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Health for all
in the
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World Health Organization
CONTENTS
V
Executive Summary
Section I.
Chapter 1.
Chapter 2.
Why renew Health for All?
Health for All: mandate and origins
Old and new challenges
1
4
Section II. Health for All in the 21st century
Chapter 3.
Chapter 4.
Chapter 5.
Values, goals and targets of Health for All in the
21st century
Policy basis for action
The role of WHO
17
26
29
Section III. Fulfilling the vision: actions for implementation
of the policy
Chapter 6.
Chapter 7.
Chapter 8.
Actions needed to make health central to development
Essential functions of sustainable health systems
Keys to successful implementation of Health for All in the
33
36
21st century
41
Annex A.
Explanatory remarks about global health targets
46
Annex B.
Selected targets related to development and poverty endorsed
at world conferences in the 1990s
51
Annex C.
Further reading
52
Annex D.
Acronyms
54
iii
Boxes
Box 1.
World conferences supporting Health for All
3
Box 2.
Primary health care (PHC): from Alma-Ata to the 21st century
5
Box 3.
Evaluation of HFA, 1979-1996
6
Box 4.
New trends influencing health in the 21st century
15
Box 5.
The right to the highest attainable standard of health
20
Box 6.
Ethics: the basis for HFA policies and practices
21
Box 7.
Equity: foundation of HFA in the 21st century
22
Box 8.
A gender perspective: recognizing the needs of women and men
23
Box 9.
Roles and functions of WHO in the 21st century
29
Box 10.
Essential public health functions
36
Box 11.
Role of governments in implementing HFA
43
Access to selected elements of primary health care, developing countries,
1983-1985 and 1991-1993
4
Figure 2.
Composition of health care expenditure, 1994-1995
7
Figure 3.
Living longer: life expectancy at birth, by level of development, 1960-2020
8
Figure 4.
Population living on less than US$ 1 a day in developing economies, 1987
and 1993
8
Distribution of deaths by cause among the richest 20% and the poorest 20%
of the global population, 1990 estimate
10
Causes of death: distribution of deaths by main causes. Developed and
developing countries, 1985, 1990 and 1996
10
Figure 7.
Elderly support ratio by level of development, 1960-2020
11
Figure 8.
Malnutrition: percentage of population underweight and overweight.
Selected countries, around 1993
13
Figure 9.
Maternal mortality: pregnancy-related deaths per 100 000 live births, 1990
13
Figure 10.
Mortality among children under five years of age in 1995-2000, by per capita
gross national product in 1995
18
Figures
Figure 1.
Figure 5.
Figure 6.
iv
EXECUTIVE SUMMARY
Health for All (HFA) in the 21st Century aims to help realize the vision of Health for All, launched at the
Alma-Ata Conference in 1978. It sets out, for the first two decades of the 21 st century, global priorities and targets
which will create the conditions for people worldwide to reach and maintain the highest attainable level of health
throughout their lives. Health for All in the 21 st century is a continuation of the HFA process
Over the past two decades primary health care (PHC), as the cornerstone of Health for All, has provided
impetus and energy to progress towards HFA. Despite gains, however, progress has been hampered for several
reasons, including insufficient political commitment to the implementation of Health for All, slow socioeconomic
development, difficulty in achieving intersectoral action for health, insufficient funding for health, rapid
demographic and epidemiological changes, and natural and man-made disasters. Further, poverty has increased
worldwide. Health has suffered most where countries have been unable to secure adequate income levels for all.
Although the 21st century brings new threats, new opportunities and approaches to overcome them are
becoming available. Globalization of trade, travel, technology and communication could yield substantial
benefits, provided serious potential adverse effects are addressed. Global environmental hazards require urgent
attention. New technologies could transform health systems and improve health. Stronger partnerships for
health between private and public sectors and civil society could lead to stronger joint action in support of HFA.
HFA is a vision that recognizes the oneness of humanity and therefore the need to promote health and to alleviate
ill-health and suffering universally and in a spirit of solidarity.
The realization of the goals of HFA depends on bolstering commitment to its key values by: providing the
highest attainable standard of health as a fundamental right; strengthening application of ethics to health
policy, research and service provision; implementing equity-oriented policies and strategies that emphasize
solidarity; and incorporating a gender perspective into health policies and strategies. These values are strongly
linked, each serving to underpin the execution of policy and strategies.
