chapter 5 achieving health for all - who

Achieving health for all

139

Chapter 5


In 1997, 158 Member States(representing 91% of the globalpopulation) reported to WHO

the findings of an evaluation ofprogress in the implementation of thestrategy for health for all in theircountries. Based on data and infor-mation provided by these reports,supplemented from internationalsources, WHO estimates that:● In 1995, 102 Member States, with

a total population of 3.4 billion(60% of the global population) hadreached at least the minimum lifeexpectancy at birth of above 60years; infant mortality rate of be-low 50 per 1000 live births; andunder-5 mortality rate of below 70per 1000 live births.

● Immunization coverage of infantsin 1996 was nearly 90% for BCGand about 80% for DPT3, measlesand poliomyelitis. For tetanus tox-oid, however, coverage of pregnantwomen was below 50% of livebirths in developing countries.

● In the developing world in 1996,coverage for antenatal care was65% of live births; for deliveries inhealth facilities, 40%; and forskilled attendance at delivery, 53%.About 90% of newborns weighedat least 2500 g at birth, and theavailable limited data show an in-crease in infant care coverage since1986.

● In 1994, at least 75% of the popu-lation in the developing world hadaccess to safe water, and 34% tosanitation services, compared with61% and 36% respectively in 1990.

● Over one-third of the world popu-lation still lack access to essential

drugs. On average, only 50% of pa-tients take their medicines cor-rectly, and up to 75% of antibiot-ics are prescribed inappropriately,even in teaching hospitals.

Findings show that substantial,though only partial, progress has beenmade in achieving the goals of theglobal strategy for health for all. Over-all survival prospects of the popula-tion worldwide have improved, butdisparities in health levels betweenand within countries have persistedand in many cases increased. In spiteof political commitment by MemberStates and the development of healthsystems based on primary health care,issues of inequalities in health statusand health care access seem not tohave been adequately or effectivelyaddressed during the past two dec-ades. The stage has been set howeverfor developing and sustaining healthsystems that are dynamic, effectiveand able to meet changing health careneeds.

More details are given in thischapter, which can be supplementedby reports prepared in each WHOregion for the third evaluation of theimplementation of the global strategyfor health for all, and reviewed by therespective regional committees in1997.

Health for all andprimary health care

Since 1952, the World Health Organi-zation, in its capacity as the directingand coordinating authority on inter-national health work, has periodically

Overall survival

prospects of the

population worldwide

have improved,

but disparities in

health levels have

in many cases

increased.

The World Health Report 1998

140

assessed the global health situation.Reports on the world health situationwere used to convey salient findingsand main problems and achievementsto the World Health Assembly. Table10 gives selected extracts from thefirst eight reports on the world healthsituation spanning from 1954 to 1989.The Fifth report, covering the period1969-1972, underlined in particularthe slow progress in improving thehealth status of developing countries,and the widening gap in health statusand access to health care between andwithin countries. The report alertedthe global community through theWorld Health Assembly to the con-tinuing inability of health services toreach out to those in dire need and toprovide, on a permanent basis, accessto health care for the entire popula-tion at a price that they could afford.Over 5 million children were dyingannually of diarrhoea, and more thanhalf of all child deaths could be tracedto malnutrition, and diarrhoeal andrespiratory diseases. Failure to con-trol such diseases of poverty pre-vented further reductions in mortal-ity rates, and in incidence rates ofmajor diseases such as malaria, schis-tosomiasis, filariasis, cholera and lep-rosy – which had even increased.

The imperative for change

Too few resources were being in-vested in the health sector, and thesewere usually spent on meeting theneeds of 10-15% of the population.Richer countries had been attractingdoctors from the poorer ones – overthree-quarters of the world’s migrantphysicians were to be found in onlyfive countries: Australia, Canada,Germany, the United Kingdom andthe United States. Although the train-ing of a physician was eight timesmore expensive than that of a medi-cal auxiliary, many developing coun-tries were still stressing the training

of physicians. Moreover, ordinarypeople had little control over theirown health care, as health profession-als were rarely willing to trust themto make decisions about their ownhealth.

In 1977, the World Health Assem-bly reaffirmed that health is a basichuman right and a worldwide socialgoal, that it is essential to the satis-faction of basic human needs andquality of life, and that it is to be at-tained by all people. The Assemblycalled for the vigorous transformationof existing health care strategies tofacilitate the attainment of health forall as defined in the Constitution ofWHO, and decided that the main so-cial target of governments and ofWHO should be the attainment by allthe people of the world by the year2000 of a level of health that wouldpermit them to lead a socially andeconomically productive life. In otherwords, as a minimum, all people inall countries should have at least sucha level of health that they are capableof working productively and of par-ticipating actively in the social life ofthe community in which they live.

There was a realistic expectationthat by the year 2000 no country, orno individual citizen, should have alevel of health below an acceptableminimum, and that the world com-munity would later adopt a new strat-egy to take people further towards thegoal of health for all in the future. Thetarget date of 2000 was intended as achallenge to all Member States. If thisinitiative was successful, the next in-termediate target would be to achievefurther improvements in health be-yond the year 2000, with a betterquality of life for all people, takinginto account changes in the demo-graphic, socioeconomic, environmen-tal and epidemiological situation.

There was a realistic

expectation that

by the year 2000

no country, or

no individual citizen,

should have a level

of health below an

acceptable minimum.


141

The strategyfor health for all

Achieving even this minimum levelof health for all people in all coun-tries implied transforming healthcare delivery and health services sup-port and management so that healthservices were made accessible to eachand every member of the community.

As stated in the Declaration ofAlma-Ata adopted in 1978, the key toattaining the goal of health for all bythe year 2000 is primary health care.Primary health care is essential healthcare based on practical, scientificallysound and socially acceptable meth-ods, and made universally accessibleto individuals and families, at a costthey can afford. It should addresstheir main health problems, provid-ing promotive, preventive, curativeand rehabilitative services accord-ingly. Since these services reflect andevolve from the local economic con-ditions and social values, they vary indifferent countries and communities,but should include at least educationconcerning prevailing health prob-lems and the methods of preventingand controlling them; promotion ofproper nutrition; an adequate supplyof safe water and basic sanitation;maternal and child health care, in-cluding family planning; immuniza-tion against the major infectious dis-eases; prevention and control of lo-cally endemic diseases; appropriatetreatment for common diseases andinjuries; and provision of essentialdrugs.

The three prerequisites for suc-cessful primary health care are amultisectoral approach, communityinvolvement and appropriate technol-ogy. All health programmes and thehealth infrastructure should be builton primary health care. The indi-vidual, the family and the communityare the basis of the health system, and

the primary health worker, as the firstagent of the health system that thecommunity deals with, is the centralhealth force. A thorough reorien-tation of the existing health systemsis required to be made as soon as fea-sible in each country – developed ordeveloping, rich or poor – through anevidence-based managerial processand through health systems research.In order to achieve this, the primedriving force is political commitment.

Political basis

Public health is the art of applyingscience in the context of politics soas to reduce inequalities in healthwhile ensuring the best health for thegreatest number. Health outcomesare related to political democracy,social and cultural development, andeconomic efficiency. Countries witha culture of democratic values andegalitarian aspirations tend to be lesshierarchical, and participation ofpeople in the design of their ownfuture is more acceptable, and evendesired. In countries that exhibit arigid social and political structure,the participation of people in shap-ing their own future has been per-ceived by some as a loss of their ownpower and a risk. The style of socio-economic development of a nation,its political orientation and the pri-ority assigned to social sectors, in-cluding investment in health promo-tion and disease prevention, illus-trate the level of commitment to theglobal goal of health for all.

Due to the political nature ofhealth care, it is not surprising to notethat in all WHO regions intersectoralcoordination and the formulation andimplementation of a healthy publicpolicy have been the most difficultachievements. The third evaluation ofthe global strategy for health for allbrings out the following issues:

Public health is

the art of applying

science in the context

of politics so as

to reduce inequalities

in health while

ensuring the best

health for the

greatest number.


142

The World Health Report 1998 Table 10. World health as assessed in the ReporSocioeconomic development Health system

Repo

rt 7

1978

-84

Repo

rt 8

1985

-89

Repo

rt 6

1973

-77

Repo

rt 5

1969

-72

Repo

rt 4

1965

-68

Repo

rt 3

1961

-64

Main

proble

msMa

inac

hieve

ments

Main

proble

msMa

inac

hieve

ments

Main

proble

msMa

inac

hieve

ments

Main

proble

msMa

inac

hieve

ments

Main

proble

msMa

inac

hieve

ments

Main

proble

msMa

inac

hieve

ments

● There had been scientific, economic and political changes, from 1959 to1960 which positively influenced health development.

● Political changes, independence, enough freedom of thought and actionand of association in the councils of the world.

● The great boom of education in some developing countries.

● More attention being given to social and economic factors influencinghealth.

● Illiteracy of adults from 48% in 1970 to 40% in 1980.

● Large-scale migration from rural to urban areas.

● Disparities between the least developed and other developing countrieshad increased.

● Degradation of living conditions in developing countries, especially in urbanareas.

● Per capita GNP – some increase in developed countries.● Adult literacy rate increased from 62% in 1985 to 66% in 1991.

● Urbanization (all over the world) and migration (in Europe).● 80% of adult population illiterate in low-income countries.

● Number of illiterate persons increased from 1970-1980.● 1000 million people living in absolute poverty, 90% of whom in rural areas.● GDP per capita had fallen – especially in Latin America and Caribbean.● Increase in unemployment from 1970-1980.

