The World Health Report 2008 Primary health Care SERVICE DELIVERY PUBLIC UNVER Now COVERAGE REFORMS REFORMS More Than lEver MAM World Health Organization
Primary Health Care Now More Than Ever The World Health Report 2008 UNIVERSAL COVERAGE REFORMS SERVICE DELIVERY REFORMS LEADERSHIP REFORMS PUBLIC POLICY REFORMS couverture_cor.indd xx-1 16.9.2008 17:07:31
The World Health Report 2008 Primary health Care NoW More Than Ever World health Organization
Primary Health Care Now More Than Ever The World Health Report 2008
WHO Library Cataloguing-in-Publication Data The world health report 2008: primary health care now more than ever. 1.World health- trends. 2. Primary health care-trends. 3. Delivery of health care. 4. Health policy. sBN978924156373 (NLM classification: W84.6) e World Health Organization 2008 Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264: fax +41 22 791 4857: e-maiL: bookorders @who int). Requ to reproduce or translate WHO publications- whether for sale or for noncommercial distribution -should be addressed ress. at the above address(fax +41 22 791 4806; e-maik permissions @/who. in the part of the World Health Organization concerning the legal status of any country, territory, city or area or of delimitation of its frontiers or boundaries. dotted lines o oximate border lines Heam organ of certain manufacturers'products does not i they are endorsed or reo ganization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary re distinguished by initial capital letters All reasonable precautions have been taken by the world Health Organization to verify the information contained in this publication. However and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Information concerning this publication can be obtained from Geneva 27. Switzerland E-mail: whr @who int Copies of this publication can be ordered from: bookorders @who int he worid Health Report 2008 was produced under the overall direction of Tim Evans (Assistant Director-General) and wim Van Lerberghe(editor-in-chief). The principal writing anan Rasanathan and Abdelhay Mechbal Other main contributors to the drafting of the report were: Anne Andermann, David Evans, Benedicte Galichet, Alec Irwin, Mary auser, Remo Meloni, Thierry Mertens, Charles Mock, Herman Montenegro, Denis Porignon and Dheepa Rajan. Organizational supervision of the report was prowided by Ramesh Shademani. Henk Bekedam, Andre Isor boxes, figures and data analysis came from: Alayne Adams, Jonathan Abrahams, Fifi Amoako Johnson, Giovanni Ancona, Chris Bailey, Robert Beaglehole, Henk Bekedam, Andre Biscaia, Paul Bossyns, Eric Buch, Andrew Cassels, Somnath Chatter, Mario Dal Poz, Pim De Graaf, Jan De Maeseneer, Nick Drager, Varatharajan Durairaj, Joan eddings, Pierre Mercenier, Pat Neuwelt, Paolo Piva, Annie Portela, Yongyut Ponsupap, Amit Prasad, Rob Ridley, Ritu Sadana, David Sanders, Salif Samake, Gera Iqbal Shah, Shaoguang Wang, Anand Sivasankara Kurup, Kenji shibuya, Michel Thieren, Nicole Valentine, Nathalie Van de Maele, Jeanette Vega, Jeremy Veillard and Bob Woollard. Valuable inputs in the form of contributions, suggestions and criticisms were received from the Regional Directors and their staff, from the Deputy Director-General Anarfi Asamoah Bah, and from the Assistant Directors-Genera I the following participants: Azrul Azwar, Tim Evans, Rica rega, Shei ntonio Duran, Alec Irwin, Mohamed Ali Jaffer, Safurah Jaafar, Pongpisut Jongudomsuk, Joseph de, Kamran Lankarini, Abdelhay Mechbal, John Martin, Donald Matheson Jan De Maeseneer, Ravi Narayan, Sydney Saul Ndeki, Adrian Ong, Pongsadhorn Pokpermdee, Thomson Prentice, Kumanan Rasanathan, Salman Rawaf, Bijan Sadrizadeh, Hugo anchez, Ramesh Shademan, Barbara Starfield, Than Tun Sein, Wim Van Lerberghe, Olga Zeus and Maria Hamlin Zuniga. s of the following participants in a one- week workshop in Bellagio, Italy . l latif, Chris Bailey, Douglas Betto Rasanathan, Myat Htoo Razak, Ramesh Shademani, Viroj Tangcharoensathien, Wim Van Lerberghe, Jeanette Vega and Jeremy Veillard. WHO working groups provided the initial inputs into the report. Th g groups, of both HQ and Regional staff included: Shelly Abdool, Ahmed Abdullatif, Shambhu Acharya, Gutschmidt, Alex Kalache Kickbusch, Yunkap Kwankam, Richard Laing, Ornella Lincetto, Daniel Lopez-Acuna, Viviana Mangiaterra ed the web site version and other electronic media. Lina Tucker Reinders provided editana Hopkins, assisted by Barbara Campanini Gael Kernen assisted on al advice. The index was prepared by June Morrison. Administrative support in the preparation of the report was provided by Saba Amdeselassie, Maryse Coutty, Melodie Fadriquela, Evelyne Omukubi and Christine Perry. credits: Director-General's photograph: WHO (p vii); introduction and overview: WHO/Marco Kokic (p x: chapters 1-6 Alayne Adam WHO/Christopher Black(p. 23) WHO/Karen Robinson(p. 41); International Federation of Red Cross and Red Crescent Societies/John Haskew(p. 63); Alayne Adams(p. 8 ) WHO/Thomas Moran(p. 99) Design: Reda Sadki Printing Coordination: Pascale Broisin and Frederique Robin-Wahlin Printed in Switzerland