Goals and targets help define the vision of HFA. The goals of HFA are to achieve an increase in life
expectancy and in the quality of life for all; to improve equity in health between and within countries; and to
ensure access for all to sustainable health systems and services. Targets are defined to spur action and to set
priorities for resource allocation. The 10 global targets in support of Health for All reflect earlier HFA targets and
are in line with those agreed at recent world conferences. Targets related to health policies and systems need to be
met if action on the determinants of health is to lead to improved health outcomes and access to care. Achieving
these targets will ensure that the goals of HFA are met. Regional and national targets will be developed within the
framework of the global policy, and will reflect the diversity of needs and priorities.
V
Global health targets
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Health equity: childhood stunting
Survival: MMR,1 CMR,2 life expectancy
Reverse global trends of five major pandemics
Eradicate and eliminate certain diseases
Improve access to water, sanitation, food and shelter
Measures to promote health
Develop, implement and monitor national HFA policies
Improve access to comprehensive essential, quality health care
Implement global and national health information and surveillance systems
Support research for health
Actions by all Member States to realize the goals of Health for All need to be guided by two policy
objectives: making health central to human development, and developing sustainable health systems to meet the
needs of people. In implementing the former objective, it is acknowledged that good health is both a resource for,
and an aim of, development. Further, the health of people, particularly the most vulnerable, is an indicator of the
soundness of development policies. Action to address the determinants of health should combat poverty, promote
health in all settings, align sectoral policies for health and ensure that health is included in planning for sustainable
development.
Health systems must be able to respond to the health and social needs of people over their life span. To do
this and building on primary health care, sustainable health systems will be developed that guarantee equity of
access to essential health functions. These functions include making quality care available across the life span;
preventing and controlling disease, and protecting health; promoting legislation and regulations in support of
health systems; developing health information systems and ensuring active surveillance; fostering the use of, and
innovation in, health-related science and technology; building and maintaining human resources for health; and
securing adequate and sustainable financing. A socially sensitive health system will take into account the
economic, sociocultural and spiritual values and needs of individuals.
The roles of WHO and governments will be decisive in ensuring that the policy leads to substantial
improvements in health. Governments will need to develop and implement policies coherent with HFA values. In
doing so, they recognize that investments in health will contribute to improvements in health outcomes and will
enhance achievement of sustainable human development goals. As the world's health advocate, WHO will
provide global leadership for the attainment of Health for All. WHO will promote international collective
action for health by developing global ethical and scientific norms and standards; international instruments that
promote and protect global health; facilitating technical cooperation among countries; strengthening decision
making through appropriate health information systems; establishing active surveillance systems; strengthening
global research capacity; providing leadership for the eradication, elimination and control of selected diseases;
and providing technical support to prevention of public health emergencies and post-emergency rehabilitation.
Progress from policy to action requires dynamic leadership, public participation and support, a clear sense
of purpose and adequate resources. To support the process of change, specific attention will be given to
strengthening policy-making capacity; developing systems of good governance; setting priorities at various levels;
strengthening and broadening partnerships for health; and implementing evaluation and monitoring systems.
Committed action at all levels - global, regional, national and local - will be crucial to transforming the
Health-for-All vision into a practical and sustainable public health reality.
1 MMR - maternal mortality rate.
2 CMR - child mortality rate.
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SECTION I1
Why renew Health for All?
Chapter 1.
origins
Health for All: mandate and
Chapter 7 describes the origins of Health for All (HFA). WHO's Constitution
provides the basis for our definition of health and the rationale for global action.
The central role of the Alma-Ata Conference in launching HFA, and the
recognition of primary health care as the key to HFA, are outlined.
WHO's constitutional mandate
"The health of all peoples
is fundamental to the
attainment of peace and
security and is dependent
upon the fullest
co-operation of
individuals and States."
"The enjoyment of the
highest attainable
standard of health is one
of the fundamental rights
of every human being."
1.
Over half a century ago, the founders of the World Health Organization defined
health as "a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity". The Constitution of WHO proclaimed, "the health of
all peoples is fundamental to the attainment of peace and security and is dependent
upon the fullest co-operation of individuals and States". This was the vision in the post
war world of the late 1940s. Our challenge for the next two decades is to build on the
achievements of the past to achieve a healthy and secure world.
2.
