Is primary health care progressing in Europe?

Primary health care (PHC) is the key to attaining the goal of health for all (HFA) by the year 2000. Also the European countries have accepted the declarations and WHO resolutions related to global and European HFA strategies. However, the implementation of regional and national strategies has met with many obstacles, caused by reluctant attitudes and poor planning and management systems. In this review the objective of PHC in industrialized countries, the evaluation process of HFA strategy, and progress in PHC in Europe in the 1980s are discussed. Lack of defined national objectives, and health information systems which are not adopted to purposes of monitoring progress in PHC are causing most of the problems in evaluation. There is a clear positive development in PHC resources and organization in the Nordic countries. Generally speaking PHC is progressing very slowly in Europe, if there is any progress at all. This can be said both about organization of health care, planning and management systems and about application of PHC principles like community participation and intersectoral collaboration. The national health information systems should be quickly revised to allow more exact monitoring of progress towards the 38 European targets and additional national targets.     

Can health promotion and primary health care achieve Health for All without a return to their more radical agenda?

Primary health care (PHC) and health promotion (HP), codifiedin the Alma Ata Declaration of 1978 and the Ottawa Charter of1986, and aiming to achieve Health for All by the year 2000(HFA 2000), are strikingly similar in their conception and evolution.Originally conceived as global strategies to reduce inequitiesin health between and within nations and emphasising intersectoraland community action, both have tended to be reduced to a morelimited and technical approach to selected diseases within nations. In the implementation of these strategies, four trends threateningthe achievement of HFA 2000 are analysed. Managerialism, manifestingin a goals and targets approach to health promotion has cometo dominate and constrict its implementation in Australia andother industrialised countries, detracting from social and environmentalimperatives and community action in addressing these. The increasingdominance of market economics and the promotion of economicgrowth at all costs is reinforcing inequities in health experienceglobally and within countries. Individualism, the philosophicalaccompaniment of market economics, has reinforced a behaviouraland lifestyle focus and undermined a collective approach toHP and PHC. Environmental degradation, a growing global threatto public health and ultimately amenable only to global economicrestructuring has been perilously ignored in the managerialistimplementation of HFA. The elements of an agenda for action are identified with somesuggested broader goals. A return to the original more radicalphilosophy underpinning the strategies of PHC and HP, it isargued, is fundamental to the achievement of HFA, even if thisis no longer possible by the year 2000.     

The national implementation of 'Proactive Health Support' in Denmark since 2017: Expectations and challenges for the telephone-based self-management program

In Denmark, as in many other Western countries, a small group of people are major hospital users and account for a large proportion of health care spending. Proactive Health Support (PaHS) is the first national Danish program that aims to reduce health care consumption targeting people at risk of becoming major users of health services. PaHS was part of the government's The sooner—the better national health policy, which includes a focus on policy programs targeting the weakest and most complex chronic patients at risk of high health care consumption. PaHS is a telephone-based self-management support program that uses a prediction model to identify people at high risk of acute hospital admissions. Reducing preventable hospital admissions and enhancing quality of life are central policy goals. The Danish policy was inspired by a Swedish policy program, and PaHS has been implemented based on policy transfer with political expectations that the Swedish results can be replicated in Denmark. The effects of PaHS are currently under study, and time will show whether expectations can be met. This paper discusses institutional conditions and expectations related to replicating a policy program and its outcomes. In addition, it highlights implementation issues that may affect the success of the policy program.     

Posyandu: a community based vehicle to improve child survival and development

The Indonesian government views health as a basic human need in order to live a productive life. HFA 2000 is a program that is part of Indonesia's national philosophy of Pancasila. Intercensal data indicates that women and children are not being reached by Indonesia's Health program, HFA 2000. Infant morality is 70/1000, maternal mortality is 4.5/1000 and the birth rate of 31/1000. These figures clearly show that the Trilogy of National development is not being shared by women and children. Indonesia developed a national health care system in the early 1980's in an attempt to bring progressive orientations and systems to mobilize all potential resources to increase health service coverage, community involvement, and intersectorial collaboration. In an effort to reduce infant and mother mortality and reduce the number of pregnancies, the 4th-5 year development plan formed an integrated service post called Posyandu which is the focus of this article. Special emphasis is paid to the role of Posyandu in efforts to overcome the major health problems faced by the women and children of Indonesia. The health care delivery system has several level, home and self care in 1st followed by community based preventative and promotive care (Posyandu), followed by basic professional care at health centers and clinics which are followed by 1st and higher referrals to district and advanced hospitals. Posyandu is a significant step towards HFA 2000 bring an integrated program of MCH, FP, nutrition, immunization and diarrheal control at the village level.     

