Through publication of this report, WHO hopes to start a global debate on the effectiveness of primary health care for reorienting national health systems. The concept of primary health care was put forward thirty years ago in all countries as a way to improve fairness in access to health care and efficiency in resource utilization. Unfortunately, primary health care was misconstrued as poor care for poor people and was dismissed by some as utopian, or a threat to the medical establishment(1). This report is an earnest attempt by WHO to reinterpret and refocus on the virtues of primary health care, which in the words of WHO Director-General "looks more and more like a smart way to get health development back on track"(2).

The report focuses on problems such as inequities in health access and outcomes, a disproportionate focus on specialist hospital care, fragmentation of health systems, and the proliferation of unregulated commercial care.

In a wide-ranging review, the report found striking inequities in health outcomes, in access to care, and in what people have to pay for care. Differences in life expectancy between the richest and poorest countries now exceed 40 years. Of the estimated 136 million pregnant women in world this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants. Globally, annual government expenditure on health varies from as little as US$ 20 per person to well over US$ 6000. For 5.6 billion people in low and middle-income countries, more than half of health care expenditure is through out-of-pocket payments. With the rising costs of health care, these personal expenditures on health push more than 100 million people below the poverty line each year. Vast differences in health exist within countries and sometimes within individual cities. In Nairobi, for example, the under-five mortality rate is below 15 per 1000 in the high-income area and 254 per 1000 in a slum(2).

Data set out in the report indicate that health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet the needs and expectations of people, especially in impoverished and marginalized groups(2). Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care, with health viewed as a product of biomedical interventions and the power of prevention largely ignored. Specialists may perform tasks that are better managed by general practitioners, family doctors, or nurses. This contributes to inefficiency, restricts access, and deprives patients of opportunities for comprehensive care. WHO estimates that better use of existing preventive measures could reduce the global burden of disease by as much as 70%(2).

In rural parts of the developing world, care tends to be fragmented into discrete initiatives focused on individual diseases or projects, with little attention to coherence and little investment in basic infrastructures, services, and staff. As the report observes, such situations reduce people to "program targets." Above all, health care is failing to respond to rising social expectations for health care that is people-centered, fair, affordable and efficient(2).

Still, the report is weak in certain aspects:

There are opportunities to start channelizing the health systems towards primary health care in all countries. There is more money being spent on health than ever before and more knowledge to address global health challenges, including better medical technology. The core strategy for tackling inequalities is to move towards universal coverage in a spirit of equity, social justice, and solidarity. Primary health care also offers the best way of coping with the ills of life in the 21st century; the globalization of unhealthy lifestyles and rapid unplanned urbanization. These trends contribute to a rise in chronic diseases like heart disease, stroke, cancer, diabetes and asthma A multisectoral approach is central to prevention as the main risk factors for these diseases lie outside the health sector.

Funding: None.

Competing interests: None stated.

1. A Summary of the 2008 World Health Report "Primary Health Care: Now More Than Ever". Available from: URL: http://www.who.int/entity/whr/2008/summary.pdf. Accessed November 29, 2008.