The WHO Constitution declares, "The enjoyment of the highest attainable
standard of health is one of the fundamental rights of every human being ...". The right
of all people to a standard of living adequate for health and well-being includes the right
to adequate food, water, clothing, housing, health care, education, reproductive health
and social services; and the right to security in the event of unemployment, sickness,
disability, old age, or lack of livelihood in circumstances beyond an individual's control.
Respect for human rights and the achievement of public health goals are
complementary.
1 This document should be read in conjunction with The world health report 1998: Life in the 21st
century - a vision for all (Geneva, World Health Organization, 1998) which provides a detailed analysis of past
trends and future projections of world health.
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Health for All and primary health care
3.
The concept and vision of Health for All (HFA) were defined in 1977z when the
Thirtieth World Health Assembly decided that the main social target of governments
and WHO in the coming decades should be "the attainment by all the citizens of the
world by the year 2000 of a level of health that will permit them to lead a socially and
economically productive life". The Declaration of Alma-Ata, adopted in 1978 by the
International Conference on Primary Health Care, which was jointly sponsored and
organized by WHO and UNICEF, stated that primary health care was the key to
attaining Health for All as part of overall development. This call for HFA was, and
remains fundamentally, a call for social justice.
4.
Health for All was conceived as a process leading to progressive improvement in
the health of people and not as a single finite target. It can be interpreted differently
according to the social, economic and health characteristics of each country. However,
there is a baseline below which no individual's health in any country should fall. All
people in all countries should have a level of health that will permit them to work
productively, and to participate actively in the social life of the community in which
they live. Health for All acknowledges the uniqueness of each person and the need to
respond to each individual's spiritual quest for meaning, purpose and belonging. At the
same time, HFA is a societal response that acknowledges unity in diversity and the need
for social solidarity. Our common humanity, and responsibility for current and future
generations, demand that we embrace HFA.
Health for All in the 21 st century
5.
Health for All in the 21st Century is a continuation of the HFA process.1 It builds
on past achievements, guides action and policy for health at all levels (international,
regional, national and local), and identifies global priorities and targets for the first two
decades of the 21 st century. Most of all, it takes account of the dramatic global changes
of the past 20 years. It is the result of an extensive and inclusive process of consultation
with and within countries - a process essential to creating ownership of the policy, and
thereby helping ensure its implementation by all partners.
6.
This document also reflects the outcomes of nine international conferences, in
which WHO participated actively, convened in the 1990s to address some of the
world's most pressing problems. All the conferences achieved consensus on priorities
for a future development agenda that would explicitly support the attainment of Health
for All. These are summarized in Box 1.
1 Resolution WHA48.16 requests the Director-General "to take the necessary steps for renewing the
health-for-all strategy together with its indicators, by developing a new holistic global health policy based on
the concepts of equity and solidarity, emphasizing the individual's, the family's and the community's
responsibility for health, and placing health within the overall development framework".
2
The call for HFA was, and
remains fundamentally, a
call for social justice.
Health for All is a process
leading to progressive
improvement in the
health of people.
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Box 1
WORLD CONFERENCES SUPPORTING HEALTH FOR ALL
Since 1990, the United Nations system has convened nine world conferences, in
which WHO participated actively, to address some of the world's most pressing
problems. These meetings have achieved a global consensus on the priorities for a
new future development agenda, including explicit support to the attainment of
Health for All as a priority.
The conferences reflect a growing convergence of opinion that democracy,
development and respect for human rights and fundamental freedoms are
interdependent and mutually reinforcing. There is concern that "top-down"
approaches to development should be balanced by genuine input from the
community to the policy-making process.
The following new approaches to development have been defined:
* Development should be centred on human beings.
* Central goals of development include the eradication of poverty, the
fulfilment of the basic needs of all people and the protection of human
rights.
* Investments in health, education and training are critical to the
development of human resources.
* The improvement of the status of women, including their empowerment, is
central to all efforts to reach sustainable development in all of its economic,
social and environmental dimensions.
* Diversion of resources away from social priorities should be avoided.
* An open and equitable framework for trade, investment and technology
transfer is critical for the promotion of sustained economic growth.
* While the private sector is vital for economic development, governments
should take an active part in formulating, regulating and monitoring health,
social and environmental policies.
These approaches are incorporated, where appropriate, in the HFA policy, and
underpin the need to consider health as the responsibility of all sectors and to
address the multiple determinants of health.
