A Time for Action on Health Inequities: Foundations of the 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All

Abstract

Global inequalities contribute to marked disparities in health and wellness of human populations. Many opportunities now exist to provide health care to all people in a person- and people-centered way that is effective, equitable, and sustainable. We review these opportunities and the scientific, historical, and philosophical considerations that form the basis for the International College of Person-centered Medicine’s 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All. Using consistent time-series data, we critically examine examples of universal healthcare systems in Chile, Spain, and Cuba.

In a person-centered approach to public health, people are recognized to have intrinsic dignity and are treated with respect to encourage their developing health and happiness. A person-centered approach supports the freedom and the responsibility to develop one’s life in ways that are personally meaningful and that are respectful of others and the environment in which we live together. Evidence suggests that health care organizations function well when they operate in a person-and people-centered way because that stimulates better coordination, cooperation, and social trust.

Health care coverage must be integrated at several interconnected levels in order to be effective, efficient, and fair. To reduce the burden of disease, integration is needed between the people seeking and delivering care, within the social network of each person, across the trajectory of each person’s life, among primary caregivers and specialists, and across multiple sectors of society. For integration to succeed across all these levels, it must foster common values and a shared vision of the future.

A Time for Far-sighted Decisions and Swift Action

Global economic inequalities and inequities in the distribution of resources contribute to enormous disparities in the current health and wellness of human populations. Many opportunities are now available to address these inequities by improving health care, but we must face the challenges of current world conditions with reason and resolve to be motivated to act decisively and effectively. Fundamental changes in many sectors of society will be required because healthcare is only one component of a complex biopsychosocial system in which environmental, economic, educational, emotional, social, cultural, and political phenomena influence one another [1]. In this article, we review the opportunities and challenges for universal health care from scientific, historical, and philosophical perspectives. We examine concrete examples of healthcare systems that are reputed to be successful using consistent time- series data to evaluate the impact of programmatic changes within their economic, sociocultural, and political context. We include insights from complex adaptive systems theory as a way to begin to address the complexity of global human systems [2]. This review describes the foundations for the Geneva Declaration on People- and Person-centered Integrated Health Care for All, which was issued as a consensus statement of the International College of Person-centered Medicine (ICPCM) in 2014.

Despite the opportunities for health promotion available today, immoderate consumption by a small minority of an increasing human population has led to a convergence of interrelated problems including an increased burden of chronic disease, massive extinction of animal and plant species, ecological degradation with climate change and unsustainable depletion of planetary resources, economic stagnation, and military conflict [3, 4]. Given these serious challenges, human well-being, health promotion, and disease prevention require integrated systemic approaches to interrelated problems in order to build resilience and maintain healthy settings in family dwellings, schools, workplaces, hospitals, and worldwide [5–7]. Living conditions on our planet may be approaching a tipping point in which the global ecological state is likely to shift in unpredictable ways, so that people need to prepare to adapt to unprecedented environmental forces [8], even though sudden transitions in the biosphere are not a certainty [9].

There are growing inequities within and between countries in access to medical, educational, and social services to help people to cope with increasingly complex challenges [7, 10, 11]. Most resources devoted to health are spent on acute treatment, while neglecting efforts for prevention and health promotion that could cut 70% of the global disease burden because the actual causes of disease are largely related to lifestyle, living conditions, and other social determinants of health [12–16] that can be changed by person-centered approaches [17, 18]. Economic stagnation can provoke austerity in spending for medical, educational, and social services, which in turn leads to further economic downturn, creating a vicious downward spiral of declining living conditions and well-being [5, 7, 11]. Without decisive, swift, and far-sighted action, unsustainable inequities in consumption and resource depletion will persist past the point at which ecological damage becomes irreversible [4].

At its Millennium Summit in 2000, the United Nations set 8 interrelated goals that were endorsed by all its 189 member states and 23 allied international organizations. The Millennium Development Goals are to halve the prevalence of extreme poverty and hunger, to promote universal primary education, to promote gender equality, environmental sustainability, and to improve health (addressing maternal and child health, AIDS, malaria and other diseases) by means of a global partnership for the development of these goals [19]. In response to these interrelated challenges, the World Health Organization (WHO) has proposed to promote integrated primary healthcare for all people [10]. According to WHO’s vision, universal health coverage means that everyone has access to the quality health services that they need without risking financial hardship from the costs of care [20]. WHO suggests that such coverage requires an integrated health system with access to essential medicines and technologies as well as sufficient well-trained and motivated healthcare workers. WHO also recognizes that the major challenge for most countries around the world will be how to expand health services to meet growing needs with limited resources. The ICPCM recognizes the social determinants of health and illness as key components in Person-centered Integrative Diagnosis (PID) within its broad bio-psychosocial framework [21].

In this article we will explore the philosophical, scientific, and historical foundations of the call by the United Nations and its World Health Organization for person-centered integrated healthcare for all as a component of the complex systems that make up human society. This article is part of a series intended to provide a knowledge base for the International College of Person-centered Medicine (ICPCM). The Geneva Declarations series began in 2012 as a way to share information from the ICPCM conferences held in Geneva, Switzerland annually [22–24]. The ICPCM general assembly approved the Declaration on Person- and People-centered Integrated Health Care for All on April 30, 2014 [25]. This article summarizes the information considered in the preparation of the 2014 declaration.

Method

As an international college committed to health promotion based on both scientific and humanistic principles, we seek to outline a coherent foundation for universal health coverage based on an integrated examination of a reason-based understanding of human nature, scientific findings about the psychobiological and social conditions requisite for health promotion, and empirical historical observations about what governance structures and styles are effective in promoting health. Public health policy must be integrated with principles and evidence from business, science, and philosophy in order to identify ways to promote health that are cost-effective, sustainable, and fair.¹

In November 2013, a committee was appointed by the ICPCM Board to prepare a draft of the declaration and a background paper. Committee members were selected from a wide range of disciplines and divergent value-based perspectives. Most of the committee was able to meet in person in November 2013 during an ICPCM-sponsored conference in Zagreb, Croatia. Committee members recommended key source material to guide the committee chair (CRC) in preparing an initial draft of the background paper for subsequent comment and revision by the whole committee through email exchanges and a series of 3 monthly teleconferences held prior to the April 2014 annual meeting in Geneva. The initial draft was extensively revised and the revised draft was also sent to other ICPCM experts and the Board for feedback. It was difficult to achieve a consensus on all the points of discussion in the preliminary background paper. Some committee members suggested that evidence-based and value-based observations and arguments should be separated, whereas most wanted to see what scientific and historical evidence was available to test philosophical claims. Eventually the committee had to focus on developing consensus about the content of the Declaration, which did not have to include all the points in the background paper. The resulting draft of the Declaration was presented, discussed, and revised again in meetings with participants at the 7^th Geneva Conference in April in order to achieve consensus, clarity, and to emphasize concrete actions that could have a practical impact. The final draft was presented at the closing session on April 30^th for approval by the general assembly.

Based on all the preceding discussion and revisions that led to the final Declaration, the background paper was revised to the form presented here following a final round of comments by each of the committee members. Given the range of fields of expertise and divergent value-based perspectives of the committee, the Declaration can be considered a consensus statement but this background article may include some statements that not all authors would agree with fully. It is intended to represent the range of considerations and perspectives taken into account in formulating the consensus Declaration, to emphasize areas of consensus but to include other key issues that require continued study and debate. If we were to reduce it to what everyone agreed with fully, then it would not really represent all the issues that were considered. Therefore, where there was substantial disagreement among committee members, we chose to acknowledge the range of opinions to allow readers to consider all perspectives. Committee members learned that to work together they had to be tolerant and respectful of divergent points of view and to learn from their differences. In other words, we found that our committee process, like other complex adaptive human systems, had to be person-centered in order to optimize its productivity. We hope that the following considerations will be read in that same spirit and will stimulate further reflection and development of these observations.

We chose not to repeat the content of the 2014 Geneva Declaration, including its description of what is meant by person-centered and people-centered care. These key terms are also described and discussed in detail elsewhere [21, 26, 27].