Repo

rt 2

1957

-60 Ma

inpro

blems

Main

achie

veme

nts

Repo

rt 1

1954

-56

Main

proble

msMa

inac

hieve

ments

● Degree of incompleteness varied considerably between different diseases, countries and parts of thesame countries and from one period to another (notification of communicable diseases).

● Two parallel and more or less disconnected systems of «medical» and «health» services – greaterattention to medical side.

● Modern concept of health as a state of physical, mental and social well-being and not merely the absence of diseaseand infirmity offered new horizons to health workers.

● Importance of public health recognized by nations/governments as a factor in social and economic development.● People’s awareness for their own participation to build up the health of the nation.● Effort to improve the quality of human life – adding life to years.● Realization that health cannot be imposed: its promotion requires teamwork within the community.

● Understanding that the problem of health must be based on precise information and precision impliesmeasurement.

● Work on establishment of indicators which would mark definitely the signs of improvement andachievements in health matters.

● Substantial increase in general government health expenditure.● Express desire to organize health planning as a part of total planning for socioeconomic development.● Establishment of central bodies for health research in the countries.

● General morbidity statistics very incomplete or non-existent in most countries.

● % of GNP on health – general trend increasing.● Public health research becoming more attractive.● Concept of national health planning in general accepted by developing countries.

● % of GNP spent on health in developing countries, 2-3% (a few US$ per capita expenditure).

● 30th World Health Assembly in 1977: Health-for-all strategy – primary health care.● % of GNP spent on health – slow increase.● Global expenditure on health research – increase.

● Some factors affected the evaluation process: not yet suitable methods, no definite baseline formeasuring, lack of information support to managerial process.

● Impressive analytical contribution from 177 Member countries for first evaluation.● Endorsement of health-for-all strategy from almost all countries.● Positive trends in mobilizing communities for health and allocation of resources.

● Slow progress due to slow reorientation of disease control programme towards people’s needs, difficult-ies in involving all those concerned with health, weak management of health care delivery system etc.

● National health expenditure devoted to local health services had decreased in least developed countries.● In 1/4 African countries per capita expenditure on health was under US$ 5.

● Slight increase in % of GNP spent by national governments for health in developing countries.● Increasing number of countries adopted policy of decentralization and delegation of responsibility to

district level.● People increasingly involved in improving their own health.


143

Achieving health for allrt on the World Health Situation, from 1954 to 1989Health status Health services

● Application of some simple technology (chlorination, fluoridation, long-acting penicillin, etc.).● Dental health services had been expanding rapidly in many countries.

● Very high infant mortality rate and maternal mortality rate in developing countries.● Half of the children died before they reached the age of five years.● Disease problems: malaria, 1.5 million deaths, smallpox still a menace.● Prevalence (millions): trachoma 400, malaria 150, yaws 50, onchocerciasis 20, leprosy 12.

● Very low vaccination coverage (no exact data).● Water supply and waste disposal systems quite inefficient.● Great shortage of water supply and sanitation in larger cities: 10-30% of dwellings without these

facilities.

● General trends towards the improvement of health status (decline in increase in height and weightand improvement in nutritional status).

● Still very high infant mortality rate and maternal mortality rate in developing countries.● Half of the children died before reaching the age of five years.● Rate of poplation growth of 3% and more per annum in some countries.● Increase in number of venereal diseases, mental disorders and anxiety states and accidents.

● Substantial reduction in infant mortality rate (in Africa by 20-30 %).● Decrease of some communicable diseases (cholera, smallpox, leprosy, yaws, trachoma, etc.).● Further development and enlargement of health services (hospitals, health centres, manpower).● Recorded progress in general education (proportion of children attending schools has risen from 2.3%

to 9%, especially in Africa).

● Some efforts in control of communicable diseases influenced decline of some of them: smallpox(40% less than in previous years), polio in developed countries, leprosy, cholera.

● Savings from some eradication programmes, for example measles in USA (1963-68), had averted10 million acute cases, saved 1000 lives and prevented more than 3000 cases of mental retardation.

● Proportion of the population over 65 expanded.

● Increase in life expectancy at birth, highest values in Europe and the Americas.● Some diseases show «withdrawal» – rapid decrease in number (smallpox in the Americas – since

April 1971 – last case in Brazil, cholera fewer notified cases, etc.).● Treatment of some diseases effective: plague, tuberculosis, yaws, etc.

● Infant mortality rate decreasing in developed (8.3-40.3/1000 live births) and in developing(130-200/1000) countries.

● Life expectancy at birth increasing (male: 53.9 years, female: 56.6).● Population over 65 increased. ● Smallpox – no new areas.● Endemic treponematoses – low prevalence.● Mortality from cardiovascular and ischaemic heart disease – decrease in some developed countries.

● Maternal mortality rate still high in some developing countries (up to 737/1000 live births).● More than 3 million people dually infected by tuberculosis and HIV.● Increased number of HIV infections.● Nutrition of children in developing countries not yet satisfactory.

● Recurrence of certain diseases: venereal, rabies, viral hepatitis, trypanosomiasis, plague.● «Population pressure» – dramatic projection of the population growth.● Malnutrition: anaemia, goitre.

● Eradication of smallpox declared 1980 by 33rd World Health Assembly.● Infant mortality rate less than 50/1000 live births in 80 countries.● Life expectancy at birth over 60 years in 98 countries.● Diarrhoeal diseases – decline in mortality, morbidity.● Mortality from cardiovascular disease in developed countries – decline.

● Life expectancy at birth increase of 1 year from 1985 to 1990.● Infant mortality rate decrease from 76 per 1000 live births in 1985 to 68 in 1991.● Birth weight over 2500 g improved from 79% in 1985 to 88% in 1991.● Disparities in health status between developed and developing countries reduced, but problem remains.

● High prevalence of parasitic diseases.● No sign of decreasing plague, venereal diseases, etc.● Increase of some diseases: cardiovascular, cancer, mental, accidents.● Big economic burden of some diseases: tuberculosis, syphilis, etc. (in USA).

● Malnutrition (protein-calorie malnutrition) a big problem – more than 100 million cases in childrenunder 5.

● Increase of population growth rate from 1.82% in 1950-55 to 2.08% in 1965-70.

● No improvement in some diseases/conditions: diabetes, acute respiratory infection, malaria,malnutrition, accidents, maternal mortality (developing countries), etc.

● Food and nutrition, 1000 million globally without enough food.● Annual increase of global population: 80 million.

● Infant mortality rate – still high: over 50/1000 live births in 79 countries.● Mortality from ischaemic heart disease increased in under 65s in most countries.

● Reawakening of the interest in the environment influenced development of «sanitary policy»which helped in the control of communicable diseases.

● Considerable attention had been paid to the education and training of manpower (more doctors,new schools, more nurses, etc.).

● Some progress had been made in the provision of community water supply – especially in Latin America.● Main progress in structural development of health services, rather than in performance.● The period 1965-68 was notable for the growing appreciation of the dangers of environmental pollution.

● Contraceptive methods – slow increase.● Number of medical schools – increase.● Drinking-water supply improved in urban areas.● Drug control laboratories established in some countries.

● Immunization coverage (DTP-3rd dose low – 15%)● Some improvements in water supply and sanitation – nullified by population growth and drought.

● Immunization coverage increased globally – to 80%.● Safe water coverage increased from 68% in 1985 to 75% in 1991.● Adequate excreta disposal increased from 46% in 1985 to 71% in 1991.● Availability of essential health care increased globally.

● Preventive and curative medicine are not easily «integrated» (antithesis between preventive andcurative medicine).

● Antisocial concentration of medicine and nursing skills in the larger cities.

● Great disparity in wealth, health and educated manpower.

● Low % of children immunized – less than 10%.● Inadequate distribution of manpower: urban/rural.● % of population with access to safe drinking-water not satisfactory in rural areas in developing

countries.

● Local health services still not reaching 10-20% of population.● 2 million children still dying because of not being immunized.● Maldistribution of health personnel (among countries, within countries, urban/rural, etc.).● Shortage of nurses – especially in Asia.

● Coverage with primary health care from 80 to 100%.● Immunization coverage by DTP– 15%.


144

● The political nature of health, ill-ness and health care.

● The value of representative de-mocracies in all countries wherehuman, political and socioeco-nomic rights are truly respected.

● The inextricable play of econom-ics, religion and culture with poli-tics in decision-making and prior-ity-setting in health.

● The value of peace and conflictresolution as essential conditionsfor physical, mental and spiritualhealth.

● The value of institutional designsthat ensure government capacity tomanage political struggles wherethe results affect people’s well-being negatively.

● The essential importance of gov-ernance in managing transitions,crises and new paradigms.

● The implications of politics andpolicy-making for WHO’s techni-cal cooperation in the future: po-litical contexts should be moni-tored in a systematic way so as tobe able to foresee some possibleimpacts on health development;and to support ministries of healthand other partners in the formula-tion of better health policies.

Experience of the past 20 years showsthat governance is one of the decisivefactors in securing the implementa-tion of primary health care goals. It isalso essential to strengthen the social,political and psychological capacity ofpeople to facilitate the shifts in val-ues and behaviours required to par-ticipate and be active in decision-making. Trust in the systems of jus-tice, protection and security must besecured. Transparent assignment ofresources, financial execution andsocial participation in the process ofdecision-making are also part of goodgovernance.

