WORLD HEALTH ORGANIZATION FIFTY-SEVENTH WORLD HEALTH ASSEMBLY Provisional agenda item 12.11 A57/14 19 April 2004
Health systems, including primary health care Report by the Secretariat
INTRODUCTION 1. In May 2003, the Fifty-sixth World Health Assembly, through resolution WHA56.6, requested Member States to take a range of actions to reinforce primary health care. It also requested the Director-General to convene a meeting to celebrate the twenty-fifth anniversary of the Declaration of Alma-Ata, and to identify future strategic directions for primary health care; to continue to incorporate the principles of primary health care in WHO’s activities and programmes; and to report on progress. 2. This report briefly reviews progress made in implementing resolution WHA56.6. The report also refers to the findings of a global review of the contribution that primary health care can be expected to make to tackling the health issues of the twenty-first century. 3. Meetings held on primary health care included the International Conference on Primary Health Care (Almaty, 23 and 24 October 2003) in commemoration of the twenty-fifth anniversary of the Declaration of Alma-Ata, and the Global Meeting on Primary Health Care (Madrid, 27 to 29 October 2003). In addition, a meeting on the twenty-fifth anniversary of the Declaration of Alma-Ata was held in Brasília (6 to 8 December 2003). 4. The meeting in Kazakhstan adopted a resolution covering health-care priorities and resource allocations, public health and population, risk factors for health, and intersectoral collaboration. 5. The global meeting in Madrid1 acknowledged the diversity of the situations faced by individual Member States as they considered their future plans for improving their health systems based on the principles of primary health care. Differences include the resources available to invest in health, the demography and epidemiology of populations, political and social systems, and the stage of development of health systems based on the principles of primary health care. 6. Despite this diversity in the degree of implementing improvements to health systems, the global meeting was able to identify a framework within which both individual Member States and the international community would be able to maintain a clear focus on applying the principles of primary health care in pursuit of health for all. The elements of the framework are: the principles and goals of primary health care; policy formulation, implementation and review; and development of health systems. Each of these elements is dynamic, evolving, and interconnected.
1
Reported on more fully in document WHO/MNC/OSD/04.
A57/14
PRINCIPLES AND GOALS OF PRIMARY HEALTH CARE 7. The principles, which are central to the philosophy of primary health care, continue to be supported by Member States and the wider international community. There is commitment to pursuing the goals of achieving health for all, improving health outcomes, and promoting equitable access to care. 8. If current goals and future needs are to be met, continuing emphasis should be laid on the following actions: devising processes to identify needs that relate to the whole population; building an intersectoral approach that addresses the determinants of health; incorporating community participation in all the processes of policy framing, health system development and wider community development; ensuring that evidence and experience are fully used by policy-makers, communities, health-care providers, and made accessible to patients and their families; ensuring that populations have access to health systems that promote health and deliver appropriate health care; and determining at national level the best way to achieve the goal of health for all among local populations. 9. In order to tackle current challenges to global health, new principles may be needed; for example, the recognition that: health is a national and global resource for social and economic development and an instrument for social cohesion; many determinants of health need to be actively addressed and managed at an international level; unilateral action by individual Member States is unlikely successfully to address health-related economic and social issues that transcend national boundaries; within civil society, individuals have responsibilities and rights for their own health and that of others; if they are to optimize improvements in health, governments should retain responsibility for securing health for their populations as a whole while working with other stakeholders; and prevention and care are complementary, not alternative, interventions. 10. The principles of primary health care have evolved over time, and will continue to evolve as new political and social paradigms emerge. This also needs to be recognized, so that a commitment can be made to keeping principles under review and to reformulating them.
POLICY DEVELOPMENT, IMPLEMENTATION AND REVIEW 11. Although the Declaration of Alma-Ata was clear on principles and indications of the core activities of primary health care, there was no explicit connection between the principles, the activities and the need to keep results under review. Policy-making in itself does not trigger implementation. A dynamic process of policy framing, implementation and review is needed as an instrument for countries rather than as a process for benchmarking or for making international comparisons. 12. WHO plans to provide support for development of a monitoring tool to assess whether the primary health care principles are being implemented. This “primary health care lens” would enable countries to track both strategic lines of work that need a long-term perspective, and the progress of short-term programmes. Doing so would help countries systematically to align implementation to policy to assure coherent execution. It would also strengthen their position in relation to international bodies and to donors.
2
A57/14
HEALTH SYSTEM DEVELOPMENT 13. In the face of complex challenges, the function of government to make a clear connection between health goals, the application of primary health care principles, and the delivery of appropriate health services has grown in importance. The health-for-all framework remains of instrumental value for the stewardship exercised by governments and other stakeholders. 14. The Declaration of Alma-Ata states that the social, economic and political characteristics of a country should determine how primary health care principles are applied in practice. This allows for diversity in the organization of health systems. Nonetheless, a core role of government is to ensure that health systems produce health benefits for the population, are based on needs, and are able to act on the determinants of health, and can deliver good-quality health care to individuals. 15. Governments, therefore, through their implementation of primary health care, play a key role in implementing the health-related Millennium Development Goals. Achievement of the goals complements implementation of health for all; and requires a public health system driven by primary health care. 16. The development of the health system needs to be driven by the principles of primary health care and related policies in order to progress towards the goal of improving population health. Thus, the capacity of the health system to deliver accessible care to all becomes more important than primary health care as a specific level. This means that to be effective primary health care must operate close to the community it serves, but does not have to be seen as a separate and distinct level of care. Therefore, enabling coordinated, patient-centred care across the continuum of prevention and care requires the development of integrated health systems that are led by primary health care yet blur the conventional distinctions between levels of care. 17. Further, disease-focused programmes should always be set in the context of a complementary and simultaneous strategy for health system development in order to assure effective and sustainable delivery. These programmes represent an opportunity to develop health systems and for that development to be based on primary health care. 18. The Executive Board at its 113th session in January 2004 noted the recommendations related to the development of health systems led by primary health care.
ACTION BY THE HEALTH ASSEMBLY 19. The Health Assembly is invited to note the above report.
=
=
=
3