WHO Library Cataloguing-in-Publication Data The world health report 2008 : primary health care now more than ever. 1.World health – trends. 2.Primary health care – trends. 3.Delivery of health care. 4.Health policy. I.World Health Organization. ISBN 978 92 4 156373 4 (NLM classifi cation: W 84.6) ISSN 1020-3311 © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who.int Copies of this publication can be ordered from: bookorders@who.int Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Printing Coordination: Pascale Broisin and Frédérique Robin-Wahlin Printed in Switzerland The World Health Report 2008 was produced under the overall direction of Tim Evans (Assistant Director-General) and Wim Van Lerberghe (editor-in-chief). The principal writing team consisted of Wim Van Lerberghe, Tim Evans, Kumanan Rasanathan and Abdelhay Mechbal. Other main contributors to the drafting of the report were: Anne Andermann, David Evans, Benedicte Galichet, Alec Irwin, Mary Kay Kindhauser, Remo Meloni, Thierry Mertens, Charles Mock, Hernan Montenegro, Denis Porignon and Dheepa Rajan. Organizational supervision of the report was provided by Ramesh Shademani. Contributions in the form of boxes, fi gures and data analysis came from: Alayne Adams, Jonathan Abrahams, Fiifi Amoako Johnson, Giovanni Ancona, Chris Bailey, Robert Beaglehole, Henk Bekedam, Andre Biscaia, Paul Bossyns, Eric Buch, Andrew Cassels, Somnath Chatterji, Mario Dal Poz, Pim De Graaf, Jan De Maeseneer, Nick Drager, Varatharajan Durairaj, Joan Dzenowagis, Dominique Egger, Ricardo Fabregas, Paulo Ferrinho, Daniel Ferrante, Christopher Fitzpatrick, Gauden Galea, Claudia Garcia Moreno, André Griekspoor, Lieve Goeman, Miriam Hirschfeld, Ahmadreza Hosseinpoor, Justine Hsu, Chandika Indikadahena, Mie Inoue, Lori Irwin, Andre Isakov, Michel Jancloes, Miloud Kaddar, Hyppolite Kalambaye, Guy Kegels, Meleckidzedeck Khayesi, Ilona Kickbush, Yohannes Kinfu, Tord Kjellstrom, Rüdiger Krech, Mohamed Laaziri, Colin Mathers, Zoe Matthews, Maureen Mackintosh, Di McIntyre, David Meddings, Pierre Mercenier, Pat Neuwelt, Paolo Piva, Annie Portela, Yongyut Ponsupap, Amit Prasad, Rob Ridley, Ritu Sadana, David Sanders, Salif Samake, Gerard Schmets, Iqbal Shah, Shaoguang Wang, Anand Sivasankara Kurup, Kenji Shibuya, Michel Thieren, Nicole Valentine, Nathalie Van de Maele, Jeanette Vega, Jeremy Veillard and Bob Woollard. Valuable inputs in the form of contributions, peer reviews, suggestions and criticisms were received from the Regional Directors and their staff, from the Deputy Director-General, Anarfi Asamoah Bah, and from the Assistant Directors-General. The draft report was peer reviewed at a meeting in Montreux, Switzerland, with the following participants: Azrul Azwar, Tim Evans, Ricardo Fabrega, Sheila Campbell-Forrester, Antonio Duran, Alec Irwin, Mohamed Ali Jaffer, Safurah Jaafar, Pongpisut Jongudomsuk, Joseph Kasonde, Kamran Lankarini, Abdelhay Mechbal, John Martin, Donald Matheson, Jan De Maeseneer, Ravi Narayan, Sydney Saul Ndeki, Adrian Ong, Pongsadhorn Pokpermdee, Thomson Prentice, Kumanan Rasanathan, Salman Rawaf, Bijan Sadrizadeh, Hugo Sanchez, Ramesh Shademani, Barbara Starfi eld, Than Tun Sein, Wim Van Lerberghe, Olga Zeus and Maria Hamlin Zuniga. The report benefi ted greatly from the inputs of the following participants in a one-week workshop in Bellagio, Italy: Ahmed Abdullatif, Chris Bailey, Douglas Bettcher, John Bryant, Tim Evans, Marie Therese Feuerstein, Abdelhay Mechbal, Thierry Mertens, Hernan Montenegro, Ronald Labonte, Socrates Litsios, Thelma Narayan, Thomson Prentice, Kumanan Rasanathan, Myat Htoo Razak, Ramesh Shademani, Viroj Tangcharoensathien, Wim Van Lerberghe, Jeanette Vega and Jeremy Veillard. WHO working groups provided the initial inputs into the report. These working groups, of both HQ and Regional staff included: Shelly Abdool, Ahmed Abdullatif, Shambhu Acharya, Chris Bailey, James Bartram, Douglas Bettcher, Eric Blas, Ties Boerma, Robert Bos, Marie-Charlotte Boueseau, Gui Carrin, Venkatraman Chandra-Mouli, Yves Chartier, Alessandro Colombo, Carlos Corvalan, Bernadette Daelmans, Denis Daumerie, Tarun Dua, Joan Dzenowagis, David Evans, Tim Evans, Bob Fryatt, Michelle Funk, Chad Gardner, Giuliano Gargioni, Gulin Gedik, Sandy Gove, Kersten Gutschmidt, Alex Kalache, Alim Khan, Ilona Kickbusch, Yunkap Kwankam, Richard Laing, Ornella Lincetto, Daniel Lopez-Acuna, Viviana Mangiaterra, Colin Mathers, Michael Mbizvo, Abdelhay Mechbal, Kamini Mendis, Shanthi Mendis, Susan Mercado, Charles Mock, Hernan Montenegro, Catherine Mulholland, Peju Olukoya, Annie Portela, Thomson Prentice, Annette Pruss-Ustun, Kumanan Rasanathan, Myat Htoo Razak, Lina Tucker Reinders, Elil Renganathan, Gojka Roglic, Michael Ryan, Shekhar Saxena, Robert Scherpbier, Ramesh Shademani, Kenji Shibuya, Sameen Siddiqi, Orielle Solar, Francisco Songane, Claudia Stein, Kwok-Cho Tang, Andreas Ullrich, Mukund Uplekar, Wim Van Lerberghe, Jeanette Vega, Jeremy Veillard, Eugenio Villar, Diana Weil and Juliana Yartey. The editorial production team was led by Thomson Prentice, managing editor. The report was edited by Diana Hopkins, assisted by Barbara Campanini. Gaël Kernen assisted on graphics and produced the web site version and other electronic media. Lina Tucker Reinders provided editorial advice. The index was prepared by June Morrison. Administrative support in the preparation of the report was provided by Saba Amdeselassie, Maryse Coutty, Melodie Fadriquela, Evelyne Omukubi and Christine Perry. Photo credits: Director-General’s photograph: WHO (p. viii); introduction and overview: WHO/Marco Kokic (p. x); chapters 1–6: Alayne Adams (p. 1); WHO/Christopher Black (p. 23); WHO/Karen Robinson (p. 41); International Federation of Red Cross and Red Crescent Societies/John Haskew (p. 63); Alayne Adams (p. 81); WHO/Thomas Moran (p. 99)
