The World Health Report 2008 Primary Health Care SERVICE DELIVERY REFORMS PUBLIC UNIVERSAL POLICY COVERAGE REFORMS REFORMS Now LEADERSHIP More REFORMS Than Ever couverture_cor.indd xx-1 16.9.2008 17:07:31 couverture_cor.indd 2-3 16.9.2008 17:07:34 The World Health Report 2008 Primary Health Care Now More Than Ever WHO Library Cataloguing-in-Publication Data The world health report 2008 : primary health care now more than ever. 1.World health – trends. 2.Primary health care – trends. 3.Delivery of health care. 4.Health policy. I.World Health Organization. ISBN 978 92 4 156373 4 (NLM classifi cation: W 84.6) ISSN 1020-3311 © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: [email protected] Copies of this publication can be ordered from: [email protected] The World Health Report 2008 was produced under the overall direction of Tim Evans (Assistant Director-General) and Wim Van Lerberghe (editor-in-chief). The principal writing team consisted of Wim Van Lerberghe, Tim Evans, Kumanan Rasanathan and Abdelhay Mechbal. Other main contributors to the drafting of the report were: Anne Andermann, David Evans, Benedicte Galichet, Alec Irwin, Mary Kay Kindhauser, Remo Meloni, Thierry Mertens, Charles Mock, Hernan Montenegro, Denis Porignon and Dheepa Rajan. Organizational supervision of the report was provided by Ramesh Shademani. Contributions in the form of boxes, fi gures and data analysis came from: Alayne Adams, Jonathan Abrahams, Fiifi Amoako Johnson, Giovanni Ancona, Chris Bailey, Robert Beaglehole, Henk Bekedam, Andre Biscaia, Paul Bossyns, Eric Buch, Andrew Cassels, Somnath Chatterji, Mario Dal Poz, Pim De Graaf, Jan De Maeseneer, Nick Drager, Varatharajan Durairaj, Joan Dzenowagis, Dominique Egger, Ricardo Fabregas, Paulo Ferrinho, Daniel Ferrante, Christopher Fitzpatrick, Gauden Galea, Claudia Garcia Moreno, André Griekspoor, Lieve Goeman, Miriam Hirschfeld, Ahmadreza Hosseinpoor, Justine Hsu, Chandika Indikadahena, Mie Inoue, Lori Irwin, Andre Isakov, Michel Jancloes, Miloud Kaddar, Hyppolite Kalambaye, Guy Kegels, Meleckidzedeck Khayesi, Ilona Kickbush, Yohannes Kinfu, Tord Kjellstrom, Rüdiger Krech, Mohamed Laaziri, Colin Mathers, Zoe Matthews, Maureen Mackintosh, Di McIntyre, David Meddings, Pierre Mercenier, Pat Neuwelt, Paolo Piva, Annie Portela, Yongyut Ponsupap, Amit Prasad, Rob Ridley, Ritu Sadana, David Sanders, Salif Samake, Gerard Schmets, Iqbal Shah, Shaoguang Wang, Anand Sivasankara Kurup, Kenji Shibuya, Michel Thieren, Nicole Valentine, Nathalie Van de Maele, Jeanette Vega, Jeremy Veillard and Bob Woollard. Valuable inputs in the form of contributions, peer reviews, suggestions and criticisms were received from the Regional Directors and their staff, from the Deputy Director-General, Anarfi Asamoah Bah, and from the Assistant Directors-General. The draft report was peer reviewed at a meeting in Montreux, Switzerland, with the following participants: Azrul Azwar, Tim Evans, Ricardo Fabrega, Sheila Campbell-Forrester, Antonio Duran, Alec Irwin, Mohamed Ali Jaffer, Safurah Jaafar, Pongpisut Jongudomsuk, Joseph Kasonde, Kamran Lankarini, Abdelhay Mechbal, John Martin, Donald Matheson, Jan De Maeseneer, Ravi Narayan, Sydney Saul Ndeki, Adrian Ong, Pongsadhorn Pokpermdee, Thomson Prentice, Kumanan Rasanathan, Salman Rawaf, Bijan Sadrizadeh, Hugo Sanchez, Ramesh Shademani, Barbara Starfi eld, Than Tun Sein, Wim Van Lerberghe, Olga Zeus and Maria Hamlin Zuniga. The report benefi ted greatly from the inputs of the following participants in a one-week workshop in Bellagio, Italy: Ahmed Abdullatif, Chris Bailey, Douglas Bettcher, John Bryant, Tim Evans, Marie Therese Feuerstein, Abdelhay Mechbal, Thierry Mertens, Hernan Montenegro, Ronald Labonte, Socrates Litsios, Thelma Narayan, Thomson Prentice, Kumanan Rasanathan, Myat Htoo Razak, Ramesh Shademani, Viroj Tangcharoensathien, Wim Van Lerberghe, Jeanette Vega and