World conferences: World Summit for Children (1990); International Conference on
Nutrition (1992); United Nations Conference on Environment and Development
(1992); World Conference on Human Rights (1993); International Conference on
Population and Development (1994); World Summit for Social Development (1995);
Fourth World Conference on Women (1995); Second United Nations Conference on
Human Settlements (Habitat II) (1996); World Food Summit (1996)..
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Chapter 2. Old and new challenges
Chapter 2 describes how, despite substantial progress in improving global health,
gains have not been shared equitably. Progress since the Alma-Ata Conference is
outlined. Current health issues and emerging threats and opportunities are
described.
Progress since Alma-Ata
7.
Over the past two decades, governments and nongovernmental organizations
have increasingly accepted HFA as their goal in their efforts to improve health (see
Box 2), and most countries have adopted primary health care. Access to the elements
of primary health care, as defined at Alma-Ata, has steadily increased, albeit with wide
variations both within populations and between countries (see Figure 1). Primary health
care, together with economic, educational and technological advances, has contributed
significantly to the worldwide decline in infant and child mortality and morbidity and to
the substantial increases in life expectancy at birth. Millions of children have survived
to adulthood as a result of early health interventions.
Governments and
nongovernmental
organizations have
increasingly accepted
HFA.
Figure 1. Access to selected elements of primary health care, developing countries,
1983-1985 and 1991-1993
□
I
T
Excreta disposal1 ■
■ 1983-1985
□ 1991-1993
Safe water supply1
i Infants immunized
2
BCG
Poliomyelitis
Measles
DPT
Tetanus (pregnant I
women)3 j-
0
L
W
4=
10
20
30
40
■
50
Coverage (%)
Percentage of population.
2 Percentage of children under one year.
3 Percentage of pregnant women.
Source: WHO.
4
60
70
80
90
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Box 2
PRIMARY HEALTH CARE (PHC): FROM ALMA-ATA TO THE 21 st CENTURY
Keys to achieving HFA: lessons and progress
* PHC as an approach has provided impetus and energy to progress towards
HFA.
* Some progress has been made in ensuring access to the original eight PHC
elements.1
* PHC remains valid as the point of entry into a comprehensive health care
system.
♦
Intersectoral action for health has not been fully achieved.
♦
Reorientation of health services and personnel to PHC principles remains
elusive.
♦
Community participation takes time and dedication by all.
HFA in the 21st century: policy objectives to reinforce the PHC approach
* Make health central to development and enhance prospects for
intersectoral action.
♦
Combat poverty as a reflection of PHC's concern for social justice.
* Promote equity in access to health care.
* Build partnerships to include families, communities and their
organizations.
* Reorient health systems towards promotion of health and prevention of
disease.
Sustainable health systems: some essential components
* Attach greater emphasis to comprehensive quality health care throughout
the life span.
* Ensure equitable access to the original eight PHC elements.
* Expand PHC elements in response to identification of new threats to
health, and opportunities to tackle these threats.
Essential health system functions that complement and support PHC
* Provide sustainable financing for PHC.
* Invest in human and institutional capacity for health.
* Optimize private and public-sector support for PHC through appropriate
regulations.
* Strengthen research to support and advance PHC.
* Implement global, national and local surveillance and monitoring systems.
1 The original PHC elements included, at least, immunization against the major infectious
diseases; education concerning prevailing health problems and the methods of identifying, preventing,
and controlling them; promotion of food supply and proper nutrition, an adequate supply of safe water,
and basic sanitation; maternal and child health care, including family planning; prevention and control
of locally endemic diseases; appropriate treatment of common diseases and injuries; promotion of
mental health; and provision of essential drugs. These should be extended and adapted to include
expanding options for immunization; reproductive health needs; provision of essential technologies for
health; health promotion, as defined in the Ottawa Charter and endorsed by resolution WHA42.44;
prevention and control of noncommunicable disease; food safety and provision of selected food
supplements.
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8.
However, despite these health gains, progress has been hampered by a number
of factors (see Box 3). The pace of improvement and the achievement of targets have
not been uniform. Disparities between countries, and among certain population groups
within countries, in health status and access to health care (including primary health
care) are greater now than they were two decades ago. Millions of people still do not
have access to certain elements of primary health care and, in many places, effective
primary health care services do not exist. While health infrastructures have physically
expanded in the past 20 years, actual provision of care has been limited by
inadequacies in national capacities. In addition, some international and bilateral
funding agencies have not significantly shifted their aid priorities towards low-income
and least-developed countries.
