Putting people at the centre of care
Nurturing community-based, localised health care is important for fostering resilience, given the need to adapt to particular contexts. Strengthening governance, supporting the workforce and addressing global power imbalances are needed to further the cause
Why does achieving the Sustainable Development Goals require people-centred health systems focused on equity and human rights?
The SDGs seek to address poverty through an integrated approach that includes concern for health and well-being and health care. Similarly, the 1978 Alma Ata Declaration on Primary Health Care saw health and well-being as influenced by economic and political factors, demanding a focus on socio-economic rights and a different approach to organising and delivering health care. The idea of people-centred health systems carries forward the Alma Ata vision, with new emphases. It recognises health systems as having four features.
First, they are social institutions comprising people and chains of relationships, situated within and influenced by their particular context. They are profoundly local by nature, and trust and power dynamics are ever-present.
Second, values shape people, relationships and practices in such systems: values such as respect, dignity, transparency, equity and the pursuit of social justice. The fairness of the processes by which decisions are made matters, not only distributional outcomes.
Third, people’s voice and needs are put first, so there is a focus on collective agency and social empowerment, and on health and well-being as people and communities define them. In some contexts, rights may be framed as claims to strengthening collective agency; for example, in Southern and Eastern Africa, ubuntu is a value that highlights reciprocity and collective interests.
Fourth, people-centred service delivery emphasises the primary care principles of prevention, promotion, closeness to community and continuity of care. In addition, intersectoral action to address the social determinants of health is needed.
Overall, the idea of people-centred health systems help us consider the actions necessary to promote public health. They put public interest and the public at their heart. They work to build collective power to promote the public’s health, and confront the exercise of dominant power, hierarchies and exclusionary practices.
The features of such systems also allow us to think about what resilience means as we confront multiple challenges and polycrises. They direct our focus to locally constituted complex relationships, seeing resilience as a phenomenon of people and relationships within systems. Strengthening health system resilience itself requires inclusive decision-making for collective agency.
How well are countries pursuing this approach?
There is substantial experience within many countries of people-centred approaches founded on local-level and community-led action to address health and well-being needs. Such experiences informed the development of the Alma Ata Declaration. Community-led action also played a key role in responding to Covid-19. Experience demonstrates that such approaches can foster capabilities, equity and inclusion, strengthen and forge new relationships, and draw on new technology. They can also hold the state to account. They are enabled by decentralising public sector authority to local governance structures.
But we don’t have very good ways of sharing these context-specific and local-level experiences. Instead, in global health there is a tendency to look for specific transferable prescriptions and to assume that the Global North will inform the Global South of ‘best practices’. But the Global South has a lot to offer from its
own experiences!
Constraints in pursuing people-centred approaches are also similar globally. Health care is commonly still rooted in biomedical paradigms that prioritise hospital-centred care rather than integrated primary health care. There’s often a command-and-control organisational practice, with power at the apex and the ‘less powerful’, including patients, at the bottom.
There is a tendency to see health care as a machine rather than a complex system rooted in people, relationships
and context. Local communities everywhere also face health challenges generated by economic and global commercial forces. It’s important to keep refocusing and galvanising action to promote the public’s health and well-being.
What key political choices must be made and by whom?
Personal choices are always political – as Robert Chambers wrote, “social change flows from individual actions”. Whatever position we hold, each of us is a part of a local health system, a national health system and the global health system. As a researcher in the South African health system I can make choices in line with a people-centred health system approach by choosing methodologies that respect people, context and relationships. Working with networks that mobilise and share local-level experience is also important. Knowledge is power, so we need to think about how we mobilise that knowledge to frame key political choices. That’s true for me, as well as for – from his very different position – South Africa’s President Cyril Ramaphosa.
Considering the public’s health and well-being, five other political choices stand out. One is to strengthen local-level public governance structures that coordinate primary and secondary healthcare providers, public and private actors, and lead respectful engagement with other sectors and with social actors, including community organisations. I also emphasise strengthening leadership across an entire system, to embed the principles of people-centred health systems. Investing more and better is another key choice – in primary health care, intersectoral action and community engagement. Public funding is critical and out-of-pocket payments have no place in a people-centred health system.
Another political choice relates to the health workforce. New skills are needed to protect and promote public health. We also need to care for the workforce so that the workforce can care for others.
Global forces surround us, even in a relatively wealthy country like South Africa. In less well-resourced countries, those forces are more immediate. Those working in global health funding agencies can support people-centred health systems in such settings by instituting more flexible approaches to channelling resources, and by embracing local knowledge and experience.
Finally, global action is needed to address the economic forces that drive the commercialisation of health care and the commercial determinants of health. Ensuring fair global rules and rebalancing power to benefit less resourced countries is critical.
