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DISH “Just”.Got ..Better..
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The World Health Report 2008

4

Primary Health Care – Now More Than Ever

in the world where access to qualifi ed providers

at childbirth is not progressing18.

Mirroring the overall trends in child survival, global trends in life expectancy point

to a rise throughout the world of almost eight

years between 1950 and 1978, and seven more

years since: a refl ection of the growth in average

income per capita. As with child survival, widening income inequality (income increases faster

in high-income than in low-income countries)

is refl ected in increasing disparities between

the least and most healthy19. Between the mid1970s and 2005, the difference in life expectancy

between high-income countries and countries in

sub-Saharan Africa, or fragile states, has widened by 3.8 and 2.1 years, respectively.

The unmistakable relation between health and

wealth, summarized in the classic Preston curve

(Figure 1.4), needs to be qualifi ed20.

Firstly, the Preston curve continues to shift12.

An income per capita of I$ 1000 in 1975 was

associated with a life expectancy of 48.8 years.

In 2005, it was almost four years higher for the

same income. This suggests that improvements

in nutrition, education21, health technologies22,

the institutional capacity to obtain and use

information, and in society’s ability to translate

this knowledge into effective health and social

action23, allow for greater production of health

for the same level of wealth.

Secondly, there is considerable variation in

achievement across countries with the same

income, particularly among poorer countries. For

example, life expectancy in Côte d’Ivoire (GDP I$

1465) is nearly 17 years lower than in Nepal (GDP

I$ 1379), and between Madagascar and Zambia,

the difference is 18 years. The presence of high

performers in each income band shows that

the actual level of income per capita at a given

moment is not the absolute rate limiting factor

the average curve seems to imply.

Growth and stagnation

Over the last 30 years the relation between economic growth and life expectancy at birth has

shown three distinct patterns (Figure 1.5).

In 1978, about two thirds of the world’s population lived in countries that went on to experience

increases in life expectancy at birth and considerable economic growth. The most impressive relative gains were in a number of low-income countries in Asia (including India), Latin America and

northern Africa, totalling 1.1 billion inhabitants

30 years ago and nearly 2 billion today. These

countries increased life expectancy at birth by

12 years, while GDP per capita was multiplied by

a factor of 2.6. High-income countries and countries with a GDP between I$ 3000 and I$ 10 000

in 1975 also saw substantial economic growth

and increased life expectancy.

In other parts of the world, GDP growth was

not accompanied by similar gains in life expectancy. The Russian Federation and Newly Independent States increased average GDP per capita

substantially, but, with the widespread poverty

that accompanied the transition from the former

Soviet Union, women’s life expectancy stagnated

from the late 1980s and men’s plummeted, particularly for those lacking education and job

security 24,25. After a period of technological and

organizational stagnation, the health system collapsed12. Public expenditure on health declined

in the 1990s to levels that made running a basic

system virtually impossible in several countries.

Unhealthy lifestyles, combined with the disintegration of public health programmes, and the

unregulated commercialization of clinical services combined with the elimination of safety

nets has offset any gains from the increase in

average GDP26. China had already increased its

Figure 1.4 GDP per capita and life expectancy at birth in 169 countriesa

,

1975 and 2005

Life expectancy at birth (years)

GDP per capita, constant 2000 international $

a Only outlying countries are named.

35

85

0

Namibia

5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000

South Africa

Botswana

Swaziland

75

65

55

45

2005

1975

5

Chapter 1. The challenges of a changing world

life expectancy substantially in the period before

1980 to levels far above that of other low-income

countries in the 1970s, despite the 1961–1963

famine and the 1966–1976 Cultural Revolution.

The contribution of rural primary care and

urban health insurance to this has been well

documented27,28. With the economic reforms of

the early 1980s, however, average GDP per capita

increased spectacularly, but access to care and

social protection deteriorated, particularly in

rural areas. This slowed down improvements to

a modest rate, suggesting that only the improved

living conditions associated with the spectacular

economic growth avoided a regression of average

life expectancy29.

