The world health report

Global health improvement and WHO: shaping the future

A world torn by gross health inequalities is in serious trouble. The global health community can do much to reduce suffering and death among vulnerable groups. WHO is changing its way of working, alongside member states and financial and technical partners, to reach key national health goals and strengthen equity. The most urgent objectives include the health-related Millennium Development Goals, the 3 by 5 target in HIV/AIDS treatment (to provide 3 million people in developing regions with access to antiretroviral treatment by the end of 2005), and addressing the growing epidemics of non-communicable diseases. The key to achieving these objectives is strengthening of health systems guided by the values of Health For All.

Strengthening health systems

We are embracing 3 by 5 and Health For All simultaneously. To link these two agendas necessitates a comprehensive engagement with health systems. Most countries will make only small advances in population health in the years ahead without substantially strengthening their health-care systems. Work toward specific targets such as the Millennium Development Goals and 3 by 5 must be organised so as to drive a broad build-up of health-care systems capacities. To improve health-care access and outcomes while narrowing equity gaps, WHO will promote the scaling-up of health-care systems based on the principles of primary health care. In the World health report 2003, the model of health-care system development led by primary health care is discussed. The report emphasises both the broad ethical commitment to equity which grounds a system based on primary health care and such a system's integrated service structure-"principled, integrated care". From a systems perspective, the potential conflict between primary health care as a discrete level of care and as an overall approach to responsive, equitable health-service provision can be reconciled.1

The political, socioeconomic, and epidemiological contexts of primary health care have changed dramatically in a quarter of a century. Yet these changes render the fundamental ethical commitments of Health For All more important than ever. WHO reaffirms the aims and values of Health For All and will work with countries to develop health systems strategies for translating these values into sustained action. The way to Health For All is through strengthening of health systems. Panel 1 shows the aims of a health system based on primary health care. In the years ahead, WHO's cooperation with countries on health-care systems improvement will be intensified as part of a broad strategic reconfiguration of the organisation's work in measurement, evidence, and health systems analysis. The World health report 2000 did much to focus the world's attention on the issue of health systems performance.16 Although methodological and process problems sparked criticism, WHO's assessment framework for health systems performance is an important instrument. Moving forward, our efforts will focus on practical work with countries to strengthen their health systems. Cooperation with countries in equitable health systems development will be an increasingly important part of WHO's mission.

Health-care systems in low-income and middle-income countries face a wide array of challenges. The World health report 2003 takes up four of the most pressing issues: the global health workforce crisis; the need for improved health information; sustainable financing; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment.

Many countries face a workforce crisis in the health sector. The shortage of qualified staff slows progress toward health targets and contributes directly to the HIV/AIDS treatment gap. In some instances, workforce constraints threaten to undermine the benefits of new financial resources and technologies becoming available to the health sector. WHO will expand its technical cooperation with countries to build the health workforce using innovative methods of training, deployment, and supervision of allied and community health workers. For example, WHO's 3 by 5 emergency mission in Kenya found that about 4000 nurses, 1000 clinical officers, 2000 laboratory staff, and 160 pharmacists or pharmacy technicians are currently unemployed in that country (WHO, unpublished). Many of these health workers could quickly receive training that would enable them to take part in HIV/AIDS treatment scale-up. WHO will assemble and disseminate emerging evidence on best policies and practices for human resources. The organisation will use its global health advocacy position to seek solutions to the brain drain problem, which by its nature demands an international strategy.

In most countries stronger, more integrated information systems are needed at district and national levels to better assess health status and trends, track health system performance, and monitor progress toward health goals.17 One example is vital registration systems-the ability to count births and deaths. Such systems are still missing for a large proportion of the world's population, especially in countries with high disease burdens. Strengthening these systems requires a collaborative effort. The Health Metrics Network, to be launched in 2004, is a broad partnership including WHO, other international organisations, bilateral agencies, foundations, ministries of health, statistical organisations, academic institutions, and civil society organisations. It will improve the availability and use of health information for policy-making, programme monitoring and assessment, monitoring of international goals such as the Millennium Development Goals, and health equity assessment.