Philosophical Foundations of Universal Health Coverage

Human Dignity and Moral Universalism

The motivation for universal health coverage is grounded fundamentally on the idea that all human beings possess equal worth and deserve equal respect, which may be referred to as the intrinsic dignity of all people [28]. The intrinsic dignity implied by the self-aware nature of human beings is a strong rational basis for the moral principle of universality, which means that what is right for one person must apply to all people who are similarly situated, regardless of gender, race, nationality, culture, religion, politics, or other distinguishing characteristics like wealth or intelligence [29]. Likewise, shared vulnerability to suffering is a corollary aspect of the dignity of self-aware human beings, and implies that what is wrong for one person must be wrong for all people who are similarly situated.

The principle of moral universalism is opposed to moral relativism, which holds that different cultures differ so much in their moral judgments that there is no basis for knowing what is right or wrong for people in other cultures [30]. There are certainly differences in normative behavior and values between cultures, but cross-cultural studies show that human beings in all cultures agree substantially on the dimensions of life that they value [31, 32]. Nevertheless, within complex systems there is much diversity at every level of organization because this facilitates flexible and sustainable adaptability to ever-changing conditions [33, 34]. Cultural diversity is thus an important consideration in efforts to articulate universal human rights [35]. There are also important differences between individuals within a given culture in values and characteristics such as self-directedness (i.e., being resourceful, purposeful, and responsible), cooperativeness (i.e., being tolerant, helpful, and principled), and self-transcendence (i.e., being able to identify with the needs and welfare of others and not only one’s selfish interests) [36, 37]. Likewise, at the social and cultural level, there are differences between the norms of different cultures in values for openness to change (self-direction vs conformity, tradition, security) and self-transcendence (benevolence, universalism vs self-enhancing power and achievement) [32, 38]. Societies that highly value openness to change emphasize the importance of liberty rights (e.g., self-directedness), those that highly value universalism (e.g. cooperativeness and self-transcendence) emphasize the importance of welfare rights, and those that highly value both may be described as fully person-centered (which recognizes the importance of both liberty and welfare rights).

In 1946 the World Health Organization of the United Nations defined health as “a complete state of physical, mental, and social well-being and more than the absence of infirmity and disease” [39]. The United Nations took a person-centered view of human rights, dedicating itself to both the liberty rights and the duties of people to help one another to facilitate the free and full development of their personalities in order to achieve health, happiness, and fulfillment. Specifically, in 1948 the General Assembly of the United Nations adopted the Universal Declaration of Human Rights (UNDR) [40], which states in its first article that “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act toward one another in a spirit of brotherhood.” According to this declaration, the self-aware nature of human beings is the foundation for all persons to be treated with equal dignity and respect, including rights to “freedom, justice and peace in the world.” Along with freedom comes responsibility according to Article 29 of the Declaration: “Everyone has duties to the community in which alone the free and full development of his personality is possible.” These liberties and duties are taken to imply welfare rights, such as education, health, social security, and time for both work and leisure (articles 24 to 28).

The 30 articles of the UNDR have been elaborated in subsequent international treaties, leading in 1976 to the International Bill of Human Rights that includes the Universal Declaration of Human Rights along with two covenants on Economic, Social and Cultural Rights and on Civil and Political Rights [41]. The UNDR is part of customary international law and has been widely translated and praised. It has also received some criticism from some countries, such as Saudi Arabia, as a secular interpretation of Judeo-Christian traditions, but other Islamic countries have supported it.

Scientific Critique of Moral Universalism

Philosophers have long recognized the intrinsic dignity of all persons because of their self-awareness [29]. Independent of any religious or spiritual considerations, there is strong scientific evidence of the unique status of human beings as self-aware beings [42, 43]. Human self-awareness provides a strong rational basis for recognition of the intrinsic dignity of all human beings. For example, Kant argued that the dignity of human beings is derived from their being self-aware and hence free and autonomous in governing their lives. Furthermore, Kant argued that reason also implies a duty for people in social groups to treat one another with respect and act in ways that can be applied universally. Technological advances in recent times have only intensified the need to recognize the responsibility to consider the well-being of others and to ensure a healthy environment for future generations [44, 45]. In other words, it can be reasonably argued that duties to contribute to social equity and environmental sustainability are necessary corollaries of personal liberty rights.

However, libertarians question the logical necessity of linking welfare rights with liberty rights and advocate an individualistic and selfish approach to living. They regard individual freedom from interference by others (i.e., “negative liberty”) as more important than other values like social equity and altruism [46, 47]. Psychological research on the personality profiles of libertarians shows that they are highly self-directed people who feel unusually separate from other people and the world, as indicated by measures of social relatedness (i.e., empathy, social warmth, cooperativeness) and moral universalism (i.e., self-transcendence, altruism) [46]. In other words, they manifest selfish and autocratic behaviors (i.e., they are self-directed individuals who are low in cooperativeness and self-transcendence). There are claims that selfishness is healthy [48, 49], even though such attitudes are often associated with unethical behavior in business organizations and communities [50].

The allegation that selfishness is healthy or even virtuous is doubtful, not only because it ignores the primacy of social bonds and relationships for human health and adaptive functioning, but also because it is not consistent with empirical research on well-being.² How well people are able to exercise their partial freedom of will to benefit others has been empirically found to strongly influence their health and happiness [29]. An intimate relationship between prosocial behavior, planning according to a mental template, and self-awareness developed in the ancestral line leading to modern humans because of the importance of emotional reconciliation, learning, and memory for survival in diurnal social groups [51–55]. For example, creative freedom activates the brain network that instantiates self-aware learning, as shown in such cooperative activities as improvisation in jazz ensembles [56]. Kindness in valued actions toward others and participation in artistic and cultural activities are crucial aspects of social engagement and group cohesion that also activate the self-awareness brain network [57] and lead to personal satisfaction and health [58, 59]. On the other hand, selfish or exploitative actions do not activate the self-awareness brain network [60].

Empirical psychobiological research has confirmed that a healthy personality requires the combination of being self-directed, cooperative, and self-transcendent [61, 62]. People with “selfish autocratic” behaviors (i.e., those who are self-directed but not cooperative and self-transcendent) tend to be unhealthy in terms of physical, mental, and social indicators of well-being, including both subjective measures [61] and objective measures of autonomic balance and metabolic profiles [63]. At the social level, indicators of distrust and inequity are strongly associated with poor health both between and within countries and communities [64–72]. When people are demoralized (i.e., low in self-directedness, cooperativeness, and self-transcendence) or societies are demoralized (i.e., do not honor both liberty and welfare rights of people and the environment), they rapidly spiral down in illness and social dysfunction [37, 73, 74]. These and other empirical findings consistently indicate that selfishness is unhealthy, supporting the proposition that both personal liberty and responsibility to others and the environment are inseparable components of well-being.

Healthy functioning requires not only liberty rights but also responsibility for the collective welfare of others and the environment. The capacity to express character strengths and ideals matures along with the brain networks that instantiate self-awareness [75, 76], and the self-awareness brain network is only activated when people are engaged in valued actions that are free, kind and fair (that is, egalitarian and non-exploitative) [37, 56, 60]. These observations about the psychobiological conditions of human self-awareness support the philosophical arguments that ground moral universalism in self-aware reasoning.

Philosophical Implications of the Psychobiology of Self-Awareness and Well-being

The intrinsic dignity of all human beings does imply rights for personal freedom, as well as duties to others to respect their freedom, but some philosophers doubt that the right to health advocated in UNDR is justified if a right to health is understood to be necessary and unconditional [77]. Personal health is only one component of a complex biopsychosocial system, so decisions about healthcare must be made in an integrated way that is conditional on other decisions about other activities. In other words, all the rights in UNDR may be conditional on one another. If someone chooses to smoke cigarettes and contracts lung cancer, must other people subsidize the costs of complications of their decisions? Isn’t it unavoidable and proper to consider economic costs and benefits of providing healthcare? Expenditures must be sustainable at each step in the practical development of healthy living conditions. On the other hand, if provision of access to clean water, land for farming, and improved education and work opportunities can be more effective in improving public health, must expensive treatments for the complications of disease be provided if that would exhaust the funds needed to correct the causes of those diseases through public work projects? Improved sickness care is not necessarily the most effective way to promote health because many personal, social, and occupational variables have strong influences on health [68, 70, 78, 79]. Yet whatever is done must be equitable or there will be decreased trust and solidarity among people, which frequently leads to a downward spiral of socioeconomic problems and ill health [72].

