The frequency of rich, adding to the challenge. As diseases betes, cardiovascular disease and cancers — and of poverty are inter-related, sharing causes that Figure 1. The challenges of a changing world are multiple and act together to produce greater Even for well-known and documented trends, disability and ill health, multi-morbidity is such as those resulting from the demographic and probably more rather than less frequent in poor epidemiologic transitions, the level of response countries.
Addressing co-morbidity — including often remains inadequate This is as important asthma, arthritis, angina, diabetes and depres- in developing countries as in the industrialized sion, and of the screening for cervical and breast world Public-health chronic diseases or adult health has to come on interventions to remove the major risk factors of top of an unfi nished agenda related to communi- disease are often neglected, even when they are cable diseases, and maternal, newborn and child particularly cost effective: they have the potential health.
But all health For example, premature tobacco-attributable systems, including those in the poorest countries, deaths from ischaemic heart disease, cerebro- will also have to deal with the expanding need and vascular disease, chronic obstructive pulmonary demand for care for chronic and noncommunicable disease and other diseases are projected to rise diseases: this is not possible without much more from 5.
Yet, two out is equally impossible without much more atten- of every three countries are still without, or only tion being paid to addressing the pervasive health have minimal, tobacco control policies With a few exceptions — the SARS epidemic, for example — the health sector has often been slow Little anticipation and slow reactions in dealing with new or previously underestimated Over the past few decades, health authorities have health challenges.
For example, awareness of the shown little evidence of their ability to anticipate emerging health threats posed by climate change such changes, prepare for them or even adapt to and environmental hazards dates back at least to them when they have become an everyday real- the Earth Summit 68, but only in recent years ity.
This is worrying because the rate of change have these begun to be translated into plans and is accelerating. Globalization, urbanization and strategies 69, Global and national policy in the poorest countries. Precisely how these will environments have often taken health issues into affect health in the coming years is more difficult consideration, initiating hasty and disruptive to predict, but rapid changes in disease burden, interventions, such as structural adjustment, growing health inequalities and disruption of decentralization, blueprint poverty reduction social cohesion and health sector resilience are strategies, insensitive trade policies, new tax to be expected.
The current food crisis has shown regimes, fi scal policies and the withdrawal of how unprepared health authorities often are for the state. Health authorities have a poor track changes in the broader environment, even after record in influencing such developments, and other sectors have been sounding the alarm bell have been ineffective in leveraging the economic for quite some time.
All too often, the accelerated weight of the health sector. Many of the critical pace and the global scale of the changes in the systems issues affecting health require skills challenges to health is in contrast with the slug- and competencies that are not found within the gish response of national health systems. The challenges of a changing world to recognize the need for expertise from beyond limited regulatory capacity, they have had more traditional health disciplines has condemned the damaging effects.
Today, the disproportionate focus Without strong policies and leadership, health on hospitals and sub-specialization has become systems do not spontaneously gravitate towards a major source of inefficiency and inequality, and PHC values or efficiently respond to evolving one that has proved remarkably resilient.
Health health challenges. As most health leaders know, authorities may voice their concern more insist- health systems are subject to powerful forces and ently than they used to, but sub-specialization influences that often override rational priority continues to prevail For example, in Member setting or policy formation, thereby pulling health countries of the Organisation of Economic Co- systems away from their intended directions The forces driving this growth include pro- With their focus on cost containment and fessional traditions and interests as well as the deregulation, many of the health-sector reforms considerable economic weight of the health indus- of the s and s have reinforced these try — technology and pharmaceuticals Box 1.
High-income countries have often been Obviously, well functioning specialized tertiary able to regulate to contain some of the adverse care responds to a real demand albeit, at least in consequences of these trends. However, in part, induced : it is necessary, at the very least, countries where under-funding compounds for the political credibility of the health system.
However, the experience of industrialized coun- tries has shown that a disproportionate focus on Figure 1. Hospital-centrism carries a considerable cost in terms of unnecessary medicalization and Health Universal access to systems people-centred care iatrogenesis77, and compromises the human and social dimensions of health73, It also carries an Healthy communities opportunity cost: Lebanon, for example, counts more cardiac surgery units per inhabitant than Current trends PHC Reform PHC Reform Germany, but lacks programmes aimed at reduc- Hospital-centrism ing the risk factors for cardiovascular disease Inefficient ways of dealing with health problems are thus crowding out more effective, efficient — Commercialization and more equitable80 — ways of organizing health care and improving health Over the last 30 years, this has contributed to pharmaceutical industries are major significant improvements in health outcomes 81, In same way In the rest of the world, the average of tion While this market grows everywhere, Yet, many low- and middle-income countries there are large differences from country to country.
