2 While the global disease burden has been shifting towards chronic conditions, health systems have not evolved to meet this changing demand. Care is fragmented, focused on acute and emergent symptoms, and often provided without the benefit of complete medical information. (WHO, 2003)

28 The overall aim that we set ourselves in this book was to compile an in-depth assessment of the health system response to the rising burden of chronic disease in each of the eight countries, by focusing on three key areas:(1) a detailed examination of the current situation;(2) a description of the policy framework and future scenarios; and(3) evaluation and lessons learnt, building on a common template developed by the editors.

29 The template was informed, to great extent, by the Chronic Care Model (CCM) developed by Wagner and colleagues in Seattle.This model presents a structure for organizing health care; it comprises four interacting components that are considered key to providing high-quality care for those with chronic health problems:self-management support,delivery system design,decision support, andclinical information systems.

35 Person-focused carePerson-focused care over time makes it possible to identify, early in life, those conditions that are likely to influence subsequent ill health and, therefore, to attempt to reduce their impact.It also provides the continuity of attention that is important in reducing the impact of chronic illnesses and reducing the likelihood of the progression to more serious illness and to more multimorbidity.

36 We need guidelines that are appropriate to person-focused care, not disease- focused care. Only primary care physicians can understand this, because they do not focus on particular organ systems and because they experience these realities every day in their practices.Primary care physicians will have to continue to advocate for primary care- oriented health systems, because it is the only hope for achieving greater equity through appropriate medical interventions.