Managing progressin implementation

To ensure that governments andWHO know whether they are mak-ing progress with the implementationof their strategies and whether thesestrategies are effective in addressingthe health concerns and improvingthe health status of the people, theOrganization’s Member States agreedat the World Health Assembly in 1981to monitor progress and evaluate theeffectiveness of their strategies atregular intervals, and to report theirfindings to the WHO governing bod-ies. Implementation was monitoredin 1983, 1988 and 1994, and evalu-ated in 1985, 1991 and 1997. Thefindings were then reviewed by theregional committees and by theWorld Health Assembly.

The process and progress in healthsystems development and the trendsin health care coverage during the lasttwo decades are highlighted below.

Health systems devel-opment

Up to 1978, the biomedical model ofhealth systems predominated, and thehealth sector was confused with themedical sector. To develop a health sys-tem, doctors and nurses were trained,hospitals established, infrastructurescreated and medicines distributed, es-pecially in towns and for populationsthat could afford them. Access to mod-ern health care was extremely limitedin many developing countries, particu-larly for rural populations. The limita-tions of the biomedical model wereevident. Fortunately, following theDeclaration of Alma-Ata in 1978, newchannels and alternative experimentsopened up increasingly credible op-tions worldwide.

Experience of the past

20 years shows

that governance is one

of the decisive factors

in securing the

implementation of

primary health

care goals.


145

The three main elements of thestrategy (which went far beyond theprevailing biomedical model) were:the development of peripheral serv-ices, an intersectoral approach andcommunity participation. The strat-egy was adopted, more or less explic-itly, by the vast majority of countries.

Changes in the economic and po-litical situation in the 1980s provedto be a major obstacle to the imple-mentation of the health-for-all strat-egy. It was adopted several years toolate for the political and social move-ments that could have provided sup-port and served as a springboard fordevelopment. So, before long, it wascriticized, distorted, taken over andinterpreted more and more restric-tively. In general, however, the resultsof the health-for-all strategy havebeen encouraging as regards the de-velopment of peripheral health serv-ices, but little has been done to pro-mote an intersectoral approach andcommunity participation.

WHO continued to support theprinciples of health for all, but organ-ized itself in such a way as to deal withprevalent diseases in developingcountries. It pushed the medical ap-proach as far as it could go, even inprevention, by giving greater empha-sis to vaccinations and vertical pro-grammes.

Appropriate preventive, curativeand community care has a central rolein the pursuit of the health-for-all tar-gets. Using adequate policy instru-ments and cost-effective manage-ment of resources, appropriate carefocuses on accessible primary care,supported by strong secondary andtertiary care, including services forpeople with special needs, in orderto ensure a high quality of care, andmaximum health gains.

Resources for health

Countries can be divided into threegroups according to the predominantmethod of financing their health sys-tem: mainly based on taxation; chieflybased on social insurance; character-ized by centrally-planned normativedistribution of government budgetfunds. With a significant increase inmost countries in the role of the pri-vate sector in the delivery of services,both equity and allocation issues arereceiving more attention. Concernshave also been raised about the qual-ity of care.

In all countries, the reform proc-ess is bedeviled by the growing costsof health services. The ageing of thepopulation, associated with an in-creased need for health care, theavailability of new treatments andtechnologies and rising public expec-tations, all exert financial pressures.Most countries are responding witha series of measures to control risingcosts. In western Europe, for exam-ple, successful macroeconomic meas-ures have given way to additional ef-forts to restrain escalating costs at theinstitutional level. In the countries intransition, this approach has been lesssuccessful, although there is someevidence of improving efficiency. Thequest for cost-containment and moreefficiency, and the imperative to iden-tify more resources, frequently takeprecedence over the health-for-allprinciples and values. Consequently,from the patient’s point of view, of-ten what is referred to as “reform”does not contain any elements of im-provement. Patients are asked to paymore and receive less.

A core concern in countries en-gaged in reforming their funding sys-tem is to balance the principle of soli-darity with pressures to establish com-petition among insurers and provid-ers. Private health insurance schemesare often operated in a manner that

With a significant

increase in the role

of the private sector

in the delivery of

services, both equity

and allocation issues

are receiving

more attention.


146

corrodes social solidarity. On thewhole, the western European coun-tries decided to retain their generalhealth care policy orientation as be-fore, but they have made majorchanges. More choice, competitionand pluralism have been introducedin tax-based systems. Insurance-based countries are paying more at-tention to cost containment, primaryhealth care and preventive services.In other regions, countries where thetax-based systems are deemed to beinsufficient are reviewing the optionof health insurance; for example, thePhilippines has adopted an expandedcomprehensive national insurancesystem, although the need to subsi-dize the poorer segments of societyis limiting its success. In the EasternMediterranean, growth of health ex-penditure since 1990 has been ratherslow, partly because of the difficulteconomic environment prevailingsince the mid-1980s and the conse-quences of the structural adjustmentprogrammes in several developingeconomies of the Region. Severalcountries have tried to mobilize thenecessary funds through alternativefinancing schemes based on cost-sharing and the development ofhealth insurance schemes.

A central issue for many countries,such as China, is improved coordina-tion and management of multiplefunding sources. Many health systemsstruggle to keep up with rising costsor are affected by national decisionsto reduce expenditure on health. Vari-ous cost recovery mechanisms aretherefore being explored. Malaysiaand Mongolia are investigating usercharges to finance certain health serv-ices, although possibly not criticalcare services.

In Africa, investment in health hasvirtually ceased. The social sectors,including the health sector, have beenhardest hit by the worsening budgetdeficits. The proportion of the GNP

allocated to health has failed to in-crease, or has even diminished. Thereis still a gross imbalance between ex-penditure on tertiary care and ex-penditure for local care, to the detri-ment of the latter. Progress in thisarea has been marginal.

In general, reliable and valid dataon health care financing are sparse inmost developing countries. In addi-tion, data on expenditures in the pri-vate sector are often difficult to ob-tain. Yet in most countries of South-East Asia, for example, 60-75% of thetotal health expenditure occurs in theprivate sector. Direct out-of-pocketspending by households appears toaccount for a major portion of privatespending in most countries in theEastern Mediterranean, while privateinsurance premiums account for alimited fraction of private spending.This means that households bear asubstantial proportion of health carecosts while having little or no finan-cial protection (i.e. insurance) in theevent of major illness or injury.

In many developing countries,additional resources for the healthsector are provided by nongovern-mental organizations and bilateraland international donors. The roleplayed by nongovernmental organi-zations in both the provision and fi-nancing of health services is grow-ing in many countries as a conse-quence of diminishing resources inpublic sectors. As the prospects offinancial assistance from many do-nor countries are not optimistic,owing to economic recession andcuts in developing assistance pro-grammes, financial institutions arebeing approached for loans aimed atsupporting health development pro-grammes. In many less developedstates, external sources of fundingsupport disease control activities andcritical health promotion services,such as campaigns related to mater-nal and child health and immuniza-

The proportion

of the GNP allocated

to health has failed

to increase, or has

even diminished.


147

tion. In these countries aid coordi-nation remains a concern.

Few countries, even the mostprosperous, are satisfied with thedistribution of financial resourcesbetween promotive and curativeservices.

In Europe, redistribution of finan-cial resources towards primary healthcare could not be confirmed by thefew existing data. Some evidenceabout the outcome of such reformpolicies comes from other indicators,such as immunization rates and infantand perinatal mortality, which mostlyimproved, although this was not con-sistent. Disparities in access betweensocial groups also persist, and in somecases have even worsened.

In the Western Pacific most coun-tries devote sufficient resources to thehealth sector and thus express theirpriority concerns in terms of issues ofequity, appropriate allocation of theresources and efficiency. This hasbecome an important issue for China,where central funds are used to bal-ance regional and rural funds.Malaysia, for example, recognizes thatthe public system should ensure thatappropriate social safety nets are inplace for those who, for economicreasons, have difficulty accessing ap-propriate care. In most countries ofthe Region, basic care of children,older citizens and those with otherspecial needs is met by governments.In Cambodia and the Lao People’sDemocratic Republic, however, theallocation to the health sector is 2%or less of the gross national product,and is not sufficient to meet basicneeds.

Data from some countries in theEastern Mediterranean show thatpublic resources are not equally dis-tributed between geographical re-gions and between social classes.They tend to favour urban and well-off populations and to generate po-larization with regard to accessibility

to health care. This aspect is furtherworsened by privatization policies. Animportant share of recurrent budgetsof ministries of health is allocated fortertiary care, thus limiting resourcesfor primary health care services, andpreventive and promotive pro-grammes. On average, 43% of na-tional health expenditure is devotedto local health care, down from 50%in the early 1980s.

Experience in some countries hasshown, however, that decentralizationmay also have negative effects suchas fragmented services, or inequity.Successful decentralization requiressufficient local administrative andmanagerial capacity and appropriatemechanisms for accountability andcitizens’ participation. In addition,there is evidence that certain areassuch as the basic framework for healthpolicy, or regulations concerning pub-lic safety, are better managed cen-trally. Decentralization of responsibil-ity for primary health care to localauthorities is not always accompaniedby a shift of financial resources. InEurope, for example, the reluctanceof hospital-based medical specialiststo accept policies that strengthen pri-mary health care and/or restrict di-rect access to secondary care are acontinuing feature. Services are stilloften characterized by the existenceof parallel vertical programmes. In-tegrated horizontal services are nev-ertheless being developed in someEuropean countries, providing a fullrange of outpatient services supple-mented by home care, in cooperationwith the social welfare services.