The World Healtb Report 2008 Primary Healtb Care-Noww More Tban Ever Contents Message from the Director-General Introduction and overview tesponding to the challenges of a changing world Growing expectations for better performance From the packages of the past to the reforms of the future Four sets of PHc reforms Seizing opportunities Chapter 1. The challenges of a changing world Unequal growth, unequal outcomes Longer lives and better health, but not everywhere Adapting to new health challenge: 7 ittle anticipation and slow reactions Trends that undermine the health systems'response 11 Hospital-centrism health systems built around hospitals and specialists Fragmentation: health systems built around priority programmes alth systems left to drift towards unregulated commercialization Changing values and rising expectations 14 Care that puts people first Securing the health of communities 16 Reliable, responsive health authorities 18 PHC reforms: driven by demand Chapter 2. Advancing and sustaining universal coverage The central place of health equity in PHC Challenges in moving towards universal coverag 27 fill the availability 28 Overcoming the isolation of dispersed populations Targeted interventions to complement universal coverage mechanisms Mobilizing for health equity Increasing the visibility of health inequities reating space for civil society participation and empowerment
iii Contents The World Health Report 2008 Primary Health Care – Now More Than Ever Message from the Director-General viii Introduction and Overview xi Responding to the challenges of a changing world xii Growing expectations for better performance xiii From the packages of the past to the reforms of the future xiv Four sets of PHC reforms xvi Seizing opportunities xviii Chapter 1. The challenges of a changing world 1 Unequal growth, unequal outcomes 2 Longer lives and better health, but not everywhere 2 Growth and stagnation 4 Adapting to new health challenges 7 A globalized, urbanized and ageing world 7 Little anticipation and slow reactions 9 Trends that undermine the health systems’ response 11 Hospital-centrism: health systems built around hospitals and specialists 11 Fragmentation: health systems built around priority programmes 12 Health systems left to drift towards unregulated commercialization 13 Changing values and rising expectations 14 Health equity 15 Care that puts people fi rst 16 Securing the health of communities 16 Reliable, responsive health authorities 17 Participation 18 PHC reforms: driven by demand 18 Chapter 2. Advancing and sustaining universal coverage 23 The central place of health equity in PHC 24 Moving towards universal coverage 25 Challenges in moving towards universal coverage 27 Rolling out primary-care networks to fi ll the availability gap 28 Overcoming the isolation of dispersed populations 30 Providing alternatives to unregulated commercial services 31 Targeted interventions to complement universal coverage mechanisms 32 Mobilizing for health equity 34 Increasing the visibility of health inequities 34 Creating space for civil society participation and empowerment 35
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever Chapter 3. Primary care: putting people first The distinctive features of primary care Effectiveness and safety are not just technical matters omprehensive and integrated responses Continuity of care A regular and trusted provider as entry point Organizing primary-care networks 52 ringing care closer to the people The primary-care team as a hub of coordination Monitoring progress Chapter 4. Public policies for the public's bealth The importance of effective public policies for health System policies that are aligned with PHc goals Aligning priority health programmes with PHC ountrywide public-health initiatives Towards health in all policies Inderstanding the under-investment 4677886733 Opportunities for better public policies Better information and evidence A changing institutional landscape Equitable and efficient global health action Chapter 5. Leadership and effective government Governments as brokers for Phc reform 82 Mediating the social contract for health Disengagement and its consequences Effective policy dialogue 86 formation systems to strengthen policy dialogue Strengthening policy dialogue with innovations from the field Building a critical mass of capacity for change Managing the political process: from launching reform to implementing it bapter 6. Tbe way forward 101 Rapid-growth health economies ow-expenditure, low-growth health economies Mobilizing the drivers of reform 108 Mobilizing the production of knowledge Mobilizing the commitment of the workforce Mobilizing the participation of people
