Health Systems: principled integrated care                  

Confronting the global health challenges examined in the previous chapters requires health
systems to be strengthened. Without this, the health goals described in this report will remain
beyond reach. The lessons learnt from past successes, including the skills and strategies
developed from the experiences of tackling polio and SARS, must be applied in combating
the HIV/AIDS treatment emergency and in working towards the Millennium Development
Goals (MDGs) .

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Health Systems: principled integrated care Progress towards these and other objectives will not be sustainable unless
specific health targets – including the “3 by 5” target of reaching three million people in
developing countries with combination antiretroviral therapy for HIV/AIDS by the end of
2005 – support a broad horizontal build-up of the capacities of health systems.
Despite the health reforms of recent decades, inadequate progress has been made in building
health systems that promote collective health improvement. Now, however, fresh opportunities are emerging. Health stands high on the international development agenda, and new
funds are becoming available for health work in poor countries. Extending health-enabling
conditions and quality care to all is the major imperative for health systems.
This chapter explores how the values and practices of primary health care, adapted to the
realities of today’s complex health landscape, might provide a basis for the improvement of
health systems. It reviews basic ideas about primary health care and clarifies the concept of
the development of health systems that are based on primary health care. It then examines
four major challenges facing health systems: the global health workforce crisis; the lack of
appropriate, timely evidence; the lack of financial resources; and the stewardship challenge of
implementing pro-equity health policies in a pluralistic environment. The final section looks
at how WHO is working with countries to clarify health systems goals and to strengthen
systems in line with primary health care principles.
The health system comprises all organizations, institutions and resources that produce actions whose primary purpose is to improve health (1). The health care system refers to the
institutions, people and resources involved in delivering health care to individuals. This chapter
is mostly concerned with health care systems. Nevertheless, health care providers are often
involved in promoting health-enabling conditions in the community. Indeed, this relationship between patient care and public health functions is one of the defining characteristics of
the primary health care approach Health Systems: principled integrated care.
The health systems performance assessment framework developed by WHO in the late 1990s
was an attempt to put into effect the primary health care concern for equity and population
health outcomes, by providing analytical tools to translate these concerns into relevantevidence. The framework drew the attention of policy-makers to issues such as the catastrophic health expenditure in a number of countries. Although this report does not directly
apply the framework, it assumes that policy-makers will use this and other relevant tools to
measure the success of an approach to health systems scale-up based on primary health care.
Valuable knowledge has been gained in recent years about how health systems work and why
they fail. Initiatives such as the European Observatory on Health Care Systems are producing
important insights (see Box 7.1), though fundamental questions remain unresolved. This
report does not propose a complete model of the development of health systems based on
primary health care, which would be impossible given the current state of evidence. The aim
is to open lines of enquiry that will be of use to countries and international health partners as
they weigh options and take action to strengthen systems, making them responsive to the
needs and demands of all, especially the poor Health Systems: principled integrated care.