The intrinsic dignity of human beings is recognized in all cultures despite differences in beliefs about how this dignity can best be supported. Disagreements about democratic, socialistic and communistic approaches to government were intense throughout the 20^th century, but each approach tried to justify itself as the best way to promote human dignity and well-being. There have always been disagreements about the advantages and disadvantages of vertical control by a leader or elite group versus more horizontal (decentralized democratic) approaches and of the forms of economic life most conducive to human well-being [74, 80, 81]. Nevertheless it is important to recognize that values like making economic profits are secondary to the fundamental goal of government to promote well-being for all people, all of whom have equal worth and deserve equal respect. If we recognize the self-aware nature of all human beings and accept the principle of moral universality, then we must always treat people as ends in themselves, not as means to an end [29].

Distinguishing Equity from Equality

Equality and equity do not necessarily mean the same thing. Equality of healthcare is an empirical concept that means that health promotion and treatments are the same everywhere, whereas equity is a value-based concept that implies a principle of fairness in access to care that is appropriate for particular situations, even though methods, utilization, and outcomes may differ [82]. Health inequities can be defined as differences in health that are “unnecessary, avoidable, unfair, and unjust” [83]. Some inequalities can be considered fair, for example when someone is well-compensated for hazardous work [84]. Other inequalities can be unavoidable, such as the differences in health between elderly and young people. What is fair and achievable in promoting the highest possible health of all people depends on the situation in which people live. Resources, traditions, and values do differ among various countries or regions, so the development of different forms of healthcare in different situations may be both fair and practical.³

With this philosophical foundation in mind, let us consider the practical history of universal coverage for all, beginning with the Alma-Ata Declaration in 1978. We seek empirical evidence of what works and what does not work in setting targets for health care and in the ways of organizing the governance of efforts to promote health and provide health care. The successes and failures of the past can help to guide how we design public health policy to meet the health care challenges we face today.

Recent History of Universal Healthcare Coverage

Effects of Decolonization on Health Care

The 1960s and 1970s was a period of newly won independence from colonial powers for many developing countries. Governments in many developing countries sought to establish high-quality programs for education, healthcare, and social services [85]. Schools and teaching hospitals were established to train physicians and nurses, often in urban areas. Unfortunately, these programs were expensive and often failed to reach people in poor and rural areas, so that morbidity and mortality in rural communities did not improve and sometimes deteriorated [85]. In response, several countries including China, Venezuela, Tanzania and Sudan implemented programs that successfully delivered a basic but comprehensive program of primary healthcare services to poor rural populations with assistance from WHO [86, 87]. These primary health care (PHC) programs emphasized local community engagement and questioned top-down management by politicians and medical professionals. Emphasis was placed on community-based preventive service and equitable access at affordable prices to curative care [85]. In PHC healthcare workers include “physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community” [88]. Thus PHC is a community-based program that “reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience” [88]. These programs run in parallel with programs to strengthen community support and horizontal integration of care for persons with disabilities, such as the WHO Community-Based Rehabilitation (CBR) program [89].

Comprehensive Primary Health Care & the Declaration of Alma-Ata

In 1978 the Declaration of Alma-Ata affirmed that health is a fundamental human right and that the attainment of the highest possible level of health is one of the most important social goals worldwide. The Declaration formally adopted the PHC model as the key means to provide comprehensive, equitable, and affordable healthcare services to all people in order to redress the existing inequalities in health between developed and developing countries, as well as within countries [88]. The International Conference on Primary Health Care at Alma-Ata took place at a time when the pre-eminent role of a central government in the provision of health, education, and welfare services was the norm in most developed countries:

“Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.” Article 5, Alma-Ata Declaration 1978 [88]

Primary healthcare was affirmed as the key to attaining this target in the spirit of social justice.

“Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.” Article 6, Alma-Ata Declaration, 1978 [88]

PHC was intended to comprehensively address the main health problems in the community, including health promotion, prevention, curative treatment, and rehabilitation. At a minimum, PHC interventions included: education concerning prevailing health problems and methods of preventing and controlling them; promotion of secure food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child healthcare, as well as family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.

As envisaged by the Alma-Ata Declaration, PHC was fundamentally person-centered and affirmed that “people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare [90].” The emphasis on PHC shifted healthcare from acute treatment in large hospitals to community-based delivery of services with a cost-effective balance of programs for health promotion, prevention, treatment, and rehabilitation. The approach was integrative with attention to the education of individuals, training and coordination within healthcare teams, communities, countries, and internationally. PHC was intersectoral, involving coordination across healthcare, agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors. The community was to be represented by leaders on community-based Primary Health Committees that would plan and implement their own healthcare services. If physicians and nurses were not available, village volunteers were to be trained to function as a formal part of the healthcare system.

National governments throughout the world quickly adopted PHC as their official approach to universal healthcare coverage. The WHO outlined a global strategy with specific goals and targets for achieving health for all by the year 2000 [90]. The declaration had been explicit in emphasizing person-centered principles that it hoped would underlie a “New International Economic Order” that would reduce social inequity and promote peace and well-being. The Alma-Ata Declaration and WHO’s global strategy for a New Economic Order proposed that increased costs for progressive development of social equity around the world could be achieved by community-based governance and reduced military spending. In the New Economic Order, according to the WHO, mutual international respect and cooperation would replace the military-economic hegemony of the West, decreasing military spending that serves to support social inequity around the world.

Soon after the Declaration of Alma-Ata was issued, it came under attack [91]. The Rockefeller Foundation sponsored a conference on Health and Population Development at its Conference Center in Bellagio, Italy in 1979 together with the World Bank and the United States Agency for International Development (USAID) [91]. The main focus of debate on international development at that time was on the impact of exponential growth in the human population on economic development and environmental sustainability [92]. Researchers and policy makers in the global North (especially USA and Western Europe) suggested that rapid population growth in the developing countries of the global South (especially Africa, Asia, Latin America, and the Middle East) were detrimental to global economic growth, social cohesion, political stability, and environmental sustainability [92–94].

Consequently policy makers promoted measures to reduce birth rates in the developing countries, including China and several other countries [92, 95, 96]. Reduced fertility did have some health and economic benefits under some conditions [92, 95], but also had undesirable demographic consequences such as an aging population and gender inequity when applied forcefully [97]. Tying foreign aid to compliance with Western priorities about family planning proved to be a double-edged sword, offering welcome opportunities for choice about family size to some women but also subjecting others to coercive policies that would be unacceptable in donor nations [98].⁴

Fortunately recognition of the social determinants of health was resurgent following the Alma-Ata Declaration, partly in response to epidemic chronic diseases in affluent countries despite the promises of molecular medicine [22, 99]. Leon Eisenberg reminded us that Virchow’s aphorism remained as true as it had been in 1848: “If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life [16].” The increased attention to social determinants of health precipitated consideration of more people-centered approaches to family planning and other public health policies. The early concerns about population growth were cast in doubt when inequality between and within countries was found to be the major determinant of global economic stagnation and ecological degradation by the time of the 1992 UN Conference on the Environment and Development in Rio de Janeiro [92, 100]. The imbalance of extreme consumption in the North and extreme poverty in the South, not population growth, were recognized as the main causes of global economic and ecological problems by 1992. Nevertheless, when the Alma-Ata Declaration was issued in 1978, many influential policy makers in some developed countries, such as the Rockefeller Foundation, World Bank, and USAID felt that the best way to promote global economic growth involved a more selective approach to primary health care [92].

