SIXTY-SECOND WORLD HEALTH ASSEMBLY Provisional agenda item 12.4
A62/8 9 April 2009
Primary health care, including health system strengthening Report by the Secretariat
1. There have been many calls for a renewal of primary health care at several international, regional, and national conferences organized by, or in collaboration with, WHO,1 and at 2008 regional committee meetings, coinciding with the 30th anniversary of the Declaration of Alma-Ata, which articulated the values of Health for All through primary health care, addressing both priority health needs and the fundamental determinants of health, so as to enable people to lead socially and economically productive lives, and thus drive overall development. 2. Member States, in their calls for a renewal of primary health care, have reaffirmed their commitment to the values of equity, solidarity and social justice, and the principles of multisectoral action and community participation. The calls represent the ambition to deal effectively with current and future challenges to health, mobilizing health professionals and lay people, government institutions and civil society around an agenda of transformation of health-system inequalities, service delivery organization, public policies, and development. 3. The health of the world’s population has improved over the last 30 years and can be partly attributed to better nutrition, water supply, sanitation, housing, and education. Although some countries have shown sustained improvement in health outcomes, others have lagged behind or even experienced reversals. In part these differences can be attributed to socioeconomic, political and ecological constraints. However, low-income countries have found it difficult to cope with rising commodity prices, recession, structural adjustment programmes, political instability, civil strife, the emergence of HIV/AIDS, and others. But differences in health outcomes are also related to investment in health and financing, decentralization, human resource and other major health-sector policies. 4. There are important lessons in the successes and failures of the last 30 years: health systems do not automatically yield the optimal and most effective balance of promotion, prevention, cure and palliation; and they do not naturally move towards the production of enhanced and more equitable health outcomes, greater solidarity and social justice. Leadership and a sense of direction require sustained commitment and an approach embedded in, and a driver of, overall development. 5. Health authorities in many countries are aware that progress towards improved health outcomes, including, but not limited to, the Millennium Development Goals, is too slow and unequal, that
Ottawa 1986, Ljubljana 1996, Jakarta 1997, Mexico 2004, Bangkok 2005, Buenos Aires 2007, Beijing 2007, Bangkok 2008, Jakarta 2008, Tallinn 2008, Ouagadougou 2008, Doha 2008.
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performance does not meet expectations, and that they are ill-prepared to respond to challenges and demands. Many recognize the potential of primary health care for providing a stronger sense of direction and unity in segmented and fragmented health systems, and for providing the framework that integrates health into all policies. 6. This dissatisfaction is echoed by international agencies, global health initiatives, donors, and civil society organizations. Consequently, global stakeholders are increasingly recognizing the need for improved health-systems performance based on the values of primary health care. 7. Further support has come from two reports published in 2008. The report of the Commission on Social Determinants of Health1 documented widening gaps in health outcomes, both within and between countries, and challenged governments to make equity an explicit policy objective in all government sectors. The Commission’s analysis of underlying social, economic, and political causes of ill-health, and of the methods most likely to provide solutions, makes a convincing case for, and endorses, a renewed focus on primary health care. 8. In addition, The world health report 20082 noted that, in rich and in poor countries alike, a health sector organized according to the tenets of primary health care had the greatest potential for producing better health outcomes, improving health equity and responding to social expectations. The report identifies the key areas where policy change is required in order to ensure that health systems are based on the values and principles of primary health care.
THE HEALTH CHALLENGES 9. There are differences not only in health outcomes between countries, but also national inequalities in access, coverage and expenditure. 10. Rising social expectations regarding health and health care, fuelled by modernization, greater access to information and improved health literacy, are driving demand for more people-centred access, better community health protection and more effective participation in decisions that affect health. There is pressure on policy makers and political leaders to steer their health systems towards health equity, social justice and solidarity. 11. There are unprecedented opportunities to do so. In recent years, countries have gained experience and knowledge; there is the mutually reinforcing demand for change from populations, policy makers and the global health community; and, as indicated by the Report of the Secretariat regarding monitoring of the achievement of the health-related Millennium Development Goals,3 there is a growing consensus that health will not improve without functioning health systems, that health systems function best when they are based on primary health care, and that there is an opportunity to align more fully the agenda for responding to specific diseases with the agenda for strengthening
1 Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008.
World Health Organization. The world health report 2008: Primary health care, now more than ever. Geneva, World Health Organization, 2008. 3
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Document EB124/10.
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health systems. The rapid expansion and growing economic and social weight of the health sector – a long-term trend across the world, with the exception of fragile States – provides leverage to obtain the policy changes that primary health care requires.
