Special Session
Washington, D.C.
30 May 2008.

Mirta Roses-Periago*,
Director,
Pan American Health Organization (PAHO/WHO).

Table of honor:
- Steve Schmidbauer, Executive Director, Child Family Health International;

- Zafrullah Chowdhury, Founder and Project Coordinator, The People's Health Centre, Bangladesh;

- Jan Maeseneer, The Network Toward Unity for Health, Ghent University;

- Hernan Montenegro, Health Systems and Services, PAHO/WHO ;

Let me thank the Global Health Council for organizing this event. We have grown accustomed to listening to the great debates and exchange of ideas and knowledge occurring in these halls. The Council has skillfully provided us for 35 years with a dynamic platform to reflect on the complex issues surrounding global health today.

I'm honored to be here today to speak about the topic of Primary Health Care - especially about a new vision for Primary Health Care.

This session is right on the mark in highlighting some of the key issues of that new vision.

That of empowering communities;
Of reallocating resources to PHC;
Of engaging the government among others;
Of tracking health outcomes;

Community health

Community health, the theme of this year's meeting, the empowerment of communities is firmly placed at the core of the Alma Ata Declaration. What is making the PHC approach timely and opportune are the changes we have witnessed worldwide since the drafting of the Declaration 30 years ago - on the social economic and political fronts.

I find myself in the fortunate company of the great majority of countries who firmly believe that the Primary Health Care approach is providing us with a unique window of opportunity to contribute towards building a more just society. A society guided by the core values of the right to the highest attainable level of health, through equity and solidarity.

At the recent Global Health and the United Nations Meeting in Atlanta's Carter Center, the Primary Health Care approach was argued to best "facilitate the integrated management of multiple conditions, a continuum of care, the engagement of communities, the provision of care close to home and prevention and health promotion in addition to treatment and cure."

30th year celebration of the Alma Ata Declaration

Regional meetings discussing the role of PHC have already been held in Buenos Aires, Argentina, and Beijing, China. This year, PHC meetings have taken place in Bangkok, Thailand, and in Ouagadougou, Burkina Faso. These will be joined later on by regional meetings in Tallinn, Estonia, and in Qatar in November. The 30th year celebration of the Alma Ata Declaration is being organized for October.

PHC Task Forces have been formed in all regions. Within the WHO, a Global Task Force on PHC was formed last year, which I jointly co-chair with Dr. Asamoa Baah, WHO's Deputy Director General. WHO is giving the finishing touches to the 2008 World Health Report on the topic of Primary Health Care, which is going to be launched in Almaty, Kazakhstan, in September.

A shared understanding is needed to drive a comprehensive PHC orientation

No any one application of the PHC approach is to be championed! What is needed is a shared understanding of some of the key forces driving a comprehensive PHC orientation - to ensure a commonality of approach by countries, civil society and the international community during implementation.

The younger generations are embracing the PHC approach as well! Some of them may need catching up with the history of Alma Ata, but let me assure they understand and speak the language of social justice. They understand the harms caused by the entrenched structural and underlying forces of exclusion and disparities.

Citizens around the world are becoming less tolerant to daily accounts of gross inequities. With heightened globalization, health problems elsewhere in the world have become our problems. Our sense of health security is being challenged, in both rich and poor nations. Our need for shared responsibility appears more attractive. That has changed.

Recent analytical and field work recognize that while health is an outcome of different and dynamic social, economic, cultural and environmental determinants and thus the responsibility of everyone, health systems have a unique role in bridging sectors and the community.

The vision of a comprehensive PHC-based health system responds to multiple challenges and needs, old and new ones, acknowledging as well the rich contributions of the Ottawa Charter for Health Promotion, the Millennium Declaration and the Commission on the Determinants of Health.

Despite some well-known distortions, we can attest to the enormous influence of the PHC approach on public policies, on the configuration of health systems, and on the thinking and actions of health workers.

Benefits accruing from the linkages between a well-functioning health system and health outcomes are common nowadays. Emerging actors, from public and private sectors alike in the field of health have fully embraced the call for action for a well-functioning health system. Disease-specific programs are increasingly looking to bridge programs with systemic approaches. The need to protect health from climate change places another urgent call for a robust, universal, multi-response health system that addresses the needs of the most vulnerable.

We cannot insert the PHC approach as an add-on strategy to our existing frameworks. A comprehensive PHC approach means more than simply adjusting it to current realities. It requires a critical examination of its meaning and purpose. It requires clear thinking of how to re-structure current health system frameworks, our research agenda, as well as our financial and incentive structures.

There is one political dimension of the PHC approach

Let me also reiterate, there is no single, golden standard application of the PHC approach. In fact its applications should be different, as these are guided by each country's historical, political, epidemiological and socio economic situation, among other factors.

What we need to be clear about is that there is one political dimension of the PHC approach which is guided by the values of - right to the highest attainable health, equity and solidarity, and by the principles of responsiveness to people's health needs, quality oriented services, government accountability, social justice, sustainability, participation and intersectoriality.

Leadership is needed more than ever before!

