The World Health Report 2008, which is being launched on 14 October, critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The World Health Organization (WHO) report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.
“The World Health Report sets out a way to tackle inequities and inefficiencies in health care, and its recommendations need to be heeded,” said WHO Director-General Margaret Chan at the launch of the report in Almaty, Kazakhstan. “A world that is greatly out of balance in matters of health is neither stable nor secure.”
The report, Primary health care – now more than ever (summary and web link to resources below), commemorates the 30th anniversary of the Alma-Ata International Conference on Primary Health Care held in 1978. That event was the first to put health equity on the international political agenda.
In a wide-ranging review, the new report found striking inequities in health outcomes, in access to care, and in what people have to pay for care. Differences in life expectancy between the richest and poorest countries now exceed 40 years. Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants.
Globally, annual government expenditure on health varies from as little as $20 per person to well over $6,000. For 5.6 billion people in low- and middle-income countries, more than half of all health care expenditure is through out-of-pocket payments.
With the costs of health care rising and systems for financial protection in disarray, personal expenditures on health now push more than 100 million people below the poverty line each year.
Vast differences in health occur within countries and sometimes within individual cities. In Nairobi, for example, the under-five mortality rate is below 15 per thousand in the high-income area. In a slum in the same city, the rate is 254 per thousand.
“High maternal, infant, and under-five mortality often indicates lack of access to basic services such as clean water and sanitation, immunizations and proper nutrition,” said Ann M. Veneman, UNICEF Executive Director. “Primary health care including integrated services at the community level can help improve health and save lives.”
Data set out in the report are indicative of a situation in which many health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet the needs and expectations of people, especially in impoverished and marginalized groups.
As the report notes, conditions of “inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability.”
To steer health systems towards better performance, the report calls for a return to primary health care, a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment.
Such lessons take on critical importance at a time of global financial crisis.
“Viewed against current trends, primary health care looks more and more like a smart way to get health development back on track, ” says Dr Chan.
As initially articulated, primary health care revolutionized the way health was interpreted and radically altered prevailing models for organizing and delivering care. It represented a deliberate effort to counter trends responsible for the “gross inequality” in the health status of populations.
In calling for a return to primary health care, WHO argues that its values, principles and approaches are more relevant now than ever before. Several findings support this conclusion. As the report notes, inequalities in health outcomes and access to care are much greater today than they were in 1978.
In far too many cases, people who are well-off and generally healthier have the best access to the best care, while the poor are left to fend for themselves. Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care, with health viewed as a product of biomedical interventions and the power of prevention largely ignored.
Specialists may perform tasks that are better managed by general practitioners, family doctors, or nurses. This contributes to inefficiency, restricts access, and deprives patients of opportunities for comprehensive care. When health is skewered towards specialist care, a broad menu of protective and preventive interventions tends to be lost.
WHO estimates that better use of existing preventive measures could reduce the global burden of disease by as much as 70%.
Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.
In rural parts of the developing world, care tends to be fragmented into discrete initiatives focused on individual diseases or projects, with little attention to coherence and little investment in basic infrastructures, services, and staff. As the report observes, such situations reduce people to “programme targets.”
Above all, health care is failing to respond to rising social expectations for health care that is people-centred, fair, affordable and efficient.
A primary health care approach, when properly implemented, protects against many of these problems. It promotes a holistic approach to health that makes prevention equally important as cure in a continuum of care that extends throughout the lifespan. As part of this holistic approach, it works to influence fundamental determinants of health that arise in multiple non-health sectors, offering an upstream attack on threats to health.
Primary health care brings balance back to health care, and puts families and communities at the hub of the health system. With an emphasis on local ownership, it honours the resilience and ingenuity of the human spirit and makes space for solutions created by communities, owned by them, and sustained by them.
The core strategy for tackling inequalities is to move towards universal coverage in a spirit of equity, social justice, and solidarity. Fairness and efficiency in service delivery are overarching goals.