Primary Health Care – Now More Than Ever iv The World Health Report 2008 Chapter 3. Primary care: putting people fi rst 41 Good care is about people 42 The distinctive features of primary care 43 Effectiveness and safety are not just technical matters 43 Understanding people: person-centred care 46 Comprehensive and integrated responses 48 Continuity of care 49 A regular and trusted provider as entry point 50 Organizing primary-care networks 52 Bringing care closer to the people 53 Responsibility for a well-identifi ed population 53 The primary-care team as a hub of coordination 55 Monitoring progress 56 Chapter 4. Public policies for the public’s health 63 The importance of effective public policies for health 64 System policies that are aligned with PHC goals 66 Public-health policies 67 Aligning priority health programmes with PHC 67 Countrywide public-health initiatives 68 Rapid response capacity 68 Towards health in all policies 69 Understanding the under-investment 71 Opportunities for better public policies 73 Better information and evidence 73 A changing institutional landscape 74 Equitable and effi cient global health action 76 Chapter 5. Leadership and effective government 81 Governments as brokers for PHC reform 82 Mediating the social contract for health 82 Disengagement and its consequences 83 Participation and negotiation 85 Effective policy dialogue 86 Information systems to strengthen policy dialogue 86 Strengthening policy dialogue with innovations from the fi eld 89 Building a critical mass of capacity for change 90 Managing the political process: from launching reform to implementing it 92 Chapter 6. The way forward 99 Adapting reforms to country context 100 High-expenditure health economics 101 Rapid-growth health economies 103 Low-expenditure, low-growth health economies 105 Mobilizing the drivers of reform 108 Mobilizing the production of knowledge 108 Mobilizing the commitment of the workforce 110 Mobilizing the participation of people 110
Contents List of Figures Figure 1. The PHC reforms necessary to refocus health systems vi Figure 3. 1 The effect on uptake of contraception of the towards health for all reorganization of work schedules of rural health centres in Niger Figure 3. 2 Lost opportunities for prevention of mother-to-child Figure 1.1 Selected best p 2 transmission of HIV(MTCT)in cote d'Ivoire: only a tiny fraction of five mortality by at least 80%, by regions, 1975-2006 he expected transmissions are actually Figure 1.2 Factors explaining mortality reduction in Portugal 3 Figure 3.3 More comprehensive health centres have better in reducing under-five mortality, Figure 3. 4 Inappropriate investigations prescribed for simulated 53 975 and 2006. in selected countries with similar rates in 1975 Figure 1. 4 GDP per capita and life expectancy at birth in 169 Figure 3. 5 Primary care as a hub of coordination: networking ountries. 1975 and 2005 within the community served and with outside partners Figure 1. 5 Trends in GDP per capita and life expectancy at birth 5 countries grouped by the 1975 GDP, 1975-2005 Figure 4.1 Deaths attrib Figure 1. 6 Countries grouped according to their total health expenditure in 2005 (international S) Figure 4.2 Annual pharmaceutical spending and number Figure 1.7 Africa' s children are at more risk of dying from traffic 7 of prescriptions dispensed in New Zealand since the accidents than European children: child road-traffic deaths per Pharmaceutical Management Agency was convened in 1993 100 000 population Figure 4.3 Percentage of births and deaths recorded in countries Figure 1. 8 The shift towards noncommunicable diseases and with complete civil registration systems, by WHo region accidents as causes of death Figure 1.9 Within-country inequalities in health and health care 10 Figure 4.4 Essential public-health functions that 30 national public-health institutions view as being part of their portfolio Figure 1.10 How health systems are diverted from PHC core 11 Figure 1.11 Percentage of the population citing health as their 15 Figure 5.1 Percentage of GDP used for health, 2005 ain concern before other issues, such as financial problems, Figure 5.2 Health expenditure in China: withdrawal of the State in the 1980s and 1990s and recent re-engagement Figure 1.12 The professionalization of birthing care: percentage 7 Figure 5.3 Transforming information systems into instruments 87 of births assisted by professional and other carers in selected for PHc reform areas, 2000 and 2005 with projections to 2015 Figure 5.4 Mutual reinforcement between innovation in the field Figure 1. 13 The social values that drive PHC and the corresponding sets of reforms Figure 5.5 A growing market: technical cooperation as part of Official Development Aid for Health. Yearly aid fiows in 2005, Figure 5.6 Re-emerging national leadership in health: the shift Figure 2.2 Three ways of moving towards universal coverag in donor funding towards integrated health systems support, and its impact on the Democratic Republic of the Congo's 2004 PHC Figure 2.3 Impact of abolishing user fees on outpatient attendance in Kisoro district, Uganda: outpatient attendance 1998-2002 Figure 2.4 Different patterns of exclusion: massive deprivation Figure 6. 