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For almost 200 years, the idea of health has been equated with freedom from disease. Developing slowly during the same period have been the explicit medical and social meanings of the word disease; and the science necessary to understand diseases. Organizing medicine according to disease is a theoretical construct that developed, in its present form, at the beginning of the nineteenth century. The idea of health as freedom from disease has been seen as increasingly inadequate, and new definitions have arisen that emphasize the ability of persons to reach social, emotional, and economic goals. This viewpoint, called an ecological theory has both fostered and found expression in the rise of primary health care. The new surge in student interest and the rising number of applications for training programs in family practice, general pediatrics, and internal medicine suggests student awareness of the economic realities favoring primary care.

The formulation of the right to health in international law lists a series of explicit measures that states must pursue in order to secure the full implementation of this right. These measures, which range from an obligation to reduce infant mortality to the development of preventive health care and family planning services, are extremely broad and open textured. This chapter seeks to examine the extent to which parameters can be placed around their meaning in a way that allows states and the broader interpretative community to agree on the nature of the practical steps required to secure their implementation. Although considerable deference must be given to states' margin of appreciation to allow for a context-sensitive implementation of these specific measures, this margin remains subject to the overriding caveat that whatever measures are adopted by states must be effective.

This chapter traces some of the key policy themes that have been central to the health sector over the last twenty years. It begins by examining the policy of primary health care (PHC), which for many countries was the foundation of their health policies in the 1980s. In the 1990s, emphasis shifted away from PHC towards issues related to the structure of the health sector. Health sector reform (HSR) or health system development (HSD) policies (as they are now more commonly known) have become a major concern of many external partners and health ministries; the chapter examines the key elements of these that were promoted in the 1990s and subsequently. The post-millennium period and a number of more recent policy issues and developments are considered, including increased globalization and the focus on human resources. The chapter concludes by looking at the implications of these policies for effective health planning.

This chapter examines archetypes of health care systems, from various European national health systems to the centrally planned model of the former Soviet Union and the market-driven US model. The chapter then analyzes two key health care policy approaches: primary health care and universal health coverage. It provides illustrations of recent and ongoing health system reforms across all world regions (covering China, Thailand, the Middle East, Brazil, Mexico, South Africa, South Korea, and India) that address—to varying degrees—questions of regulation, financing, resource allocation, the nature of service provision, and principles of universality, access, affordability, quality, and equity within the politics of their context. In addition, it provides an overview of the building blocks of health care systems including facilities, different types of health care personnel, problems around health workforce migration, technology, and the powerful role of the pharmaceutical industry.

This chapter examines the World Health Organization's (WHO) strategic response to the call for a New International Economic Order (NIEO) and how it was able to contribute to the new international order in the field of public health. More specifically, it considers the discrepancy between the NIEO and WHO policies and how this discrepancy was created through the maneuvering of the WHO leadership and staff rather than negotiations between North and South. It shows how strategic adaptation enabled the WHO to satisfy the expectations of developing countries while safeguarding the organization's material and ideational goals. It also explains how, by reinterpreting the meaning of the principles of socioeconomic development, equity, and self-reliance, the WHO secretariat was able to present its central agenda—Health for All by the Year 2000 through promotion of primary health care—as loyally following the logic of the NIEO, without compromising the organization's commitment to its constitution and to new perceptions in public health knowledge.

Maintaining a normal life for as long as possible, being in familiar surroundings cared for by a relative, and supported by health professionals well known to them, have all been found to be aspects of home care services valued by patients and carers. Home is, therefore, both the place where most people spend most of their last months of life and the place where most would want to die, although many do not achieve this. The primary location of palliative care therefore remains in the community, under the care of the patient's GP and district nurse. This chapter explores the quality of palliative care provided in the community in the UK, the relationship between primary care services and specialist palliative care services, and suggests a community view of the extension of specialist palliative care services to non-cancer patients. It begins, however, with an overview of the provision of health and social care in the community in the UK, with particular emphasis on recent changes which have impacted on palliative care.