Selective Primary Health Care

Some policy-makers in highly developed countries favored their own vertical control over healthcare initiatives and rejected the core PHC principle that communities in developing countries would have authority for planning and implementing their own healthcare services. However, there was not a common policy in all high-income countries; in particular, there were substantially different approaches between welfare-oriented states and more market-driven states. For example, some welfare-oriented developed countries, such as Spain, developed community-oriented primary care systems and have achieved a high life expectancy at a much lower cost than competitive market-driven systems [101]. Nevertheless, many experts in more market-driven countries dismissed the Declaration of Alma-Ata as too idealistic, too comprehensive, too expensive, and unachievable because it lacked specific targets [85, 91]. They proposed an alternative approach labeled as “Selective Primary Health Care” (SPHC) that was more selective (i.e., narrowly targeted) and vertically controlled rather than community-based. While the debate between selective versus comprehensive primary healthcare continued, the United Nation’s Children’s Fund (UNICEF) launched its Children’s Revolution in 1982/83 to promote four specific social and scientific advances for improving the health and nutrition of the world’s children. UNICEF focused only on PHC interventions that contributed most cost-effectively to reducing child mortality in developing countries, including infant growth monitoring, oral rehydration solutions, breastfeeding, and immunization [102].

UNICEF’s Children’s Revolution provided a model for achieving health for all by targeting for action a prioritized list of diseases without addressing the controversial issue of top-down control versus person-centeredness. A conference on Good Health at Low Cost was held in 1985 where presenters provided detailed analyses of successful programs in developing areas, such as Costa Rica, China, Kerala, and Sri Lanka that identified a number of measures that allowed progress in healthcare despite limited resources [102]. Nevertheless, the debate between selective and comprehensive primary healthcare continued throughout the 1980s [85].

Chile as an example of Selective and Comprehensive PHC Programs

There have been reputedly successful PHC programs in countries in transition to high income (e.g. Chile), in the West (e.g., Spain), and in low- to middle-income countries (e.g., Cuba) [12, 101, 103, 104]. As shown in Table 1, The UN’s Health Development Index (HDI), comprised of measures of life expectancy, schooling, and gross national income (GNI) per capita, provided consistent time-series data to allow comparisons.

Table 1.

Human Development Index (HDI) trends from 1980 to 2013 in the US, Spain, Chile and Cuba based on the 2014 Human Development Report [105].

	Life Expectancy at birth	Expected Years of Schooling	Mean Years of Schooling	GNI* per capita (2011PPP$)	HDI
Mean OECD
2013	80.0	15.7	11.4	36,628	0.876
US
1980	73.8	14.1	11.9	29,633	0.825
1990	75.2	15.2	12.3	36,638	0.858
1995	76.0	15.7	12.7	39,079	0.875
2000	76.8	15.3	12.7	46,551	0.883
2005	77.6	15.9	12.8	50,203	0.897
2010	78.5	16.4	12.9	49,849	0.908
2013	78.9	16.5	12.9	52,308	0.914
SPAIN
1980	75.1	12.6	5.0	18,605	0.702
1990	77.0	14.2	6.0	23,452	0.755
1995	77.9	15.7	7.7	25,004	0.802
2000	79.0	15.9	8.4	29,819	0.826
2005	80.4	16.0	8.9	32,098	0.844
2010	81.7	16.8	9.5	31,415	0.864
2013	82.1	17.1	9.6	25,947	0.869
Mean Latin America & Caribbean
2013	74.9	13.7	7.9	13,767	0.740
CHILE
1980	69.1	11.3	6.4	7,756	0.640
1990	73.7	12.8	8.1	8,778	0.704
1995	75.1	12.0	8.4	12,380	0.724
2000	76.9	12.9	8.8	14,233	0.753
2005	78.3	14.0	9.5	15,684	0.785
2010	79.2	14.9	9.8	17,921	0.808
2013	80.0	15.1	9.8	20,804	0.822
CUBA
1980	73.8	12.1	6.5	9,983	0.681
1990	74.6	12.3	8.5	13,225	0.729
1995	75.4	11.3	9.2	8,891	0.710
2000	76.7	12.2	9.6	10,926	0.742
2005	77.7	14.6	9.9	13,841	0.786
2010	78.7	16.2	10.2	18,011	0.824
2013	79.3	14.5	10.2	19,844	0.815

^*GNI: Gross National Income; PPP$= purchasing power parity dollars

The example of Chile is particularly informative because it illustrates the impact of shifting policies and results over the past few decades. Chile has good average health indicators but marked economic inequality [104]. Chile provides nearly universal health care coverage through a social health insurance system with two separate programs: (i) a public health insurance system called the National Health Fund (Fonasa) that provides for three-fourths of the population including the indigent and people with low- and middle-incomes; and (ii) a private health insurance system that is composed of several for-profit private insurers (Isapres), which covers about one-sixth of the population, namely those with higher incomes who can afford risk-adjusted policies they chose according to their ability to pay. Before 2005 there were large differences between Fonasa and the Isapres, but legislation in 2005 attempted to reduce these differences to the extent that the government could afford. Health conditions in Chile have improved substantially along with the economy over the last few decades throughout a series of different approaches to health care. As shown in Table 1, the UN’s Health Development Index, comprised of measures of life expectancy, schooling, and gross national income (GNI) per capita, has risen steadily from 0.640 in 1980 to 0.822 in 2013, an increase of 28% that moved Chile into the high human development category [105].

In 2014, Chile ranked 33^rd in the WHO’s rankings of health care systems worldwide, flanked by Australia in 32^nd rank and Denmark in 34^th rank and above the USA at 37^th rank. However, the level of health varies markedly across socioeconomic groups, and much more work is needed to address equity in health, education, and socioeconomic conditions in an integrated manner despite a series of efforts at selective and then comprehensive PHC. In 1973 Augusto Pinochet led a military coup backed by the CIA that succeeded in overthrowing the democratically-elected socialist regime of President Salvador Allende in Chile. Pinochet was appointed President by the military junta in 1974 and ruled as dictator until 1990. In 1980, the libertarian (neoliberal) policies of economists trained at the University of Chicago were authorized by Pinochet under a new constitution. These policies resulted in privatization of much public property that had been nationalized under Allende and his predecessor. Parts of the education and health care systems were also privatized. There was a major banking crisis in 1982, inequity worsened, and health care facilities for the public deteriorated severely [104]. Gradually the global indicators of health, education, and wealth improved by 1990. As shown in Table 1, the overall HDI increased 1% per year between 1980 to 1990. Average life expectancy increased 0.67% per year from 69.1 years in 1980 to 73.7% in 1990. In Average expected years of schooling increased 0.62% per year from 11.3 in 1980 to 12.0 years in 1990. Average income per capita increased even more, 1.3% per year from $7756 in 1980 to $8778 in 1990.

Then for the next decade beginning in March 1990 with the election of a democratic government, the main goal of the new center-left coalition was to reduce poverty by stimulation of the economy broadly. Selective PHC was introduced. During the 1990s, Chile followed the management recommendations of the World Bank. Specific programs were introduced for child and adult acute respiratory diseases that led to a reduction in mortality for these particular problems. However, the constitution developed under Pinochet continued. This constitution created the legal framework that, with modifications since the return of elections, the country still observes. One of the main aspects of this constitution is the introduction of a “binomial” voting system, which effectively eliminated the multi-party system and favored two parties in the form of coalitions of previously existing ones. This binomial system has been the subject of much of the debate since the 90s and is seen as undemocratic and perpetuating the military’s legacy. In fact, average life expectancy and income showed small gains, and expected levels of education fell and then recouped its loss, so the overall HDI grew weakly (0.704 to 0.753), rising 0.70% per year from 1990 to 2000.