Primary health care also offers the best way of coping with three ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned urbanization, and the ageing of populations. These trends contribute to a rise in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, that create new demands for long-term care and strong community support. A multisectoral approach is central to prevention, as the main risk factors for these diseases lie outside the health sector.
As the report notes, health systems will not naturally gravitate towards greater fairness and efficiency. Deliberate policy decisions are needed. The evidence and arguments set out in the report should help in this task.
“We are, in effect, encouraging countries to go back to the basics,” says Dr Chan. “Thirty years of well-monitored experience tell us what works and where we need to head, in rich and poor countries alike.”
Additional information:
For those unable to be at the press conference at Almaty, WHO will provide audio and video files, and a transcript following the media briefing. The World Health Report is available in English and Russian, the Introduction and Overview in English, French, Spanish and Russian and a short summary of the report in English, French and Spanish. Country examples of diverse primary health care experiences, a news release, photos, posters and video and audio files can be viewed at: www.who.int/whr/2008.
The login is WHR08 (all CAPS) and the password is whrph.
Media contacts:
In Almaty:
Christopher Black, Multimedia Communications officer, WHO, Mobile: +41 79 472 60 54; +7 (777) 785 0774; E-mail: blackc@who.int
Gaya Gamhewage, Team Leader, Corporate Communications, WHO, Mobile: +41 79 475 55 63; E-mail: gamhewageg@who.int
John Budd, Regional Communication Officer; UNICEF; CEE CIS Region, Mobile: +41 79 431 15 37; Office: +41 22 909 5429; E-mail: jbudd@unicef.org
Sultan Khudaibergenov, Communication officer, UNICEF Tel: +77012279914; E-mail: skhudaibergenov@unicef.org
In Geneva:
Dick Thompson, News Team Leader WHO, Tel: + 41 22 791 1492; Mobile: + 41 79 475 55 34; E-mail : thompsond@who.int
Sharad Agarwal, Communications officer, WHO, Tel:+ 41 22 791 1905; Mobile: +41 79 621 52 86 ; E-mail: agarwals@who.int
Fadéla Chaib, Communications officer, WHO, Tel: + 41 22 791 3228; Mobile: + 41 79 475 55 56; E-mail: chaibf@who.int
Mervyn Fletcher, Communications officer, UNICEF, Tel: +41 22 9095433; Mobile: +41 79 666 8831; E-mail: mfletcher@unicef.org
Summary of the World Health Report 2008
"Primary Health Care: Now More Than Ever"
Primary health care was put forward thirty years ago as a set of values, principles and approaches aimed at raising the level of health in deprived populations. In all countries, it offered a way to improve fairness in access to health care and efficiency in the way resources were used. Primary health care embraced a holistic view of health that went well beyond a narrow medical model. It recognized that many root causes of ill health and disease lie beyond the control of the health sector and thus must be tackled through a broad whole-of-society approach. Doing so would meet several objectives: better health, less disease, greater equity, and vast improvements in the performance of health systems.
Today, health systems, even in the most developed countries, are falling short of these objectives. Although remarkable strides have been made to improve health, combat disease and lengthen life spans, people worldwide are dissatisfied with existing health systems. One of the greatest worries is about the cost of health care. This is a realistic concern since 100 million people fall into poverty each year paying for health care. Millions more are unable to access any health care.
The source of the problem is that health systems and health development agendas have evolved into a patchwork of components. This is evident in the excessive specialization in rich countries and donor-driven, single disease-focused programmes in poor ones. A vast proportion of resources are spent on curative services, neglecting prevention and health promotion that could cut 70% of global disease burden. In short, health systems are unfair, disjointed, inefficient and less effective than they could be. Moreover, without substantial reorienting, today's struggling health systems are likely to be overwhelmed by the growing challenges of aging populations, pandemics of chronic diseases, new emerging diseases such as SARS, and the impacts of climate change.
"Rather than improving their response capacity and anticipating new challenges, health systems seem to be drifting from one short-term priority to another, increasingly fragmented and without a clear sense of direction," says World Health Report 2008 entitled Primary Health Care – Now More Than Ever.