Finally, there is a set of low-income countries, representing roughly 10% of the world’s

population, where both GDP and life expectancy

stagnated30. These are the countries that are

considered as “fragile states” according to the

“low-income countries under stress” (LICUS)

criteria for 2003–200631. As much as 66% of the

population in these countries is in Africa. Poor

governance and extended internal confl icts are

common among these countries, which all face

similar hurdles: weak security, fractured societal relations, corruption, breakdown in the rule

of law, and lack of mechanisms for generating

legitimate power and authority32. They have a

huge backlog of investment needs and limited

government resources to meet them. Half of

them experienced negative GDP growth during

the period 1995–2004 (all the others remained

below the average growth of low-income countries), while their external debt was above average33. These countries were among those with

the lowest life expectancy at birth in 1975 and

have experienced minimal increases since then.

The other low-income African countries share

many of the characteristics and circumstances

of the fragile states – in fact many of them have

suffered protracted periods of confl ict over the

last 30 years that would have classifi ed them as

fragile states had the LICUS classifi cation existed

at that time. Their economic growth has been

very limited, as has been their life-expectancy

gain, not least because of the presence, in this

group, of a number of southern African countries

that are disproportionally confronted by the HIV/

AIDS pandemic. On average, the latter have seen

some economic growth since 1975, but a marked

reversal in terms of life expectancy.

What has been strikingly common to fragile

states and sub-Saharan African countries for

Life expectancy (years)

0

Figure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975–2005*

50

45

Chinah

55

60

65

70

75

80

1000 2000 3000 4000 5000 6000 7000 8000 9000 10 000

Middle-income

countriesb

Russian Federation

and NISg

Low-income African countriesf

Low-income

coutriesd

Indiac

Fragile statese

20 000 25 000 30 000

a 27 countries, 766 million (M) inhabitants in 1975, 953 M in 2005.

b 43 countries, 587 M inhabitants in 1975, 986 M in 2005 .

c India, 621 M inhabitants in 1975, 1 103 M in 2005.

d 17 Low-income countries, non-African, fragile states excluded, 471 M inhabitants in 1975, 872 M in 2005.

e 20 Fragile states, 169 M inhabitants in 1975, 374 M in 2005.

f 13 Low-income African countries, fragile states excluded, 71 M inhabitants in 1975, 872 M in 2005.

g Russian Federation and 10 Newly Independent States (NIS), 186 M inhabitants in 1985, 204 M in 2005.

h China, 928 M inhabitants in 1975, 1 316 M in 2005.

High-income countriesa

* No data for 1975 for the Newly Independant States. No historical data for the remaining countries.

Sources: Life expectancy, 1975, 1985: UN World Population Prospects 2006; 1995, 2005: WHO, 9 November 2008 (draft); China: 3rd, 4th and 5th National Population censuses, 1981, 1990 and 2000. GPD: 200737.

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Neonatal mortality rate,

by education of mother

No education Primary education Secondary or higher education

Bolivia

2003 Colombia

2005 Lesotho

2003 Nepal

2006 Philippines 2003

0

20

40

60

80

100

Births attended by health professional (%),

by education of mother

Benin

2001 Bolivia

2003 Botswana 1998 Cambodia 2005 Peru

2000

Sources: (60, 61, 62, 63).

11

Chapter 1. The challenges of a changing world

to recognize the need for expertise from beyond

traditional health disciplines has condemned the

health sector to unusually high levels of systems

incompetence and ineffi ciency which society can

ill afford.

Trends that undermine the health

systems’ response

Without strong policies and leadership, health

systems do not spontaneously gravitate towards

PHC values or effi ciently respond to evolving

health challenges. As most health leaders know,

health systems are subject to powerful forces and

infl uences that often override rational priority

setting or policy formation, thereby pulling health

systems away from their intended directions71.

Characteristic trends that shape conventional

health systems today include (Figure 1.10):

Q a disproportionate focus on specialist, tertiary

care, often referred to as “hospital-centrism”;

Q fragmentation, as a result of the multiplication

of programmes and projects; and

Q the pervasive commercialization of health care

in unregulated health systems.

With their focus on cost containment and

deregulation, many of the health-sector reforms

of the 1980s and 1990s have reinforced these

trends. High-income countries have often been

able to regulate to contain some of the adverse

consequences of these trends. However, in

countries where under-funding compounds

limited regulatory capacity, they have had more

damaging effects.