A socialist president, Lagos, was elected in 2000 with the support of the same coalition as the previous two Christian Democratic governments, and served until 2006. Lagos’s election motto was “crecer con igualdad” (“to grow with equality”). He was elected with the intention to foster greater social solidarity (i.e., to reduce inequity and increase trust) and to improve mental and physical health overall. One of the explicit goals of the left-wing coalition of the Lagos government was to empower people to recognize their legal right to health care and equal opportunity to access it, regardless of socioeconomic variables, as a progressive alternative to selective benefits and inequity in access to, and quality of, care. In 2004 Chile passed a law that made it the first example in Latin America of a universal health care system with a legal guarantee incorporating principles of universal access, quality, and limits to the maximum expenditure for health expenses for families according to their ability to pay, and protection [104]. This program, called Universal Access with Explicit Guarantees (Acceso Universal con Guarantias Explicitas, AUGE), was first implemented in 2005 [106]. Covered services under AUGE were added as permitted from income derived from a 1% increase in the consumer (Value-added) tax (i.e., VAT went from 18% to 19%), increased taxation of tobacco, and increased revenue from associated economic growth and customs revenues. Coverage decisions were made by democratically elected officials and they were prioritized according to an algorithm based on conditions with the greatest burden of disability, treatments with greatest evidence-based effectiveness, availability of capacity within the health care system to deliver service, costs, and social consensus. Universal coverage was introduced for many predefined diseases in 2004 and then coverage was progressively increased as resources permitted [104]. Although there was a shift from a libertarian to an egalitarian paradigm, the reform actually maintained a segregated system of public and private health care. People often sought private treatment if they could afford it when there the public services were inadequate. Little was done to reduce inequity in education or income, so socioeconomic inequity remained marked. The persistent socioeconomic inequity in Chile is accompanied by high rates of smoking, obesity, and suicide, and there has been little discernable improvement in life expectancy under UHC, which remains somewhat selective [104]. Critics of AUGE point out that it has mainly strengthened the private insurance subsystem and not the public one, so that there is greater inequity, as has been typical of the results of recent efforts toward health sector reform in Latin America [107]. Consequently, users of the public subsystem are more dissatisfied than they had been with the system in operation between 1990 and 2005. The ineffective policymaking of the coalition of the Christian Democrats that had ruled under various leaders since 1990, particularly the failure of the public transportation system in Santiago, led to the election of a right-wing President (Pinera) in 2010. However, Pinera’s popularity rapidly declined when he was unable to handle serious problems efficiently, and Michelle Bachelet, a physician and health minister in the Lagos government, returned as President in 2014.

Despite the difficulty that Chilean governments have had in implementing effective and efficient policies, the overall HDI increased slightly from 0.785 in 2005 to 0.822 in 2013, a rise of 0.59% per year between 2005 and 2013 (which can be compared to the 0.70% rise per year between 1990 and 2000 prior to the election of Lagos). Average income has increased 4.1% per year whereas the gains in expected life expectancy (0.27% per year) and expected years of schooling (0.98% per year) have been smaller. Universal coverage was introduced for most diseases in 2005, progressively increasing the number of covered conditions as they could be afforded [104]. However, only about 52% of complaints can be related to conditions covered by AUGE, and long-term rehabilitation programs for chronic physical and mental conditions are still not guaranteed [103, 104, 106].

Despite substantial improvements in coverage and access, much pro-rich inequity and unmet need remains in Chile in income, education, and health, particularly in specialized health care [108] and traditionally under-resourced areas such as mental health and developmental disorders [109, 110]. In any case the progress of general health care in countries such as Chile or Brazil shows the path of healthcare development for other low- and middle-income countries in Latin America. It is important to note that US retirees living in Panama and Mexico have expressed more satisfaction with outpatient services in these countries than in the USA because they perceived service to be more person-centered [111].

Results in Chile suggest that without integrated intersectoral change the overall HDI has increased along with the overall economy. However, changes in specific policies about health care delivery from libertarian to selective PHC to comprehensive PHC have led to only modest rates of change (0.6 to 1.0% per year) in the overall level of human well-being. Even these modest changes are highly significant and the full impact of introducing comprehensive PHC will take many more years to evaluate. Policy changes in healthcare do not have their full impact on global indicators like life expectancy immediately because health depends on cumulative effects across the lifespan and on educational and socioeconomic factors that have yet to be integrated with health reform in Chile. However, there is little reason for optimism about future results from the current system until it reduces inequities between its public and private subsystems.

Spain as an example of Comprehensive PHC

Spain provides another informative example of the impact of economic, social, and political influences on the development and maintenance of an equitable universal health care system. Spain’s economy flourished with unprecedented increases in international investment and domestic industrialization between 1959 and 1974 when Franco, its dictator (1939–1975), approved the introduction of neoliberal policies with the guidance of OECD and IMF in order to end Spain’s international isolation [112]. This “Spanish Economic Miracle” ended after Franco’s death in 1975 as part of a global financial crisis associated with high oil prices and an extended period of stagflation. During the transition to democratic rule from 1975 to 1985, Spain experienced sluggish growth with slow progress in reducing inflation because of the global financial crisis of that time [112]. After joining the European Union in 1986, Spain began to expand its domestic output, domestic employment increased, and inflation slowed. There was another substantial boost to the economy when the Euro currency was introduced during the period 1999–2007. From 2008 to the present, a global economic crisis precipitated a crash in the value of property in Spain, which in turn led to a collapse of credit because banks hit by bad debt reduced their lending, causing a recession. Unemployment rose and government revenues decreased, but the Spanish government kept spending to stimulate the economy, leading to huge government debts by 2010. The government rescued the savings bank system that accounted for nearly 50% of the whole banking system in Spain. The delay in reducing government spending has made the financial crisis harder now that the government has introduced austerity policies that dramatically reduce government spending on health, education, and research.

Spain’s rating on the Human Development Index (see Table 1) has shown a steady increase until it has just begun to show the impact of the economic crisis in 2013 by a decrease of average income to the levels of 1995. In spite of this, the HDI was 0.869 in 2013, which places it in the high human development category of 187 countries and territories surveyed by the UN (see Table 1). Between 1980 and 2013, its HDI increased from medium human development (HDI = 0.702) to high human development (HDI = 0.869), an increase in HDI of 23.8% or an average annual increase of 0.65% per year. As shown in Table 1, life expectancy in Spain has long been high, and increased from 75.1 years in 1980 to 82.1 years in 2013, which is a strong increase of 2.8% per year. Average income per capita also increased strongly and steadily from 18,605 parity dollars in 1980 to 32,098 parity dollars in 2005 (an increase of 72.5% over 25 years or 2.9% per year). After 2005 income began a steady decline to 25,947 international dollars by 2013, which is a decrease of 19.2% over 8 years or 2.4% per year.

Despite the decline in income after 2005, HDI has continued to rise due to the influence of improvements in education and life expectancy. Education has been relatively less well-developed in Spain; the mean years of schooling for people age 25 and older in 1980 was only 5 years in 1980, but nearly doubled by 2013 when it reached 9.6 years of schooling on average. Expected years of schooling increased moderately from 12.6 years in 1980 to 17.1 years in 2013, an increase of 37.9% over 33 years or 1.1% per year.

Spain has a universal healthcare system in which health services are predominantly funded through general taxation. The General Health Act of 1986 was a major step forward in the completion of a community healthcare system based in catchment areas covered by a public primary care center (PCC) in which physicians are paid by salary and not by activity. In 2002 transfer of governance from the central government to the seventeen “Autonomous Communities” (ACs) or regions was completed. The Health System Cohesion Act was passed in 2003 to provide some loose coordination and agreement with a countrywide Council of the National Health System (NHS). Nevertheless, Spain has one of the more decentralized health systems in the world, with over 97% of the health budget controlled by the regions [113].

There is much variation in the healthcare system between regions, even though all the regions are community-oriented and organized around the primary care centers that promote integrated care. For example, Catalonia has a separate purchase and provider system: planning and purchasing depends from the Department of Health, whereas a mix of publicly owned organizations and private companies working under contract with the public administration provide care for local areas. The catchment areas for primary care, specialized care (e.g. mental health care), and hospital care follow a vertically integrated system (e.g. 5 areas of community primary care are covered by a single community mental health centre, and 4 areas of community mental healthcare are covered by a single general hospital). In other regions such as Andalusia and the Basque Country private companies play a very minor role and the regional public department of health includes central planning, purchasing and provision. In spite of their differences the 17 regional health systems are moving toward an integrated care system following a chronic care model [114, 115]. This is also the case for specialized care subsystems, such as mental health, which have developed different systems of vertical integration with the primary care system and the hospital care [113, 116].