For are creating the same distortions. The pressure example, Japan and the United States have 5—8 times more magnetic resonance imaging MRI units per million inhab- from consumer demand, the medical professions itants than Canada and the Netherlands.
For computerized and the medico-industrial complex 88 is such that tomography CT scanners, the differences are even more private and public health resources flow dispro- pronounced: Japan had These differences show that the market at the expense of investment in primary care. Donors have also used their influence more towards setting up disease specialists and technologies, and keep costs control programmes than towards reforms that under control.
They have done this by introduc- would make primary care the hub of the health ing supply-side measures including reduction of system The results While urban health by and large revolves around of these efforts have been mixed, but the evolving hospitals, the rural poor are increasingly con- technology is accelerating the shift from special- fronted with the progressive fragmentation of ized hospital to primary care.
The challenges of a changing world as an interim strategy to achieve equitable health Malawi, a hospital saw 88 nurses leave for better outcomes, they sprang from a concern for the paid nongovernmental organization NGO pro- slow expansion of access to health care in a con- grammes in an month period A focus on programmes and projects is gramme exists — overlooking people who have the particularly attractive to an international com- misfortune not to fit in with current programme munity concerned with getting a visible return priorities.
It is well adapted to command- trust if they are considered as mere programme and-control management: a way of working that targets: services then lack social sustainability.
This is not just a problem for the population. Health authorities may at fi rst be seduced by constrained and donor-dependent countries. They the straightforwardness of programme funding have had the merit of focusing on health care in and management, yet once programmes multiply severely resource-constrained circumstances, and fragmentation becomes unmanageable and with welcome attention to reaching the poorest unsustainable, the merits of more integrated and those most deprived of services.
The re-inte- Many have hoped that single-disease control gration of programmes once they have been well initiatives would maximize return on invest- established is no easy task. In many, if not most low- and middle-income Often the opposite has proved true. The limited countries, under-resourcing and fragmentation sustainability of a narrow focus on disease con- of health services has accelerated the develop- trol, and the distortions it causes in weak and ment of commercialized health care, defi ned here under-funded health systems have been criti- as the unregulated fee-for-service sale of health cized extensively in recent years Short-term care, regardless of whether or not it is supplied advances have been short-lived and have frag- by public, private or NGO providers.
With parallel previously unheard of proportions in countries chains of command and funding mechanisms, that, by choice or due to a lack of capacity, fail to duplicated supervision and training schemes, regulate the health sector. The discrepancy in salaries between Commercialization often cuts across the regular public sector jobs and better-funded public-private divide Health-care delivery in programmes and projects has exacerbated the many governmental and even in traditionally human resource crisis in fragile health systems.
In these same countries, and rising expectations The reason why health systems are organized moonlighting civil servants make up a consid- around hospitals or are commercialized is largely erable part of the unregulated commercial sec- because they are supply-driven and also corre- tor, while others resort to under-the-counter spond to demand: genuine as well as supply- payments,, The public-private debate of the induced.
Health systems are also a reflection last decades has, thus, largely missed the point: of a globalizing consumer culture. Yet, at the for the people, the real issue is not whether their same time, there are indications that people are health-care provider is a public employee or a aware that such health systems do not provide private entrepreneur, nor whether health facili- an adequate response to need and demand, and ties are publicly or privately owned.
As commodity that can be bought and sold on a fee- societies modernize and become more affluent for-service basis without regulation or consumer and knowledgeable, what people consider to be protection The reasons are changes People tend to regard health services straightforward: the provider has the knowledge; more as a commodity today, but they also have the patient has little or none. The provider has other, rising expectations regarding health and an interest in selling what is most profitable, health care.
People care more about health as but not necessarily what is best for the patient. They expect their families tion reports or newspaper articles that express and communities to be protected from risks and outrage at the breach of the implicit contract of dangers to health. They want health care that trust between caregiver and client Those who deals with people as individuals with rights and cannot afford care are excluded; those who can not as mere targets for programmes or beneficia- may not get the care they need, often get care they ries of charity.
