From my perspective the author’s diagnosis is essentially right. There is overall consensus that recent decades have seen an increase in inequities in general and health in particular. Some LDC countries are even showing deteriorating health outcome averages (in some cases due to the HIV/AIDS pandemic). In light of the 3 key Reports they refer to, the authors also provide us with the causes for this explosion in health inequities.
It is not only that health systems have not improved or in many cases have frankly deteriorated from the already difficult situation they used to face. This has happened also and mainly because the social determinants of health have also got worse especially for many of the poor. But the picture is even more complex, the issue is the result also because the gap between the poor and the rich and also in between all socio economic groups (gradient) has clearly worsened. The epidemiological transition has also been quoted as a contributing factor for such complex scenario.
I would expect an increasing degree of consensus in the above diagnosis. Nevertheless, what is still missing is consensus in the solutions. As rightly pointed out by the authors, the three alluded Reports coincide in general with the need to renew the PHC paradigm BUT taking into account the new developments. It is a matter of raising and reaffirming the equity value and accordingly, to contextualize PHC policy within the context of the changing world and the emergence of new actors. In this regard the PHC renewal process being launched by WHO’s DG with an emphasis on the social determinants of health, is a central step forward. This process requires strong advocacy by all actors but more than anything, it requires achieving global political consensus and will. The financial, environmental, energy and food crisis could and should be the triggering factor to achieve this huge political change. We may not have any other chance to avoid more disaster.
I think all of us have responsibilities to in reducing health inequalities but there needs to be leadership in order to achieve concerted, useful action, commensurate with the challenge. Certainly governments have the prime responsibility both in mandating and resourcing WHO as well as leading national processes. WHO has a huge responsibility to move forward with such a mandate. It needs to lead and converge disparate global efforts being focussed on few diseases towards a concerted new PHC strategy based on equity with a comprehensive approach which delivers universal health systems and improved social determinants of health. Civil Society needs also to get empowered in order to represent in a participatory way the voice of the excluded and the poor. This needs to be a two way bottom up and top down approach, if it is to work in a democratic, effective and sustainable way with full respect of human rights. The private sector also needs to come along within the framework of financial, managerial and technological resources subordinated to people’s and government need and lead. All the above should result in a transformation of daily health practice as the WHR 2008 on PHC clearly points out: universal access, putting people first, intersectoral action; and all led by effective, participatory government.
There have been criticisms that private foundations, the big health spenders, are too technocratic and disease-specific to make the most of their impact. Evidence shows that those criticisms have a degree of certainty. As referred above, though, many of those initiatives have appeared in response to a failure of global and national governance to address old and new health threats. The way forward needs not less private sector involvement but more and as discussed, more comprehensive, government leadership and beyond the margins of the health sector per se. Only such comprehensive approaches and processes will be able to deal with diseases in an equitable and effective way but more than anything, will improve health equity and contribute to better governance and democracy in full respect of ethical and human rights imperatives.