Hospital-centrism: health systems built around

hospitals and specialists

For much of the 20th century, hospitals, with

their technology and sub-specialists, have gained

a pivotal role in most health systems throughout

the world72,73.Today, the disproportionate focus

on hospitals and sub-specialization has become

a major source of ineffi ciency and inequality, and

one that has proved remarkably resilient. Health

authorities may voice their concern more insistently than they used to, but sub-specialization

continues to prevail74. For example, in Member

countries of the Organisation of Economic Cooperation and Development (OECD), the 35%

growth in the number of doctors in the last 15

years was driven by rising numbers of specialists (up by nearly 50% between 1990 and 2005

– compared with only a 20% increase in general

practitioners)75. In Thailand, less than 20% of

doctors were specialists 30 years ago; by 2003

they represented 70%76.

The forces driving this growth include professional traditions and interests as well as the

considerable economic weight of the health industry – technology and pharmaceuticals (Box 1.4).

Obviously, well functioning specialized tertiary

care responds to a real demand (albeit, at least in

part, induced): it is necessary, at the very least,

for the political credibility of the health system.

However, the experience of industrialized countries has shown that a disproportionate focus on

specialist, tertiary care provides poor value for

money72. Hospital-centrism carries a considerable

cost in terms of unnecessary medicalization and

iatrogenesis77, and compromises the human and

social dimensions of health73,78. It also carries an

opportunity cost: Lebanon, for example, counts

more cardiac surgery units per inhabitant than

Germany, but lacks programmes aimed at reducing the risk factors for cardiovascular disease79.

Ineffi cient ways of dealing with health problems

are thus crowding out more effective, effi cient –

and more equitable80 – ways of organizing health

care and improving health81.

Since the 1980s, a majority of OECD countries

has been trying to decrease reliance on hospitals,

Figure 1.10 How health systems are diverted from PHC core values

Commercialization

Hospital-centrism

Fragmentation

PHC Reform

PHC Reform

Current trends

Health equity

Universal access to

people-centred care

Healthy communities

Health

systems

The World Health Report 2008

12

Primary Health Care – Now More Than Ever

specialists and technologies, and keep costs

under control. They have done this by introducing supply-side measures including reduction of

hospital beds, substitution of hospitalization by

home care, rationing of medical equipment, and

a multitude of fi nancial incentives and disincentives to promote micro-level effi ciency. The results

of these efforts have been mixed, but the evolving

technology is accelerating the shift from specialized hospital to primary care. In many highincome countries (but not all), the PHC efforts

of the 1980s and 1990s have been able to reach

Box 1.4 Medical equipment and

pharmaceutical industries are major

economic forces

Global expenditure on medical equipment and devices has

grown from US$ 145 billion in 1998 to US$ 220 billion in 2006:

the United States accounts for 39% of the total, the European

Union for 27%, and Japan for 16%90. The industry employs

more than 411 400 workers in the United States alone, occupying nearly one third of all the country’s bioscience jobs91. In

2006, the United States, the European Union and Japan spent

US$ 287, US$ 250 and US$ 273 per capita, respectively, on

medical equipment. In the rest of the world, the average of

such expenditure is in the order of US$ 6 per capita, and

in sub-Saharan Africa – a market with much potential for

expansion – it is US$ 2.5 per capita. The annual growth rate

of the equipment market is over 10% a year92.

The pharmaceutical industry weighs even more heavily in the

global economy, with global pharmaceutical sales expected

to expand to US$ 735–745 billion in 2008, with a growth rate

of 6–7%93. Here, too, the United States is the world’s largest

market, accounting for around 48% of the world total: per

capita expenditure on drugs was US$ 1141 in 2005, twice

the level of Canada, Germany or the United Kingdom, and 10

times that of Mexico94.

Specialized and hospital care is vital to these industries, which

depend on pre-payment and risk pooling for sustainable funding of their expansion. While this market grows everywhere,

there are large differences from country to country. For

example, Japan and the United States have 5–8 times more

magnetic resonance imaging (MRI) units per million inhabitants than Canada and the Netherlands. For computerized

tomography (CT) scanners, the differences are even more

pronounced: Japan had 92.6 per million in 2002, the Netherlands 5.8 in 200595. These differences show that the market

can be infl uenced, principally by using appropriate payment

and reimbursement incentives and by careful consideration

of the organization of regulatory control96.

a better balance between specialized curative

care, fi rst contact care and health promotion81.

