Introduction and Overview
Why a renewal of primary health care (PHC), and why now, more than ever? The immediate answer is the palpable demand for it from Member States – not just from health professionals, but from the political arena as well.
Globalization is putting the social cohesion of many countries under stress, and health systems, as key constituents of the architecture of contemporary societies, are clearly not performing as well as they could and as they should.
People are increasingly impatient with the inability of health services to deliver levels of national coverage that meet stated demands and changing needs, and with their failure to provide services in ways that correspond to their expectations. Few would disagree that health systems need to respond better – and faster – to the challenges of a changing world. PHC can do that.
There is today a recognition that populations are left behind and a sense of lost opportunities that are reminiscent of what gave rise, thirty years ago, to Alma-Ata’s paradigm shift in thinking about health. The Alma-Ata Conference mobilized a “Primary Health Care movement” of professionals and institutions, governments and civil society organizations, researchers and grassroots organizations that undertook to tackle the “politically, socially and economically unacceptable” 1 health inequalities in all countries. The Declaration of Alma-Ata was clear about the values pursued: social justice and the right to better health for all, participation and solidarity1. There was a sense that progress towards these values required fundamental changes in the way health-care systems operated and harnessed the potential of other sectors.
The translation of these values into tangible reforms has been uneven. Nevertheless, today, health equity enjoys increased prominence in the discourse of political leaders and ministries of health2, as well as of local government structures, professional organizations and civil society organizations.
The PHC values to achieve health for all require health systems that: “Put people at the centre of health care”3. What people consider desirable ways of living as individuals and what they expect for their societies – i.e. what people value – constitute important parameters for governing the health sector. PHC has remained the benchmark for most countries’ discourse on health precisely because the PHC movement tried to provide rational, evidence-based and anticipatory responses to health needs and to these social expectations4,5,6,7. Achieving this requires trade-offs that must start by taking into account citizens’ “expectations about health and health care” and ensuring “that [their] voice and choice decisively influence the way in which health services are designed and operate”8. A recent PHC review echoes this perspective as the “right to the highest attainable level of health”, “maximizing equity and solidarity” while being guided by “responsiveness to people’s needs”4. Moving towards health for all requires that health systems respond to the challenges of a changing world and growing expectations for better performance. This involves substantial reorientation and reform of the ways health systems operate in society today: those reforms constitute the agenda of the renewal of PHC.
1. Primary health care: report of the International Conference o 1. n Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978, jointly sponsored by the World Health Organization and the United Nations Children’s Fund. Geneva, World Health Organization, 1978 (Health for All Series No. 1).
2. Dahlgren G, Whitehead M. Levelling up (part 2): a discussion paper on European strategies for tackling social inequities in health. Copenhagen, World Health Organization Regional Office for Europe, 2006 (Studies on social and economic determinants of population health No. 3).
3. WHO Regional Office for South-East Asia and WHO Regional Office for the Western Pacific. People at the centre of health care: harmonizing mind and body, people and systems. Geneva, World Health Organization, 2007.
4. Renewing primary health care in the Americas: a position paper of the Pan American Health Organization. Washington DC, Pan American Health Organization, 2007.
5. Saltman R, Rico A, Boerma W. Primary health care in the driver’s seat: organizational reform in European primary care. Maidenhead, England, Open University Press, 2006 (European Observatory on Health Systems and Policies Series).
6. Report on the review of primary care in the African Region. Brazzaville, World Health Organization Regional Office for Africa, 2003.
7. International Conference on Primary Health Care, Alma-Ata: twenty-fifth anniversary. Geneva, World Health Organization, 2003 (Fifty-sixth World Health Assembly, Geneva, 19–28 May 2003, WHA56.6, Agenda Item 14.18).
8. The Ljubljana Charter on Reforming Health Care, 1996. Copenhagen, World Health Organization Regional Office for Europe, 1996.