1 Contribution of general gov in some countries, marginalization of the poor in others. Births and private out-of-pocket expenditure to the yearly growth attended by medically trained personnel (percentage), by income in total health expenditure per capita, percentage, weighter averages group Figure 2. 5 Under-five mortality in rural and urban areas, the 29 Figure 6.2 Projected per capita health expenditure in 2015, slamic Republic of Iran, 1980-2000 apid-growth health economies (weighted averages itputs in the midst of 31 Figure 6.3 Projected per capita health expenditure in 2015, low disaster: Rutshuru, the Democratic Republic of the Congo expenditure, low-growth health economies (weighted averages Figure 6. 4 The progressive extension of coverage by community- 107 owned, community-operated health centres in Mali, 1998-2007
v Contents Figure 1. The PHC reforms necessary to refocus health systems towards health for all xvi Figure 1.1 Selected best performing countries in reducing under- fi ve mortality by at least 80%, by regions, 1975–2006 2 Figure 1.2 Factors explaining mortality reduction in Portugal, 1960–2008 3 Figure 1.3 Variable progress in reducing under-fi ve mortality, 1975 and 2006, in selected countries with similar rates in 1975 3 Figure 1.4 GDP per capita and life expectancy at birth in 169 countries, 1975 and 2005 4 Figure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975−2005 5 Figure 1.6 Countries grouped according to their total health expenditure in 2005 (international $) 6 Figure 1.7 Africa’s children are at more risk of dying from traffi c accidents than European children: child road-traffi c deaths per 100 000 population 7 Figure 1.8 The shift towards noncommunicable diseases and accidents as causes of death 8 Figure 1.9 Within-country inequalities in health and health care 10 Figure 1.10 How health systems are diverted from PHC core values 11 Figure 1.11 Percentage of the population citing health as their main concern before other issues, such as fi nancial problems, housing or crime 15 Figure 1.12 The professionalization of birthing care: percentage of births assisted by professional and other carers in selected areas, 2000 and 2005 with projections to 2015 17 Figure 1.13 The social values that drive PHC and the corresponding sets of reforms 18 Figure 2.1 Catastrophic expenditure related to out-of-pocket payment at the point of service 24 Figure 2.2 Three ways of moving towards universal coverage 26 Figure 2.3 Impact of abolishing user fees on outpatient attendance in Kisoro district, Uganda: outpatient attendance 1998–2002 27 Figure 2.4 Different patterns of exclusion: massive deprivation in some countries, marginalization of the poor in others. Births attended by medically trained personnel (percentage), by income group 28 Figure 2.5 Under-fi ve mortality in rural and urban areas, the Islamic Republic of Iran, 1980–2000 29 Figure 2.6 Improving health-care outputs in the midst of disaster: Rutshuru, the Democratic Republic of the Congo, 1985–2004 31 Figure 3.1 The effect on uptake of contraception of the reorganization of work schedules of rural health centres in Niger 42 Figure 3.2 Lost opportunities for prevention of mother-to-child transmission of HIV (MTCT) in Côte d’Ivoire: only a tiny fraction of the expected transmissions are actually prevented 45 Figure 3.3 More comprehensive health centres have better vaccination coverage 49 Figure 3.4 Inappropriate investigations prescribed for simulated patients presenting with a minor stomach complaint in Thailand 53 Figure 3.5 Primary care as a hub of coordination: networking within the community served and with outside partners 55 Figure 4.1 Deaths attributable to unsafe abortion per 100 000 live births, by legal grounds for abortions 65 Figure 4.2 Annual pharmaceutical spending and number of prescriptions dispensed in New Zealand since the Pharmaceutical Management Agency was convened in 1993 66 Figure 4.3 Percentage of births and deaths recorded in countries with complete civil registration systems, by WHO region, 1975–2004 74 Figure 4.4 Essential public-health functions that 30 national public-health institutions view as being part of their portfolio 75 Figure 5.1 Percentage of GDP used for health, 2005 82 Figure 5.2 Health expenditure in China: withdrawal of the State in the 1980s and 1990s and recent re-engagement 84 Figure 5.3 Transforming information systems into instruments for PHC reform 87 Figure 5.4 Mutual reinforcement between innovation in the fi eld and policy development in the health reform process 89 Figure 5.5 A growing market: technical cooperation as part of Offi cial Development Aid for Health. Yearly aid fl ows in 2005, defl ator adjusted 91 Figure 5.6 Re-emerging national leadership in health: the shift in donor funding towards integrated health systems support, and its impact on the Democratic Republic of the Congo’s 2004 PHC strategy 94 Figure 6.1 Contribution of general government, private pre-paid and private out-of-pocket expenditure to the yearly growth in total health expenditure per capita, percentage, weighted averages 101 Figure 6.2 Projected per capita health expenditure in 2015, rapid-growth health economies (weighted averages) 103 Figure 6.3 Projected per capita health expenditure in 2015, low expenditure, low-growth health economies (weighted averages) 105 Figure 6.4 The progressive extension of coverage by communityowned, community–operated health centres in Mali, 1998–2007 107 List of Figures