Over the last 30 years, this has contributed to

signifi cant improvements in health outcomes81,82.

More recently, middle-income countries, such as

Chile with its Atención Primaria de Salud (Primary Health Care)83, Brazil with its family health

initiative and Thailand under its universal coverage scheme84 have shifted the balance between

specialized hospital and primary care in the

same way85. The initial results are encouraging:

improvement of outcome indicators86 combined

with a marked improvement in patient satisfaction87. In each of these cases, the shift took place

as part of a move towards universal coverage,

with expanded citizen’s rights to access and social

protection. These processes are very similar to

what occurred in Malaysia and Portugal: right

to access, social protection, and a better balance

between reliance on hospitals and on generalist

primary care, including prevention and health

promotion6

.

Industrialized countries are, 50 years later,

trying to reduce their reliance on hospitals,

having realized the opportunity cost of hospitalcentrism in terms of effectiveness and equity.

Yet, many low- and middle-income countries

are creating the same distortions. The pressure

from consumer demand, the medical professions

and the medico-industrial complex88 is such that

private and public health resources fl ow disproportionately towards specialized hospital care

at the expense of investment in primary care.

National health authorities have often lacked the

fi nancial and political clout to curb this trend and

achieve a better balance. Donors have also used

their infl uence more towards setting up disease

control programmes than towards reforms that

would make primary care the hub of the health

system89.

Fragmentation: health systems built around

priority programmes

While urban health by and large revolves around

hospitals, the rural poor are increasingly confronted with the progressive fragmentation of

their health services, as “selective” or “vertical”

approaches focus on individual disease control

programmes and projects. Originally considered

13

Chapter 1. The challenges of a changing world

as an interim strategy to achieve equitable health

outcomes, they sprang from a concern for the

slow expansion of access to health care in a context of persistent severe excess mortality and

morbidity for which cost-effective interventions

exist97. A focus on programmes and projects is

particularly attractive to an international community concerned with getting a visible return

on investment. It is well adapted to commandand-control management: a way of working that

also appeals to traditional ministries of health.

With little tradition of collaboration with other

stakeholders and participation of the public, and

with poor capacity for regulation, programmatic

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Primary Health Care – Now More Than Ever

The chapter argues that, in general, the

response of the health sector and societies to

these challenges has been slow and inadequate.

This refl ects both an inability to mobilize the

requisite resources and institutions to transform

health around the values of primary health care

as well as a failure to either counter or substantially modify forces that pull the health sector

in other directions, namely: a disproportionate

focus on specialist hospital care; fragmentation of

health systems; and the proliferation of unregulated commercial care. Ironically, these powerful trends lead health systems away from what

people expect from health and health care. When

the Declaration of Alma-Ata enshrined the principles of health equity, people-centred care and

a central role for communities in health action,

they were considered radical. Social research

suggests, however, that these values are becoming mainstream in modernizing societies: they

correspond to the way people look at health and

what they expect from their health systems.

Rising social expectations regarding health and

health care, therefore, must be seen as a major

driver of PHC reforms.

Unequal growth,

unequal outcomes

Longer lives and better health,

but not everywhere

In the late 1970s, the Sultanate of Oman had only

a handful of health professionals. People had to

travel up to four days just to reach a hospital,

where hundreds of patients would already be

waiting in line to see one of the few (expatriate)

doctors. All this changed in less than a generation1

. Oman invested consistently in a national

health service and sustained that investment over

time. There is now a dense network of 180 local,

district and regional health facilities staffed by

over 5000 health workers providing almost universal access to health care for Oman’s 2.2 million

citizens, with coverage now being extended to foreign residents2

. Over 98% of births in Oman are

now attended by trained personnel and over 98%

of infants are fully immunized. Life expectancy

at birth, which was less than 60 years towards

the end of the 1970s, now surpasses 74 years.

The under-fi ve mortality rate has dropped by a

staggering 94%3

.

In each region (except in the African region)

there are countries where mortality rates are now

less than one fi fth of what they were 30 years

ago. Leading examples are Chile4

, Malaysia5

,

Portugal6

and Thailand7

(Figure 1.1). These

results were associated with improved access to

expanded health-care networks, made possible

by sustained political commitment and by economic growth that allowed them to back up their

commitment by maintaining investment in the

health sector (Box 1.1).

