Three global health reports: towards a growing consensus?
Corresponding Author Claudia Hanson, Prins Leopold Institute for Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium. E-mail: firstname.lastname@example.org
In 1978, the inspiring Alma Ata declaration on Primary Health Care put the need for people-centred comprehensive primary care for the first time on the international agenda. But in the context of limited resources and high disease burden in poor countries, these grand ideas were rapidly reduced to a few selective ‘cost-effective’ interventions deemed affordable (Walsh & Warren 1979). This approach to health has dominated over the past 30 years and contributed more recently to the proliferation of global health initiatives, but left the health systems partly neglected with too little resources.
Doubts about reaching the Health Millennium Development Goals (MDGs), in particular MDG5 on Maternal Health, again fuel calls for a more comprehensive approach to health care in low-income countries. It is against this background that the 30th birthday of Alma Ata in September 2008 was given attention by international agencies and academic institutions to discuss new strategies to overcome the unfruitful international divide between health systems strengthening and disease-specific interventions. One focus of a conference in Antwerp was looking for synergies between disease-specific intervention and health systems strengthening. An example of HIV/AIDS programmes in Africa has been elaborated from this point of view (ITG 2008).
Overlooking the need for comprehensive people-centred primary health care and for reduction of global health inequities may also become increasingly politically incorrect, as the effects of neglecting these issues have been widely publicised, supported by a wealth of evidence recently summarised in three important health reports published in the autumn of 2008: WHO’s World Health Report (WHO 2008), the final report of the Commission on Social Determinants of Health (CSDC 2008) and the Global Health Watch 2 (People’s Health Movement et al. 2008).
The World Health Report 2008 revisits the Alma Ata vision as a set of values and principles for guiding the development of health systems: ‘Primary Health Care – Now More Than Ever’. The report thoroughly analyses health systems and identifies the need for major reforms in four areas: universal coverage, people-centred service delivery, ‘healthy public policies’ and leadership. The report suggests that primary health care, underpinned by social justice, equity and solidarity, is feasible and urges governments and the international community to more seriously consider people’s needs and to adapt service delivery to changing epidemiological patterns.
A bit earlier a report commissioned by WHO on social determinants of health, ‘Closing the Gap in a Generation’, was published. The final report summarises the work and recommendation of a diverse international group of scientists and practitioners. Formally launched in 2005, the Commission was organised in knowledge networks to compile evidence on policies and interventions to address inequalities and social determinants of health. Its recommendations cover three areas: daily living conditions; the inequitable distribution of power, money and resources; and methods to measure and understand the problems and assess the impact of action.
The third report, ‘Global Health Watch 2’, is often labelled ‘The Alternative World Health Report’. Two NGO movements, the People’s Health Movement and the Global Equity Gauge Alliance, together with a large number of individuals and institutions wrote their second report aimed to draw attention to often neglected drivers of ill-health, the ‘political and economic choices, or the current form of globalisation’. The report concludes that the current dominant model of development, based on market liberalisation and commercial globalisation, has not only failed to deliver ‘health for all’, but also places the world at the brink of an environmental crisis.
The three reports have been written with distinctive motives, have different backgrounds and use different perspectives. WHR 2008 concentrates mainly on the health system and health policies. CSDH provides a broad range of evidence on the importance of the proximate and distant determinants of health. GHW2 looks at health mainly from a political perspective. However, the three reports agree in much of their analysis and recommendations. The reports criticise the negative effects of unregulated commercialisation and the lack of leadership for health both at national and international levels. All reports stress the importance of better leadership to provide universal protection for health and comprehensive primary health care responding to the need of the people.
Globalisation and markets
All reports see globalisation and market liberalisation as having contributed to increased inequities in health. They point to the negative effects of commercialisation of health care, in both private and public sectors and criticise the current macroeconomic policies, which have undermined primary health care, e.g. by encouraging user fees. The GHW2 accuses neoliberal policies of having failed to deliver on the promise of renewing economic growth in the poorest countries to decrease poverty and ill-health. Instead, the gap in life expectancy at birth between populations in low-income countries and in OECD member state countries has widened by 9 months in the last 20 years.