However, true leadership will be only realized if we succeed in showing concretely to a larger and more receptive audience how a well- functioning health system based on PHC can contribute towards building a more equitable society.

The Millennium Declaration has given us the challenge but also the opportunity to earn this leadership. I would argue that there is an historical continuity between the vision of Health For All/PHC, and the most ambitious commitment to combat poverty ever undertaken by the international community in the UN Millennium Declaration.

The MDG call to action has triggered a courageous effort for improving the lives of the world's poorest citizens by 2015, through a joint commitment of both developed and developing countries.

We cannot fail to answer to this call. We need to change the way we work.

It is halfway point to the deadline set to meet the MDGs. Dr. Chan underscored at the 61st WHA: "If we want to reach the health-related [MDG] goals, we must return to the values, principles, and approaches of primary health care."

International evidence suggests that health systems based on a strong PHC orientation have better and more equitable health outcomes. They are more efficient, have lower health care costs, and can achieve higher user satisfaction. It is precisely this evidence that we need to share more widely.

The good news is that many countries have managed to build health systems that effectively guarantee universal and equitable access, are collective and participatory, while ensuring efficiency, effectiveness, and quality. All of these systems are based on primary health care.

A common denominator of these successful experiences is strong political will, and concerted and sustained efforts by all members of society.

The myth that PHC is too expensive is dead wrong! On the contrary, I would argue that not following a PHC approach ends up being much more costly in the long run. Even countries with limited resources, that have followed the PHC approach, have been able to build systems that are universal, equitable and sustainable and deliver better results and more satisfied citizens.

Wealthy nations without a PHC approach, on the other hand, end up having health systems that are extremely expensive vis-a-vis outcomes obtained (value for money). They are highly inequitable and fail to satisfy the needs and expectations of their citizens.

I am not speaking about ideal health systems. I am speaking about real-life, working, current systems. There are many countries here that have built and in some instances rebuilt those systems and that can show with satisfaction the positive results those systems have produced and will continue to produce.

These are systems capable of protecting the population under any circumstances; resistant and resilient in the face of crises, as demonstrated during the recent history; health systems capable of reacting rapidly and developing urgent strategies, based on PHC, in order to provide protection to the population, and that can rebuild themselves on the bases and principles of PHC to respond to multiple current and future challenges coming from the demographic and epidemiological shifts.

The way forward.

Most countries require profound structural changes in their health systems, to contribute effectively to social protection, to guaranteeing the right to health of all citizens, and to social unity:

A. A critical issue speaks to health system segmentation. By this I mean the co-existence of subsystems resulting from different financing sources and arrangements - reflecting social segmentation by ability to pay or participation in the labor market. In fact, this structural problem deepens inequality between social groups and leads to social exclusion, mainly by the poor and those in the informal sector.

B. Public financing deficits for health, coupled with inadequate distribution of resources and low-level efficiencies are also in need of change. In the public-private financing mix, the proportion of private expenditures has continued to prevail for over three decades. What is the impact of this? High-level, direct out-of-pocket expenditures by lower-income families with the danger of precipitating them even deeper into poverty.

C. The role of the health workforce - while sufficiently recognized as the most essential component of a health system, they remain ill prepared to work in a PHC context. There are no quick solutions to this issue, rather long-term, sustainable and comprehensive policies, aimed at improving traditional imbalances between education and services, and solving problems of migration, multiple employment and unemployment, civil service careers, and labor sector skills.

D. The strengthening of the State's stewardship capacity is needed to ensure a leadership role in -

• Sectoral management, that is, public policy formulation, execution, and evaluation
• Regulation of public insurance mechanisms and access to health goods
• Supervision and control of interventions and results
• Execution of the essential public health functions.
• Economic-financial management and the generation of resources.

The discussion by countries on the achievements of health-related MDGs at the 61st WHA reiterated the call to building systems that create better health. A cautionary warning was made that progress towards reaching the health-related MDGs could not be sustained without adequate investment in health systems.

As we advocacy in our speech at the opening ceremony at the Geneva Health Forum 2008 that took place last week, I would like to conclude that -

In the spirit of this meeting, and to successfully address the health determinants and affirm the right to health, I invite you to join me in building a multi-stakeholder coalition of interested parties, to ensure that a health system based on Primary Health Care represents a feasible and politically appealing policy option. We need to capture the interest and enthusiasm of a broad number of partners. Not only the like-minded.

We need and want the PHC of Alma-Ata firmly rooted in the passion and commitment of 1978 and with the projection and capacity to transform current health systems. We need them urgently. They are indispensable to the viability and sustainability of human society in the 21st century, when 7 billion people with extended life expectancy are bound to share the same and only planet.

Thank you very much.

For more information, please contact Diaz, Eng. Katia (WDC) Director's Office Web Master / Montenegro, Dr. Hernan (WDC), Health Systems and Services, PAHO/WHO.

*** This speech has an antecedent in the speech gave by Dr. Roses at the Geneva Health Forum 2008 during the celebration of the 61st. World Health Assembly.