Chapter 7: Health Systems: principled integrated care
Enduring principles in a changing environment
The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries (see the example in Box 7.2). Advances in health technology have transformed many aspects of medical practice and raised expectations concerning the types of functions and services that health systems should provide.
Box 7.2 Primary care in a changing environment: the "health houses" of the Islamic Republic of Iran
The Government of the Islamic Republic of Iran has invested strongly in training health care providers. Primary health care facilities, popularly known as "health houses", provide an active network staffed by community health workers, or behvarzes, who are trained and regularly supervised by staff from district health centres. The behvarzes provide basic care and advice on many aspects of maternal and child health and common communicable diseases. They also record local health information through the "vital horoscope" data system, which includes information collected during annual household visits. This system provides valuable information for planning services both locally and nationally. There are high levels of community involvement in the delivery of community-based health care; 90% of the population belongs to a health insurance scheme, and some schemes are explicitly designed to protect the poor.
Today, the Islamic Republic of Iran faces several challenges to maintaining these achievements in a changing environment. The country's epidemiological profile has changed, partly as a consequence of the success of the strategy led by primary care. The major burden of disease is attributable to noncommunicable diseases and injuries, though there are some differences between richer and poorer provinces. Urbanization is increasing, with an associated change in lifestyle. The private health sector is increasing. Clinical case management is often not as evidence-based as it could be. A recent study on health financing demonstrated that the financing system is not as equitable as had been thought: out-of-pocket payments are high, and the poor are less well protected from catastrophic health expenditures than they were previously.
The government is moving to respond to these new challenges. It is already beginning to reorient the primary health care activities delivered in health houses. Technical guidelines for interventions and training for different cadres of health worker are being reviewed as part of an effort to improve quality of care. There are discussions about a common benefit package, what it should include and by whom it should be provided; specifically, how to involve private providers more effectively in the delivery of critical interventions, both preventive and curative, for example through contracting. The different insurance schemes are being reviewed within a broader analysis of overall health system financing, and there are debates about what sort of organizational arrangements within the public sector would enhance the quality and efficiency of public providers.
The institutional context of health policy-making and health care delivery has also changed. Government responsibilities and objectives in the health sector have been redefined, with private sector entities, both for-profit and not-for-profit, playing an increasingly visible role in health care provision. The reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentralization and health sector reform have had mixed effects on health care system performance (4).
The ideas and activities associated with primary health care have themselves undergone changes. In the 1980s, the approach termed "selective primary health care" gained favour. By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged "vertical" programme structures. These programmes produced important gains, for example in immunization coverage and child mortality reduction, but were at odds with the comprehensive vision of primary health care developed at Alma-Ata, notably its emphasis on tackling the socioeconomic determinants of ill-health. In the 1990s, the World Bank recommended a set of core public health interventions and a package of essential clinical services influenced by primary health care models, though critics questioned whether these strategies responded adequately to the messages of equity and community participation delivered at Alma-Ata (5).
Originally, primary health care and the health-for-all movement represented an effort to change practices and structures in the health sector based on population health criteria. Subsequent health sector reform efforts have often been steered by criteria largely extrinsic to health (for example, broad commitments to decentralization or civil service reform, or the need to reduce government spending). Reaffirmation of primary health care principles by global health stakeholders signals a recognition of the need to return to population health criteria as the basis for decisions affecting how health care services are organized, paid for and delivered.