Health Systems: principled integrated care It is useful to understand primary health care as involving both core principles and a variable set of basic activities. For the purposes of this discussion, it is the principles that are most significant(3), including: universal access to care and coverage on the basis of need; commitment to health equity as part of development oriented to social justice; community participation in defining and implementing health agendas intersectoral approaches to health Enduring principles in a changing environment The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries(see the example in Box 7. 2). Advances in health technology have transformed many aspects of medi cal practice and raised expectations concerning the types of functions and services that health systems should provide The institutional context of health policy-making and health care delivery has also changed Government responsibilities and objectives in the health sector have been redefined, with in health care provision. The r profit and not-for-profit, playing an increasingly visible role reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentralize tion and health sector reform have had mixed effects on health care system performance (4) The ideas and activities associated with primary health care have themselves undergone changes In the 1980s, the approach termed "selective primary health care"gained favour By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged"" programme structures. These programmes produced Box 7. 2 Primary care in a changing environment: the"health houses"of the Islamic Republic of Iran The Government of the Islamic Republic of Iran has invested strongly in tion is increasing, with an associated change in lifestyle. The private training health care providers. Primary health care facilities, popularly health sector is increasing. Clinical case management is often not as known as"health houses, provide an active network staffed by com- evidence-based as it could be. A recent study on health financing dem- munity health workers, or behvarzes, who are trained and regularly su- onstrated that the financing system is not as equitable as had been ervised by staff from district health centres. The behvarzes provide basic thought: out-of-pocket payments are high, and the poor are less well are and advice on many aspects of maternal and child health and com- protected from catastrophic health expenditures than they were previously mon communicable diseases. They also record local health information The government is moving to respond to these new challenges. It through the"vital horoscope" data system, which includes information is already beginning to reorient the primary health care activities deliv- ollected during annual household visits. This system provides valuable ered in health houses. Technical guidelines for interventions and train- information for planning services both locally and nationally. There are ing for different cadres of health worker are being reviewed as part of high levels of community involvement in the delivery of community-based an effort to improve quality of care. There are discussions about a com- health care: 90% of the population belongs to a health insurance scheme, mon benefit package, what it should include and by whom it should be and some schemes are explicitly designed to protect the poor provided; specifically, how to involve private providers more effectively Today, the Islamic Republic of Iran faces several challenges to main. in the delivery of critical interventions, both preventive and curative, for taining these achievements in a changing environment. The country's example through contracting. The different insurance schemes are epidemiological profile has changed, partly as a consequence of the being reviewed within a broader analysis of overall health system success of the strategy led by primary care. The major burden of disease financing, and there are debates about what sort of organizational is attributable to noncommunicable diseases and injuries, though there arrangements within the public sector would enhance the quality and are some differences between richer and poorer provinces. Urbaniza. efficiency of public providersHealth Systems: principled integrated care 107 It is useful to understand primary health care as involving both core principles and a variable set of basic activities. For the purposes of this discussion, it is the principles that are most significant (3), including: – universal access to care and coverage on the basis of need; – commitment to health equity as part of development oriented to social justice; – community participation in defining and implementing health agendas; – intersectoral approaches to health. Enduring principles in a changing environment The global, national and local environments in which primary health care values must be translated into action have changed fundamentally in the past 25 years. Key demographic and epidemiological shifts include ageing populations, the explosion of HIV/AIDS, and the expanding double burden of diseases in low-income and middle-income countries (see the example in Box 7.2). Advances in health technology have transformed many aspects of medi￾cal practice and raised expectations concerning the types of functions and services that health systems should provide. The institutional context of health policy-making and health care delivery has also changed. Government responsibilities and objectives in the health sector have been redefined, with private sector entities, both for-profit and not-for-profit, playing an increasingly visible role in health care provision. The reasons for collaborative patterns vary, but chronic underfunding of publicly financed health services is often an important factor. Processes of decentraliza￾tion and health sector reform have had mixed effects on health care system performance (4). The ideas and activities associated with primary health care have themselves undergone changes. In the 1980s, the approach termed “selective primary health care” gained favour. By focusing on the technical challenges of delivering limited basic interventions in poor areas, this strategy encouraged “vertical” programme structures. These programmes produced Box 7.2 Primary care in a changing environment: the “health houses” of the Islamic Republic of Iran The Government of the Islamic Republic of Iran has invested strongly in training health care providers. Primary health care facilities, popularly known as “health houses”, provide an active network staffed by com￾munity health workers, or behvarzes, who are trained and regularly su￾pervised by staff from district health centres. The behvarzes provide basic care and advice on many aspects of maternal and child health and com￾mon communicable diseases. They also record local health information through the “vital horoscope” data system, which includes information collected during annual household visits. This system provides valuable information for planning services both locally and nationally. There are high levels of community involvement in the delivery of community-based health care; 90% of the population belongs to a health insurance scheme, and some schemes are explicitly designed to protect the poor. Today, the Islamic Republic of Iran faces several challenges to main￾taining these achievements in a changing environment. The country’s epidemiological profile has changed, partly as a consequence of the success of the strategy led by primary care. The major burden of disease is attributable to noncommunicable diseases and injuries, though there are some differences between richer and poorer provinces. Urbaniza￾tion is increasing, with an associated change in lifestyle. The private health sector is increasing. Clinical case management is often not as evidence-based as it could be. A recent study on health financing dem￾onstrated that the financing system is not as equitable as had been thought: out-of-pocket payments are high, and the poor are less well protected from catastrophic health expenditures than they were previously. The government is moving to respond to these new challenges. It is already beginning to reorient the primary health care activities deliv￾ered in health houses. Technical guidelines for interventions and train￾ing for different cadres of health worker are being reviewed as part of an effort to improve quality of care. There are discussions about a com￾mon benefit package, what it should include and by whom it should be provided; specifically, how to involve private providers more effectively in the delivery of critical interventions, both preventive and curative, for example through contracting. The different insurance schemes are being reviewed within a broader analysis of overall health system financing, and there are debates about what sort of organizational arrangements within the public sector would enhance the quality and efficiency of public providers