Box 3
EVALUATION OF HFA, 1979-1996
In many countries, progress towards HFA is hampered by:
*
*
*
*
*
*
*
*
*
*
*
*
insufficient political commitment to the implementation of HFA;
failure to achieve equity in access to all PHC elements;
the continuing low status of women;
slow socioeconomic development;
difficulty in achieving intersectoral action for health;
unbalanced distribution of, and weak support for, human resources;
widespread inadequacy of health promotion activities;
weak health information systems and no baseline data;
pollution, poor food safety, and lack of safe water supply and sanitation;
rapid demographic and epidemiological changes;
inappropriate use of, and allocation of resources for, high-cost technology;
natural and man-made disasters.
Based on three major evaluations of the Global Strategy for Health for All.
9.
Following the Alma-Ata Conference, a long period elapsed before significant
levels of human and financial resources were reoriented towards primary health care.
Even today, in many countries, public health systems and services are under-resourced
and poorly maintained. Often, a lack of expertise in health policy and management has
impeded progress in developing flexible and responsive health systems, although the
situation varies widely between countries. Also, professional interests that favour
curative, clinical medicine over preventive and promotive public health continue to
dominate policy-making and decision-making in the health sector. Care for the
disabled, terminally ill and frail aged remains, on the whole, poorly supported.
10.
Some development and economic policies, combined with demographic and
epidemiological changes, have increased the burden of disease with which health
systems have to contend. Health services are paying the price for this and for the failure
of governments to fund long-term measures to promote and protect health.
6
A lack of expertise in
health policy and
management has
impeded progress.
Health services are paying
the price for certain
economic policies.
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In the poorest countries,
a lack of funding for
health and social services,
and an inability of
governments to raise
domestic and
international funds for
health, seriously hamper
progress towards HFA.
11.
In the poorest countries, a lack of funding for health and social services, and an
inability of governments to raise domestic and international funds for health, seriously
hamper progress towards HFA. In other countries, failure to establish or maintain
essential health system functions has led to stagnation or deterioration in the health
status of populations. Emerging and re-emerging diseases constitute a significant threat
to health. Rapid growth of private health care in many middle-income countries has
had mixed impact on public-sector services. In some cases, it has contributed to rising
costs, inefficient care, and unequal access to health care. In advanced industrialized
countries, the basis of health care reforms consists of cost control, expanding choices for
individuals, and ensuring quality care in the face of population ageing and rapid
increases in the price of and demand for new technologies. In most countries, private
and public-sector health care providers have not established effective partnerships,
further hampering health development (see Figure 2).
Composition of health care expenditure, 1994-1995
o 100
I!
35
o
55
1
5 50
2
□ Private expenditure
*5
I
■ Public expenditure
65
45
____
0
Developing world
Developed world
Level of development
Source: Sector Strategy Paper - Health, Nutrition and Population, World Bank 1997.
X
Substantial health gains
People are living longer:
the average life
expectancy at birth has
increased from 46 years
in the 7 950s to 65 years
in 1995.
12.
At the same time, the world has seen considerable gains in health over the past
50 years. These gains have been due not only to advances in science, technology,
public health and medicine, but also to expanded infrastructures, increased literacy,
rising incomes, and improved nutrition, sanitation, education and opportunities,
particularly for women. The incidence of infectious diseases has declined in many
countries and smallpox has been eradicated. Control and prevention of diseases, such
as measles, poliomyelitis, and diphtheria, have greatly reduced childhood mortality and
morbidity. People are living longer: the average life expectancy at birth has increased
from 46 years in the 1950s to 65 years in 1995 (see Figure 3). The gap in life
expectancy between rich and poor countries has narrowed, from 25 years in 1955 to
13.3 years in 1995.
7
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Living longer: life expectancy at birth,
by level of development, 1960-2020
90
80
71
2
ra
0)
60
IS
o
40
a>
30
c
3o
Q.
X
— Developed market economies
— Economies in transition
— Developing countries (excluding LDCs)
— Least developed countries (LDCs)
—Total WHO Member States
5 20
10
0
1960
1980
2000
2020
Year
Source: United Nations Population Division, World Population Prospects: The 1996 Revision (United Nations, New York, 1997forthcoming).
k Population living on less than US$1 a day
in developing economies, 1987 and 1993
I
I
U1987
■ 1993
□ 1987
■ 1993
Europe and Central Asia
Middle East and North Africa
Latin America and the Caribbean
Sub-Saharan Africa
East Asia and the Pacific
South Asia
-T600
500
400
300
200
100
o
0
■
i
i
10
20
30
—
i
40
Percentage of population
Number of persons (millions)
Source: Poverty Reduction and the World Bank: Progress and Challenges in the 1990s. Washington, D.C., World Bank 1996.