Overall, progress in the world has been considerable. If children were still dying at 1978 rates,

there would have been 16.2 million deaths globally in 2006. In fact, there were only 9.5 million

such deaths12. This difference of 6.7 million is

equivalent to 18 329 children’s lives being saved

every day.

But these fi gures mask signifi cant variations

across countries. Since 1975, the rate of decline in

under-fi ve mortality rates has been much slower

in low-income countries as a whole than in the

richer countries13. Apart from Eritrea and Mongolia, none of today’s low-income countries has

reduced under-fi ve mortality by as much as 70%.

The countries that make up today’s middle-income

countries have done better, but, as Figure 1.3

illustrates, progress has been quite uneven.

Deaths per 1000 children under five

a No country in the African region achieved an 80% reduction.

50

0

100

150

Chile

(THE 2006:

I$ 697)b

Malaysia

(THE 2006:

I$ 500)b

Portugal

(THE 2006:

I$ 2080)b

Oman

(THE 2006:

I$ 382)b

Thailand

(THE 2006:

I$ 346)b

1975 2006

Figure 1.1 Selected best performing countries in reducing under-five

mortality by at least 80%, by regions, 1975–2006a,*

b Total health expenditure per capita 2006, international $.

* International dollars are derived by dividing local currency units by an estimate

of their purchasing power parity compared to the US dollar.

3

Chapter 1. The challenges of a changing world

Some countries have made great improvements

and are on track to achieve the health-related

MDGs. Others, particularly in the African region,

have stagnated or even lost ground14. Globally,

20 of the 25 countries where under-fi ve mortality is still two thirds or more of the 1975 level

are in sub-Saharan Africa. Slow progress has

been associated with disappointing advances in

access to health care. Despite recent change for

the better, vaccination coverage in sub-Saharan

Africa is still signifi cantly lower than in the rest

of the world14. Current contraceptive prevalence

remains as low as 21%, while in other developing

regions increases have been substantial over the

past 30 years and now reach 61%15,16. Increased

contraceptive use has been accompanied by

decreased abortion rates everywhere. In subSaharan Africa, however, the absolute numbers of

abortions has increased, and almost all are being

performed in unsafe conditions17. Childbirth care

for mothers and newborns also continues to face

problems: in 33 countries, less than half of all

births each year are attended by skilled health

personnel, with coverage in one country as low as

6%14. Sub-Saharan Africa is also the only region

Box 1.1 Economic development and investment choices in health care: the improvement of

key health indicators in Portugal

Portugal recognized the right to health in its 1976 Constitution, following its democratic revolution. Political pressure to reduce large

health inequalities within the country led to the creation of a national health system, funded by taxation and complemented by public

and private insurance schemes and out-of-pocket payments8,9. The system was fully established between 1979 and 1983 and

explicitly organized around PHC principles: a network of health centres staffed by family physicians and nurses progressively covered

the entire country. Eligibility for benefi ts under the national health

system requires patients to register with a family physician in a

health centre as the fi rst point of contact. Portugal considers this

network to be its greatest success in terms of improved access

to care and health gains6

.

Life expectancy at birth is now 9.2 years more than it was 30

years ago, while the GDP per capita has doubled. Portugal’s

performance in reducing mortality in various age groups has

been among the world’s most consistently successful over the

last 30 years, for example halving infant mortality rates every

eight years. This performance has led to a marked convergence

of the health of Portugal’s population with that of other countries

in the region10.

Multivariate analysis of the time series of the various mortality

indices since 1960 shows that the decision to base Portugal’s

health policy on PHC principles, with the development of a

network of comprehensive primary care services11, has played

a major role in the reduction of maternal and child mortality,

whereas the reduction of perinatal mortality was linked to the

development of the hospital network. The relative roles of the

development of primary care, hospital networks and economic

growth to the improvement of mortality indices since 1960 are

shown in Figure 1.2.