The efficiency of the Spanish healthcare system caught international attention in 2000 [117] and there has been continued interest in its successes [101, 114]. However the ongoing financial crisis may have a huge adverse impact on the Spanish healthcare system, particularly since 2012 when Spain reduced its budget in health, education and research while providing major support to the banking system. As a consequence of reduced government support, inequities in health services are increasing due to reduced service to the most vulnerable members of society, as described in the 2014 annual report of the Spanish Society of Public Health Policy (SESPAS) [118, 119]. Public health experts have proposed some potential remedies to maintain equity and to fund services based on their healthcare value, but these have not yet been approved [119].

In summary, the progress that Spain has made in human development stems from efforts to respect both liberty and welfare rights. The recent financial threats to healthcare services in Spain underscore the need to recognize the value of maintaining equity in healthcare in person- and people-centered ways that are efficient, effective, and sustainable [119].

Cuba as an Example of Comprehensive PHC

Cuba currently ranks 44th in the world in human development [105]. It is a socialist country that provides free high-quality health care, free university and graduate school education, and subsidized food and utilities. Cuba is self-sufficient in production of food, but it does extensive international trade, including trade with the nearby USA. The educational system is the best in Latin America, and encourages vocational training [120]. Unemployment is very low (1.8%) and literacy is very high (99.8%) [121]. There is virtually no homelessness, and nearly 85% of Cubans own their own home and pay no property taxes. However, liberty rights are severely limited by Cuba’s totalitarian regime (see http://www.hrw.org/world-report/2013/country-chapters/cuba; http://www.heritage.org/index/). Cuban law limits free speech and assembly, and there is international concern about respect for judicial due process [122]. Cuban emigrants express a mixture of hope and worry about how Cuba will be able to transition from a dictatorship to a democracy in the future [123].

The current status of human development in Cuba stands in stark contrast to its condition as a colony prior to the revolutionary take-over by Fidel Castro in 1959. In the 1950s prior to the revolution, 5 out of 6 Cubans lived in shacks or were homeless, 80% were unemployed and underfed, and 2 out of 3 children didn’t attend school. The poor conditions of Cubans under colonial control provoked an anti-imperialist stance in Castro, who was inspired by the ideology of Lenin and Marx [120, 124]. In 1961 Castro introduced totalitarian socialist reforms including expansion of healthcare and education, and formed an economic and political alliance with the Soviet Union [121, 125]. Under Castro’s leadership, the HDI of Cuba has increased from low during the 60s to high at present. Between 1980 and now, Cuba’s HDI increased 0.55% per year from medium human development (HDI = 0.681 in 1980) to high human development (HDI = 0.815 in 2013), as shown in Table 1. Life expectancy increased slightly each year from 73.8 in 1980 to 79.3 in 2013, an increase of 0.23% per year. Mean years of schooling for people over age 25 increased from 6.5 years in 1980 to 10.2 years in 2010, and has remained stable since then. Expected years of education hovered around 12 years for two decades (1980–2000), and then two or three years of education beyond high school became the expected norm (see Table 1).

Average income in Cuba has more than doubled from $9983 in 1980 to $19844 in 2013, an average increase of 3.2% per year (Table 1). However, income was unstable during the 1980s because of US trade embargo against Cuba (known as “the blockade”, el bloqueo) and unpredictable fluctuation in the harvesting and market price of sugar cane [124]. There was a dramatic fall in average income from $13,225 in 1990 to $8,891 in 1995 as a result of reduced trade and the end of Soviet subsidies when the Soviet Union dissolved in 1991. The tightening of the US trade embargo against Cuba in 1992 also contributed until it was relaxed in October 2000. The embargo raised the cost of medical supplies and food [126]. The economic crisis in Cuba resulted in poor nutrition, increased rates of infectious disease and violent deaths, and deterioration of the public health infrastructure despite the government’s steadfast support. Despite these problems, mortality levels for children and women were low as a result of preferential access to scarce resources. The health impact was absorbed mostly by adult men and the elderly, and was mitigated by combined effects of a well-functioning universal and equitable health care system and food rationing supported by social solidarity based on grassroots organizations [125, 127]. To improve the economy, rather than reducing its commitment to education, Cuba intensified its educational efforts to be self-sufficient in food, develop the expertise needed for biomedical and other non-agricultural exports, and produce domestic innovations to substitute for foreign imports [121]. Consequently Cuba became more self-sufficient economically, and educational attainment and primary health care once again flourished in access and quality, particularly educating many teachers and non-agricultural experts [121, 125].

The pattern of human development in Cuba illustrates how universal health care and education can help to promote equitable and sustainable economic growth through the promotion of human capital and social solidarity. However, welfare rights with moderate economic security have been attained at the cost of restricted liberty rights, so Cuban society is an integrated collectivist system, but it is not person-centered.

The Cuban model provides an informative contrast to the health sector reforms of the 1990s in other Latin American health systems in which governments were urged by donors and international financial institutions to privatize health care and to separate the purchaser and provider functions. For example, Colombia followed such market-oriented health care reform and has been unable to realize its goals of universality, improved equity, efficiency and quality, whereas Cuban health care has been successful in providing free and equitable care of good quality with fewer financial resources [107]. The varying approaches and results with the segregated healthcare subsystems in Chile have already been discussed. These findings in different Latin American countries underscore the importance of organizing healthcare reform in ways that are simultaneously integrated, people-centered, and person-centered.

Critique of the Debate between Selective versus Comprehensive PHC

The examples of selective and comprehensive PHC that we have considered illustrate the interdependence of healthcare policies with other social, cultural, economic, and political variables. The benefits of healthcare policies are clearly part of complex sociocultural systems, as we will discuss later. Either selective or comprehensive PHC systems can be productive under some conditions, but their benefits may also be limited unless they are integrated, person-centered, and people-centered, as shown in the examples of Chile, Spain, and Cuba.

The debate about selective versus comprehensive PHC confounded several distinct issues. Studies in both business management and health care delivery have shown that healthy functioning involves goals and values that are SMART or SMARTER (that is, Specific, Measurable, Attainable, Realistic/Relevant, Timely, Ethical/Ecological, and Rewarding) [128, 129]. The selective targets of the World Bank and UNICEF were reasonable ways to achieve success with limited resources. However, top-down control by remote governors was often perceived by the people receiving aid as inconsistent with their human need for creative freedom and their social-political need for autonomy; the evidence of economic exploitation of developing countries by wealthier countries seemed to many to be inconsistent with human welfare rights [85].

Several other reasons besides the opposition of the World Bank have been suggested for why comprehensive community-based PHC did not achieve its goal of health for all by the year 2000 [85]. First, many people considered PHC as a cheap form of second-quality care, so, if they could afford to do so, they bypassed primary care for secondary and tertiary medical centers with better trained staff and medical technology. Second, many natural disasters, the HIV epidemic, and wars impaired service delivery between 1978 and 2000. Third, most financial resources were still directed to large urban hospitals, and politicians used PHC as a way to reduce expenses and their commitments to equity were not sustained. Fourth, difficulties in oversight of broad, community-based programs allowed corruption, so donors preferred vertical, narrow, short-term programs that could be frequently changed. In 2000, the WHO concluded that the failure of PHC resulted from inadequate funding and insufficient training and equipment for healthcare workers at all levels [130]. This led to such inadequate service that people had no option but to bypass the primary care level in many countries, although there were successful PHC programs, as we have described in the previous section.

Critics of market-driven approaches to health care have argued that the inadequate funding of PHC was the result of a shift in economic policy [3, 131], as was seen in Chile under the Pinochet regime. The main criticism has been the charge that the neoliberal emphasis on economic profits became a major obstacle to high-quality universal health care during the 1980s and 1990s when neoliberalism was becoming increasingly dominant [11, 131, 132]. In 1993 the World Bank’s World Development Report considered investment in healthcare primarily as a means to create profits for donor countries, not to improve the health of people in debtor countries. The so-called “Health Sector Reform” was and is seen in developing countries as being imposed by neoliberal economists from the USA and Europe, rather than reflecting the needs and rights of people in developing countries [85]. In exchange for economic assistance, the World Bank regularly insisted on the privatization of healthcare services while reducing local and national control [11, 85]. Unfortunately, a frequent consequence of such policies has been to increase inequity, social distrust, morbidity, mortality, and corruption rather than to promote social justice [3, 11, 131]. In contrast, where development has been locally directed, comprehensive primary healthcare has been able to deliver improved health and quality of life at a reasonable cost in diverse circumstances, including Brazil, Chile, China, Costa Rica, Cuba, Iran, New Zealand, Spain, and Taiwan [11, 12, 101, 103, 133].

