The World Healtb Report 2008 Primary Healtb Care-Nouo More Tban Ever delivery, through different mechanisms and for problems of today and tomorrow will require different reasons, is not only less effective than stronger collective management and accountabil- it could be, but suffers from a set of ubiquitous ity guided by a clearer sense of overall direction shortcomings and contradictions that are sum- and purpose marized in box 1 Indeed, this is what people expect to happen The mismatch between expectations and As societies modernize, people demand more erformance is a cause of concern for health from their health systems, for themselves and authorities. Given the growing economic weight their families, as well as for the society in which and social significance of the health sector, it they live. Thus, there is increasingly popular is also an increasing cause for concern among support for better health equity and an end to politicians: it is telling that health-care issues exclusion; for health services that are centred vere,on average, mentioned more than 28 times on people's needs and expectations; for health in each of the recent primary election debates in security for the communities in which they live; the United States. Business as usual for health and for a say in what affects their health and that systems is not a viable option. If these shortfalls of their communities23, in performance are to be redressed, the health 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 Box 1 Five common shortcomings of alignment of health systems with these values health-care delivery and provide todays PHC movement with reinvigo rated social and political backing for its attempts to reform health systems. Inverse care. People with the most means-whose needs for ealth care are often less -consume the most care. whereas those with the least means and greatest health problems con- From the packages of the past to me the least. Public spending on health services most the reforms of the future often benefits the rich more than the poor in high-and low- income countries alike Rising expectations and broad support for the Impoverishing care. Wherever people lack social vision set forth in Alma-Ata's values have not and payment for care is largely out-of-pocket at the point of lways easily translated into effective transfor service, they can be confronted with catastrophic expenses. mation of health systems. There have been cir Over 100 million people annually fall into poverty because they cumstances and trends from beyond the health have to pay for health care. sector-structural adjustment, for example frag of health-care providers and the narrow focus of many ed and fragmenting care. The excessive specializa- over which the phc movement had little influ- disease control programmes discourage a holistic approach ence or control. Furthermore, all too often, the to the individuals and the families they deal with and do no PHC movement has oversimplified its message, ppreciate the need for continuity in care. Health services resulting in one-size-fits-all recipes, ill-adapted poor and marginalized groups are often highly fragmented to different contexts and problems.As a result and severely under-resourced, while development aid often national and global health authorities have at ids to the fragmentation times seen PHC not as a set of reforms. as was Unsafe care. Poor system design that is unable to ensure safety intended, but as one health-care delivery pro- nfections, along with medication errors and other avoidable gramme among many, providing poor care for adverse effects that are an underestimated cause of death poor people. Table 1 looks at different dimen sions of early attempts at implementing PHC and Misdirected care Resource allocation clusters around cura- contrasts this with current approaches. Inherent tive services at great cost, neglecting the potential of primary in this evolution is recognition that providing a prevention and health promotion to prevent up to 70% of the disease burden,20. At the same time, the health sectorlacks sense of direction to health systems requires the expertise to mitigate the adverse effects on health from set of specific and context-sensitive reforms that ther sectors and make the most of what these other sectors respond to the health challenges of today and an contribute to health21 prepare for those of tomorrowPrimary Health Care – Now More Than Ever xiv The World Health Report 2008 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 sum￾marized in Box 1. The mismatch between expectations and performance is a cause of concern for health authorities. Given the growing economic weight and social signifi cance 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 accountabil￾ity 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 reinvigo￾rated social and political backing for its attempts to reform health systems. 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 transfor￾mation of health systems. There have been cir￾cumstances and trends from beyond the health sector – structural adjustment, for example – over which the PHC movement had little infl u￾ence or control. Furthermore, all too often, the PHC movement has oversimplifi ed its message, resulting in one-size-fi ts-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 pro￾gramme among many, providing poor care for poor people. Table 1 looks at different dimen￾sions 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 specifi c and context-sensitive reforms that respond to the health challenges of today and prepare for those of tomorrow. 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 con￾sume the least10. Public spending on health services most often benefi ts the rich more than the poor11 in high- and low￾income 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 specializa￾tion 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 cura￾tive 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