The Greek health care system relies on expensive medical inputs to deliver basic health care services, and is characterized by a lack of primary care focus, which disallows care integration and coordination, particularly in chronic care management. Consequently, care delivery remains fragmented and disjointed and often results in access to care disparities. This chapter proposes three areas where structural reform is essential to address budgetary constraints, improve coverage, and deliver better quality of care. First, the health care financing and contracting model and reimbursement mechanisms need to be overhauled. Transitioning to a funding system through general taxation would be advantageous in increasing levels of coverage over the short- to medium-term, but needs to be accompanied by significant changes in the provision and contracting of services to improve efficiency and quality. Second, the role of primary health care needs to be strengthened so that it becomes the backbone of health service delivery. And, finally, pharmaceutical policy needs fundamental review, including a re-alignment of the different incentives on the supply and the demand side. These reforms require a mix of structural and tactical interventions by decision-makers.

This chapter gives an overview of the history of lay health workers and the diversity of current practice. It examines how the concept of community health workers originated in the 1970s as part of a holistic approach to primary health care. International case studies are used to illustrate the traditions that have since emerged in both the global South and North America. Lessons learnt from programme implementation highlight the importance of community ownership and supportive health systems. In the UK an increasing emphasis on self care and health prevention has led to several major initiatives, including the Expert Patient Programme, health trainers and community health champions. The chapter also considers independent social action on health and how this relates to more professionally directed programmes.

This chapter focuses on the key questions of who should set priorities, and how. It also examines the complex issues of the underlying factors and attitudes towards priorities. It argues that priority-setting is the most important part of the planning process, and yet it is often not given sufficient attention. It also argues that priority-setting involves a combination of techniques and value judgements.

All countries are developing countries because today every country is undergoing an economic transition. Less developed countries or “developing” countries (in the usual use of the term) may become “developed” countries, in the sense that industrialization contributes more economic value than agriculture. However, many industrialized countries are undergoing a transition to a “postmodern” economy, in which manufacturing contributes less value than information and services. A few countries are losing ground in income and creation of wealth and in that sense are “de-developing”. Occupational health tends to be left out of plans and strategies for development. This is a mistake because occupational health can contribute a great deal to economic progress by providing family income security, protecting the most economically productive segment of the population, reducing the cumulative burden of disability, making health gains at a time when costs are low, and promoting equity in the workplace. In many countries, occupational health, with extensions of care to dependents, in the form of a social security health system has been the foundation for health care and social security as the economy develops. The World Health Organization advocates integration of a package of “Basic Occupational Health Services” into the primary health care system as countries develop. Occupational health is typically viewed as a consumptive expense, one that consumes resources but does not provide a tangible return. A better way to think of occupational health is as an investment, which pays off in worker health and fitness, lower costs for medical care, greater productivity and social well being.

The chapter reconstructs a narrative of health services development in post-Independence India by examining relationships of the state, community, and Primary Health Care approach through existing literature. It combines materialist explanations with analyses of bureaucratic power and cultural hegemony to explain the maldistribution of health care. It argues that a critical analysis of the bio-politics and political economy of health care over the past century must consider five ‘missing links’ in the dominant discourse of HSD policy, that is, the unaffordability of the Euro-American institutional model of over-medicalized health care; the validity of plurality of knowledge; the dominant culture and ethics of health care providers; the prevalent physical, social and cultural iatrogenesis; and complexity of ‘the community’.

Strengthening health systems in poorer countries has long been a focal point in development aid debates. Visionary models of comprehensive primary health care caught the global imagination in the late 1970s but were quickly eclipsed with the rise of neoliberal globalization in the 1980s, truncated into ‘selective’ silos appealing to donor nations. ‘Investing in health’ for economic growth eclipsed more humanitarian principles for health assistance. Corporate philanthropies began to set health agendas resonant with those of a century earlier, while private health care financing and delivery models that grew under neoliberalism’s first wave (structural adjustment) have yet to yield to the evidence of the efficiencies of public health care models. The current push to achieve Universal Health Coverage captures the ongoing tension between the interests of private capital and the need for public goods.

