Reflections on the future of primary health care Gerald Bloom Institute of Development Studies, UK Presented to Colloquium on Primary Health Care in Times of Globalisation Institute of Tropical Medicine, Antwerp November 2008

Alma Ata Declaration Position statement by international organisations (WHO and UNICEF) Consensus on post-colonial/post-revolutionary health system development strategies State of the art on the organisation of primary care services Political statement and vision of ideal health system

Position statement by international organisations (WHO and UNICEF)

Consensus on post-colonial/post-revolutionary health system development strategies

State of the art on the organisation of primary care services

Political statement and vision of ideal health system

… 30 years later the Declaration Many more actors in international health - WHO and UNICEF are redefining their roles Emergence of pluralistic health systems - growing gap between reality and language of policy and international agreements Continued agreement on value of primary health care and there is much more evidence on good practice models The values of universal access persist but there is a tension between the post-colonial vision and current development realities

Many more actors in international health - WHO and UNICEF are redefining their roles

Emergence of pluralistic health systems - growing gap between reality and language of policy and international agreements

Continued agreement on value of primary health care and there is much more evidence on good practice models

The values of universal access persist but there is a tension between the post-colonial vision and current development realities

… 30 years later health and health services Expansion of global health sector (infrastructure, personnel, logistics, programmes, information) Major divergence between countries in health system performance and health status Growing concern about the implications of health inequalities for political stability, global health and peaceful development

Expansion of global health sector (infrastructure, personnel, logistics, programmes, information)

Major divergence between countries in health system performance and health status

Growing concern about the implications of health inequalities for political stability, global health and peaceful development

… 30 years later the development context Globalisation, spread of markets and new patterns of inequality and poverty Rapid changes in population, demography, ecology and the burden of disease Many more health sector actors Multiplication of channels for information flow (including on health-related issues)

Globalisation, spread of markets and new patterns of inequality and poverty

Rapid changes in population, demography, ecology and the burden of disease

Many more health sector actors

Multiplication of channels for information flow (including on health-related issues)

Building primary health care services: scaling up and rolling out Evidence on effective low-cost interventions Gap between actual and potential access to effective services Resource commitments to reduce this gap Limited evidence on how to improve access to interventions in different development contexts Nostalgia, advocacy or practical strategy for health system development?

Evidence on effective low-cost interventions

Gap between actual and potential access to effective services

Resource commitments to reduce this gap

Limited evidence on how to improve access to interventions in different development contexts

Nostalgia, advocacy or practical strategy for health system development?

Markets for health-related goods and services Spread of markets for health-related goods and services and blurring of boundaries between public and private Market segmentation between social groups New communication technologies and channels of flow of information and influence The creation of institutions for influencing these markets has lagged behind

Spread of markets for health-related goods and services and blurring of boundaries between public and private

Market segmentation between social groups

New communication technologies and channels of flow of information and influence

The creation of institutions for influencing these markets has lagged behind

Changing demand for health services Increased burden of chronic diseases including HIV Increased availability of treatment (effective and ineffective) Many influences on health seeking (mass media, internet, advertising, advocacy groups) Political pressure for long-term public finance

Increased burden of chronic diseases including HIV

Increased availability of treatment (effective and ineffective)

Many influences on health seeking (mass media, internet, advertising, advocacy groups)

Political pressure for long-term public finance

Risks of epidemics Rapid urbanisation, industrialisation and changing patterns of animal husbandry Large populations with increased susceptibility to infection Increased national and international concern about possible epidemics Effective responses require effective public health services which command the trust of the public and cross-border cooperation

Rapid urbanisation, industrialisation and changing patterns of animal husbandry

Large populations with increased susceptibility to infection

Increased national and international concern about possible epidemics

Effective responses require effective public health services which command the trust of the public and cross-border cooperation

(Re-)Building effective health systems Strategies based on an understanding of existing systems Changing roles of households, citizen groups, private actors (local and international) and government Support for the creation of new social contracts between providers and users of health services Creation of regulatory partnerships Build the government’s reputation for competence and fairness

Strategies based on an understanding of existing systems

Changing roles of households, citizen groups, private actors (local and international) and government

Support for the creation of new social contracts between providers and users of health services

Creation of regulatory partnerships

Build the government’s reputation for competence and fairness

The politics of primary health care Economic crisis, social protection and access to health care Regulating national and international health systems Creating partnerships for primary health care Building political coalitions that recognise the importance of interests and power

Economic crisis, social protection and access to health care

Regulating national and international health systems

Creating partnerships for primary health care

Building political coalitions that recognise the importance of interests and power