHC networks 52–6
people-centredness, vs conventional health care 43
person-centred, and provider’s job satisfaction 46
political endorsement of PHC reforms 93
priority health programmes 67
progressive roll-out of PHC, vs scaling up of priority
preventive interventions 28–9
rapid response capacity 68–9
reforms, driven by demand 18–19
regular and trusted provider as entry point 50–2
responsibility for a well-identifi ed population 53–4
social values and corresponding reforms 18
staff–clients direct relationship 42
under-investment 71–2
see also health systems
primary health care (PHC) reforms
adapting to country context 100
commitment of workforce 110
four interlocking sets xvii, 114
high-expenditure health economies 101–3
low-expenditure, low-growth health economies 105–8
mobilizing the drivers of reform 108–10
participation of people 110–11
rapid-growth health economies 103–5
primary-care networks 52–6
entry point 50–2
relocation 53
primary-care providers, responsibilities 56
primary-care team, as a hub of coordination 55–6
priority preventive interventions
scaling up 28–9
vs progressive roll-out of PHC 28–30
product development 109
professionalization
ambulatory care 55
birthing care 17, 28
participation and negotiation 85
project management units 91
public funding, conditional cash transfers 33
public policy-making xix–xx, 63–75
Primary Health Care – Now More Than Ever
118
The World Health Report 2008
institutional capacity for development 74–5
opportunities for better public policies 73–4
policies in other sectors 64, 70
systems policies 64
towards health in all policies 69–70
under-investment 71–2
unpopular public policy decisions 72–3
public-health interventions 64, 67–8
essential public-health functions (30 NIPHs) 75
impact assessment guidelines (EU) 75
initiatives 68
R
rapid-growth health economies 103–5
Regional Network on Equity in Health (EQUINET) 109
research
GAVI Health System Strengthening grants 110
product development to fi eld implementation 109
Research and Training in Tropical Diseases (TDR) 109
response-to-demand approach 53–4
risk factors
developing countries chronic disease burden 65
in terms of overall disease burden 8
risk reduction
patient safety and better outcomes 44
vs hospital-centrism 11
river blindness, Onchocerciasis Control Programme (OCP) 107,
109
road-traffi c accidents 7, 8, 71
rural health centres
information and communication technologies 51
reorganization of work schedules 42
Russian Federation, GDP and health 4–5
Ss
alt, dietary reduction 65
SARS pandemic, establishment of national public health
agencies 64
scaling up, limited number of interventions 28–9
Senegal, lead poisoning 71
Seventh Futures Forum, senior health executives 72
Singapore, Medisave accounts 50
skills base, extension workers 28
social cohesion 111
social contract for health 82–3
social demand, and political environment 35
social determinants of health 69
social inequities 36
social protection schemes, Latin America 33
South Africa
Equity Gauges 88
family empowerment and parent training programmes 48
South-East Asia, professionalization of birthing care 17
South-East Asian Region (SEARO) 76
stakeholder collaboration, to tackle health inequalities 88
state and health-care system 83
absence/withdrawal from health provision 83
disengagement and its consequences 83–4
Sub-Saharan Africa
abortions, increased, in unsafe conditions 3
Abuja Declaration target of 15 106
contraceptive prevalence 3
GDP per capita 7
increase in external funds 106
professionalization of birthing care 17
Sultanate of Oman
investment in a national health service 2
under-fi ve mortality 1975 and 2006 3
systems policies, for human resources 66
T Tajikistan, under-fi ve mortality 1975 and 2006 3 Tanzania
budget allocation formulae/contract specifi cations 30
inequalities in health/health care 10
treatment plans for safe motherhood 48
targeting, social protection schemes 33
technical cooperation, Offi cial Development Aid for Health,
yearly aid fl ows (2005) 91
Thailand
30 Baht universal coverage reform 89
Decade of Health Centre Development 86
Declaration of Patients’ Rights 48
First Health Care Reform Forum (1997) 86
inappropriate investigations prescribed 53
policy dialogue 86
strengthening policy dialogue with fi eld model innovations
89
under-fi ve mortality 1975–2006 2
universal coverage scheme 25
tobacco industry, efforts to limit tobacco control 73
tobacco taxes 65
tobacco-attributable deaths 9, 71–2
total health expenditure (THE), 2000–2005 100
conditional cash transfers 33
contribution of general government, private pre-paid and
private out-of-pocket expenditure 101
countries/groups 6
projected per capita health expenditure in 2015 103
rate of growth 100
toxic waste disposal 108
trachoma programme 71
Trade-Related Aspects of Intellectual Property Rights (TRIPS)
76
traffi c accidents 7, 8, 71
119
Index
tropical diseases 109
Tunisia, institutional capacity for health-sector governance 92
Turkey
patterns of exclusion 28
retraining of nurses and physicians 67
universal coverage scheme 25
U
Uganda
allocations to districts 30
outpatient attendance 27
UNICEF/WHO Integrated Management of Childhood Illness
initiatives 46
United Kingdom
career in primary care, fi nancial competitiveness 67
Health Action Zones 36
Poor Laws Commission 34
public-health observatories in England 89
United States
Alaska, staff–clients in PHC, direct relationship 42
in favour of health equity 15
magnetic resonance imaging (MRI) units per capita 12
per capita expenditure on drugs 12
universal access, people-centred primary care 104
universal coverage schemes 25–6
best practices 26
challenges in moving towards 27–8
targeted interventions to complement 32–3
three ways of moving towards 26
unregulated commercial services 31–2
V
vaccination, comprehensiveness/coverage 49
W
women’s health
abortion, legal access vs unsafe abortion 65
birthing care, professionalization 17, 28
contraceptive prevalence, sub-Saharan Africa 3
empowering users to contribute to their own health 48
health-care response to partner violence 47
work circumstances, change and adverse health effects 70
work schedules, reorganization in rural health centres 42
workforce, critical to PHC reforms 110
World Health Organization
List of Essential Medicines 66
offi ces 113
Seventh Futures Forum of senior health executives 72
World Trade Organization (WTO), consideration of health in
trade agreements 76
ZZ
aire, health budget cuts 7
Zambia
health budget cuts 7
incentives to health workers to serve in rural areas 67
life expectancy at birth 4
under-fi ve mortality 1975 and 2006 3



Headquarters
World Health Organization
Avenue Appia 20
1211 Geneva 27, Switzerland
Telephone: (41) 22 791 21 11
Facsimile: (41) 22 791 31 11
E-mail: inf@who.int
Web site: http://www.who.int
WHO Regional Offi ce for Africa
Cité du Djoue
P.O. Box 06
Brazzaville, Congo
Telephone: (47) 241 39100
Facsimile: (47) 241 39503
E-mail: webmaster@afro.who.int
Web site: http://www.afro.who.int
WHO Regional Offi ce for the Americas/
Pan American Sanitary Bureau
525, 23rd Street N.W.