Problems associated with humanresources vary in different regions.In the Americas, the expansion ofhuman resources has in particularbeen limited by recent cutbacks inspending by the public sector, precipi-tated by the downturn in theeconomy. Another factor has beenhigh management turnover because

Successful

decentralization

requires local

administrative and

managerial capacity

and mechanisms for

accountability and

citizens’ participation.


148

of changes in government and direc-tion and the lack of a personnel policyand of appropriate incentives to mo-tivate personnel.

In South-East Asia, on the otherhand, the absolute and relative num-bers of most categories of health per-sonnel have risen. Most countries areexamining their personnel policiesand formulating plans; expanding andstrengthening the capacities of edu-cation and training institutions; andupdating and reorienting the cur-ricula to meet the changing needs ofthe health services. Countries con-tinue to make use of other trainingresources in the Region to supplementtheir own training opportunities.

Investment in human resourcesfor health has been such that in mostcountries in the Eastern Mediterra-nean Region, the resources allocatedfor personnel consume 60-70% of thetotal budget of ministries of health.Recent demographic and epidemio-logical changes have resulted in anincrease in the overall ratios of hu-man resources for health, especiallynursing and midwifery personnel.This can be attributed to the in-creased number of nursing institutesand increased demand, and is theoutcome of health policies launchedseveral years ago. Measures adoptedinclude incentives to work in remoteand rural areas (e.g. in Iraq), and theinvolvement of nongovernmental or-ganizations in training health person-nel (e.g. in the Islamic Republic ofIran).

In many African countries, the lowoutput of health institutions and poorperformance of health personnel re-main major concerns. The brain draincontinues, undermining the publicsector’s capacity to respond to healthneeds. The phenomenon of unem-ployment among school leavers isparticularly affecting the health sec-tor. Although some initiatives havebeen taken, they are of limited scope

and will need to be encouraged andexpanded since they have provedtheir effectiveness in some cases.

In the Eastern Mediterranean,although human resources have beenproduced and deployed in largernumbers, their distribution is not bal-anced among the different levels ofcare, nor is it always equitable withincountries, or balanced between vari-ous categories. Some countries (e.g.Lebanon and Pakistan) have morephysicians than nursing/midwiferypersonnel because of cultural or em-ployment factors, or shortages in edu-cation and training facilities. Thereare problems of absorbing graduates(e.g. in the Islamic Republic of Iran),and of low intake of nationals in nurs-ing institutes, for cultural reasons.The recruitment and deployment ofhealth personnel may be carried outby a central government body irre-spective of real needs, and rapidprogress in technology and increasedpublic awareness of needs may alsobe causing pressure. Health person-nel are concentrated in the capital orother cities, where university hospi-tals and other secondary and tertiarycare institutions exist. This disparity– fewer physicians assigned to pri-mary health care despite more physi-cians joining the services – raises sev-eral issues. In addition to the factorsmentioned above, primary health caremay not be attractive for physicianswhen it is remote and without incen-tives.

Examples in other regions includethe Philippines, where the output ofeducational institutions does notmatch what the service needs. Amongits many health initiatives, New Zea-land is attempting to address this is-sue with specific purchasing agree-ments for educational institutions. Sin-gapore has recognized the need to sup-port the training of nurses in order toaddress similar concerns. China is ex-ploring market mechanisms to meet

Most countries

are examining their

personnel policies;

strengthening

the capacities of

training institutions;

and reorienting the

curricula to meet the

changing needs of

the health services.


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health service needs – encouragingpractitioners to run their own clinicsor consultations, and encouraginghealthy competition between medicalinstitutions to improve efficiency andreduce costs, thus matching demandfor care at different levels.

In the Americas, the most impor-tant constraint is the failure to developa model of human resource needs inhealth in coordination with traininginstitutions, and the trend towards pro-fessional medical specialization per-sists, with a steady rise in the numberof physicians. The health workforcecontinues to be largely female and con-centrated in nursing. Reduced em-ployment in health and the changes infinancing resulting from state reformhave influenced policies related to thedevelopment of new human resourcesfor health in most countries. At thesame time there are no signs that thegeographical and social distribution ofhealth workers has improved; they re-main highly concentrated in the cit-ies, to the detriment of rural areas andurban peripheries. Virtually all coun-tries are aware of the urgent need torectify this situation. The appearanceof new factors in the health sector jobmarket (banks, NGOs, other agencies)has meant significant changes in themechanisms and processes involved inthe regulation of health care and thehealth professions. Meanwhile, how-ever, structural action needed for solv-ing the problem is often postponed orconsidered unviable.

In the Western Pacific, the mainstrategy is continually to upgrade theskills of the workforce through edu-cation and training, with particularemphasis on continuing education.Upgrading is seen as a particularlyimportant issue in China. Cambodiais revitalizing its health systemthrough a national continuing educa-tion programme. Continuing educa-tion is an explicit priority in Kiribatiand the Philippines.

In Europe, the implementation ofpolicies to develop primary healthcare is accompanied by the introduc-tion of schemes for training generalpractitioners/family physicians, or forthe retraining of physicians already inpractice. Some countries are devel-oping family physician services witha parallel community nursing service,where one did not already exist. Alsothere is a tendency to create aca-demic departments of general prac-tice/family medicine and to introducethe subject into the undergraduatecurriculum of medical students.

Most countries in South-East Asiahave also taken steps to increase pro-duction of certain categories of healthpersonnel, including voluntary work-ers, in order to improve and expandcoverage, especially at the communitylevel. A few have established new cat-egories of personnel and new train-ing programmes in an effort to meetincreasing and changing health serv-ice needs. For example, Maldives isnow conducting a diploma course inprimary health care to train middle-level managers and Myanmar hasestablished a new institute which of-fers a degree in community health toprepare public health officers incharge of basic health services in pe-ripheral areas. There is, however, atendency of educational institutionsto seek “quality” in the abstract, withinsufficient attention to the real needsof the communities and their limitedresources. Deficiencies in training fa-cilities, teaching capability and re-sources are also constraints.

In the Americas, on the otherhand, countries usually have a vari-ety of institutions that, working in iso-lation, make decisions about trainingand education needs. The institutionsresponsible for training human re-sources have tended to neglect edu-cation in public health, health policy,and health management.

There is a

tendency to create

academic departments

of general

practice/family

medicine and to

introduce the subject

into the undergraduate

curriculum of

medical students.


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In Africa, many countries madethe development of infrastructurethe focus of their health policy, butthe results obtained were uneven inview of limited investment capacity.Hospitals continue to consume thelargest share of the health budget,sometimes at the expense of healthcentres. Maintenance of facilities andequipment is inadequate, not onlybecause of financial constraints butalso for cultural reasons. Quite often,achievements could not be sustainedwithout international cooperation.

In the Americas, in contrast to the1970s, infrastructure developmentpolicy in the past 15 years has stag-nated and is currently one of the com-ponents with the greatest need forsupport. Generally, health policy doesnot provide for the development ofphysical infrastructure such as facili-ties and equipment. This means thatequipment is not procured on thebasis of an evaluation of the healthneeds of the population. In the ma-jority of countries, technical servicesare not an integral part of the healthcare system, nor are maintenanceplans for hospital equipment. Equip-ment is not utilized because it is in-appropriate, because of lack of per-sonnel who know how to use it, orbecause of minor faults and a lack ofspare parts. In addition, ministries ofhealth generally do not have a suffi-cient budget for repairing and main-taining infrastructure and equipment,so that international assistance is of-ten the only recourse.

The physical infrastructure inmany South-East Asian countries hascontinued to expand, particularly atthe primary and first referral levels.Health care facilities in the privatesector have expanded, as reflected bythe increasing number of private hos-pital beds. However, maintenance ofinfrastructure appears to be a prob-lem in many countries, and commu-nities are becoming involved in estab-

lishing, equipping and maintainingthe health infrastructure in somecountries. Most countries have givenpriority to upgrading the health infra-structure, particularly in rural areas.Remote health facilities are oftenlinked by telecommunications. Im-proving the infrastructure is oftenhampered by staffing difficulties andshortage of spare parts. Moreover,improvements may not systematicallybenefit poorer populations. Nepal, SriLanka and Thailand have compre-hensive networks of health facilitiesextending to the village level. Accessto primary health care has been con-siderably improved, and work is nowbeing undertaken to ensure planneddevelopment and maintenance. As-sistance from international fundingagencies has also been very useful inthat respect.

In the Eastern Mediterranean,initiatives have recently been takento ensure equitable distribution of theinfrastructure. Many countries haveopted to specify catchment areas asthe unit for planning health services,and in general physical infrastructurehas received considerable attentionand investment, often benefiting frombilateral and multilateral assistanceprojects. Construction and renovationof secondary and tertiary hospitals hasalso developed, but at a slower rate.Accessibility to health servicesreached 82% in 1990 and has beensustained. Further expansion of cov-erage has been hampered by civilstrife in some countries and by thehigh cost in remote areas. Outreachand mobile teams are used as alter-natives to static units to serve scat-tered and remote populations. Linkedto accessibility are two other param-eters, coverage and utilization. Thereported pattern of utilization variesamong and within countries.Underutilization is sometimes due toa lack of availability of budgetary re-sources for drugs, physicians, health

Hospitals continue

to consume the

largest share of

the health budget,

sometimes at

the expense of

health centres.


