Introduction and Overview
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 influence or control. Furthermore, all too often, the PHC movement has oversimplified its message, resulting in one-size-fits-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 specific and context-sensitive reforms that respond to the health challenges of today and prepare for those of tomorrow.
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 financing 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 find a voice within the policy and decisionmaking processes. The necessary reorientation of health systems has to be based on sound scientific 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 defined 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 define the role of health systems in society.
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.