They are willing to respect health do not need, and invariably pay too much. The homes, often for crippling fees. This is what protection of health and access to care is often makes it a matter of concern for politicians and, taken for granted,, Increasing prosperity, much more than was the case 30 years ago, one access to knowledge and social connectivity are of the main reasons for increasing support for associated with rising expectations.
The challenges of a changing world more egalitarian than others, but on the whole Box 1. This gives policy- Figure 1. It is, therefore, not surprising that a breakdown makers less leeway to ignore the social dimen- of the health-care system — or even the hint of a breakdown sions of their policies than they might have had — can lead to popular discontent that threatens the ambitions previously, People are often unaware of the full scope of Figure 1.
Most Swedish citizens, for example, were probably unaware that the dif- Poland Ukraine Russian Federation ference in life expectancy between year-old Bulgaria Germany men from the highest and lowest socioeconomic Italy Sweden Israel groups was 3. Intol- Peru Argentina erance to inequality in health and to the exclusion Brazil United States of population groups from health benefits and Venezuela Bolivia social protection mirrors or exceeds intolerance Republic of Korea China to inequality in income.
In most societies, there is Japan Malaysia wide consensus that everybody should be able to Bangladesh India take care of their health and to receive treatment Indonesia Morocco when ill or injured — without being bankrupted Egypt Pakistan and pushed into poverty The desire for better care and while basic care for all continues to be a widely protection of health, for less health inequity and distributed, intensely held, social goal The for participation in decisions that affect health attitudes in lower income countries are less well is more widespread and more intense now than known, but extrapolating from their views on it was 30 years ago.
Therefore, much more is income inequality, it is reasonable to assume expected of health authorities today. They want it to Much public and private health care today is come from providers with the integrity to act organized around what providers consider to be in their best interests, equitably and honestly, effective and convenient, often with little atten- with knowledge and competence. The demand tion to or understanding of what is important for competence is not trivial: it fuels the health for their clients Things do not have to be that economy with steadily increased demand for way.
As experience — particularly from indus- professional care doctors, nurses and other trialized countries — has shown, health services non-physician clinicians who play an increas- can be made more people-centred. This makes ing role in both industrialized and developing them more effective and also provides a more countries For example, throughout the world, rewarding working environment Regrettably, women are switching from the use of traditional developing countries have often put less emphasis birth attendants to midwives, doctors and obste- on making services more people-centred, as if tricians Figure 1.
People-centredness is not a luxury, it is a to health care by relying on non-professional necessity, also for services catering to the poor. Where strategies exclusion and avoid leaving people at the mercy of for extending PHC coverage proposed lay workers unregulated commercialized health care, where as an alternative rather than as a complement to the illusion of a more responsive environment professionals, the care provided has often been carries a hefty price in terms of fi nancial expense perceived to be poor This has pushed people and iatrogenesis.
Whereas cultural and politi- tance of cultural and relational competence, cal explanations for health hazards vary widely, which was to be the key comparative advantage of there is a general and growing tendency to hold community health workers.
Citizens in the devel- the authorities responsible for offering protection oping world, like those in rich countries, are not against, or rapidly responding to such dangers Politicians in respectful and trustworthy They want health rich as well as poor countries increasingly ignore care to be organized around their needs, respect- their duty to protect people from health hazards ful of their beliefs and sensitive to their particular at their peril: witness the political fall-out of the situation in life.
They do not want to be taken poor management of the hurricane Katrina dis- advantage of by unscrupulous providers, nor do aster in the United States in , or of the they want to be considered mere targets for dis- garbage disposal crisis in Naples, Italy. Knowledge more vocal about it. In poor and rich countries, is spreading beyond the community of health people want more from health care than interven- professionals and scientific experts. Concerns tions.
In the ency may at times tempt governments to withdraw wake of the Ottawa Charter for Health from their social responsibilities for fi nancing Promotion, a much wider array of issues con- and regulating the health sector, or from service stitute the health promotion agenda, including delivery and essential public health functions. Whether by choice or because of exter- that affects health and quality of life In recent nal pressure, the withdrawal of the state that years, it has been complemented by growing con- occurred in the s and s in China and the cerns for a health hazard that used to enjoy little former Soviet Union, as well as in a considerable visibility, but is increasingly the object of media number of low-income countries, has had visible coverage: the risks to the safety of patients Significantly, Reliable, responsive health authorities it has created social tensions that affected the During the 20th century, health has progressively legitimacy of political leadership There may be disa- able skepticism about the way and the extent to greement as to how broadly to defi ne the welfare which health authorities assume their respon- state and the collective goods that go with it,, sibilities for health.