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staff and equipment or to the avail-ability of alternative acceptable serv-ices, whether provided by traditional,private or nongovernmental organi-zations. Facilities constructed thanksto donations from nongovernmentalorganizations or communities orthrough loans are often not includedin proposals for recurrent budgetsdue to poor coordination betweenplanning and financial departments.

Public facilities – buildings, equip-ment and supplies – are not usuallywell maintained, because of lack offinancial resources and qualified per-sonnel. Few countries have adequaterepair and maintenance workshops,whether centralized or decentralized.Some countries contract out for main-tenance and repair of biomedicalequipment. Underuse of equipmentmay result from poor maintenance orfrom shortage of necessary suppliessuch as chemicals. Ministries ofhealth cannot compete with privatefirms in attracting scarce qualifiedrepair and maintenance technicians.There is a need for resources to beprovided through bilateral and mul-tilateral cooperation in this area.

Since hospitals are the main con-sumers of health care resources, theyhave been at the centre of health carereform in every European country.There have been many changesaimed at increasing patient satisfac-tion, rationalizing resources andachieving better outcomes. Mostcountries claim moderate to gooddevelopment in this area, althoughthe pace of change has been slowerthan desired. The number of hospi-tal admissions has varied widely, evenbetween countries with similar levelsof economic and health development.Hospitalization all over Europe hasshifted further from chronic and sim-ple surgical procedures to acute, dayhospitals and shorter length of stay,and complicated pathologies andtreatments. On average, the number

of hospital beds per 1000 populationhas decreased in all parts of the Re-gion, most notably in some countriesof eastern Europe. On the whole,however, the costs of hospital treat-ment have probably increased, bothin absolute terms and as a proportionof total health expenditure. Progresshas been made regarding alternativesto hospitalization such as day surgery,day care and home care.

Increasingly, countries in all re-gions are endeavouring to ensurequality of care, through the identi-fication and constructive use of bestpractices and the optimal use of ex-isting resources. In 1993, the Euro-pean Forum for Medical Associationsstated that ensuring quality of care isan ethical, educational and profes-sional responsibility inherent in themedical professions. Good progressis being made in European countriesfollowing the achievement of consen-sus on quality indicators, e.g. for dia-betes management and obstetricaland perinatal care. Outcomes in cen-tral European countries have beenidentical to those in western Europe,while at the same time quality of carehas been achieved with less frequentuse of technology-intensive interven-tions.

In the Americas, although somecountries have set up a classificationsystem to define the levels of poten-tial risk to the health of the popula-tion, based on quality and safety cri-teria, greater organization is stillneeded for its use in practice. In onecountry for example, only 0.8% of thefacilities evaluated had some methodfor treating hazardous solid waste.

In the Eastern Mediterranean,countries have undertaken assess-ment of health services to identifynew entry points to improve perform-ance. Some countries (e.g. Bahrain,Egypt, Jordan, Morocco) have initi-ated quality control programmes atselected levels of care. Capacity-

Countries in all regions

are endeavouring

to ensure quality

of care, through

constructive use

of best practices

and the optimal

use of existing

resources.


152

building and training of health per-sonnel in techniques and methodolo-gies of quality of care continue.

Many countries are turning tocommunity participation as a partof the action needed to reinvigoratethe strategy for health for all, e.g.Bahrain, Egypt, Oman and Sudan.Other examples include Mongolia,which is redirecting services by mak-ing use of a new type of family-oriented practitioner, and Cook Is-lands, Samoa and Vanuatu, wherenurse/community practitioner pro-grammes are being pursued. In In-dia, community participation is beingencouraged for the procurement ofmedical equipment for hospitals, andcost-sharing schemes have been in-troduced for the maintenance ofhealth facilities. For improving drugaccessibility and affordability, com-munity cost-sharing schemes are be-ing implemented in Indonesia,Myanmar, Nepal and Thailand. Somecommunities are also participating inthe procurement of equipment.

Health care coverage

Health care delivery systems

The objective of a comprehensivehealth care delivery system is to pro-vide services to deal with existinghealth problems through the best uti-lization of available resources. Na-tional health care delivery systems aremeasured against four criteria: impacton the health problems of the popu-lation; coverage of the population inrelation to the resources allocated;efficiency of services in attaining theobjectives at minimum possible cost;and the effectiveness of activities thatare health-related, though not carriedout by the health services. As a rule,only a small number of patients re-quire the intervention of highly spe-cialized medical care services, and

most can be satisfactorily treatedthrough adequate primary care, sup-ported by appropriate technology,and by people themselves throughguided self-care.

Major difficulties in the function-ing of health care facilities are: thelack of specific definitions of promo-tive, preventive, curative, rehabilita-tive and supportive functions for eachlevel of care; the uneven distributionof health care facilities; the absenceof regional networks with proper re-ferral links; the lack of appropriatelytrained personnel, its maldistributionand the inappropriate combination ofeducation and specialization; insuffi-cient management training; and thelack of simple low-cost material andmethods designed for, and adapted to,local conditions.

Conventional health care deliverysystems, as developed in some afflu-ent countries, are unlikely to providea suitable model for other countriesbecause the solutions they imply aretoo costly and, therefore, irrelevant.The aim is to achieve a proper bal-ance between need and supply, cen-tralization and decentralization, andcosts and effects, and greater flexibil-ity of the whole system of health caredelivery, including referral.

In integrated health services allservice units in a geographical areaform a functional unit. The trend isto extend the range of the service unitto the periphery. In the more afflu-ent countries where chronic condi-tions prevail, high priority should begiven to integrating acute care in ageneral hospital with the functions ofoutpatient care and institutions forextended care. In the developingcountries, where infectious condi-tions prevail, the emphasis should beon the integration of preventive pro-grammes in existing or developinghealth care services. Integrated dis-ease control should be part of the de-velopment process.

Many countries are

turning to community

participation as a part

of the action needed

to reinvigorate

the strategy for

health for all.


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Since 1981, the trend has beentowards improvement in health carecoverage as a result of the followingfactors: the extent of government,political and social commitment toachieving health for all; the commit-ment of financial resources for healthby governments and the mobilizationof resources by individuals and com-munities; growing management capa-bilities for programme implementa-tion among health personnel and atcommunity level. In general, healthpersonnel are being better trainedand oriented to communicating andworking more effectively with theirpeers, with government, with othersectors, and with individuals and com-munities.

But many problems still remain.The percentage of the populationcovered with essential services hasincreased, but millions of people re-main without access to water andsanitation services and to the basicelements of care because the in-creases in the services available havenot kept pace with the increases inpopulation. The gap between theavailability of different elements ofhealth care in developed countriesand in the least developed countriesis widening, although there are gen-eral improvements, even in the poor-est group of countries. There are alsowide gaps within countries, betweenrich and poor and even between dif-ferent areas within countries, oftenexacerbated by the economic declineof the 1980s and 1990s. Services areoften fragmented and coordinationbetween the public and private sectorsand with nongovernmental organiza-tions needs improvement. The qual-ity of care is generally high in mostdeveloped countries, although theoveravailability of drugs and of tech-nology can lead to other problems.

Health education

In the late 1970s health educationunits were set up in many countriesthroughout the world, but policy de-velopment was not a priority. Activi-ties focused mainly on information-giving and on campaigns around life-style-related issues in the developedworld, and infectious diseases in de-veloping countries. Starting in 1986,the five action areas of the OttawaCharter for Health Promotion (healthypublic policy, supportive environ-ments, community action, personalskills and reorienting health services)set the agenda for health promotion.Follow-up conferences in Adelaide(1988) and in Sundsvall (1991) elabo-rated the concept further and devel-oped a more holistic and intersectoralapproach to promoting and protectinghealth, particularly in developed coun-tries. Greater emphasis was given to asettings approach to health such as, forexample, the development of healthycities, health-promoting schools, is-lands, municipalities and villages, hos-pitals and workplaces. Gradually amore decentralized approach to healtheducation and health promotion de-veloped, with subregions or provincestaking over responsibilities from na-tional institutions. Health promotionwith its emphasis on intersectoral ac-tion and settings provided the frame-work within which health educationremained an important component.Developments in communicationstechnology revolutionized the poten-tial for health promotion. Meanwhile,increasingly greater emphasis is givento the development of healthy publicpolicies backed up by the necessarylegislation and resources.

Nutrition

One-fifth of the population of devel-oping countries does not have accessto enough food to meet basic needs.

Greater emphasis

is given to the

development of healthy

public policies

backed up by the

necessary legislation

and resources.


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Low-income countries with a fooddeficit continue to face declining foodproduction and complex emergenciesthat have displaced massive numbersof people, (see Chapter 4). The preva-lence of protein-energy malnutritionin children under 5 in developingcountries declined from at least 42%in 1975 to over 31% in 1996, indicat-ing that in general dietary protein hadbecome widely available. Anaemia,mostly due to iron deficiency, was themost common nutritional deficiencyworldwide in the 1970s and remainsso. Over the past 20 years there hasbeen some decrease in the prevalenceof iodine deficiency disorders, par-ticularly in recent years followingnear-universal salt iodization by 1995in most countries affected. Vitamin Adeficiency is decreasing worldwide,but severe forms are still common inparts of sub-Saharan Africa.Foodborne illnesses continue to be amajor public health concern in bothdeveloped and developing countries.

Water supply and sanitation

In 1972, the United Nations Confer-ence on the Human Environmentbrought environmental concerns toglobal attention for the first time. Inthe mid-1970s there were approxi-mately 3 billion people in the devel-oping world, only 38% of whom hadsafe drinking-water and 32% ad-equate sanitation. In 1978 the Inter-national Drinking-Water Supply andSanitation Decade was launched withthe stated goal of clean water and ad-equate sanitation for all by the year1990.