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever List of Bores Box 1 Five common shortcomings of health-care delivery xiv Box 4.1 Rallying society's resources for health in Cuba 65 Box 2 What has been considered primary care in well-resourced xvi Box 4. 2 Recommendations of the Commission on Social contexts has been dangerously oversimplified in resource- Determinants of health constrained settings Box 4.3 How to make unpopular public policy decisions Box 4.4 The scandal of invisibility: where births and deaths are not counted Box 4.5 European Union impact assessment guidelines Box 1.2 Higher spending on health is associated with better outcomes, but with large differences between countries Box 5.1 From withdrawal to re-engagement in China Box 1.3 As information improves, the multiple dimensions of growing health inequality are becoming more apparent Box 5.2 Steering national directions with the help of policy 86 dialogue: experience from three countries Box 1.4 Medical equipment and pharmaceutical industries are Box 5.3 Equity Gauges: stakeholder collaboration to tackle health 88 Box 1. 5 Health is among the top personal concerns 15 Box 5. 4 Limitations of conventional capacity building in low-and 91 Box 2.1 Best practices in moving towards universal coverage 26 Box55F g leadership in health in the aftermath of war Box 2.2 Defining"essential packages": what needs to be done to 27 and economic collapse Box 2.3 Closing the urban-rural gap through progressive expansion of PHC coverage in rural areas in the Islamic Republic Box 6.1 Norway 's national strategy to reduce social inequalities in health of ran Box 2.4 The robustness of PHC-led health systems: 20 years of Box 6.2 The virtuous cycle of supply of and demand for primary expanding performance in Rutshuru, the Democratic Republic of Box 6.3. From product development to field implementation research makes the link Box 2.5 Targeting social protection in chile 33 Box 2.6 Social policy in the city of Ghent, Belgium: how local authorities can support intersectoral collaboration between ealth and welfare organizations Box 3.1 to promote patient safety and better outcomes Box 3.2 When supplier-induced and consumer-driven demand determine medical advice: ambulatory care in India Box 3.3 The health-care response to partner violence against Box 3. 4 Empowering users to contribute to their own health 48 Box 3. 5 Using information and communication technologies to 51 improve access, quality and efficiency in primary care
Primary Health Care – Now More Than Ever vi The World Health Report 2008 Box 1 Five common shortcomings of health-care delivery xiv Box 2 What has been considered primary care in well-resourced contexts has been dangerously oversimplifi ed in resourceconstrained settings xvii Box 1.1 Economic development and investment choices in health care: the improvement of key health indicators in Portugal 3 Box 1.2 Higher spending on health is associated with better outcomes, but with large differences between countries 6 Box 1.3 As information improves, the multiple dimensions of growing health inequality are becoming more apparent 10 Box 1.4 Medical equipment and pharmaceutical industries are major economic forces 12 Box 1.5 Health is among the top personal concerns 15 Box 2.1 Best practices in moving towards universal coverage 26 Box 2.2 Defi ning “essential packages”: what needs to be done to go beyond a paper exercise? 27 Box 2.3 Closing the urban-rural gap through progressive expansion of PHC coverage in rural areas in the Islamic Republic of Iran 29 Box 2.4 The robustness of PHC-led health systems: 20 years of expanding performance in Rutshuru, the Democratic Republic of the Congo 31 Box 2.5 Targeting social protection in Chile 33 Box 2.6 Social policy in the city of Ghent, Belgium: how local authorities can support intersectoral collaboration between health and welfare organizations 35 Box 3.1 Towards a science and culture of improvement: evidence to promote patient safety and better outcomes 44 Box 3.2 When supplier-induced and consumer-driven demand determine medical advice: ambulatory care in India 44 Box 3.3 The health-care response to partner violence against women 47 Box 3.4 Empowering users to contribute to their own health 48 Box 3.5 Using information and communication technologies to improve access, quality and effi ciency in primary care 51 Box 4.1 Rallying society’s resources for health in Cuba 65 Box 4.2 Recommendations of the Commission on Social Determinants of Health 69 Box 4.3 How to make unpopular public policy decisions 72 Box 4.4 The scandal of invisibility: where births and deaths are not counted 74 Box 4.5 European Union impact assessment guidelines 75 Box 5.1 From withdrawal to re-engagement in China 84 Box 5.2 Steering national directions with the help of policy dialogue: experience from three countries 86 Box 5.3 Equity Gauges: stakeholder collaboration to tackle health inequalities 88 Box 5.4 Limitations of conventional capacity building in low- and middle-income countries 91 Box 5.5 Rebuilding leadership in health in the aftermath of war and economic collapse 94 Box 6.1 Norway’s national strategy to reduce social inequalities in health 102 Box 6.2 The virtuous cycle of supply of and demand for primary care 107 Box 6.3. From product development to fi eld implementation − research makes the link 109 List of Boxes