Fundamental requirements for health-care systems guided by primary health care principles also include proequity financing and stewardship mechanisms that can ensure that quality health-care services are accessible for the whole population, including poor and marginalised groups. Solutions to these challenges must take account of national and local specificities and should negotiate a health-care delivery landscape that is more complex than at the time of Alma-Ata. WHO will work closely with countries to shape health-system development strategies that are pro-equity and driven by primary health care. Excellent work in this direction has already been done in some countries, and lessons can be more widely applied. For example, Chile is carrying through a promising reform of the health-care system, with a primary health care focus and explicit strategies for improving equity. These strategies could be applicable in other middle-income countries (see panel 2).

Panel 1: Features of a health-care system based on primary care
A health-care system based on primary health care will

  • build on the Alma-Ata principles of equity, universal access, community participation, and intersectoral approaches
  • take account of broader population-health issues, reflecting and reinforcing public-health functions
  • create the conditions for effective provision of services to poor and excluded groups
  • organise integrated and seamless care, linking prevention, acute care and chronic care across all components of the health system
  • continuously assess and strive to improve performance
  • Strengthening of health systems is pivotal to the effort to put countries back at the centre of WHO's work. This was one of my pledges when I sought the post of Director- General. In cooperation with member states, Regional Directors, and WHO country staff, we are taking steps to ensure that all WHO representatives in countries have the resources and the authority to run their offices as efficient, accountable units responsive to local needs. Additional resources are being deployed to priority country offices for building capacity in HIV/AIDS control and development of health-care systems. Further, all Assistant Directors- General have been asked to assess the work of their respective clusters and to propose specific steps for moving resources from headquarters to regions and countries. WHO will remain a strong voice in international debates on all issues that affect health. But results in countries will be the primary measure of the organisation's success-on 3 by 5, the Millennium Development Goals, control of non-communicable diseases, and health systems.

    Panel 2: Health-system improvement based on primary health care in a middle-income country: the example of Chile

    Since 1990, building on Alma-Ata principles, Chile has progressively implemented a primary-health-care approach focused on the community and the family. The country's current health sector reform is explicitly based on primary health care and a pro-equity orientation. Reform measures aim to equip primary care establishments throughout the country as family and community health centres (centros de salud familiar y comunitaria) able to bring complete, integrated care within reach of the whole population. Innovative measures to promote equitable access for marginalised and vulnerable groups have been built in-for example through outreach programmes aimed at rural and indigenous populations. Epidemiological data on usage patterns have been used to redistribute staff and other resources at health facilities to provide more efficient service to vulnerable groups (such as children and older adults), reduce waiting times during peak usage periods, and increase client satisfaction.18 In 2000, 265 health centres (consultorios) extended their opening hours to better meet client demands, enabling a 23% increase in the number of patients seen. By the following year, a total of 483 publicsector health-facilities had adopted the same system. In 2000, 550 primary-care facilities throughout the country improved their responsiveness through measures including remodelling of reception and clinical spaces, introduction of priority service windows, extended opening hours, and prioritisation of clients based on clinical criteria rather than order of arrival. These measures enabled 97% of the facilities to eliminate early morning waiting lines (

    Chile's health sector reform has been combined with decentralisation and has generated a model of local network management (gestion en red) that gives increased autonomy to closely integrated local networks of primary care centres and referral facilities. These locally networked facilities coordinate their activities to achieve service improvements such as minimising the length of time patients must wait for referral appointments. Strong commitment from the country's political leadership has accelerated the reform process. Recently passed legislation guarantees universal access to treatment for 56 conditions which together account for 80% of Chile's mortality. The law stipulates that a patient's total annual copayment will not exceed 20% of the cost of services, nor surpass the equivalent of 1 month's family income (