International Conference Centre
Geneva, Switzerland.
25 May 2008.
Mirta Roses-Periago*,
Director, Pan American Health Organization (PAHO/WHO).
Opening Ceremony
- Professor Louis Loutan, President of the Organizing Committee, Geneva Health Forum;
- M. Bernard Gruson, Director-General, University Hospitals of Geneva;
- Professor Jean-Louis Carpentier, Dean, Faculty of Medicine, University of Geneva;
- M. Manuel Tornare, Incoming Mayor, City of Geneva;
- Representative of the Swiss Federal Government;
- His Excellency Professor Gilbert Balibaseka Bukenya, Vice-President, Republic of Uganda;
- Dr. Anarfi Asamoa-Baah, Deputy Director-General, WHO;
Dear Colleagues;
Let me thank the Geneva Health Forum for organizing this event and to our hosts the Swiss government.
Let me also applaud the Forum's efforts for providing a dynamic, multi-stakeholder platform to reflect on the complex issues of global access to health. It is only by engaging society at large that we will begin having true impact on the intractable health problems of today. I would like to especially commend the Forum's interest in linking policy to practice, as in providing an equal voice to all actors in the field.
I'm honored to be here today and to have the opportunity to speak about the topic of
Primary Health Care(PHC) - in particular about Primary Health for the New Century.
I have good news for you today!
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.
There are few endeavors as noble as being able to contribute towards the attainment of all peoples' inalienable right to health and well-being, to living their lives to its fullest potential.
Just during these past weeks several partners have addressed the powerful role of the
Primary Health Care approach. The World Council of Churches participating in the session on
Achieving the MDG Goals through Primary Health Care, the International Federation of Red Cross
and Red Crescent Societies (IFRC) holding their fourth annual Global Health and Care Forum with
the topic of Primary Health Care. I will be joining Dr. Chan in addressing the topic of Primary
Health Care at the Global Health Council's Annual upcoming meeting in Washington DC.
Recently at the Global Health and the United Nations Meeting in Atlanta, a joint WHO, UNFPA and UNICEF call for improved outcomes for women
urged for a fundamental rethinking of approaches to cut the number of maternal deaths.
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."
In April, the International Conference on Primary Health Care and Health Systems in
Africa - and I look forward to hearing more from Professor Balibaseka on this
important meeting - the region reaffirmed the principles of the Alma-Ata Declaration,
highlighting in the Ouagadougou Declaration for an "update of national health policies and
plans according to the PHC approach with a view to strengthening health systems to achieve
the Millennium Development Goals."
In my own Region of the Americas, over 60 countries from all over the globe attending the
Buenos Aires International Conference on Health for Development - From Alma Ata to the
Millennium Declaration, last year, affirmed that
"equity, solidarity and universality
should govern health and development systems and policies, and that the PHC strategy must
guide the structure and operations of the health systems at all levels and for all."
The dialogue for a common understanding of a PHC approach and a PHC based health system has began at the WHO. This is most needed.
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.
We look forward with great enthusiasm to hearing about the extraordinary experiences in
implementing the PHC approach in all regions of the world. As Dr. Chan has said on numerous
occasions, the countries have fully embraced the PHC approach in multiple ways.
The younger generations are embracing the PHC approach as well! In Buenos Aires we saw side by side passionate debates between the founding men or women, the senior champions of primary health care and the younger generations. The baton was being passed on to a new cadre of professionals and activists representing multiple sectors and perspectives. Some of these younger generations 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.
The recent meetings focusing on PHC have recognized these linkages and the need for shared
responsibility, and above all, for shared action - These meetings, as well as 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 emerging vision of a robust and strengthened health system is well within the spirit of Alma-Ata. Highlighted today are some of the guiding concepts of Alma Ata's like participation, intersectoriality and response to health determinants.
That is why I applaud the objective of this Forum in seeking to bridge perspectives from a multiplicity of actors.
The vision of a comprehensive PHC based health system that gives response to multiple challenges and needs, old and new ones, acknowledges 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.
This new vision has been enriched by contributions from political and moral philosophy, and by the new development economy. As Amartya Sen points out - producing a new configuration of frameworks for social policy and governmental action.