This chapter examines how the World Health Organization (WHO), under the leadership of Director-General Gro Harlem Brundtland, strategically adapted to the “new policy environment” that was created by the neoliberal reforms in the health sector. In the late 1990s, the WHO underwent programmatic and organizational changes in an attempt to pacify the exogenous forces and to strategically adapt to the logic of neoliberalism. The central component of the WHO leadership's strategic adaptation to the new environment was the replacement of a social logic with economic logic as the foundation for the organization's decisions and policies. This chapter shows how WHO officials justified investment in health by emphasizing the importance of health for economic development rather than as a fundamental part of a nation's social development, while also adopting cost-effective calculations to introduce the concept of the “new universalism,” which rejected primary health care and rigid market-oriented approaches while maintaining the WHO's “central task” of alleviating poverty by improving health.

Many assume that the health sector is the central government agency for health. Yet very often, health sectors are actually “illness care” sectors that give little concern to the production or maintenance of health. This chapter argues that this state of affairs needs to change so that health sectors do become stewards of the health of the population they are established to serve. Achieving such a health sector will require strong and determined leadership that is able to ensure that curative functions are effective, while also ensuring that disease prevention and health promotion flourish. This is vital to governing for health. This chapter examines the importance of primary health care, disease prevention, and health promotion. The chapter plays particular attention to community strategies, including community ownership of health services, and public health functions, including health impact assessments and Health in All Policies.

This chapter analyzes how wartime and postwar needs—combined with the creation of the United Nations (UN) and the World Health Organization (WHO), late imperialism, and decolonization processes—shaped a more muscular, if still fragmented, international health arrangement than prior intergovernmental, colonial, and charitable agencies. It examines the role of Cold War and development ideologies—which together shaped relations between so-called First (capitalist bloc) and Third (non-aligned) World countries, as well as the alternative presented by the Second (communist bloc) World—on the players, precepts, and practices of international health. It discusses WHO’s initial disease eradication approach built on the legacy of earlier actors and activities; its subsequent endorsement of primary health care in contrast to these narrowly conceived top-down disease campaigns; and the waning of WHO at the field’s fulcrum, coincident with the growing dominance of neoliberal globalization and eventual displacement of international health by global health.

This chapter outlines the historical roots of health inequities. It focuses on the African continent, where life expectancy is the shortest and health systems are weakest. The chapter describes the impoverishment of countries by colonial powers, the development of the global human rights framework in the post-World War II era, the impact of the Cold War on African liberation struggles, and the challenges faced by newly liberated African governments to deliver health care through the public sector. The influence of the World Bank and the International Monetary Fund’s neoliberal economic policies is also discussed. The chapter highlights the shift from the aspiration of “health for all” voiced at the Alma Ata Conference on Primary Health Care in 1978, to the more narrowly defined “selective primary health care.” Finally, the chapter explains the challenges inherent in financing health in impoverished countries and how user fees became standard practice.

Although rural Canada makes up 95% of the country’s land mass, Canada is becoming increasingly urbanized as cities grow and the rural proportion has declined and aged. These changes have socio-economic impacts on rural communities, including ability to deliver health and social services for aging rural populations. The challenges of aging in rural communities, such as disparities in access to services, are compounded when living with dementia. This chapter reviews the Canadian dementia care context, issues and challenges in rural dementia care, and Canadian research addressing these issues. The chapter describes the Rural Dementia Action Research (RaDAR) Program based in the western Canadian province of Saskatchewan, which has been focused on rural dementia care for over 20 years. Key RaDAR projects include the development of an interdisciplinary specialist memory clinic serving rural and remote areas, and rural primary health care memory clinics to increase access to coordinated team-based care in rural communities.

This chapter examines how the Primary Health Care (PHC) reform initiated by director-general Halfdan Mahler (1973–1988) yielded increasing returns to regional power. While the reform’s policy goals were not attained, it nevertheless transformed the WHO’s structure. Its side-effect was to deepen the WHO’s regional fragmentation. The chapter first introduces the Primary Health Care (PHC) agenda, whose implementation hinged on national ownership and consent. The regional offices’ privileged ties to national policy-makers thus turned them into reform gatekeepers. Mahler therefore delegated organizational resources and discretion to the regions so that they could implement PHC. Yet, as it turned out that PHC was not implemented, Mahler became a critic of regionalization. Regionalization was also criticized in external and internal evaluations of the WHO, and even states such as the US attempted to recentralize the WHO. Nonetheless, all recentralization attempts were defeated and the new regional competencies generated vested interests of their own.