Health for All in the 21st Century - an executive summary of the WHO's draft policy

Health for All (HFA) in the 21st Century is a World Health Organization (WHO) draft policy developed to help attain the goals of Health for All set forth at the Alma Ata Conference in 1978. The policy establishes, for the first 2 decades of the 21st century, global priorities and targets to create conditions supportive of people worldwide to reach and maintain the highest attainable level of health throughout their lives. Built upon past achievements in the context of the major global changes experienced during the past 2 decades, Health for All (HFA) in the 21st Century continues the HFA process, and is the result of a comprehensive process of consultation both with and within countries. While progress has been made over the past 20 years using primary health care to achieve HFA, a number of factors have prevented the ultimate attainment of HFA, with health most adversely affected in the relatively poorer countries. Both new threats and opportunities will present in the 21st century. The goals and targets for attaining the vision of HFA are discussed.     

Transfer of Health for All policy - What, how and in which direction? A two-case study

BACKGROUND: This article explores the transfer of World Health Organization's (WHO) policy initiative Health for All by the Year 2000 (HFA2000) into national contexts by using the changes in the public health policies of Finland and Portugal from the 1970's onward and the relationship of these changes to WHO policy development as test cases. Finland and Portugal were chosen to be compared as they represent different welfare state types and as the paradigmatic transition from the old to new public health is assumed to be related to the wider welfare state development. METHODS: The policy transfer approach is used as a conceptual tool to analyze the possible policy changes related to the adaptation of HFA into the national context. To be able to analyze not only the content but also the contextual conditions of policy transfer Kingdon's analytical framework of policy analysis is applied. CONCLUSIONS: Our analysis suggests that no significant change of health promotion policy resulted from the launch of HFA program neither in Finland nor in Portugal. Instead the changes that occurred in both countries were of incremental nature, in accordance with the earlier policy choices, and the adaptation of HFA program was mainly applied to the areas where there were national traditions.     

Venezuela's Barrio Adentro: an alternative to neoliberalism in health care.

Throughout the 1990s, all Latin American countries but Cuba implemented health care sector reforms based on a neoliberal paradigm that redefined health care less as a social right and more as a market commodity. These reforms were couched in the broader structural adjustment of Latin American welfare states as prescribed by international financial institutions since the mid-1980s. However, since 2003, Venezuela has been developing an alternative to this neoliberal trend through its health care reform program, Misión Barrio Adentro (Inside the Neighborhood). In this article, the authors review the main features of the Venezuelan health care reform, analyzing, within their broader sociopolitical and economic contexts, previous neoliberal health care reforms that mainly benefited transnational capital and domestic Latin American elites. They explain the emergence of the new health care program, Misión Barrio Adentro, examining its historical, social, and political underpinnings and the central role played by popular resistance to neoliberalism. This program not only provides a compelling model of health care reform for other low- to middle-income countries but also offers policy lessons to wealthy countries.     

Evaluation of the European strategy for Health for All by the Year 2000.

For the first time ever, Europe has a concrete, comprehensive and forward-looking health policy framework. Forming part of the worldwide movement for Health for All (HFA) by the Year 2000, the European regional HFA strategy, embodied in 38 specific targets. has been developed by the 33 Member States of the WHO European Region. Completed in 1985, the first evaluation of overall progress in implementing this new health policy has shown that the regional targets may be ambitious but they are viable and realistic. Certain countries have already achieved some of the targets, but even in these countries efforts are still needed to improve equity among social groups. Performance in key areas such as orientation towards primary health care and the provision of safe water and adequate sanitary facilities, although improving, is still not at the levels hoped for and these remain priority items. Even more serious difficulties are apparent in other areas such as healthy lifestyles and the quality of care. The quality of the information available, even in an area as developed as Europe, also leaves much to be desired. The gaps and weaknesses identified must be tackled urgently if the goal of HFA is to be achieved, but there are encouraging signs that the HFA movement in Europe has now really started.     

Evaluating the WHO Assessment Instrument for Mental Health Systems by comparing mental health policies in four countries

Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. As a result, WHO has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy. This paper demonstrates the utility and limitations of WHO-AIMS by applying the model to four countries with different cultures, political histories and public health policies: Iraq, Japan, the Philippines and The former Yugoslav Republic of Macedonia. WHO-AIMS provides a useful model for analysing six domains: policy and legislative framework; mental health services; mental health in primary care; human resources; education of the public at large; and monitoring and research. This is especially important since most countries do not have experts in mental health policy or resources to design their own evaluation tools for mental health systems. Furthermore, WHO-AIMS provides a standardized database for cross-country comparisons. However, limitations of the instrument include the neglect of the politics of mental health policy development, underestimation of the role of culture in mental health care utilization, and questionable measurement validity.     