Washington, D.C. 20037, USA
Telephone: (1) 202 974 3000
Facsimile: (1) 202 974 3663
E-mail: webmaster@paho.org
Web site: http://www.paho.org
WHO Regional Offi ce for South-East Asia
World Health House
Indraprastha Estate
Mahatma Gandhi Road
New Delhi 110002, India
Telephone: (91) 112 337 0804/09/10/11
Facsimile: (91) 112 337 0197/337 9395
E-mail: registry@searo.who.int
Web site: http://www.searo.who.int
WHO Regional Offi ce for Europe
8, Scherfi gsvej
2100 Copenhagen Ø, Denmark
Telephone: (45) 39 17 17 17
Facsimile: (45) 39 17 18 18
E-mail: postmaster@euro.who.int
Web site: http://www.euro.who.int
WHO Regional Offi ce for the Eastern
Mediterranean
Abdul Razzak Al Sanhouri Street
P.O. Box 7608
Nasr City
Cairo 11371, Egypt
Telephone: (202) 670 25 35
Facsimile: (202) 670 2492/94
E-mail: webmaster@emro.who.int
Web site: http://www.emro.who.int
WHO Regional Offi ce for the
Western Pacifi c
P.O. Box 2932
Manila 1000, Philippines
Telephone: (632) 528 9991
Facsimile: (632) 521 1036 or 526 0279
E-mail: pio@wpro.who.int
Web site: http://www.wpro.who.int
International Agency for
Research on Cancer
150, cours Albert-Thomas
69372 Lyon Cédex 08, France
Telephone: (33) 472 73 84 85
Facsimile: (33) 472 73 85 75
E-mail: www@iarc.fr
Web site: http://www.iarc.fr
Offi ces of the World Health Organization
PRIMARY
HEALTH
CARE
REFORMS
As nations seek to strengthen their health systems, they are increasingly
looking to primary health care (PHC) to provide a clear and comprehensive
sense of direction. The World Health Report 2008 analyses how primary
health care reforms, that embody the principles of universal access, equity
and social justice, are an essential response to the health challenges of
a rapidly changing world and the growing expectations of countries and
their citizens for health and health care.
The Report identifi es four interlocking sets of PHC reforms that aim
to: achieve universal access and social protection, so as to improve
health equity; re-organize service delivery around people’s needs and
expectations; secure healthier communities through better public policies;
and remodel leadership for health around more effective government and
the active participation of key stakeholders.
This Report comes 30 years after the Alma-Ata Conference of 1978 on
primary health care, which agreed to tackle the “politically, socially and
economically unacceptable” health inequalities in all countries. Much has
been accomplished in this regard: if children were still dying at 1978 rates,
there would have been 16.2 million child deaths globally in 2006 instead
of the actual 9.5 million. Yet, progress in health has been deeply and
unacceptably unequal, with many disadvantaged populations increasingly
lagging behind or even losing ground.
Meanwhile, the nature of health problems is changing dramatically.
Urbanization, globalization and other factors speed the worldwide
transmission of communicable diseases, and increase the burden of
chronic disorders. Climate change and food insecurity will have major
implications for health in the years ahead thereby creating enormous
challenges for an effective and equitable response.
In the face of all this, business as usual for health systems is not a
viable option. Many systems seem to be drifting from one short-term
priority to another, increasingly fragmented and without a strong sense
of preparedness for what lies ahead.
Fortunately, the current international environment is favourable to a
renewal of PHC. Global health is receiving unprecedented attention. There
is growing interest in united action, with greater calls for comprehensive,
universal care and health in all policies. Expectations have never been
so high.
By capitalizing on this momentum, investment in primary health
care reforms can transform health systems and improve the health of
individuals, families and communities everywhere. For everyone interested
in how progress in health can be made in the 21st century, the World
Health Report 2008 is indispensable reading.