Figure 1.2 Factors explaning mortality reduction in Portugal, 1960–2008

Relative weight of factors (%)

Growth in GDP per capita (constant prices)

Development of hospital networks (hospital

physicians and nurses per inhabitant)

Development of primary care networks (primary

care physicians and nurses per inhabitant)

86% reduction of

infant mortality

71% reduction of

perinatal mortality

89% reduction in

child mortality

96% reduction in

maternal mortality

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The World Health Report 2008

16

Primary Health Care – Now More Than Ever

Care that puts people fi rst

People obviously want effective health care

when they are sick or injured. They want it to

come from providers with the integrity to act

in their best interests, equi tably and honestly,

with knowledge and compe tence. The demand

for competence is not trivial: it fuels the health

economy with steadily increased demand for

professional care (doctors, nurses and other

non-physician clinicians who play an increasing role in both industrialized and developing

countries)129. For example, throughout the world,

women are switching from the use of traditional

birth attendants to midwives, doctors and obstetricians (Figure 1.12)130.

The PHC movement has underestimated the

speed with which the transition in demand from

traditional caregivers to professional care would

bypass initial attempts to rapidly expand access

to health care by relying on non-professional

“community health workers”, with their added

value of cultural competence. Where strategies

for extending PHC coverage proposed lay workers

as an alternative rather than as a complement to

professionals, the care provided has often been

perceived to be poor131. This has pushed people

towards commercial care, which they, rightly or

wrongly, perceived to be more competent, while

attention was diverted from the challenge of more

effectively incorporating professionals under the

umbrella of PHC.

Proponents of PHC were right about the importance of cultural and relational competence,

which was to be the key comparative advantage of

community health workers. Citizens in the developing world, like those in rich countries, are not

looking for technical competence alone: they also

want health-care providers to be understanding,

respectful and trustworthy132. They want health

care to be organized around their needs, respectful of their beliefs and sensitive to their particular

situation in life. They do not want to be taken

advantage of by unscrupulous providers, nor do

they want to be considered mere targets for disease control programmes (they may never have

liked that, but they are now certainly becoming

more vocal about it). In poor and rich countries,

people want more from health care than interventions. Increasingly, there is recognition that the

resolution of health problems should take into

account the socio-cultural context of the families

and communities where they occur133.

Much public and private health care today is

organized around what providers consider to be

effective and convenient, often with little attention to or understanding of what is important

for their clients134. Things do not have to be that

way. As experience – particularly from industrialized countries – has shown, health services

can be made more people-centred. This makes

them more effective and also provides a more

rewarding working environment135. Regrettably,

developing countries have often put less emphasis

on making services more people-centred, as if

this were less relevant in resource-constrained

circumstances. However, neglecting people’s

needs and expectations is a recipe for disconnecting health services from the communities they

serve. People-centredness is not a luxury, it is a

necessity, also for services catering to the poor.

Only people-centred services will minimize social

exclusion and avoid leaving people at the mercy of

unregulated commercialized health care, where

the illusion of a more responsive environment

carries a hefty price in terms of fi nancial expense

and iatrogenesis.

Securing the health of communities

People do not think about health only in terms of

sickness or injury, but also in terms of what they

perceive as endangering their health and that of

their community118. Whereas cultural and political explanations for health hazards vary widely,

there is a general and growing tendency to hold

the authorities responsible for offering protection

against, or rapidly responding to such dangers136.

This is an essential part of the social contract

that gives legitimacy to the state. Politicians in

rich as well as poor countries increasingly ignore

their duty to protect people from health hazards

at their peril: witness the political fall-out of the

poor management of the hurricane Katrina disaster in the United States in 2005, or of the 2008

garbage disposal crisis in Naples, Italy.

Access to information about health hazards in

our globalizing world is increasing. Knowledge

is spreading beyond the community of health

professionals and scientifi c experts. Concerns

about health hazards are no longer limited to

the traditional public health agenda of improving

17

Chapter 1. The challenges of a changing world

the quality of drinking water and sanitation to

prevent and control infectious diseases. In the

wake of the 1986 Ottawa Charter for Health

Promotion137, a much wider array of issues constitute the health promotion agenda, including

food safety and environmental hazards as well as

collective lifestyles, and the social environment

that affects health and quality of life138. In recent

years, it has been complemented by growing concerns for a health hazard that used to enjoy little

visibility, but is increasingly the object of media

coverage: the risks to the safety of patients139.