With the publication of the report on 14 October, WHO hopes to start a global conversation on the effectiveness of primary health care as a way of reorienting national health systems. WHO Director-General, Margaret Chan, wrote in a recent editorial in the journal The Lancet: "Above all, primary health care offer(s) a way to organize the full range of health care, from households to hospitals, with prevention equally important as cure, and with resources invested rationally in the different levels of care."
Actually, WHO hopes to revive the conversation. Primary health care was officially launched in 1978, when WHO member states signed the Alma Ata Declaration. That was 30 years ago. A few countries pursued the ideal. But, says Dr Chan: "The approach was almost immediately misunderstood."
Primary health care was misconstrued as poor care for poor people. It was also seen as having an exclusive focus on first-level care. Some dismissed it as utopian and others thought it a threat to the medical establishment.
In the World Health Report, WHO proposes that countries make health system and health development decisions guided by four broad, interlinked policy directions. These four represent core primary health care principles.
Universal coverage: For fair and efficient systems, all people must have access to health care according to need and regardless of ability to pay. If they do not have access, health inequities produce decades of differences in life expectancies not only between countries but within countries. These inequities raise risks, especially of disease outbreaks, for all.
Providing coverage to all is a financial challenge, but most systems now rely on out-of-pocket payments which is the least fair and effective method. WHO recommends financial pooling and pre-payment, such as insurance schemes. Brazil began working towards universal coverage in 1988 and now reaches 70% of its population.
People-centred services: Health systems can be reoriented to better respond to people's needs through delivery points embedded in communities. The Islamic Republic of Iran's 17 000 "health houses" each serve about 1500 people and are responsible for a sharp drop in mortality over the last two decades, with life expectancy increasing to 71 years in 2006 from 63 years in 1990. New Zealand's Primary Health Care Strategy, launched in 2001, has as part of its core strategy an emphasis on prevention and management of chronic diseases. Cuba's "polyclinics" have helped give Cubans one of the longest life expectancies (78 years) of any developing country in the world. Brazil's Family Health Programme provides quality care to families in their homes, at clinics and in hospitals.
Healthy Public Policies: Biology alone does not explain many gaps in longevity, such as the 27-year difference in Glasgow's rich and poor neighbourhoods. In fact, much of what impacts health broadly lies outside the influence of the health sector. Ministries of trade, environment, education and others all have their impact on health, and yet little attention is generally paid to decisions in these ministries that have health impacts. WHO believes they should all be part of deliberations and that a "health in all policies" approach needs to be integrated broadly throughout governments. This will require a shift in political calculations since some of the greatest health impacts can be achieved through early childhood development programmes and education of women, but those benefits are unlikely to be seen during a single politician's term or terms in office.
Leadership: Existing health systems will not naturally gravitate towards more fair, efficient (those that work better) and effective (those that achieve their goals) models. So, rather than command and control, leadership has to negotiate and steer. All components of society – including those not traditionally involved in health – have to be engaged, including civil society, the private sector, communities and the business sector. Health leaders need to ensure that vulnerable groups have a platform to express their needs and that these pleas are heeded. There is enormous potential to be tapped. In half of the world's countries, health issues are the greatest personal concern for a third of the population. Wise leadership requires knowledge of what works. Yet health systems research is an area that is often severely under funded. In the United States of America, for example, health systems research claims only 0.1% of the nation's health budget expenditure. Yet research is needed to generate the best evidence as a basis for health decision.
By aiming at these four primary health care goals, national health systems can become more coherent, more efficient, more fair and vastly more effective.
Progress is possible, in all countries. Now, more than ever, there are opportunities to start changing health systems towards primary health care in all countries. The challenges are different for countries with different income levels, but there are commonalities. There is more money being spent on health than ever before and more knowledge to address global health challenges, including better medical technology. There is also now recognition that threats and opportunities in health are shared across the world. Aid is important for some countries, but the vast majority of health spending comes from domestic sources. Even today, in Africa, 70% of all resources for health come from domestic funds. Thus most countries have the ability to start moving towards and enjoying the benefits of primary health care.