8
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Poverty and growing inequities
Health has suffered most
where economies have
been unable to secure
adequate income for all,
where social systems have
collapsed, and where
natural resources have
been poorly managed.
Poverty is a major cause
of undernutrition and illhealth.
13.
However, despite some gains, certain health gaps between and within countries
have widened. There are alarming trends in the incidence of a number of diseases, and
projections suggest that some achievements will not be able to be maintained in the
future. The debt crisis of the 1980s resulted in many countries reducing their support
for health and social services. Dramatic political changes in the 1990s in several
countries, often accompanied by civil unrest, seriously impaired and retarded health
and economic development. Health has suffered most where economies have been
unable to secure adequate income for all, where social systems have collapsed, and
where natural resources have been poorly managed. A host of global and local
environmental and social problems continue to add to the burden of disease and illhealth.
14.
The number of people living in absolute poverty and despair is growing steadily
despite unprecedented wealth creation worldwide in the past two decades. Today,
nearly 1300 million people live in absolute poverty (see Figure 4). Poverty is a major
cause of undernutrition and ill-health; it contributes to the spread of disease,
undermines the effectiveness of health services and slows population control. Morbidity
and disability among the poor and disadvantaged groups lead to a vicious spiral of
marginalization, to their remaining in poverty, and in turn, to increased ill-health.
15.
The poor bear a disproportionate share of the global burden of ill-health and
suffering. They often live in unsafe and overcrowded housing, in underserved rural
areas or periurban slums. They are more likely than the well off to be exposed to
pollution and other health risks at home, at work and in their communities. They are
also more likely to consume insufficient food, and food of poor quality, to smoke
tobacco, and to be exposed to other risks harmful to health. Overall, this undermines
their ability to lead socially and economically productive lives and leads to a different
distribution of causes of death (see Figure 5). The inequities and increasing gaps
between rich and poor in many countries and communities, even as economic growth
continues, threaten social cohesion and, in several countries, contribute to violence and
psychosocial stress.
Demographic and epidemiological changes
16.
Improvements in health status throughout the world, associated with
achievements in public health and economic growth, have led to a number of
demographic and epidemiological changes (see Figure 6 and Figure 7). Increased life
expectancy, lower birth rates and a rise in noncommunicable diseases, combined with
exposure to new threats, define the challenges for the future. Sheer population
numbers in some countries, and high resource consumption in others, compromise the
chances of meeting the future needs of the world's people.
Population ageing is
placing significant
pressure on social
support systems and
requires a shift in health
services.
17.
One result of successful social and economic development is that all populations
are ageing. The rate of increase in the number of people older than 65 years is higher
in middle- and low-income countries than in advanced industrialized countries.
Although in many countries the elderly are healthier than before, population ageing
often results in an increase in noncommunicable diseases, disability, and mental
disorders. This trend is already placing significant pressure on social-support systems, as
well as requiring a shift in health services. Also, in some countries, the demographic
transition will result in an absolute increase in the number of young people and
consequent pressures on health and educational services, as well as on employment.
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Distribution of deaths by cause among the richest 20% and the poorest 20%
of the global population,1990 estimate
100
BHHI8
90 —
W
JC.
80 -
<D
■o
70 —
1H
59
60 -
o
O)
ro
c
CD
O
CD
Q_
-J- ■
50 —
85
40 30 —
32
20 -
10 -
9
7
Poorest 20%
Richest 20%
0
EJ
□
Group I : deaths from communicable diseases; maternal and perinatal deaths;
deaths from nutritional causes
Group II : deaths from noncommunicable diseases
Group III: deaths following injuries
Based on: Gwatkin, D.R. (personal communication, 1997).
Figure 6 Causes of death: distribution of deaths by main causes
Developed and developing countries, 1985, 1990 and 1996
1% i%
5% 1%
17%
D
E
V
E
L
O
P
E
D
1996
1990
1985
23%
23%
21%
21%
8%
3%
3%
46%
48%
D
E
V
E
L
O
P
I
N
G
Total: 12 116
Total: 11 438
Total: 11 047
8%
16%
17%
44%
45%
24%
43%
17%
16%
6%
5%
7%
6%
10%
Total: 37 068
7%
9%
9%
Total: 39 921
Total: 38 415
Total in thousands, percentages refer to "total".
|
Source: WHO.
