Chapter 7: Health Systems: principled integrated care
Health Systems: principled integrated care
To meet the formidable challenges described earlier, this chapter calls for the reinforcement of health systems to be based on the core principles of primary health care as outlined at Alma-Ata in 1978: universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approaches to health. These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 25 years. Four important issues that health systems must confront are examined: the global health workforce crisis, inadequate health information, lack of financial resources, and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment.
Confronting the global health challenges examined in the previous chapters requires health systems to be strengthened. Without this, the health goals described in this report will remain beyond reach. The lessons learnt from past successes, including the skills and strategies developed from the experiences of tackling polio and SARS, must be applied in combating the HIV/AIDS treatment emergency and in working towards the Millennium Development Goals (MDGs). Progress towards these and other objectives will not be sustainable unless specific health targets -- including the "3 by 5" target of reaching three million people in developing countries with combination antiretroviral therapy for HIV/AIDS by the end of 2005 -- support a broad horizontal build-up of the capacities of health systems.
Despite the health reforms of recent decades, inadequate progress has been made in building health systems that promote collective health improvement. Now, however, fresh opportunities are emerging. Health stands high on the international development agenda, and new funds are becoming available for health work in poor countries. Extending health-enabling conditions and quality care to all is the major imperative for health systems.
This chapter explores how the values and practices of primary health care, adapted to the realities of today's complex health landscape, might provide a basis for the improvement of health systems. It reviews basic ideas about primary health care and clarifies the concept of the development of health systems that are based on primary health care. It then examines four major challenges facing health systems: the global health workforce crisis; the lack of appropriate, timely evidence; the lack of financial resources; and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The final section looks at how WHO is working with countries to clarify health systems goals and to strengthen systems in line with primary health care principles.
The health system comprises all organizations, institutions and resources that produce actions whose primary purpose is to improve health (1). The health care system refers to the institutions, people and resources involved in delivering health care to individuals. This chapter is mostly concerned with health care systems. Nevertheless, health care providers are often involved in promoting health-enabling conditions in the community. Indeed, this relationship between patient care and public health functions is one of the defining characteristics of the primary health care approach.
The health systems performance assessment framework developed by WHO in the late 1990s was an attempt to put into effect the primary health care concern for equity and population health outcomes, by providing analytical tools to translate these concerns into relevant evidence. The framework drew the attention of policy-makers to issues such as the catastrophic health expenditure in a number of countries. Although this report does not directly apply the framework, it assumes that policy-makers will use this and other relevant tools to measure the success of an approach to health systems scale-up based on primary health care.
Valuable knowledge has been gained in recent years about how health systems work and why they fail. Initiatives such as the European Observatory on Health Care Systems are producing important insights (see Box 7.1), though fundamental questions remain unresolved. This report does not propose a complete model of the development of health systems based on primary health care, which would be impossible given the current state of evidence. The aim is to open lines of enquiry that will be of use to countries and international health partners as they weigh options and take action to strengthen systems, making them responsive to the needs and demands of all, especially the poor.
Box 7.1 The European Observatory on Health Care Systems
Countries in the European Region -- diverse in terms of language, history and wealth -- have an array of approaches to the organization of health systems. The European Observatory on Health Care Systems and policies seeks to disseminate information on more than a decade of change, analysing the reforms and generating evidence on what works in different contexts and why. It ensures that Europe's national policy-makers can set their own experiences in the European context and make comparisons across borders, draw on thematic and comparative analysis of the key challenges they face, and have access to clear, practical evidence.
The Observatory is a partnership that brings together the WHO Regional Office for Europe, governments (Greece, Norway and Spain), international and nongovernmental agencies (the European Investment Bank, the Open Society Institute, and the World Bank) and academia (the London School of Economics and Political Science and the London School of Hygiene and Tropical Medicine). All the Observatory's materials are available on its web site.1
Information and monitoring. The Health System in Transition series of 70 country profiles provides analytical answers to a standard set of questions and uses clear definitions to create a baseline of information, drawing attention to what is distinct about a particular country. The Observatory covers the whole European Region and some additional OECD countries, to allow systematic comparisons and the review of reforms over time.
Analysis. The Observatory produces comprehensive studies on key health system and policy areas, including hospitals, funding, regulation, European enlargement, social health insurance, purchasing, primary care, pharmaceuticals, mental health, human resources, and targets. It uses secondary or meta-analytical research, bringing together experts from across Europe to synthesize existing findings, to work country experiences into a conceptual framework and to draw out practical lessons and options.
Dissemination. Engaging with policy-makers and their advisers helps ensure they can use the information and analyses generated. The Observatory runs seminars and workshops for small groups of high level policy-makers, often in partnership with agencies supporting health system and policy reform, on matters such as funding options, the implications of EU accession for new Member States, or equity.
1 www.observatory.dk.