World Health Report 2008 – getting back to basics

December 24, 2008

     By Duncan Green     

My thanks to colleague Tom Noel for sending over a handy summary of the World Health Organization’s latest overview. 30 years after the Alma Ata declaration on Primary Health Care, the WHO is reaffirming the importance of PHC in guaranteeing universal access, social protection and health systems designed around people’s needs and participation.

The World Health Report identifies three big problems:

1. a disproportionate focus on specialist hospital care;
“provides poor value for money… carries a considerable cost in terms of unnecessary medicalisation and …crowds out more effective, efficient – and more equitable – ways of organizing health care and improving health’
2. fragmentation of health systems;
‘programmes compete for scarce resources, staff and donor attention, while the structural problems of health systems – funding, payment and human resources – are hardly addressed’.
3. the proliferation of unregulated commercial care.
User fees have been introduced ‘in an attempt to compensate for the chronic under-funding of the public health sector and the fiscal stringency of structural adjustment… those who cannot afford care are excluded; those who can may not get the care they need, often get care they do not need, and invariably pay too much… unregulated commercialized health systems are highly inefficient and costly: they exacerbate inequality, and they provide poor quality and, at times, dangerous care that is bad for health.

The report concludes that universal health coverage is ‘simply part of the package of core obligations that any legitimate government must fulfill vis-à-vis its citizens’ …. ‘There is no getting away from the need for massive and sustained investment to expand and maintain health districts in the long term’.

But thinking about primary health care has evolved since Alma Ata. PHC now means that a person should have a say in how their district health team responds to health problems in their community. When it cannot do so, it has to be able to refer patients on or call for support from specialists, hospitals, diagnostic centres, social services, or self-help groups, and help the patient to navigate this complex environment. This kind of PHC ‘results in lower health-care costs for similar health outcomes and greater patient satisfaction’.

The report focuses on healthcare as a social contract. It calls for a shift away from monitoring results on morbidity, resource usage and service production towards monitoring the achievement of social objectives. Among these are ‘the imperative of universal access to high quality and safe care without financial penalty, the importance of continuity of care, and the need to understand the social, cultural and economic context in which all men, women and families of a given community live’. Evidence shows that mobilizing social movements is key to achieving this.
The report echoes much of Oxfam’s analysis:

– universal access without financial penalty is key to achieving good health
– massive and sustained increases in financing from domestic and international resources are key
– health systems are being undermined by fragmentation and commercialization
– commercial claims of quality, efficiency and effectiveness are often illusory
– universal access is being undermined by structural adjustment, bio-medical industrial interests and fragmentation
– longer-term financing mechanisms must be developed and supported

But the report is weak in some aspects:
– It accepts pre-payment schemes that can exclude poor people (although it does support massive state subsidy of these, and notes that tax-revenue funded systems are a type of pre-payment pooled financing scheme)
– It stops short of calling for publicly provided services, saying that the type of provider is  not ‘the critical issue’, but rather that the regulation of those providers is the critical factor. Oxfam’s experience suggests that state provision itself, not just regulation, is a vital component of universal access. In fact, the evidence shows that further private sector growth in health care delivery can come at a direct cost to progress towards achieving universal access, as Oxfam’s forthcoming paper on health will argue.

A recent Financial Times report illustrates the problem in China, where research published in the Lancet shows that the average cost of a single hospital admission is almost equivalent to annual per capita income. The researchers found that “More than 35 per cent of urban households and 43 per cent of rural households have difficulty affording healthcare, go without, or are impoverished by the costs”. Medical costs faced by Chinese patients have soared over the past two decades, as declining state support for hospitals and doctors has prompted them to increase prices for treatment and drugs.
The Chinese government has issued proposals for reforms intended to create a “basic medical health system” covering both urban and rural areas by 2020, but the plan has been widely criticised for lacking detail on crucial issues such as funding.
This is not just a health issue, but also an economic one, since the fear of medical fees is making people save rather than spend their income on other goods and services. As China’s exports slow, unlocking this internal demand could help maintain China’s growth.


December 24, 2008
Duncan Green