Surveys show a trend of but, in modernizing states, the social and politi- diminishing trust in public institutions as guar- cal responsibility entrusted to health authori- antors of the equity, honesty and integrity of the ties — not just ministries of health, but also local health sector,, Nevertheless, on the whole, governmental structures, professional organiza- people expect their health authorities to work tions and civil society organizations with a quasi- for the common good, to do this well and with governmental role — is expanding.
These recent trends attest to tems change. It opens fresh opportunities for gen- prevailing doubts about how well health authori- erating social and political momentum to move ties are able to provide stewardship for the health health systems in the directions people want them system, as well as to the rising expectations for to go, and that are summarized in Figure 1. Experience from countries as rising social expectations.
In other words, an optimum secure the health of communities. Across these response to aspirations for a bigger say in health reforms is the imperative of engaging citizens and policy matters would be evidence of a structured other stakeholders: recognizing that vested inter- and functional system of checks and balances.
PHC reforms: Figure 1. They are not just there in the form of moral convictions espoused by an intellectual Service delivery reforms vanguard. Increasingly, they exist as concrete Universal coverage reforms Chapter 3 social expectations felt and asserted by broad Chapter 2 groups of ordinary citizens within modernizing societies. Thirty years ago, the values of equity, people-centredness, community participation and self-determination embraced by the PHC move- Health authorities that Communities where ment were considered radical by many.
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These root causes have to be tackled through intersectoral and cross-government action. The basis Chapter 2 The central place of for this is the set of reforms that health equity in PHC 24 aim at moving towards universal Moving towards universal coverage 25 coverage, i. Deeply life in rural Canada prompted Matthew Anderson unequal opportunities for health combined with — to launch a tax-based health insur- endemic inequalities in health care provision ance scheme that eventually led to countrywide lead to pervasive inequities in health outcomes 3.
Unfortunately, equally shocking lose-lose is causing increasing intolerance of the whole situations abound today across the world. More spectrum of unnecessary, avoidable and unfair than 30 years after the clarion call of Alma-Ata differences in health4. They stem from inequitable method for fi nancing health-care ser- social stratification and political inequalities vices: out-of-pocket payments by the sick or their that lie outside the boundaries of the health sys- families at the point of service.
For 5. Income and social status matter, as do the people in low- and middle-income countries, over neighbourhoods where people live, their employ- half of all health-care expenditure is through out- ment conditions and factors, such as personal of-pocket payments. This deprives many families behaviour, race and stress 5. Health inequities of needed care because they cannot afford it. Also, also fi nd their roots in the way health systems more than million people around the world exclude people, such as inequities in availability, are pushed into poverty each year because of access, quality and burden of payment, and even catastrophic health-care expenditures 2.
There is in the way clinical practice is conducted6. Left to a wealth of evidence demonstrating that fi nancial their own devices, health systems do not move protection is better, and catastrophic expenditure towards greater equity. Most health services — less frequent, in those countries in which there hospitals in particular, but also fi rst-level care is more pre-payment for health care and less — are consistently inequitable providing more out-of-pocket payment.
Conversely, catastrophic and higher quality services to the well-off than expenditure is more frequent when health care to the poor, who are in greater need7,8,9, Dif- has to be paid for out-of-pocket at the point of ferences in vulnerability and exposure combine service Figure 2.
These 5 interventions reach well beyond the traditional realm of health-service policies, relying on the mobilization of stakeholders and constituencies outside the health sector They include 0 Q reduction of social stratification, e. Advancing and sustaining universal coverage adequate pay, using labour intensive growth the same: pooling pre-paid contributions col- strategies, promoting equal opportunities for lected on the basis of ability to pay, and using women and making free education available, these funds to ensure that services are available, etc.
Universal cover- developing social networks at community level, age is not, by itself, sufficient to ensure health introducing social inclusion policies and poli- for all and health equity — inequalities persist in cies that protect mothers while working or countries with universal or near-universal cover- studying, offering cash benefits or transfers, age — but it provides the necessary foundation 9. Indeed, in countries against exposure to health hazards, e.
As with from unfair dismissal from their jobs. There is now wide- which they have little influence. Yet, they do spread consensus that providing such coverage is have a responsibility to address health inequal- simply part of the package of core obligations that ity.