AN AGENDA FOR ACTION 12. There are four broad policy areas for essential changes: dealing with health inequalities by moving towards universal coverage; putting people at the centre of service delivery; integrating health into public policies across sectors; and providing inclusive leadership for health governance. 13. The changes rely on the alignment of the different components or building blocks of health systems, i.e. the health workforce; the health information system; the systems to provide access to medical products, vaccines, and technologies; the financing system; and leadership and governance, and on the way they jointly translate health-sector inputs into overall outcomes.1 14. The policies must be shaped by the Member States themselves, and tailored to the specificities of each country. The global health community must also use its power of mobilization and influence to facilitate the renewal. 15. Dealing with health inequalities by moving towards universal coverage. This means moving towards a sufficient supply of service networks (inclusive of the human resources, infrastructure, resources, management and steering required), where financial and other barriers to access are removed, and where families are protected against the financial consequences and impoverishment that may result from seeking care. Moving towards universal coverage constitutes the core strategy to ensure that health systems contribute to health equity, social justice, and the elimination of exclusion. It does not, however, eliminate the need for tackling the social determinants of health inequalities, through a whole-of-society approach as recommended by the Commission on Social Determinants, nor does it preclude the need for efforts at reaching the unreached or for systematic monitoring and documentation of health inequalities and exclusion. 16. Depending on the national context, a step-by-step progression towards universal coverage requires a combination of (i) the extension of health-care networks where they are not available; (ii) the shift from reliance on user fees levied on the sick to the solidarity and protection provided by pooling and prepayment; and (iii) the development of mechanisms of social health protection. In highas well as in low-income countries, present levels and trends of domestic expenditure on health could allow for a greater degree of universality. 17. In many countries, purchase of an essential set of health interventions for all is beyond national capacity. Increased external financial assistance for health will be required for some years to come, including through innovative mechanisms. Scepticism about aid effectiveness has been replaced by recognition of the need for donors to direct financial flows towards country-led priorities and initiatives in ways that strengthen existing infrastructures, reduce fragmentation and duplication, and minimize transaction costs. Channelling aid in ways that build up the institutional capacity to manage the financing of the system can accelerate the extension of service networks together with the development of social health protection. This would improve synergies between external and domestic World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva, World Health Organization, 2007. 1
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funding: the visibility and strategic importance of external funding should not obscure the fact that more than 75% of health expenditure in the average low-income country comes from domestic sources. 18. The move towards universal coverage also remains an unfinished agenda in high-income countries, where cost containment is having a serious effect on equity of treatment. 19. Putting people at the centre of service delivery. Health services must pay far more attention to putting the patient first, and to continuity and integration of care. The organization of a comprehensive continuum of care along the life-cycle is particularly important, encompassing the full range of health actions, from prevention and promotion to curative and palliative care. The public, private-for-profit, or private-not-for-profit nature of health care delivery is far less critical than the degree to which services, in each context, can be organized so as to present these actions. 20. To ensure that services deliver appropriate care, they have to be designed and organized around close-to-client networks of primary care teams, with the responsibility for the health of a defined population, and with the capacities to coordinate the inputs of hospitals, specialists, and other services (including supplies and logistics) that can contribute to the health of that population. In many countries, health districts are an appropriate planning unit for organizing service delivery in line with these principles. 21. The health-care delivery landscape has become far more complex over the last decades. Along with governmental services, the offer of care now generally includes a range of providers, governmental and nongovernmental, for-profit and not-for-profit, and a range of services, including traditional medicine. This variety can add value to service delivery, provided its responsiveness to the variety of problems and expectations and its entrepreneurial dynamism is harnessed to contribute to improved health and health equity, and mechanisms are in place to ensure safety and consumer protection. 22. There are currently new opportunities for countries to take advantage of recent reviews of experience with different, context-sensitive approaches to the integration of traditional and conventional medicine, building on that accumulated knowledge to contribute to the necessary reorientation of health care delivery towards people-centred primary care. 23. Putting people at the centre of service delivery is not merely a question of designing the appropriate service delivery models. The improvement of basic health infrastructures, services and the workforce requires long-term commitment and investment. Given the critical shortage of health workers and the immediate impact on health, investment in the health workforce, including through professional associations and training institutions, is decisive, in high- as well as in low-income countries. 24. Multisectoral action and health in all policies. The deliberations of the regional committees, the Report of the Commission on Social Determinants of Health and The world health report 2008 have reiterated the need to step up efforts to improve health by acting on wider social, economic, and environmental causes of ill health and health inequalities. 25. Better public policies, within and beyond the health sector, represent a huge untapped potential to improve health. Public health interventions, from public hygiene and disease prevention to health promotion and the establishment of a rapid response capacity are of critical importance for health outcomes and for securing and sustaining public trust in the health system.
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26. Public authorities, across all government sectors, must also assume their responsibilities for ensuring that health considerations are given their rightful place in the deliberations on other policy domains, such as gender equality, consumer protection or labour policies. Health authorities must create the conditions under which other sectors can incorporate health considerations within their policies and outcomes. Health impact assessments offer promising avenues for more concrete multisectoral policy dialogue. 27. Inclusive leadership and effective government for health. In many countries there is a need for substantial reinvestment in country capacity to govern the health sector. The enhanced responsibilities must be accompanied by new forms of leadership for health, particularly in a context where political and administrative decentralization offers both challenges and opportunities. 28. While each Member State has its own way of governing its health system, health ministries have the ultimate responsibility for health-system development. However, given the complexity of the health sector, the responsibility has to be exercised through collaborative models of policy dialogue with multiple stakeholders, from professional organizations to United Nations agencies, from development banks to civil society, from women’s and youth groups to networks of patients. 29. These new ways of operating will require reinvestment commensurate with the growth and weight of the health sector in society, in leadership capacities, in the gathering and use of information, and in knowledge and research. There is a clear need for building more effective, more proactive and more collaborative ways of governing the health sector. 30. An earlier version of this report was considered by the Executive Board at its 124th session in January 2009.
ACTION BY THE HEALTH ASSEMBLY 31. The Health Assembly is invited to consider the draft resolutions contained in resolutions EB124.R8 and EB124.R9.
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