In 1980, safe water supply wasavailable to about 50% of the worldpopulation, while adequate sanitationwas available to about 35%. In 1985,an average of 55% of the populationsin developing countries had safe wa-ter. By 1990 the figure had risen to66%. The figures for excreta disposal

were 31% in 1985 and 53% in 1990.There are great differences betweenand within countries, particularly be-tween urban and rural areas. From1990 to 1994 the number of peoplewithout sanitation increased by nearly300 million, totalling almost 3 billionfor developing countries in 1994 (seeFig. 17). This figure is projected toincrease to over 3 billion by the year2000. From 1990 to 1994 nearly 800million people gained access to safewater supplies but, due to populationgrowth, the number of unserved de-creased only from 1.6 billion in 1990to 1.1 billion in 1994. The rural popu-lation remains at a disadvantage: in1994, sanitation coverage in rural ar-eas was a mere 18% whereas it was63% in urban areas; access to wateramounted to 70% in rural areas and82% in urban areas.

There are positive developmentshowever. The focus is shifting fromdrinking-water quality alone towardsoverall improvement of the environ-ment. Public policies aimed at creat-ing a healthy environment are becom-ing more generally accepted.

Maternal and child health

The range of health care needs thatcan arise during and just after preg-nancy make the challenge of ensur-ing the access of all women to relevantservices complex. Current global es-timates show that in the developingworld approximately 65% of pregnantwomen receive at least one antenatalvisit during pregnancy; 40% of de-liveries take place in health facilities;and slightly more than half of all de-liveries are assisted by skilled person-nel. This contrasts sharply with de-veloped countries, where practicallyevery woman receives regular careduring pregnancy, delivery and thepostpartum period.

Postpartum care has been a rela-tively neglected aspect of maternity

Public policies

aimed at creating

a healthy environment

are becoming more

generally accepted.


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care. It does not feature in the goalsset at major international conferencesand the lack of reporting is an indica-tion of low priority. Less than one-thirdof developing countries report nationaldata, and levels of coverage can be aslow as 5%. Estimates based on the lim-ited data available indicate a coverageof 35% at the global level. This lowlevel of care is disturbing, since timelyinterventions during the postpartumperiod can prevent deaths of bothmothers and newborn infants, and canreduce the incidence of long-termpregnancy-related illnesses.

In developed market economiesand economies in transition, well over90% of pregnant women receivedantenatal care in 1996. Deliveries tookplace in health facilities and were at-tended by skilled personnel. In theleast developed countries, while nearly50% receive antenatal care, only 30%deliver in health facilities or haveskilled attendants. In other develop-ing countries the numbers are around70% and 60% respectively. Worldwide,only every third woman receives carefrom a skilled health professional in thepostpartum period. Estimates of anae-mia in pregnancy are less than 20% indeveloped market economies andeconomies in transition, but are above50% elsewhere.

In 1965, only about 9% of all mar-ried women of reproductive age indeveloping countries, or their part-ners, were using a method of contra-ception. Today this figure is approach-ing 60% worldwide. However, the fer-tility-regulating needs of large seg-ments of the world population remainunmet by the currently availablemethods and services.

These indicators of maternalhealth care utilization have a numberof limitations. They do not, for exam-ple, reflect the content or quality ofthe care provided.

Just as maternal health is depend-ent on many factors, newborn and

Box 26. WHO’s Expanded Programme on Immunization (EPI)

One of the most dramatic current goals for EPI is the eradication of poliomyelitisby the year 2000. While there are still difficulties in raising the resources neededto ensure that the job is finished on time, all the indications are that progresstowards the goal is on target. Reported BCG and DTP3 coverages have re-mained steady since 1990 at about 90% and 80%, respectively. Countries ingreatest need have reported a slow, but steady improvement for DTP3 cover-age, increasing from 26% in 1988 to 44% in 1996. At least 86 countries havenow introduced hepatitis B vaccine into their routine immunization programme,and at least 25 have introduced Haemophilus influenzae type B (Hib) vaccine.

The managerial process of immunization programmes has particular fea-tures which differ from those of other programmes. EPI has strongly recom-mended that annual operational plans be developed looking at all managerialaspects of health. Such activities have provided a good basis for measuringprogramme effectiveness.

EPI has been instrumental in establishing links between partners in im-munization, enhancing the use of funds in ways which support other parts ofthe health sector as well as immunization.

EPI has focused attention on countries in greatest need – those requiringtechnical and financial support. Such countries have low national programmeimplementation capacity and have received little support compared to othercountries which are financially and technically stronger. Support for immuni-zation in the area of, for instance, training has resulted in improvements inother areas of health care.

For a long time, surveillance has been regarded as an unwelcome neces-sity for immunization programmes, and not carried out well. Through thepolio eradication initiative, the entire surveillance system has been revital-ized to the extent that many countries now report polio data weekly. In addi-tion, an effort has been made to include other infectious diseases in thesame reporting system, e.g. yellow fever, dengue and meningitis.

A basic requirement for all national immunization programmes is an intactand functional cold chain. This facility is useful for many other primary healthcare products not used by EPI. Stock control training for management of vaccinesalso facilitates the management of other commodities used in health centres.

EPI promotes safe injections for immunization and for all other purposes.EPI has developed auto-destruct syringes which can be used only once be-fore they block and have to be disposed of. The method of disposal of anyautodestruct or disposable syringe and needle is important, and EPI hasdeveloped and promoted the use of “safe boxes” which successfully disposeof them and prevent these sharp items from contaminating the environment.

While vitamin A is not a vaccine, the target group of infants and mothersis the same, at least in countries where the vitamin deficiency exists. Bygiving the inexpensive vitamin orally at the same time as immunizations, thecost for both commodities is reduced.

The most devastating illnesses (including measles) of children living indeveloping countries is dealt with by the strategy of integrated managementof childhood illnesses. By supporting this initiative, EPI has helped to pro-duce a comprehensive teaching programme for training health care workers.


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child health are also strongly relatedto the social, economic and health sta-tus of the mother. Most infant mor-bidity and mortality could be pre-vented through the provision of ad-equate water supplies and sanitationfacilities at community level, goodnutrition of mother and child, andaccess to first-level care includinggood immunization coverage. Avail-able – often limited – informationshows that coverage of infant care bytrained personnel has increased since1985, but more importantly indicatesthe large differences that continue toexist between countries.

Immunization

In the early 1980s there were threeconcerns with regard to immuniza-tion: immunization levels were low;supplies of vaccines and infrastruc-ture for their dissemination were in-adequate; and the immunizable dis-eases were limited primarily to diph-theria, pertussis, tetanus, polio, mea-sles and tuberculosis.

The Expanded Programme onImmunization was established in1974 and immunization service deliv-ery was rapidly improved by stafftraining; the development of securecold chains; and the availability ofroutine immunization. Success wasmeasured by vaccine coverage levels,and successful reduction in the inci-dence of some diseases through wide-spread immunization made it possi-ble to consider the elimination of dis-eases such as measles and neonataltetanus, or even the eradication ofsome diseases such as poliomyelitis(Box 26). Since 1991, polio has beeneradicated from the Americas andmany other parts of the globe. Thetarget is its eradication by the year2000. Map 9 shows reported inci-dence in 1987 and 1997.

Global policies and strategies forimmunization have been adopted by

WHO 98137

B. Reported incidence, 1997a

Certified polio free0 cases1–10 cases>10 casesNo data available

Reported number

a–Data as of February 1998.

–Data for the African Region relate to 1996–1997.

1980 1985 1990 1995 19960

20406080

100Global polio immunization coverage, 1980-1996

Infa

nts

imm

unize

d(%

)

Year

LYT

9802

6

3354

82 82 82

Map 9. Polio


157

virtually all countries of the world.Overall immunization rates againstthe six vaccine-preventable childhooddiseases have increased from less than50% in 1980 to over 80% worldwidein 1995.

Neonatal tetanus is now a targetfor elimination with a possibility ofsuccess by 2000. A time-frame for theglobal elimination of measles will beset by the year 2000. The vaccine forhepatitis B has been added to thestandard list, as has the vaccine foryellow fever in endemic areas. Mean-while, some 20% of the world’s chil-dren, most of whom are among thepoorest and least privileged, continueto be unreached by immunization(Fig. 20). Some countries, even somewith adequate infrastructure and fi-nancial capacity, report consistentlylow coverage.

In developing countries andeconomies in transition, constraints tothe maintenance of even 80% immu-nization coverage include inadequatefinancing, poor facilities and the needto upgrade the entire system. In manyleast developed countries, especiallyin Africa, sustaining high coverageremains problematic owing to the al-most universal constraints of insuffi-cient funding, equipment, supplies,cold-chain and transport; lack oftrained personnel; inadequate accessto facilities; and poor receptivity onthe part of the population.

In the developed market econo-mies, immunization rates have beenincreasing since the early 1990s. Inthe economies in transition they de-clined in the early 1980s but havebeen increasing in recent years. In thedeveloping countries, immunizationrates have increased dramatically,while in the least developed coun-tries, immunization rates increasedfrom less than 20% in the early 1980sto more than 60% in the mid-1990s.In the developing countries, whereneonatal tetanus remains a major

19961995

19941993

19921991

19901985

1980

80

60

40

20

0 0

20

40

60

80

69

54

1216

1315

1313

13

64

49

1920

1920

1919

20

5956

2021

2021

2119

21

Fig. 20. Unimmunized infants, 1980-1996 a

a These data include only those countries that have reported data as of 22 October 1997.