Contents List of Tables Table 1 How experience has shifted the focus of the PHc movemen Table 3.1 Aspects of care that distinguish conventional health 43 care from people-centred primary care Table 3.2 Person -centredness: evidence of its contribution to quality of care and better outcomes Table 3.3 Comprehensiveness: evidence of its contribution to 4 quality of care and better outcomes Table 3. 4 Continuity of care: evidence of its contribution to quality of care and better outcomes Table 3. 5 Regular entry point: evidence of its contribution to quality of care and better outcomes Table 4. 1 Adverse health effects of changing work Table 5.1 Roles and functions of public-health observatories in Table 5. 2 Significant factors in improving institutional capacity 92 health-sector governance in six countries
vii Contents Table 1 How experience has shifted the focus of the PHC movement xv Table 3.1 Aspects of care that distinguish conventional health care from people-centred primary care 43 Table 3.2 Person-centredness: evidence of its contribution to quality of care and better outcomes 47 Table 3.3 Comprehensiveness: evidence of its contribution to quality of care and better outcomes 48 Table 3.4 Continuity of care: evidence of its contribution to quality of care and better outcomes 50 Table 3.5 Regular entry point: evidence of its contribution to quality of care and better outcomes 52 Table 4.1 Adverse health effects of changing work circumstances 70 Table 5.1 Roles and functions of public-health observatories in England 89 Table 5.2 Signifi cant factors in improving institutional capacity for health-sector governance in six countries 92 List of Tables
The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever Director-General's message When I took office in 2007. I made clear my commitment to direct WHOs attention towards primary health care. More important than my own conviction, this reflects the widespread and growing demand for primary health care from member states. This demand in turn displays a growing appetite among policy makers for knowledge related to how health systems can become more equitable, inclusive and fair shift towards the need for more compre hensive thinking about the performance of the health system as a who This year marks both the 60th birth- day of WHO and the 30th anniversary of the Declaration of Alma-Ata on Primary Health Care in 1978. While our global health context has changed remarkably over six decades, the values that lie at the core of the wHo Constitution and those that informed the alma-Ata declaration have been tested and remain true. Yet, despite enormous progress in health globally, our collective fail- ures to deliver in line with these values are painfully obvious and deserve our greatest attention We see a mother suffering complications of labour without access to qualified support, a child missing out on essential vaccinations, an inner-city slum dweller living in squalor. We see the absence of protection for pedestrians alongside traffic-laden roads and highways, and the impoverishment arising from direct payment for care because of a lack of health insurance. These and many other everyday realities of life personify the unacceptable and avoidable shortfalls in the performance of our hea In moving forward, it is important to learn from the past and, in looking back, it is clear that can do better in the future. Thus, this World Health Report revisits the ambitious vision of primary health care as a set of values and principles for guiding the development of health systems. The Report represents an important opportunity to draw on the lessons of the past, consider the challenges that
Primary Health Care – Now More Than Ever viii The World Health Report 2008 Director-General’s Message When I took offi ce in 2007, I made clear my commitment to direct WHO’s attention towards primary health care. More important than my own conviction, this refl ects the widespread and growing demand for primary health care from Member States. This demand in turn displays a growing appetite among policymakers for knowledge related to how health systems can become more equitable, inclusive and fair. It also refl ects, more fundamentally, a shift towards the need for more comprehensive thinking about the performance of the health system as a whole. This year marks both the 60th birthday of WHO and the 30th anniversary of the Declaration of Alma-Ata on Primary Health Care in 1978. While our global health context has changed remarkably over six decades, the values that lie at the core of the WHO Constitution and those that informed the Alma-Ata Declaration have been tested and remain true. Yet, despite enormous progress in health