Jeremy Veillard. WHO working groups provided the initial inputs into the report. These working groups, of both HQ and Regional staff included: Shelly Abdool, Ahmed Abdullatif, Shambhu Acharya, Chris Bailey, James Bartram, Douglas Bettcher, Eric Blas, Ties Boerma, Robert Bos, Marie-Charlotte Boueseau, Gui Carrin, Venkatraman Chandra-Mouli, Yves Chartier, Alessandro Colombo, Carlos Corvalan, Bernadette Daelmans, Denis Daumerie, Tarun Dua, Joan Dzenowagis, David Evans, Tim Evans, Bob Fryatt, Michelle Funk, Chad Gardner, Giuliano Gargioni, Gulin Gedik, Sandy Gove, Kersten Gutschmidt, Alex Kalache, Alim Khan, Ilona Kickbusch, Yunkap Kwankam, Richard Laing, Ornella Lincetto, Daniel Lopez-Acuna, Viviana Mangiaterra, Colin Mathers, Michael Mbizvo, Abdelhay Mechbal, Kamini Mendis, Shanthi Mendis, Susan Mercado, Charles Mock, Hernan Montenegro, Catherine Mulholland, Peju Olukoya, Annie Portela, Thomson Prentice, Annette Pruss-Ustun, Kumanan Rasanathan, Myat Htoo Razak, Lina Tucker Reinders, Elil Renganathan, Gojka Roglic, Michael Ryan, Shekhar Saxena, Robert Scherpbier, Ramesh Shademani, Kenji Shibuya, Sameen Siddiqi, Orielle Solar, Francisco Songane, Claudia Stein, Kwok-Cho Tang, Andreas Ullrich, Mukund Uplekar, Wim Van Lerberghe, Jeanette Vega, Jeremy Veillard, Eugenio Villar, Diana Weil and Juliana Yartey. The editorial production team was led by Thomson Prentice, managing editor. The report was edited by Diana Hopkins, assisted by Barbara Campanini. Gaël Kernen assisted on graphics and produced the web site version and other electronic media. Lina Tucker Reinders provided editorial advice. The index was prepared by June Morrison. Administrative support in the preparation of the report was provided by Saba Amdeselassie, Maryse Coutty, Melodie Fadriquela, Evelyne Omukubi and Christine Perry. Photo credits: Director-General’s photograph: WHO (p. viii); introduction and overview: WHO/Marco Kokic (p. x); chapters 1–6: Alayne Adams (p. 1); WHO/Christopher Black (p. 23); WHO/Karen Robinson (p. 41); International Federation of Red Cross and Red Crescent Societies/John Haskew (p. 63); Alayne Adams (p. 81); WHO/Thomas Moran (p. 99). Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Printing Coordination: Pascale Broisin and Frédérique Robin-Wahlin Printed in Switzerland The World Health Report 2008 Primary Health Care – Now More Than Ever Contents Message from the Director-General viii Introduction and Overview xi Responding to the challenges of a changing world xii Growing expectations for better performance xiii From the packages of the past to the reforms of the future xiv Four sets of PHC reforms xvi Seizing opportunities xviii Chapter 1. The challenges of a changing world 1 Unequal growth, unequal outcomes 2 Longer lives and better health, but not everywhere 2 Growth and stagnation 4 Adapting to new health challenges 7 A globalized, urbanized and ageing world 7 Little anticipation and slow reactions 9 Trends that undermine the health systems’ response 11 Hospital-centrism: health systems built around hospitals and specialists 11 Fragmentation: health systems built around priority programmes 12 Health systems left to drift towards unregulated commercialization 13 Changing values and rising expectations 14 Health equity 15 Care that puts people fi rst 16 Securing the health of communities 16 Reliable, responsive health authorities 17 Participation 18 PHC reforms: driven by demand 18 Chapter 2. Advancing and sustaining universal coverage 23 The central place of health equity in PHC 24 Moving towards universal coverage 25 Challenges in moving towards universal coverage 27 Rolling out primary-care networks to fi ll the availability gap 28 Overcoming the isolation of dispersed populations 30 Providing alternatives to unregulated commercial services 31 Targeted interventions to complement universal coverage mechanisms 32 Mobilizing for