Introduction and Overview
These four sets of PHC reforms are driven by shared values that enjoy large support and challenges that are common to a globalizing world. Yet, the starkly different realities faced by individual countries must inform the way they are taken forward. The operationalization of universal coverage, service delivery, public policy and leadership reforms cannot be implemented as a blueprint or as a standardized package.
In high-expenditure health economies, which is the case of most high-income countries, there is ample financial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established universal coverage system with targeted measures to reduce exclusion. In the large number of fast-growing health economies – which is where 3 billion people live – that very growth provides opportunities to base health systems on sound primary care and universal coverage principles at a stage where it is in full expansion, avoiding the errors by omission, such as failing to invest in healthy public policies, and by commission, such as investing disproportionately in tertiary care, that have characterized health systems in high-income countries in the recent past. The challenge is, admittedly, more daunting for the 2 billion people living in the low-growth health economies of Africa and South-East Asia, as well as for the more than 500 million who live in fragile states. Yet, even here, there are signs of growth – and evidence of a potential to accelerate it through other means than through the counterproductive reliance on inequitable out-of-pocket payments at points of delivery – that offer possibilities to expand health systems and services. Indeed, more than in other countries, they cannot afford not to opt for PHC and, as elsewhere, they can start doing so right away.
The current international environment is favourable to a renewal of PHC. Global health is receiving unprecedented attention, with growing interest in united action, greater calls for comprehensive and universal care – be it from people living with HIV and those concerned with providing treatment and care, ministers of health, or the Group of Eight (G8) – and a mushrooming of innovative global funding mechanisms related to global solidarity. There are clear and welcome signs of a desire to work together in building sustainable systems for health rather than relying on fragmented and piecemeal approaches30.
At the same time, there is a perspective of enhanced domestic investment in re-invigorating the health systems around PHC values. The growth in GDP – admittedly vulnerable to economic slowdown, food and energy crises and global warming – is fuelling health spending throughout the world, with the notable exception of fragile states. Harnessing this economic growth would offer opportunities to effectuate necessary PHC reforms that were unavailable during the 1980s and 1990s. Only a fraction of health spending currently goes to correcting common distortions in the way health systems function or to overcoming system bottlenecks that constrain service delivery, but the potential is there and is growing fast.
Global solidarity – and aid – will remain important to supplement and suppport countries making slow progress, but it will become less important per se than exchange, joint learning and global governance. This transition has already taken place in most of the world: most developing countries are not aid-dependent. International cooperation can accelerate the conversion of the world’s health systems, including through better channelling of aid, but real progress will come from better health governance in countries – lowand high-income alike.
The health authorities and political leaders are ill at ease with current trends in the development of health systems and with the obvious need to adapt to the changing health challenges, demands and rising expectations. This is shaping the current opportunity to implement PHC reforms. People’s frustration and pressure for different, more equitable health care and for better health protection for society is building up: never before have expectations been so high about what health authorities and, specifically, ministries of health should be doing about this.
By capitalizing on this momentum, investment in PHC reforms can accelerate the transformation of health systems so as to yield better and more equitably distributed health outcomes. The world has better technology and better information to allow it to maximize the return on transforming the functioning of health systems. Growing civil society involvement in health and scale-efficient collective global thinking (for example, in essential drugs) further contributes to the chances of success.
During the last decade, the global community started to deal with poverty and inequality across the world in a much more systematic way – by setting the MDGs and bringing the issue of inequality to the core of social policy-making. Throughout, health has been a central, closely interlinked concern. This offers opportunities for more effective health action. It also creates the necessary social conditions for the establishment of close alliances beyond the health sector. Thus, intersectoral action is back on centre stage. Many among today’s health authorities no longer see their responsibility for health as being limited to survival and disease control, but as one of the key capabilities people and societies value31. The legitimacy of health authorities increasingly depends on how well they assume responsibility to develop and reform the health sector according to what people value – in terms of health and of what is expected of health systems in society.
30. The Paris declaration on aid effectiveness: ownership, harmonisation, alignment, results and mutual accountability. Paris, Organisation for Economic Co-operation and Development, 2005.
31. Nussbaum MC, Sen A, eds. The quality of life. Oxford, Clarendon Press, 1993.