Global Health Watch 1 in one file

Health care systems | B1
4) selective and efficiency driven cost-effectiveness analysis; and
5) public sector failures.
It would be impossible to provide a detailed chronological or historical account
of how health care systems have been undermined in recent decades,
not least because the ways in which health care systems have developed or
deteriorated have varied from country to country. However, the wide-ranging
factors and policies that have undermined the PHC Approach are discussed
so as to produce guiding principles for health care systems development in
the future. The chapter then sets out in section 3 a case for the central role of
governments and the public sector within health care systems, and concludes
by outlining an agenda of principles and priorities for the revitalizing of health
care systems in section 4.
1 Remembering Alma Ata and the Primary Health Care Approach
The Alma Ata Declaration, sponsored by WHO and UNICEF, arose from the
observation of failings in health care systems, as well as the positive results
from health programmes in countries such as Nicaragua, Costa Rica, Guatemala,
Honduras, Mexico, India, Cuba, Bangladesh, the Philippines and China
(Commission on the Social Determinants of Health 2005). The term ‘Primary
Health Care Approach’ came to be associated with the health care elements
of the Declaration and can be summarised as follows:
• First, it stresses a comprehensive approach to health by emphasizing ‘upstream
interventions’ aimed at promoting and protecting health such as
improving household food security, promoting women’s literacy and increasing
access to clean water. This places a greater emphasis on preventive
interventions and counters the biomedical and curative bias of many health
care systems, and promotes a multi-sectoral approach to health.
• Second, it promotes integration – of different clinical services within health
facilities, of health programmes and of different levels of the health care
system. This recommendation was partially in response to the limitations
of ‘vertical’, stand-alone disease control programmes and to the observation
that hospitals in many countries were not adequately involved in strengthening
primary-level health care.
• Third, it emphasizes equity. This recommendation would, for example, aim
to correct the neglect of rural populations, as well as socially and economically
marginalized groups, within many health care systems.
• Fourth, it advocates the use of ‘appropriate’ health technology, and health
care that is socially and culturally acceptable.
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