LYT

9802

2

BCG DTP3 Measles vaccineb

Vaccine

bMeasles vaccine coverage is among children up to 2 years.

Perc

enta

ge

Year

problem, immunization rates withtetanus toxoid have grown but stillremain quite low at below 50% cov-erage.

Locally endemic diseases

Approaches and progress in the eradi-cation, elimination and control of in-fectious diseases have been dealt withelsewhere in this report, especially inChapter 2. In the context of primaryhealth care, the approach to diseasecontrol is the following:● Selected diseases are targeted for

eradication, elimination and con-trol where cost-effective interven-tions are available and their widerapplication operationally feasible,e.g. poliomyelitis, leprosy andfilariasis.

● Integrated packages of cost-effec-tive interventions are developedand promoted for disease clustersto ensure optimal impact on healthstatus and make better use of re-


158

sources. Examples of this approachare the Expanded Programme onImmunization which aims to con-trol six major childhood diseasesthrough immunization; the Inte-grated Management of ChildhoodIllness that focuses on five majorchildhood killers; and the recentmove towards integrating activitiesfor the control of clusters of tropi-cal diseases (Box 27).

● Capacity at national and global lev-els is reinforced to recognize andrespond rapidly and effectively tooutbreaks of emerging and re-emerging diseases. For example,mechanisms are being establishedby WHO for a global surveillancesystem supported by a team of ex-perts who can be at the location ofan outbreak anywhere in the worldwithin 24 hours of being officiallynotified.

Provision of essential drugs

In 1978, the lack of drugs for the pub-lic sector, especially for primaryhealth care, was identified as a sig-nificant problem. Although countrieswere spending 20-40% of their scantyhealth budgets on importing drugs,most of the people in rural areas andurban slums had no access to thesedrugs. At all levels of the health sys-tem – from the national level to thehospital to the patient – many coun-tries lacked drugs in sufficient quan-tities. At the same time, many drugswere available in private pharmaciesbut were out of reach of the majorityof the population. Today althoughsome problems (unequal access, irra-tional use, lack of resources) remainunchanged, new challenges haveemerged. Securing rational use ofdrugs by health care providers and thepublic is not easy in an environmentwhere resistance to antibiotics is in-creasing rapidly and where new dis-eases are emerging. Also difficult isthe implementation of existing rules,regulations and standards to ensurethat drugs on the market are safe,effective and of acceptable quality inthe absence or the scarcity of humanand financial resources, political com-mitment and physical infrastructure.

There have nevertheless beenimprovements in a number of coun-tries in the Eastern Mediterraneanand South-East Asia Regions. In

Box 27. Integrated disease control

An integrated approach to disease control requires the establishment of clearpriorities on the basis of epidemiological analysis and existing resources andopportunities, as well as careful assessment of the potential effectiveness andsustainability of proposed interventions. Such an approach should be initiatedas a development process, which could be progressively extended to otherpriority areas, and eventually become a sustainable health care service.

Action has been taken since 1996 to integrate activities between groupsof diseases where appropriate, starting in five countries, the Islamic Repub-lic of Iran, Mauritania, Saudi Arabia, the United Republic of Tanzania (Zanzi-bar) and Yemen. The geographical distribution of intestinal parasitic infec-tions, schistosomiasis, filariasis, malaria, leprosy, vaccine-preventable dis-eases and other diseases and the approaches to their control are quitedifferent in these countries. As a consequence these Member States, work-ing closely with the programme on control of tropical diseases in WHO, havedeveloped national plans of action for integrated disease control, which in-clude surveillance activities, and which are now being implemented. Thiswork was carried out by the ministries of health in collaboration with otherministries as well as with the WHO regional offices and the relevant pro-grammes at WHO headquarters. Particular attention is being paid to themost common requirements for disease control and to the most pressingneeds of the population.

With the tools and strategies now available, the integrated approach canbecome a reality in many areas where there are various communicable dis-eases and where the epidemiological circumstances and the resources aresuch as to provide a good opportunity for success. However, as much moreexperience is needed in this area, it will be necessary to continue the initia-tive for several more years.

Better coordination and the combining of resources would appreciablyenhance the health impact of control efforts against communicable diseasesin tropical areas, an approach that is attractive to both ministries of healthand development agencies because it is more cost-effective. However, verycareful joint planning is essential if the expected benefits are to be realized.The activities in the five countries should yield valuable information that willenable this approach to be progressively extended to other areas.


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Africa, access to drugs is still inequi-table even though it has been im-proved by introducing cost recoveryas part of the Bamako Initiative andother similar initiatives (Map 10).

In the Americas, drug legislationand regulation have constituted a pri-ority component of health sectorreferm in many countries – the ob-jective being to create and/or updatethe legal framework to improve thesupply and rational use of drugs.Three major problems have beenidentified with respect to public poli-cies on essential drugs: the annualbudget is low in terms of the need forcoverage; the supply is ineffective;and while a distribution system exists,it does not function properly. Therehave been budget cutbacks in the so-cial sector, and many countries haveadopted different sources of financ-ing, with patients paying more of thecosts. The private sector constitutes78% of the total pharmaceutical mar-ket in Latin America.

Drug consumption accounts forabout one-third of total health spend-ing in the Eastern Mediterranean,and in many countries a relativelyhigh percentage of private spendinggoes towards the purchase of drugs.This pattern is especially pronouncedin Egypt, Morocco and Yemen, whereup to 70% of total health spending isfor pharmaceuticals, most of itthrough private financing. Drug se-lection, procurement and distributionpresent the most problems, espe-cially for countries in greatest need.Limited budgets for drugs havestimulated the search for alternativefinancing methods, such as cost-shar-ing or revolving funds to ensure ac-cessibility of drugs for those in realneed. Local drug production inEgypt, Islamic Republic of Iran, Jor-dan, Morocco and Pakistan coversmore than 80% of the total drug con-sumption, and is rapidly growing inother countries of the Region,

Proportion of population>95%81–95%50–80%<50%No data available

Map 10. Populations with regular access to essential drugsA. 1987 estimates

WHO 98062

WHO 98063

B. 1997 estimates

Proportion of population>95%81–95%50–80%<50%No data available

strongly supported by governments.However, most countries have noclear policy regulating drug produc-tion to ensure the availability of es-sential drugs and vaccines.

A common constraint in countriesin South-East Asia is the limited gov-ernment budget for drugs. Distribu-tion systems are inefficient, are notwell planned, and do not take intoaccount seasonal variations in drugrequirements related to epidemio-


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logical disease patterns. In manycountries, donor support from inter-national agencies is making a signifi-cant impact on the availability ofgood-quality essential drugs. Tax ex-emption for the importation of essen-tial drugs and the introduction of ge-neric drug policies and price regula-tions in general, and for essentialdrugs in particular, is facilitating ac-cess to essential drugs in many coun-tries. In addition, the increasing in-volvement of the private sector in theprovision of health services includingdrugs is making essential drugs moreaccessible to all citizens in severalcountries that have introduced cost-sharing mechanisms. Public healthservices are focusing more on the sec-tions of the population who are lessable to fend for themselves, whilewealthier people use the services ofthe private sector. Availability has im-proved, and eight out of 10 countriesin the Region produce essentialdrugs.

Although European countriesspend up to 30% of health care fundson medicines, in all countries thereis widespread unnecessary and inap-propriate prescription, dispensingand use of medicines. A carefullyplanned combination of regulatoryand educational measures accompa-nied by continuous monitoring can beeffective in improving drug use, buttoo little is known about the final ef-fect on the health of patients. In west-ern Europe access to drugs is ensuredthrough extensive publicly-financedhealth care delivery schemes, but incentral and eastern Europe there hasbeen a marked shift towards privatefinancing of drugs. The accompany-ing irrational use of drugs has createdproblems as regards access andaffordability for larger parts of thepopulation.

WHO’s response

Strengthening national health admin-istrations has been one of the majorobjectives of WHO since its creation.Starting in 1950, WHO has advocatedthe integration of specialized healthservice activities in a general healthprogramme. The focus was onstrengthening local health services,integrating mass campaigns againstspecific diseases into general healthservices, carrying out research onpublic health practices, and provid-ing essential preventive and curativehealth facilities to all the population,especially in remoter districts wherehealth services are often non-existent.In 1962, the World Health Assemblyconsidered that the creation of a net-work of minimum basic services mustbe regarded as an essential pre-invest-ment operation, without which agri-cultural and industrial developmentwould be hazardous, slow and uneco-nomical. In 1965, WHO outlined twopossible approaches for integratingmass campaigns into the generalhealth services: sequential campaignsand the pre-eradication programme.The need for evaluation was recog-nized, but progress was slow.

In the 1970s WHO took up theconcept of country health program-ming as “a significant innovation”. Itwas understood as a systematic proc-ess of assessing a country’s healthproblems in their socioeconomic con-text, identifying areas susceptible tochange and formulating priority pro-grammes to induce such change. Anew approach of primary health carefor the promotion of national healthservices was adopted in 1975, takinginto account the socioeconomic as-pects of health and the relatedintersectoral action. In 1994, WHO’sNinth general programme of workplaced “integrating health and humandevelopment into public policies” asthe top priority.

WHO’s Ninth

general programme

of work placed

“integrating health

and human

development into

public policies”

as the top priority.