The Independent Evaluation Group of the World Bank acknowledges that the World Bank Group has continued the same market-driven approach to enhancing human development for the past three decades even though its methods have “often led to shortfalls in meeting the intended objectives within the planned time frames” [134]. It attributes its frequent failures to the ambitious nature of the complex objectives, recurrent inadequacies in initial risk analysis and contingency planning with its system of vertical control, and difficulty integrating the efforts of different units within the Bank [134].

Organizational theorists in health care and business suggest that vertical control and the absence of person-centeredness are inherently ineffective and inefficient ways to manage complex adaptive systems or to promote well-being [135, 136]. Many economists have questioned the fundamental assumption that free markets are efficient, effective, or fair [137–140].⁵ There is much soul-searching around the world about how to organize a primary care system that can operate in the 21^st century in a way that is fair, equitable, accessible, cost effective, sustainable and able to promote general well-being [141]. Market-driven policy makers often claim that inequality in income and health are the price that societies must pay in order to maximize economic efficiency, but others reject the suggestion that inequality is an inevitable cost of economic productivity [138, 140]. For example, claims of the inevitability of inequality in productive economies are contradicted by evidence from Scandinavian countries that are consistently among the healthiest countries in the world. In particular, Denmark has had a strong, consistent, stable economy for several decades without a recent history of colonial exploitation or reliance on unusual resources of lucrative materials like oil. Nevertheless, Denmark is consistently one of the most equal, healthy, and happy countries in the world [72]. The health of its people and its economy go hand in hand because low rates of unemployment and universal health coverage produce a stable productive economy [142].

On the other hand, international business leaders sometimes complain that Denmark is a difficult place to make profits because operating costs are high due to the expensive welfare system that puts people’s health and happiness over business profitability [143]. As a result, some international businesses prefer to invest more in poorer countries where workers are more willing to work under adverse conditions for relatively low pay. Nevertheless, the World Bank Group ranks Denmark 5 out of 189 economies in terms of the ease of doing business there; its rank is exceeded only by Singapore, Hong Kong, New Zealand, and the USA, so it is the easiest place to do business in Europe [144]. Denmark and other Scandinavian countries are examples of how both people and business can flourish when public policies are person- and people-centered and integrated.

Current Challenges in Global Public Health

In both high-income and low- to middle-income countries there is a growing need for a shift to person-centered integrated health care. This has been recognized in the United States of America where the Institute of Medicine has called for a shift to person-centered integrated healthcare in order to improve healthcare quality and cost-effectiveness [145–147]. In view of the success of person-centered approaches and the failure of market-driven approaches to healthcare, both the World Bank Group and the World Health Organization have instituted changes in their policies and programs that encourage person-centered care.

US President Barack Obama nominated Jim Yong Kim to be President of the World Bank Group and he was formally elected by the G24 group of developing countries in April 2012. Dr. Kim is an American physician and anthropologist who supports universal health coverage and has led successful community-based health delivery programs in developing countries. He has emphasized local community input along with cost-effectiveness in his health care initiatives, including the HIV program of the WHO that he directed. His stated goal for the World Bank Group is to reduce extreme poverty and inequality around the world by 2030. He has reorganized the administrative structure of the World Bank Group to reduce administrative costs and increase collaboration of social scientists with all departments [148]. He has alerted the international community that climate change threatens both health and economic stability, particularly in poor countries [149].

These changes in direction at the World Bank reflect growing appreciation that wealth and profits cannot be measured solely by money and material production. In particular, the ability to work is strongly influenced by education and health—which is also a value in itself. The UN’s Human Development Index (HDI) combines income with years of education and longevity, and can also be adjusted to take into account the impact of inequalities in wealth and gender on health and wealth [150]. These indices indicate a general rise in the wealth, education, and health of developing countries (“the South”) since the 1990s [151]. It is expected that the aggregate production of three leading developing countries (Brazil, China, and India) will surpass the aggregate production of Canada, France, Germany, Italy, the United Kingdom, and the United States of America by 2020. Given the increasing influence of Southern countries, it is timely for the World Bank and other international programs of economic aid from the North to adopt more inclusive and person-centered policies in order to be in a reasonable position to play an effective role in the global growth in health and wealth when they no longer represent the world’s dominant economies [74].

The value of health and longevity is indicated by the fact that many people will trade off income, pleasure, and convenience for an increase in life expectancy [152]. Although there is a great need for refined indicators to assess the non-economic value of healthy and fulfilling lives, one simple measure of value in health decisions can be constructed in terms of the value of life years (VLY). Such indicators can enable countries to make decisions to promote “full income” by combining increased income in materials and services (GDP) and in human longevity (VLY) in response to investments. About 24% of the gain in full income between 2000 and 2008 in low-income and middle-income countries came from gains in VLYs [152].

Even when there is economic growth in material income, other aspects of human development such as advances in health, education, and social services do not necessarily follow [151]. Improvement in health requires specific policies designed to facilitate its progress, as has been recommended by the WHO. The WHO has renewed its commitment to person-centered, integrated healthcare for all people with a renewed emphasis on primary healthcare as the key to improving health in developing countries [153–155]. The 2008 World Health Report was devoted to PHC and emphasized four guiding principles [12]: (1) universal coverage, because inequality raises the risks for all people, especially of disease outbreaks; (2) people-centered care, because delivery of services in the community increases longevity, as demonstrated in Iran, New Zealand, Cuba, and Brazil; (3) healthy public policies, because biology alone cannot explain gaps in longevity and many sectors of government (such as trade, environment, education) have policies that influence health; and (4) leadership must negotiate and steer, but not command and control, because health systems will not gravitate toward being fair, efficient, and effective without person-centered leadership.

Ways to bring the full income (i.e., wealth and health) of underdeveloped countries into convergence with developed countries have recently been considered in depth by a commission of leading economists on behalf of the medical journal Lancet on the 20^th anniversary of the 1993 World Development Report that had focused on health [152]. The Lancet commission concluded in its report “World Health 2035: A world converging within a generation” that there will be an enormous payoff for countries if they invest in public health [152]. If appropriate investments are made now, the developing countries will see increases in health and economics that bring them into convergence with developed countries by 2035. Focusing on reductions in rates of infectious, child, and maternal mortality to low levels can be achieved for all by 2035. The commission recommended two “pro-poor pathways” for achieving universal health coverage. In the first pathway, publicly financed insurance would cover essential health-care interventions to achieve equity in coverage and to reduce non-communicable diseases and injuries through inexpensive population-based and clinical interventions. In the second pathway, a larger benefit package would be provided free to the poor and financed by a range of fiscal policies, such as increased taxation of tobacco and other harmful substances, as well as reducing subsidies to fossil fuels and funding inexpensive interventions for non-communicable diseases and injuries. Such progressive universalism would produce huge gains in health for poor people, thereby achieving a convergence in health within one generation [152]. Such gains could be achieved by domestic funding in most countries. However, some countries would initially benefit from external financial aid that would repay itself in terms of global productivity, in addition to its intrinsic moral and humanistic value.

The 2010 World Health Report dealt with financing universal coverage [156], and the 2013 World Health Report considers what research is needed to help achieve universal coverage [157]. These reports view universal health coverage as a dynamically progressive process, rather than as a fixed minimum package as was done with SPHC. Universal health coverage therefore requires progress on several fronts simultaneously in a stepwise fashion: the range of services that are available to people, the proportion of the costs of those services that are covered, and the proportion of the population that is covered. WHO intends to focus on health service integration in order to promote greater people-centered services, efficiency and value for money, and also intends to shift away from categorical disease-focused programs.