Health care expenditure in the Nordic countries

International comparisons of health care expenditure are associated with many different kinds of problems. One type of problem is due to heterogenous definitions and to difficulties with conversion to common prices. Such problems are present also if one selects homogeneous countries as, for example, the Nordic countries, which have a similar GDP per capita and social system. In this paper we compare the health care expenditure in the Nordic countries to illustrate the significance of these problems in international comparisons. We also correct the latest available OECD statistics for local nursing homes, which are not included in health care expenditure for Denmark but are included for the other Nordic countries, and also for the care of the mentally retarded, which is not included in health care expenditure for Denmark or, after 1985, for Sweden. In addition, comparisons of health care expenditure are presented with different currency conversion factors. The comparisons show, for example, that Sweden has a higher expenditure share of gross domestic product (GDP) than Denmark, even after corrections have been made, but that the difference between the countries becomes considerably smaller, from 37% higher expenditure for Sweden without correction to 12-15% after correction.     

Historical and social context for birth planning in Iceland

Birth planning, a major women's health strategy, is affected by many community factors: literacy, education, employment, infant mortality, the status of women, and the dispersion of health care services. Iceland has the highest birth rate of all Nordic countries, and one of the highest in the Western world. A developed country with a national health system available to all, Iceland has nevertheless been influenced by distinct social, economic, cultural, and environmental forces. In this article I explore the phenomenon of birth planning and related factors that affect the health and development of women in Iceland. Recent gains by women, particularly women's integration into higher education and the professions and increased political participation, are expected to help bridge the existing gap between the status of women in Iceland and in Nordic and other Western European countries. The framework for examining broader community factors that influence birth planning is applicable to any country or subpopulation group. By examining others’ experiences, nurses can better assess complex needs and plan strategies for their own populations.     

Health for all: the dream and the reality

What has become clear in the 10 years since Alma-Ata is the global split between the health of the "haves" and the "have nots". This split is not a clean one and there are a number of countries spread out along the line from poorest to richest. Many of these countries are progressing along this line at a speed measurable with familiar indicators: increases in per capita income and literacy, decreases in maternal and under-5s mortality rates. Progress is uneven: 64 countries (40% of the world's population) experience more than 80% of the world's under-5s deaths and more than 90% of the maternal mortality. Although under-5s mortality is projected to be much lower by the year 2000, Africa and southern Asia are predicted to have unacceptably high rates of 100 deaths/1000 live births. Even though solutions are available to fundamental health problems, the progress has been slow. In the industrial countries an important step has been the creation of a European region-wide strategy for health for all. In 1980 the 33 European Member States of WHO set 38 targets and designated 65 indicators for systematic and routine monitoring by countries. An evaluation in 1985 revealed that European members had made strong efforts to monitor progress and a number of countries had formulated national strategies in line with the regional one. Canada and the US have also taken steps in adopting national strategies: Canada has made strides in organization of health services, the US in recognizing the inequities in the availability of health services to low income populations. In developing countries a few countries have made significant progress beyond what had been expected, especially Costa Rica, Sri Lanka, and Kerala State in India as measured in reduced infant mortality rates. An analysis by Caldwell showed that these countries had a number of conditions in common: reasonable level of female education and female autonomy, a politically active community, and easy access to health services promoting maternal and child care, immunization, family planning, home visits and food availability. The poorest countries have lacked these conditions and their progress has been slow and painful.     

Health coverage in Italy

Italy, as other developed European countries, has a national health service (NHS) that, in principle, offers universal health care and coverage to Italians and other legal (non-Italian) residents who have full access to health care. Although Italy has always spent less for health care than other European countries (Italy, in 2002, spent about 8% of its gross national product for health care, which is approximately half the level of spending in the U.S.), the government's lack of control over spending remained the most relevant problem. To enhance the capability to control and monitor the system, mainly in terms of expenditures and costs, from the late 1990s to the present, new health reforms were introduced. These reforms were in the context of a wider change involving other politics and administrative aspects, with a strong push to decentralize the decisions and the accountability at the regional level. Now, each region has an individual Health Regional Fund allocated for health care, along with the subsequent need to implement regional and individualized strategies to assure the governance of the cost and quality of care. The National Department of Health now is solely responsible to control and monitor the delivery of the essential level of care at the regional level, and they have maintained the governance of the drug policy. Although the changes synthesized above will require a long period to be fully implemented, a few negative effects have already occurred. Nevertheless, all citizens in Italy will have full access to any level of care, without any restrictions, for complex and costly procedures (as no explicit selection/adverse criteria were implemented), and the current policy on drugs does not imply any barriers for people (as essential drugs are directly and fully reimbursed by the NHS, with a small copayment being the only intervention that may be occasionally implemented when considered necessary).     