Reliable, responsive health authorities

During the 20th century, health has progressively

been incorporated as a public good guaranteed

by government entitlement. There may be disagreement as to how broadly to defi ne the welfare

state and the collective goods that go with it140,141,

but, in modernizing states, the social and political responsibility entrusted to health authorities – not just ministries of health, but also local

governmental structures, professional organizations and civil society organizations with a quasigovernmental role – is expanding.

Circumstances or short-term political expediency may at times tempt governments to withdraw

from their social responsibilities for fi nancing

and regulating the health sector, or from service

delivery and essential public health functions.

Predictably, this creates more problems than it

solves. Whether by choice or because of external pressure, the withdrawal of the state that

occurred in the 1980s and 1990s in China and the

former Soviet Union, as well as in a considerable

number of low-income countries, has had visible

and worrisome consequences for health and for

the functioning of health services. Signifi cantly,

it has created social tensions that affected the

legitimacy of political leadership119.

In many parts of the world, there is considerable skepticism about the way and the extent to

which health authorities assume their responsibilities for health. Surveys show a trend of

diminishing trust in public institutions as guarantors of the equity, honesty and integrity of the

health sector123,142,143. Nevertheless, on the whole,

people expect their health authorities to work

for the common good, to do this well and with

foresight144. There is a multiplication of scoring

Figure 1.12 The professionalization of birthing care: percentage of births assisted

by professional and other carers in selected areas, 2000 and 2005

with projections to 2015a

Percentage of births

a Source: Pooled data from 88 DHS surveys 1995–2006, linear projection to 2015.

Lay person

0

100

Sub-Saharan

Africa

60

40

20

2000 2005 2015

South and South-East

Asia

2000 2005 2015

Middle East, North Africa

and Central Asia

2000 2005 2015

Latin America and

the Caribbean

2000 2005 2015

80

Traditional birth

attendant

Other health

professional

Doctor

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POcMXqkJkPWYFmwIax H6 7E 65 0D JM 3U 1W H5 2X LU IR 85 TW T5 CG 79 KJBGIUhieHBeZswv

POcMXqkJkPWYFmwIax ZP H4 HV NC 9Y 8Q MQ A5 IE CT 5Q J6 4Y 5I LZ IU fxrAfYIWlXuERTOL

POcMXqkJkwaSEoFnPPPWYFmwIaxPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxwaSEoFnPPPOcMXqkJkwaSEoFnPPPOcMXqkJkPWYFmwIax
PWYFmwIaxPOcMXqkJkwaSEoFnPPPOcMXqkJkwaSEoFnPPPWYFmwIaxwaSEoFnPPPOcMXqkJkPWYFmwIax
PWYFmwIaxPOcMXqkJkwaSEoFnPPwaSEoFnPPPOcMXqkJkPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxPWYFmwIaxwaSEoFnPPPOcMXqkJk
waSEoFnPPPOcMXqkJkPWYFmwIaxPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxwaSEoFnPPPOcMXqkJkPOcMXqkJkwaSEoFnPPPWYFmwIax
PWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxwaSEoFnPPPOcMXqkJkPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxPOcMXqkJkwaSEoFnPPPWYFmwIaxPOcMXqkJkwaSEoFnPP

thank you

SatelSatellite*Deals – TNTADMIN@cboy.eachright.com

The above email is a scam. If you still think is legitimate, but you’re still concerned, then follow these steps:

Ten Minutes 10 minutes.

How to check if you received a scam email

  1. Google the details.

    Do a Google search for the persons name/company name that the email has come from.

  2. Confirm the details.

    Visit their website and look for a phone number or email address. Search for the website yourself. Do not assume the details in the email are valid.

  3. Confirm using the information you have found

    Using the details you have researched, call or email the business and ask them to verify the information within the email.

  4. Check if the email has been sent to multiple people

    Google snippets of the email text to see if the same format has been used in the past. eg “Army officer from Syria but now living with the United Nations on asylum”

Most of us know someone who is vulnerable to these types of attacks. Fortunately, if you’re aware of the presence of these scams, and armed with some basic knowledge on identifying them, you can greatly reduce your chances people you know becoming a victim. Please help them by sharing this information on Facebook or Twitter using the #telltwo and #takefive hashtags.
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