Introduction and Overview
Four sets of PHC reforms
This report structures the PHC reforms in four groups that reflect 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 first 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 financial 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 does too little to offset the health consequences of social stratification. 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 profile that it has often masked the broader PHC agenda. The resulting confusion has been compounded by the oversimplification 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 efficiency, of health care organized as peoplecentred primary care. Despite variations in the specific terminology, its characteristic features (person-centredness, comprehensiveness and integration, continuity of care, and participation of patients, families and communities) are well identified15,27. Care that exhibits these features requires health services that are organized accordingly, with close-to-client multidisciplinary teams that are responsible for a defined 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 sufficient to respond to people’s desires to live in conditions that protect their health, support health equity 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 stratification.
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 efficiencies; 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 financing, which are supportive of the reforms that promote equity and peoplecentred 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 influence 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 specific 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.
Box 2 What has been considered primary care in well-resourced contexts has been dangerously oversimplified in resource-constrained settings
Primary care has been defined, 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 acceptable 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 specific 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 financed through out-of-pocket payments on the erroneous assumption that it is cheap and the poor should be able to afford it.
3. WHO Regional Office for South-East Asia and WHO Regional Office for the Western Pacific. People at the centre of health care: harmonizing mind and body, people and systems. Geneva, World Health Organization, 2007.
14. Xu K et al. Protecting households from catastrophic health expenditures. Health Affairs, 2007, 6:972–983.
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. Starfield 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.