HFA与PHC的全球发展政策导向及策略

30年前,世界卫生组织提出了2000年人人享有卫生保健(HFA)目标和初级卫生保健(PHC)的全球战略。至此,HFA和PHC一直引导世界各国卫生系统的发展方向,指引各成员国朝着人人享有卫生保健这一宏伟目标迈进。当世界迈入21世纪之际,HFA与PHC是否仍然是各国卫生系统的发展方向?其内涵发生了哪些变化?在评价和衡量HFA和PHC实施效果方面国际上有哪些新的进展等问题。这些问题的研究与重新思考将对我国目前卫生改革导向有重要的启迪。     

Health care reforms and developing countries--a critical overview

Although health care reforms have been implemented in both developed and developing countries since the 1980s, there has been little discussion of the historical, social and political contexts in which such reforms have taken place. Health care reforms in developing countries, for instance, have been an integral component of structural adjustment policies, yet scant attention has been paid to these connections nor to their implications. The basic assumptions behind the reforms, and in particular, the ideological underpinnings of health care reorganization, need to be taken into account when considering long-term strategies and policies to provide health services in developing countries.     

Mongolian Health Sector Strategic Master Plan (2006‐2015): A foundation for achieving universal health coverage

Nearly half of the countries in the world are in the process of reforming and strengthening their health care systems. More recently, even low‐income and middle‐income countries such as Mongolia have focused increasing attention on achieving universal health coverage (UHC). At this critical point, it is necessary to track recent progress and adjust health care strategies and planning. Therefore, this study analyzed changes in the health sector toward achieving UHC based on relevant literature, government documents, and framework analysis. We also investigated how basic principles of UHC were incorporated and reflected in Mongolia's Health Sector Strategic Master Plan. This study clarified the achievements of and challenges facing the health sector that remain or emerged during the plan's implementation over the last decade. Furthermore, all of the reviewed Master Plan strategies were underpinned by basic principles of UHC. However, strategies set out in the next Master Plan will require adjustments and innovative measures to respond to current challenges. This study may be used as a reference for other developing countries to track UHC achievements and serve as a guide to establishing a nation‐wide strategic plan.     

Health for all by the year 2000: alcohol and the Nordic countries

One of the European targets in the "Health for all by the year 2000" programme is to reduce alcohol consumption significantly by the turn of the century. This article describes how this target, and especially the 25% goal included in it, has been adopted in the Nordic countries. With the exception of Denmark, alcohol has for a long time been regarded as a serious public health problem, and the reduction of total consumption of alcohol has been held as one of the most important ways of combating alcohol problems. In the 1980s Sweden and Norway have accepted the European 25% goal with the least reservations. In Finland the target has been regarded as unrealistic. Yet Finland, like Iceland, has accepted the goal of reducing total alcohol consumption but left the amount unspecified. In Denmark, controlling total alcohol consumption has been consistently held to be an irrelevant way to reduce alcohol problems. The alcohol policy measures suggested to reach the targets are the classical ones: price increases, restrictions in alcohol availability, and more efficient information and education. One cannot, however, avoid the observation that very few concrete measures have been taken so far and that many forces work against a reduction in alcohol consumption. The European alcohol target has affected alcohol policy in the Nordic countries in terms of target setting and programme design. It remains to be seen whether the forces advocating more restrictive alcohol control policy will be strong enough to generate concrete action plans and implement the accepted targets in actual alcohol policy measures.     

Implementation of promotion and prevention activities in decentralized health systems: comparative case studies from Chile and Brazil

The policies for restructuring health systems in Latin America during the 1990s have included an emphasis on changing in the model of health care delivery to one that incorporates prevention and promotion activities. At the same time, health systems have been decentralized in their management, allowing room for greater variation in local interpretation and implementation of policy directives. Despite rhetoric and policy debate, there is no documentation or evaluation of actual experiences of prevention and promotion within decentralized health systems in Latin America. This paper explores the ways in which the national structure of a health system influences the implementation of activities for prevention and promotion through a comparison of the experiences in four local health systems in each of Brazil and Chile. These experiences in Brazil and Chile are presented by key themes of national health system structure, local health system structure, partnership and intersectorality, human resources and introducing a family health approach. Five clear factors emerge as operating at the national level that influence prevention and promotion activities in local health systems: vertical (Chile) versus horizontal (Brazil) structure of health system; greater awareness of prevention and promotion issues in Chile; greater urban bias in Chile compared with Brazil; strategies to attract human resources to primary care and rural areas; importance of local capacity building especially in rural areas. This account of case study experiences in Brazil and Chile provides a series of examples of arrangements and strategies that can facilitate implementation and usefully highlights a number of issues that policy-makers and health system managers need explicitly to consider. As such, the paper hopes to provoke debate about the structures and strategies for supporting the implementation of prevention and promotion programmes in Latin America and further health systems research in this field.