In itself, this is a political achievement exacerbate or mitigate health inequalities and that shapes the modernization of society.
The question, therefore, is not the 20th century. The opportunity now exists for if, but how health leaders can more effectively low- and middle-income countries to implement pursue strategies that will build greater equity comparable approaches.
Costa Rica, Mexico, in the provision of health services. Other countries are weighing sim- coverage: universal access to the full range of ilar options The technical challenge of moving personal and non-personal health services they towards universal coverage is to expand coverage need, with social health protection.
Whether the in three ways Figure 2. Public expenditure The third dimension, the height of coverage, Extend to uninsured on health i. Expanding the breadth of coverage context of disengagement of the state and dwin- is a complex process of progressive expansion dling public resources for health. Most undertook and merging of coverage models Box 2. Dur- these measures without anticipating the extent ing this process, care must be taken to ensure of the damage they would do.
In many settings, safety nets for the poorest and most vulnerable dramatic declines in service use ensued, par- until they also are covered. It may take years to ticularly among vulnerable groups 20, while the cover the entire population but, as recent experi- frequency of catastrophic expenditure increased. Particularly in these countries, however, it is crucial to move towards pre-payment systems from a very early stage and to resist the temptation to rely on user fees.
Coordinate funding sources. In order to organize universal coverage, it is necessary to consider all sources of funding in a country: public, private, external and domestic.
In low-income countries, it is particularly important that international funding be channelled through nascent pre-payment and pooling schemes and institutions rather than through project or programme funding. Routing funds in this way has two purposes. Combine schemes to build towards full coverage. Many countries with limited resources and administrative capacity have experi- mented with a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes, as a way to foster pre-payment and pooling in preparation for the move towards more comprehensive national systems Such schemes are no substitute for universal coverage although they can become building blocks of the universal system Realizing universal coverage means coordinating or combining these schemes progressively into a coherent whole that ensures coverage to all population groups15 and builds bridges with broader social protection programmes Advancing and sustaining universal coverage Box 2.
This has been one of the key strategies in improving the effectiveness of health systems and the equitable distribution of resources. It is supposed to make priority setting, rationing of care, and trade-offs between breadth and depth of coverage explicit.
In most cases, their scope has been limited to maternal and child health care, and to health problems considered as global health priorities. Q It should specify what should be provided at primary and secondary levels. Q The implementation of the package should be costed so that political decision-makers are aware of what will not be included if health care remains under-funded. This has resulted risk that people will incur catastrophic expenses in substantial increases in the use of services, when they are sick.
Finally, it provides the means especially by the poor In Uganda, for example, to re-invest in the availability, range and quality service use increased suddenly and dramatically of services. Challenges in moving Pre-payment and pooling institutionalizes solidarity between the rich and the less well-off, towards universal coverage All universal coverage reforms have to fi nd com- and between the healthy and the sick.
It lifts bar- promises between the speed with which they riers to the uptake of services and reduces the increase coverage and the breadth, depth and height of coverage. However, the way countries devise their strategies and focus their reforms Figure 2. In some countries, a very large part of the pop- 30 ulation lives in extremely deprived areas, with an absent or dysfunctional health-care infra- 20 structure. Ensuring access to quality care in these vices are grossly inadequate or fragmented, the settings entails grappling with the diseconomies basic health-care infrastructure needs to be built of scale connected with small, scattered popula- or rebuilt, often from the ground up.
These areas tions; logistical constraints on referral; difficulties are always severely resource-constrained and linked to limited infrastructure and communica- frequently affected by confl icts or complex emer- tions capacities; and, in some cases, more specific gencies, while the scale of under-servicing, also technical complications, such as maintaining in other sectors, engenders logistical difficulties patient records for nomadic groups. A different challenge is extending coverage in Health planners in these settings face a funda- settings where inequalities do not result from the mental strategic dilemma: whether to prioritize a lack of available health infrastructure, but from massive scale-up of a limited set of interventions the way health care is organized, regulated and, to the entire population or a progressive roll-out above all, paid for by official or under-the-counter of more comprehensive primary-care systems on user charges.
These are situations where under- a district-by-district basis. Such pat- number of priority programmes is rolled out terns of exclusion occur in countries such as simultaneously to all the inhabitants in the Colombia, Nicaragua and Turkey Figure 2. It deprived areas. Related titles. Carousel Previous Carousel Next.
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