Introduction and Overview
Growing expectations for better performance
The support for a renewal of PHC stems from the growing realization among health policymakers 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 fixes currently touted as cures for the health sector’s ills. There is also a growing realization that conventional health-care 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 significance 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.
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 benefits 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.
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. Starfield 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 five-country survey. Health Affairs, 2002, 21:182–191.