Introduction and overview Second, the nature of health problems is chang-I changes and making health systems more effec ng in ways that were only partially anticipated,I tive and equitable are often missed. Global and nd at a rate that was wholly unexpected. Ageing increasingly, national policy formulation proc and the effects of ill-managed urbanization and esses have focused on single issues, with various globalization accelerate worldwide transmis- constituencies competing for scarce resources, sion of communicable diseases, and increase while scant attention is given to the underlying the burden of chronic and noncommunicable constraints that hold up health systems develop disorders. The growing reality that many indi- ment in national contexts Rather than improv viduals present with complex symptoms and ing their response capacity and anticipating new multiple illnesses challenges service delivery challenges, health systems seem to be drifting to develop more integrated and comprehensive from one short-term priority to another, increas- se management. A complex web of interrelated ingly fragmented and without a clear sense of factors is at work, involving gradual but long-direction term increases in income and population, climate Today, it is clear that left to their own devices, change,challenges to food security, and social health systems do not gravitate naturally towards tensions, all with definite, but largely unpredict- the goals of health for all through primary health ble, implications for health in the years ahead. care as articulated in the Declaration of Alma- Third, health systems are not insulated from Ata. Health systems are developing in directions the rapid pace of change and transformation that contribute little to equity and social justice that is an essential part of today's globaliza- and fail to get the best health outcomes for their tion. Economic and political crises challenge money. Three particularly worrisome trends can state and institutional roles to ensure access, be characterized as follows delivery and financing Unregulated commer- a health systems that focus disproportionately on cialization is accompanied by a blurring of the a narrow offer of specialized curative care: boundaries between public and private actors, health systems where a command-and-control while the negotiation of entitlement and rights approach to disease control, focused on short- s increasingly politicized. The information age term results, is fragmenting service delivery has transformed the relations between citizens, a health systems where a hands-off or laissez- professionals and politicians faire approach to governance has allowed In many regards, the responses of the health unregulated commercialization of health to sector to the changing world have been inad flourish equate and naive. Inadequate, insofar as they not only fail to anticipate, but also to respond These trends fly in the face of a comprehensive appropriately: too often with too little, too late and balanced response to health needs. In a num- or too much in the wrong place. Naive insofar as ber of countries, the resulting inequitable access, a systems failure requires a systems solution- impoverishing costs, and erosion of trust in health not a temporary remedy. Problems with human care constitute a threat to social stability resources for public health and health care, finance, infrastructure or information systems Growing expectations for better invariably extend beyond the narrowly defined health sector, beyond a single level of policy pur The support for a renewal of PHC stems from the view and, increasingly, across borders: this raises the benchmark in terms of working effectively growing realization among health policy-makers across government and stakeholders that it can provide a stronger sense of direction While the health sector remains massively and unity in the current context of fragmenta under-resourced in far too many countries,I tion of health systems, and an alternative to the the resource base for health has been growing assorted quick fixes currently touted as cures consistently over the last decade. The opportu for the health sectors ills. There is also a grow nities this growth offers for inducing structural ing realization that conventional health-care XIxiii Introduction and Overview Second, the nature of health problems is chang￾ing in ways that were only partially anticipated, and at a rate that was wholly unexpected. Ageing and the effects of ill-managed urbanization and globalization accelerate worldwide transmis￾sion of communicable diseases, and increase the burden of chronic and noncommunicable disorders. The growing reality that many indi￾viduals present with complex symptoms and multiple illnesses challenges service delivery to develop more integrated and comprehensive case management. A complex web of interrelated factors is at work, involving gradual but long￾term increases in income and population, climate change, challenges to food security, and social tensions, all with defi nite, but largely unpredict￾able, implications for health in the years ahead. Third, health systems are not insulated from the rapid pace of change and transformation that is an essential part of today’s globaliza￾tion. Economic and political crises challenge state and institutional roles to ensure access, delivery and fi nancing. Unregulated commer￾cialization is accompanied by a blurring of the boundaries between public and private actors, while the negotiation of entitlement and rights is increasingly politicized. The information age has transformed the relations between citizens, professionals and politicians. In many regards, the responses of the health sector to the changing world have been inad￾equate and naïve. Inadequate, insofar as they not only fail to anticipate, but also to respond appropriately: too often with too little, too late or too much in the wrong place. Naïve insofar as a system’s failure requires a system’s solution – not a temporary remedy. Problems with human resources for public health and health care, fi nance, infrastructure or information systems invariably extend beyond the narrowly defi ned health sector, beyond a single level of policy pur￾view and, increasingly, across borders: this raises the benchmark in terms of working effectively across government and stakeholders. While the health sector remains massively under-resourced in far too many countries, the resource base for health has been growing consistently over the last decade. The opportu￾nities this growth offers for inducing structural changes and making health systems more effec￾tive and equitable are often missed. Global and, increasingly, national policy formulation proc￾esses have focused on single issues, with various constituencies competing for scarce resources, while scant attention is given to the underlying constraints that hold up health systems develop￾ment in national contexts. Rather than improv￾ing their response capacity and anticipating new challenges, health systems seem to be drifting from one short-term priority to another, increas￾ingly fragmented and without a clear sense of direction. Today, it is clear that left to their own devices, health systems do not gravitate naturally towards the goals of health for all through primary health care as articulated in the Declaration of Alma￾Ata. Health systems are developing in directions that contribute little to equity and social justice and fail to get the best health outcomes for their money. Three particularly worrisome trends can be characterized as follows: Q health systems that focus disproportionately on a narrow offer of specialized curative care; Q health systems where a command-and-control approach to disease control, focused on short￾term results, is fragmenting service delivery; Q health systems where a hands-off or laissez￾faire approach to governance has allowed unregulated commercialization of health to fl ourish. These trends fl y in the face of a comprehensive and balanced response to health needs. In a num￾ber of countries, the resulting inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability. Growing expectations for better performance The support for a renewal of PHC stems from the growing realization among health policy-makers that it can provide a stronger sense of direction and unity in the current context of fragmenta￾tion of health systems, and an alternative to the assorted quick fi xes currently touted as cures for the health sector’s ills. There is also a grow￾ing realization that conventional health-care