globally, our collective failures to deliver in line with these values are painfully obvious and deserve our greatest attention. We see a mother suffering complications of labour without access to qualifi ed support, a child missing out on essential vaccinations, an inner-city slum dweller living in squalor. We see the absence of protection for pedestrians alongside traffi c-laden roads and highways, and the impoverishment arising from direct payment for care because of a lack of health insurance. These and many other everyday realities of life personify the unacceptable and avoidable shortfalls in the performance of our health systems. In moving forward, it is important to learn from the past and, in looking back, it is clear that we can do better in the future. Thus, this World Health Report revisits the ambitious vision of primary health care as a set of values and principles for guiding the development of health systems. The Report represents an important opportunity to draw on the lessons of the past, consider the challenges that Wh cle W m It also shift tow hensive of the h This day of W
Director- General's Message ie ahead, and identify major avenues for health While universally applicable, these reforms systems to narrow the intolerable gaps between do not constitute a blueprint or a manifesto for aspiration and implementation action. The details required to give them life in These avenues are defined in the Report as each country must be driven by specific condi- four sets of reforms that reflect a convergence tions and contexts, drawing on the best available between the values of primary health care, the evidence. Nevertheless, there are no reasons why expectations of citizens and the common health any country-rich or poor- should wait to begin performance challenges that cut across all con- moving forward with these reforms. As the last texts. They include: three decades have demonstrated. substantial a universal coverage reforms that ensure that progress is possible health systems contribute to health equity Doing better in the next 30 years means that social justice and the end of exclusion, pri- we need to invest now in our ability to bring marily by moving towards universal access actual performance in line with our aspirations. and social health protection expectations and the rapidly changing realities of a service delivery reforms that re-organize our interdependent health world United by the health services around people's needs and common challenge of primary health care, the expectations, so as to make them more socially time is ripe, now more than ever, to foster joint relevant and more responsive to the changing learning and sharing across nations to chart the world, while producing better outcomes most direct course towards health for all a public policy reforms that secure healthier communities, by integrating public health actions with primary care, by pursuing healthy public policies across sectors and by strength ening national and transnational public health Dr Margaret Chan interventions: and eral a leadership reforms that replace disproportion- World Health Organization ate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participa tory, negotiation-based leadership indicated by the complexity of contemporary health systems
ix Director-General’s Message lie ahead, and identify major avenues for health systems to narrow the intolerable gaps between aspiration and implementation. These avenues are defi ned in the Report as four sets of reforms that refl ect a convergence between the values of primary health care, the expectations of citizens and the common health performance challenges that cut across all contexts. They include: Q universal coverage 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; Q service delivery reforms that re-organize health services 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; Q public policy reforms that secure healthier communities, by integrating public health actions with primary care, by pursuing healthy public policies across sectors and by strengthening national and transnational public health interventions; and Q leadership 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 indicated by the complexity of contemporary health systems. While universally applicable, these reforms do not constitute a blueprint or a manifesto for action. The details required to give them life in each country must be driven by specifi c conditions and contexts, drawing on the best available evidence. Nevertheless, there are no reasons why any country − rich or poor − should wait to begin moving forward with these reforms. As the last three decades have demonstrated, substantial progress is possible. Doing better in the next 30 years means that we need to invest now in our ability to bring actual performance in line with our aspirations, expectations and the rapidly changing realities of our interdependent health world. United by the common challenge of primary health care, the time is ripe, now more than ever, to foster joint learning and sharing across nations to chart the most direct course towards health for all. Dr Margaret Chan Director-General World Health Organization