In view of the inequities and increasing burden of chronic diseases in aging populations in developed countries, these goals are expected to be beneficial in all countries regardless of their current income level [157]. The benefits of equitable person-centered healthcare would be substantial in both the USA and Europe because of the strong social determinants of health [72]. For example, within the strongest economy in Europe, many German people feel insecure and threatened by “inequality and rampant, uncaring capitalism” so that Chancellor Merkel has been pushed to form a coalition supporting greater social welfare in Germany [158]. Inequity in the social determinants of health within and between countries can be rectified by person-centered approaches to enable health, prosperity, and cultural diversity to flourish once again.

Healthcare as a Complex Adaptive System

In addition to accumulating empirical evidence that person-centered public health is more effective than public health that is vertically controlled and/or market-driven, there has been substantial gain in theoretical knowledge of the management of healthcare organizations as complex adaptive systems [136, 159]. Many of the historical mistakes in the design and management of health care systems and foreign aid programs could have been averted if there had been a better understanding of the dynamics of complex systems at the time. At least we are now in a position to avoid repeating past mistakes.

Complex adaptive systems operate in ways that are fundamentally different from deterministic additive systems (see Table 2).⁶ Complex adaptive systems are composed of many components that reciprocally influence one another, so that they behave more like evolving living organisms than like simple systems or machines with separable parts. Consider a society made up of many people endowed with self-awareness. Each person is made up of multiple organs, but health is a characteristic of the organism as a whole. Likewise, multiple people make up a community and interact socially within that community. These communities may be more-or-less tightly coordinated as federations or nations. The properties of such nested dynamic systems have been thoroughly studied mathematically with important lessons for the management of healthcare organizations [136] and other complex systems like business organizations and economic markets [135]. Complex adaptive systems provide an important model for understanding difficult problems involving many interacting adaptive agents, such as managing health care systems, understanding economic markets, encouraging innovation in dynamic economies, providing for sustainable human growth, preserving ecosystems, and promoting health [162].

Table 2.

Comparison of Complex Adaptive Systems and Deterministic Additive Systems

Complex Adaptive Systems	Deterministic Additive Systems
Holism System cannot be reduced to its parts because it depends on relationships among entities	Reductionism System can be reduced to separate parts or discrete entities
Indeterminism outcomes predictable probabilistically	Determinism outcomes predictable with certainty
Nonlinear dynamic relationships influence of forces is multiplicative (nonlinear) with feedback loops tipping points with sudden marked change	Linear relationships influence of forces is additive gradual incremental change
Focus on adaptive variation	Focus on averages
Local initiative	Global control
Metaphor of morphogenesis (life-like evolution)	Metaphor of assembly (machine-like operation)
Behavior emerges co-actively from bottom-up and top-down simultaneously (person-centered management)	Behavior specified from top down (elite vertical management)
Self-similarity of fundamental functions of all components (like persons)	Specialized functions by elite governors (like autocratic experts)

One principle of the management of healthcare organizations as complex systems is the need for intersectoral coordination to promote the health of people and the welfare rights of people in society as a whole. There is reciprocal feedback in influence across many sectors of society, such as health, education, food security, industry, military spending, economics, and sustainable resource utilization, which all influence one another, social trust, and health [7]. Effective, efficient, and fair policies require integration across efforts toward health promotion, disease prevention, cure, rehabilitation, and palliation. Public health planning requires intersectoral coordination of planning and service delivery because of the reciprocal influences that various sectors have on one another. If complex systems, such as people, corporations, or cultural and economic institutions, behave in ways that are not equitable and person-centered, they tend to deteriorate in a downward spiral of conflict and divisiveness.⁷ There is a crucial need for integrated efforts among the UN member states and allied international organizations in order to achieve their Millennium goals in health, education, environmental sustainability, and social equity by 2015 and beyond [19].

A second basic principle is that management of complex human systems must be person-centered in order to promote health by satisfying the liberty rights of persons, rather than based on vertical control. Complex healthcare systems cannot be treated like machines because the people who are their components are self-aware and cannot flourish without the opportunity to be self-directed, cooperative, and creatively free [62, 136]. Much of the burden of disease in the world is related to the disparities between and within wealthy and poor countries: the burden of disease is largely related to the stresses of affluent lifestyles in developed countries and to insecure and inadequate supplies of food, water, and other basic resources in poor countries. Therefore progress toward global equity in consumption would directly benefit everyone; equity would involve affluent people being more moderate consumers and generous producers, and poor people being more self-sufficient as producers and consumers.

People in health-promoting societies must be both free and responsible to one another and contribute as well as they can to the effective functioning of the greater social and environmental whole in which they are embedded. Social systems cannot function optimally unless there is mutual respect and trust for one another. Consequently effective functioning of complex organizations depends on cooperation and co-active communication among people, that is, simultaneously top-down input from experts and bottom-up input from people with needs. This interactive communication based on trust in commitment to fairness allows creative adaptation that is sensitive to local resources, traditions, and needs, thereby assuring sustainability, equity, and inclusiveness without the inefficiency of top-down bureaucratic regulation. It also provides excellent opportunities for leadership by creative people to inspire others to join them in contributing to increased social equity and trust, thereby stimulating all sectors of a society and the planet as a whole [62, 159]. Effective leadership requires a coaching approach in which people function creatively (i.e., they are self-directed, cooperative, and self-transcendent) [62].

A third principle of complex healthcare organizations is that they are self-organizing in ways that are unpredictable (or at best difficult to predict) in response to small differences in local situations. Tolerance and acceptance of social, cultural, ecological, and historical diversity rather than insistence on uniformity is characteristic of well-functioning communities [165], like other adaptive systems [33, 34], and is a human value worth supporting in itself [35, 166]. Diversity within and between components of a complex adaptive system assures their resilience in the face of ever-changing conditions. Underlying this diversity are fundamental principles that are common to all people and groups that are the components of human systems, like being self-aware, belonging to a family, group or community, and needing mutual trust and respect in order to be satisfied, healthy, and resilient [33, 34]. When there is recognition of the intrinsic dignity of all along with an enthusiastic appreciation of diversity, then all people can flourish in the particular ways that reflect the unique history of their development, resources, and cultural traditions.

Conclusions and Recommendations of the 2014 Geneva Declaration

Market-driven approaches to public health are often excessively costly and ineffective in promoting health because they ignore the fundamental principles of complex adaptive systems, the primacy of human dignity, and the ethical imperative for equity and universality, thereby undermining liberty rights, welfare rights, and respect for diversity. In contrast, person-centered approaches can improve economic productivity, social trust, and health because they are realistic and sustainable ways to manage the complex interactions of people co-existing and developing under diverse conditions. Re-orienting the global economy to address health disparities will take consistent vision and commitment. We need effective leaders in all sectors of society, including creative leadership from successful entrepreneurs who want to contribute to a sustainable healthy world. If corporations have the rights of a person, then they also must accept the duties of a person. The social responsibility of businesses and entrepreneurs is occasionally put into practice. For example, the Bill and Melinda Gates Foundation is dedicated to the belief that “all people deserve the chance to live healthy, productive lives” [167]. In order to optimize effectiveness, such entrepreneurial efforts need to be coordinated as integrated components of a person-centered universal healthcare system, as envisioned by the WHO. Accordingly, we call on the diverse people and organizations interested in improving public health to work together as proposed in the 2014 Geneva Declaration for Person- and People-centered Integrated Health Care for All.

The market-driven and person-centered approaches to universal health coverage need to be integrated in ways consistent with what we know about complex adaptive systems, as is outlined in the recent initiatives of the WHO for PHC [10, 12, 20, 130, 156] and the objectives expressed by the new leader of the World Bank Group [148, 149]. This will require rethinking the priorities of economic development that have been framed without adequate consideration of health values and outcomes. Integrated, person-centered health for all is a wise and realistic choice that can benefit all people. There is no other reasonable, equitable, effective, and sustainable path for the people of the world. We cannot redress all the inequalities in society at once without causing unreasonable hardships, but we need to begin to work together in an equitable and progressive manner toward universal health care for all.