The CSDH also underlines that ‘globalization’s enlarged and deepened markets are inherently disequilizing’ and that these mainly reward countries with more productive assets such as human and financial capital. The WHR 2008 engages in the most detailed analysis of progress in health; increases in GDP mostly resulted in increased life expectancy, but with huge differences in life expectancy in countries with similar per capita income and health spending. The report concludes that ‘healthy public policies’ are crucial for providing universal access and social protection and regulate commercialisation of clinical services.
But there are also positive sides to globalisation, such as the extensive exchange between countries and the expression of solidarity and global commitment to eliminate poverty. All three reports underline the favourable effects of the Millennium Declaration and the MDGs on increase of funding for health and better knowledge and understanding of health and its determinants. According to the CSDH, ‘The Millennium Development Goals reflect an unprecedented global concern to effect real, sustainable change in the lives of the people in poor countries’.
Primary health care and universal protection
The WHR 2008 argues that there is substantial evidence for the comparative advantages of people-centred primary health care offering comprehensive and integrated care, allowing for participation of patients, families and communities and providing a continuum of care. The CSDH also concludes that ‘health care systems contribute most to improving health and health equity where the institutions are organised around the principle of universal coverage and where the system as a whole is organised around primary health care’. The GHW2, although less explicit on primary health care, advocates putting peoples’ need in the centre of care and for good balance between population-based approaches and individualised health care.
The three reports suggest a growing consensus to go for universal protection in health using pooling and pre-payment schemes, being critical of voluntary insurance schemes as they risk exclusion of parts of the society. Financing should be either tax-based or financed through compulsory social health insurance to allow for risk-pooling and progressive health financing. Particularly the CSDH and the GHW2 urge donors to increase funding for health and realise the UN goal of 0.7% of the GDP of donor countries for development aid. More fundamentally, strengthening of national and international tax systems to limit tax evasion could make more public funding for health available. Other suggestions for innovative financing mechanisms, e.g. the Tobin tax on foreign currency transactions or a tax on airline tickets, are put forward. All reports call for a reassessment of the fragmented health aid funding system and propose that external funds need to be progressively re-channelled in ways that strengthen health systems’ capacities to implement universal coverage. The WHR 2008 looks not only at the financing side of universal protection, but also at the content of the proposed health care package, which should consider changing needs resulting from epidemiological shifts as well as emerging challenges such as ageing and increased urbanisation.
The way forward
The unprecedented attention towards the MDG has shown the importance of highly visible follow-up of progress and shortcomings to keep the momentum of international recognition and support. The global health equity surveillance system put forward by the CSDH might be a new powerful tool to measure and promote progress towards health for the poor. The commission also recommends to include health equity impact assessment in economic agreements, e.g. in trade, TRIPS, water, labour and food. Tracking of progress in health equity and health equity assessment in all sectors are also put forward as important elements of global governance, but needs to be put in the appropriate policy. But will the convincing evidence today be translated into evidence-based health policies? Will the evidence that ‘the right policies matter’ contribute to sharpening of future health policies?
Finally, evidence and policies needs to be put into practice. Leadership is needed at all levels, now more than ever. The reports have exposed what has not worked, and some of the reasons, and highlighted examples of good results where the ‘right’ policies were applied. We need to streamline the approaches, introduce the required changes of the International Health Aid Architecture and clarify the roles of International Institutions. Much of the international discussion has also recently shifted towards looking for opportunities of disease-specific intervention to strengthen health care systems. The consensus is growing that functioning and responsive health systems are key for success. The Accra Agenda for Action provides an excellent platform for the countries to act and assume the leadership in directing the activities based on their development strategies (http://www.oecd.org/dac/effectiveness/accrahlf). Better evidence, policy and leadership will thus hopefully this time lead to improved people-centred primary care and better health.