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Current trends in health systemreform include increased openness tomarket forces and recognition of therole of the private sector, at times cou-pled with reduction – or what is some-times referred to as “rightsizing” – ofpublic institutions; decentralization;and an emphasis on health care fi-nancing methods, including insur-ance and user fees, with widespreadconcern about resource mobilizationand cost containment. WHO has pio-neered work on monitoring healthequity to inform national policies inthe health and other sectors, for ex-ample supporting work in Lithuania,Sri Lanka and Zimbabwe, that ex-plores ways of using existing routinedata to produce policy-oriented re-ports on national trends in equity inhealth and health care. Other coun-tries now are asking for practical, low-technology methods to carry out simi-lar work. A review of internationalexperience with health insuranceschemes covering people in the non-formal sector of the economy hasbeen completed, as part of researchinto ways of moving from limited touniversal risk-sharing in low- andmiddle-income countries.

Technological progress can im-prove prevention, diagnosis and treat-ment, but cannot substitute for hu-man resources. The quantity, distri-bution and performance of healthworkers is central to the efficiency ofthe health system since they accountfor as much as 70% of the recurrenthealth budget.

From 1948 to the late 1960s,WHO’s objective was to increasenumbers of conventional health per-sonnel, with special emphasis on doc-tors and nurses and the rapid expan-sion of medical and nursing schools.Training in public health was also ex-panded. In the 1960s and 1970s, theemphasis was on auxiliary personnelto ensure services in isolated rural anddifficult-access areas, spurred by the

health-for-all policy in the latter pe-riod. From the 1970s to the present,the health personnel teacher traininginitiative achieved a worldwide im-pact, with the recognition of healthpersonnel education as a careerspecialty. Health personnel educationresearch has led to many innovationsand improved understanding of adultlearning and clinical decision-makingbehaviour. Starting in the 1980s, therelevance of health personnel to na-tional needs has been assessed, tobring about a reorientation of plan-ning, training and utilization. TheWHO fellowships programme has al-ways been considered relevant tothese processes.

The present concerns over costand value for money have resulted inimportant changes in the way healthcare is being provided. A greater em-phasis on outpatient and home-basedservices has led to the growth of newcategories of providers in developedcountries, often with very narrowscopes of practice. In the early 1990sa project was initiated to provideMember States with a set of tools tofacilitate the planning of human re-sources for health as well as the moni-toring of performance. Some of thematerials which have been developedinclude the WHO toolkit for plan-ning, training and management; mod-els for projecting workforce supplyand requirements; and a manual onworkload indicators of staffing needs.

The cost and availability of re-sources will continue to be a preoc-cupation in the health sector. Theemphasis on care throughout the lifespan will require close coordinationand continuity in the provision of pre-ventive and promotive, curative andrehabilitative services. Health serv-ices of the future will be provided bymultidisciplinary teams and the exist-ing mandates of the establishedhealth professions cannot continue tobe maintained. The public and

Technological

progress can improve

prevention, diagnosis

and treatment,

but cannot substitute

for human resources.


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private sectors need to develop effec-tive partnerships, and the existing dis-crepancies between them in incen-tives and rewards need to be nar-rowed. Regardless of which sector isproviding services, clinical decisionsshould take into account social andeconomic implications and moral andethical aspects. The client communi-ties of the future will be much betterinformed and more discriminating,and will demand a direct role in deci-sions over their health. In order tocope with these changes, all healthprofessionals will need new coreskills, none of which are at presentadequately addressed – such as healtheconomics and management, ethicsand computer skills – in addition tothe skills required in their own spe-cial fields.

In recognition of the need for themedical profession to participate inglobal development, some medicalschools have decided to teach interna-tional health as a discipline (Box 28).

As health technologies becomemore complex and costly, and as theapplication of new and existing tech-nologies becomes more refined, mak-ing the right decisions about the allo-cation of often scarce resources hasbecome more difficult.

Reproducibility and comparabil-ity of results are essential to the suc-cess of health laboratories. In 1972,the World Health Assembly adopteda resolution on standardization of di-agnostic materials. In 1976, WHOestablished the first international ex-ternal quality assessment scheme(IEQAS) in clinical chemistry to as-sist countries in developing their ownnational schemes for laboratory stand-ardization and quality assurance. Cur-rently, 262 key laboratories in 113countries are participating in theWHO IEQASs. Unfortunately, thehigh cost of modern laboratory tech-nology is an impediment to its trans-fer to countries in need.

Box 28. Global medicine needed in the 21st century

Medical schools rightly focus teaching on the national disease and publichealth panorama. However, many fail to teach even a minimum about theglobal health situation. Students of natural science, humanity, economicsand agronomy in most countries are generally taught more about globalaspects of their disciplines. Consequently, the medical profession has a weakervoice than other professions in the discourse about global development. Thesituation is improving in some medical schools, partly because of the inclu-sion of international health as a discipline.

A five-week full-time course in global medicine has been given twice ayear since 1996 at the Karolinska Institute, the medical university in Stock-holm, Sweden. It has become the most popular of the elective courses in thecurriculum and is presently taken by half of the students. The aim is to teachhow socioeconomic, cultural and environmental factors determine the healthof nations and how the global burden of disease and demographic patternsvary between and within countries. Later training in clinical medicine is put inboth a historical and a global perspective by a review of the disease transi-tion, from infectious diseases and malnutrition affecting mainly children tovarious patterns of chronic diseases in adults. Students learn to use differ-ent sources of health and demographic indicators in problem-based learningsessions where they analyse the health profiles of different countries. Thedivision of countries into developing and industrialized is replaced by a newtaxonomy with several groups reflecting the continuum of health status thatis determined by both economic development and degree of equity. Globalvariations in health policy and health service systems, modern as well astraditional, and the work of international health organizations are reviewed.Teaching about food security and food culture ends the first part of the course.

The last two weeks of teaching are given by either of the Medical Col-leges in Blantyre, Malawi, and Trivandrum, India. Students pay for their owntravel and the Karolinska Institute pays the tuition fees from its core budget.Students learn about cost-effectiveness as they admire the clinical skills ofthe teachers in India and in Africa with access to few of the diagnostic tech-niques used in Sweden. It comes as a surprise to students to learn howmuch health can be improved with few resources if the primary health carestrategy is optimally applied. Home visits to families under guidance fromcommunity nurses provide unique understanding of the tremendous globalinequity in health-determining life conditions. Collaborative projects and re-ciprocal exchanges of students and teachers result from the contact cre-ated. Students’ evaluations are very positive and their comments (e.g. “I lostprejudices and gained a new view of the world”) indicate that the impact goesfar beyond learning new facts. The course provides knowledge and perspec-tives that will be useful in the next century whether the student goes on towork in pharmaceutical research, clinical practice or becomes an actor inthe discourse on global development.

Personal communication from Dr H. Rosling, Professor in International Health,Karolinska Institute, Stockholm, Sweden.


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WHO has always emphasized theprovision and improvement of thequality of radiological services for di-agnosis and therapy in public healthcare, areas that have seen spectacu-lar progress. In industrialized coun-tries a number of technologically ad-vanced imaging modalities (e.g. com-puterized tomography and magneticresonance imaging) have becomeavailable not only in university hospi-tals and specialized health centres butalso in regional and district hospitals.In developing countries the mostpositive trend is the rapid increase ofdiagnostic ultrasound units, includingtheir availability in rural areas.

About two-thirds of the popula-tion in developing countries have noaccess to essential radiological serv-ices. To respond in the most optimalway to the needs of such countries,WHO developed the basic radiologi-cal system during the period 1975-1985 and in 1995, technical specifi-cations were published for its updatedversion, the WHO imaging system forradiography. Technical specificationsfor general-purpose and special-purpose ultrasound scanners werepublished, as well as four manuals toprovide logistic support in using thesetechnologies.

The international pharmacopoeia,which was established by the FirstWorld Health Assembly in 1948, setsout recommended procedures ofanalysis and specifications for phar-maceutical substances. It offers analternative to the often very sophisti-cated and expensive methods de-scribed in other pharmacopoeias. Itis most typically used as a referencetool for the development of nationalstandards, as well as for day-to-day

quality testing of imported pharma-ceutical products for locally manufac-tured drugs and for teaching material.

Since 1982 WHO has docu-mented the increase in counterfeitand poor-quality drugs in interna-tional commerce. Most counterfeitdrugs contain fewer active ingredientsthan claimed, wrong ingredients, orno ingredient at all, which makesthem less effective or even toxic.WHO organized an internationalworkshop on the subject in 1997,which recommended the establish-ment of adequate and vigorous na-tional regulatory systems and of aninternational network of drug regu-latory offices, as well as closer collabo-ration with customs, police, profes-sional organizations and the pharma-ceutical industry.

The Organization first recog-nized the potential benefit of tradi-tional medicine and launched aninitiative to assess health servicesprovided by traditional practitionersin 1978. To this day, a large propor-tion of the population in many de-veloping countries still relies mainlyon traditional practitioners and me-dicinal plants to satisfy primaryhealth care needs. Since 1991, WHOhas promoted the integration of tra-ditional medicine into nationalhealth care systems and the properuse of traditional medicine throughthe development of technical guide-lines and international standards,particularly in the field of herbalmedicines and acupuncture. Themajor objective now is to reach in-ternational agreement on policies,regulations, registration and techni-cal standards in traditional medicine,particularly at the regional level.

About two-thirds

of the population in

developing countries

have no access to

essential radiological

services.

chapter 5 achieving health for all - who

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