Most health systems around the world remain heavily focused on illness and do relatively little to optimize health and thereby minimize the burden of illness, especially for vulnerable groups. Failure to improve the underlying conditions for health is compounded by insufficient allocation of resources to address priority needs with equity (universality, accessibility and affordability). Instead, when engaged in public debate on health care, jurisdictions tend to focus on high-cost items that preoccupy administrators. This short-sighted focus overlooks ‘upstream factors’: health-promoting environments and workplaces, primary prevention, e.g., nutrition education, immunization, antenatal care, physical activity, smoking prevention, and social policies that influence literacy, employment, crime, housing quality, and community well-being.

In particular, there is a global need to improve the response to the surging chronic disease burden. Research indicates that much of this burden is preventable by acting on modifiable behaviors, e.g., smoking, fitness, weight control; and about half of those who do develop these conditions can be prevented from progressing to complicated forms through attention to secondary prevention by identifying and engaging in early intervention for persons at risk, e.g., blood pressure screening and glucose monitoring. However, many decision makers remain preoccupied with acute-care issues, crisis-prone yet glamorized, even overlooking important ‘downstream considerations’, e.g., long-term care, home care, whose availability determines the speed with which acute-care patients may move to more appropriate levels of care.

This review is for two main audiences: clinicians and health care decision makers, two groups so focused on patient care and the administrative and financial challenges of illness management that they may overlook why people become ill in the first place, why they often present with advanced disease, why so many lack social support for their care, and what could be done to enhance their health prospects. The aim is to advocate for more integrated and universally accessible health systems, building on a sound foundation of primary health care (PHC) and public health (PH).

The underlying rationale is the reality that health is mostly made in homes, communities and workplaces, and only a minority of ill-health can be repaired in clinics and hospitals. Whenever seriously addressed as a matter of health policy, PH and PHC are considered essential and sustainable cornerstones in building a sustainable health system for the 21st century. However, despite a virtual global consensus that these are the most critical components, there is considerable imbalance in the priority accorded to them in health policy and in higher education in most countries.

There are numerous reasons for this, ranging from the dominance of an outmoded industrial view of health services development that favors specialized biotechnologies over a better understanding of health determinants that could lead to improved prevention strategies, to the motivations behind particular career choices, influenced as these often are by consideration of remuneration, lifestyle and personal prestige. It is, therefore, important for policy makers and health leaders in all countries to identify the needed roles from a health systems standpoint, to plan for a more integrated approach, and to adjust strategic incentives to achieve the changes that are so clearly needed.