A new vision of sustainable human development has emerged, with deeper connections between economic development, democracy and social protection leading to a new formulation of social and health policies and their relations and complementarity with health systems.
This perspective has given health a more prominent place on the global development agenda, therefore, strengthening the role of health in public policies. Health is an important driver of economic growth, apart from being an essential component of human development.
The PHC approach has been influential in
- Recognizing the relationship between health and economic development, and social productivity - Commission on Macroeconomics and Health
- Realizing the potential for citizen participation in health-related decision-making - civil society for a policy dialogue
- Highlighting the indisputable role of the State in bringing leadership to the issue of equitable health development
- Highlighting the nature and limitations of a free market approach to health
- Re-stating the need for action on health determinants and for intersectoral action - Commission on Social Determinants of Health
- Conveying a sense of urgency in correcting inequities in health.
Benefits accruing from the linkages between a well-functioning health system and health outcomes are common nowadays. The net of recognized benefits of a functioning health system has been cast wide open, placing a high demand on the need of a concerted way forward.
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 is another high demand for robust, universal, multi-response health systems that are close to the most vulnerable people.
Innovative and visionary perspectives are being sought to quickly move us to finding solutions, to move us into action, to prioritize. Perspectives are being sought which prevent us from falling into a comfort zone of stale debates.
Leadership is needed more than ever before!
Let me be clear at this point.
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.
Let me 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.
A unique window of opportunity stands before us - particularly for those of us who have fought for the longest of time to mainstream the idea that without a well-functioning health system health gains could only be achieved at high costs, and could hardly be sustained.
However, true leadership will be only realized if we succeed in showing concretely to
a larger and more receptive audience today how a well- functioning health system based on
PHC can contribute towards building a more equitable society. As Dr. Chan well said this week
during her opening remarks, leadership is not mandated, it is earned.
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. The key goals have been translated into concrete targets with specific time tables, and accountability at all levels: international, regional and country, as well as municipal and community. We cannot fail to answer to this call. We need to change the way we work.
It is halfway point to the period set for the fulfillment of the MDGs. As Dr. Chan
underscored in her message on Monday at the inauguration of the 61st World Health Assembly:
"If we want to reach the health-related [MDG] goals, we must return to the values, principles,
and approaches of primary health care."
Building PHC-based Health Systems
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.
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 of Argentina and Uruguay; 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.
Let me spend the next minutes on the way forward.
Most countries of our Region 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. We need to address health system segmentation - The existence of subsystems due to different financing sources and arrangements, reflecting social segmentation by ability to pay or insertion in the labor market. This structural feature consolidates and deepens inequality between social groups and is a factor in social exclusion. It keeps the poor and the informal on the outside.
B. Equally pervasive is the current organizational fragmentation- a coexistence of infrastructure and capacities of various subsystems without coordination and with even less integration. This elevates the costs due to duplication, creates greater transaction costs and also generates different types and levels of quality of services.
C. Public financing deficit for health, with inadequate distribution of expenditure and low levels of efficiency has been detrimental as well. In the public-private financing mix, the proportion of private expenditure has prevailed for more than three decades. This high level of direct out-of-pocket expenditure has a greater impact on lower-income families that face the danger every day of falling into poverty because of catastrophic expenditures.
D. Weakness of the institutional capacity in the national health authority (that is, the State), particularly affecting its functions of -
- Sectoral management, that is, public policy formulation, execution, and evaluation
- Regulation of, for example, public insurance mechanisms and access to health goods
- Supervision and control of interventions and results
- Carrying out essential public health functions.
- Economic-financial management and the generation of resources.
This week's discussion on the achievements of the 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 I said a moment ago, we have a window of opportunity to answer this call and to fully embrace a health system based on PHC orientation.
In the spirit of this Forum, 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.
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.
More information:
Director's presentation
Director's speech Spanish version: La Atención Primaria de Salud (APS) en el nuevo siglo
WHO Release: World Health Assembly sets bold new action for WHO
For
more information, please contact Diaz, Eng. Katia (WDC)
Director's Office Web Master / Brito, Dr. Pedro, Health Systems and Services Area Manager.