10
Infectious and parasitic diseases
Perinatal and maternal causes
Cancers
Chronic obstructive pulmonary disease
Diseases of the circulatory system
] Other and unknown causes
A51/5
Figure 7. Elderly support ratio* by level of development, 1960-2020
35
30
C
o
i
25
QO
Q.
20
O
O)
5
c
Q
O
0)
Q.
15
♦
Developed market economies
B
Economies in transition
M
Developing countries (excluding LDCs)
A — Least developed countries
- - - TOTAL WHO MEMBER STATES
10
5
0
1960
2000
1980
2020
Year
* Percentage of the population aged 65 and above as a percentage of the population aged 20 to 64.
Source: United Nations Population Division, World Population Prospects: The 1996 Revision (United Nations, New York, forthcoming).
18.
In general, urbanization has improved the quality of life and health in many
countries. However, it adversely affects the social environment when it outstrips the
capacity of the infrastructure to meet people's needs. This is particularly apparent in
the rapidly growing periurban settlements of large cities. There are well documented
links between uncontrolled urban growth and the spread of infectious diseases. In
addition, overcrowding and poor working conditions can lead to anxiety, depression
and chronic stress, and have a detrimental effect on the quality of life of families and
communities. Changes in family structure and living arrangements have had a
significant impact on people's health and their capacity to cope with health and social
problems. Disruption of traditional rural cultures has, in many cases, led to the erosion
of social support systems.
Communicable diseases, malnutrition and maternal
mortality
In many of the poorest
parts of the world,
poverty-related diseases
will remain major
contributors to the
burden of disease.
19.
There has been substantial progress in disease prevention and control and a
worldwide decline in communicable diseases. However, new and old infectious
diseases, such as malaria, tuberculosis and acquired immunodeficiency syndrome
(AIDS) will remain important threats to global health in the next century. Projections
are uncertain because of the potential of travel and trade, urbanization, migration and
microbial evolution to amplify these diseases. The development of drug resistance
further increases the risk, as will the emergence of currently unknown pathogens. The
burden of infectious disease remains particularly high among children in the developing
world, due to interaction of perinatal factors, poor nutrition and diseases such as acute
respiratory infections, diarrhoea, measles and malaria. Successful control of these
conditions in childhood will have beneficial impacts on many causes of ill-health in
adulthood and therefore their prevention in infancy and early childhood must continue
to be a priority in many parts of the world.
11
AS 1/5
20.
Efforts to reduce malnutrition in children in the poorest countries have stagnated.
Particularly high rates of malnutrition are reported in south Asia and sub-Saharan Africa
(see Figure 8). An estimated 168 million children aged less than five years in the
developing world are now malnourished, almost a billion people cannot meet their
basic daily requirements for energy and protein and more than two billion suffer from
micronutrient deficiencies. This hampers physical and cognitive development and
exacerbates the cycle of poverty and deprivation. Maternal deaths are still
unacceptably common (see Figure 9). Approximately 585 000 women died of
pregnancy-related causes in 1990, more than 99% of them in developing countries,
indicating a low level of development and poor performance of health systems in these
countries. Unless sustainable and effective health interventions and poverty reductions
are given priority, these conditions will continue to add to the burden of disease in
developing countries.
Noncommunicable diseases
21.
Noncommunicable diseases are a heterogeneous group that includes major
causes of death, such as ischaemic heart disease, diabetes and cancer, and disability,
such as mental disorders. Today, they contribute significantly to the global burden of
disease. If current trends in tobacco use, a high-fat diet and obesity, and other health
risks continue, such diseases will become the dominant causes of death, disease and
disability worldwide by the 2020s. Tobacco use is a risk factor for some 25 diseases
and, while its effects on health are well known, the sheer scale of its impact on disease,
now and in the future, is still not fully appreciated.
Tobacco use is a risk
factor for some
25 diseases ...the sheer
scale of its impact on
disease, now and in the
future, is still not fully
appreciated.
Violence, injuries and social disintegration
22.
Violence occurs in different forms in different societies, including tribal or ethnic
conflict, gang warfare, and family violence. In some countries, exposure to violence in
the entertainment media, combined with easy access to weapons, and use of alcohol
and illicit drugs, has contributed to an increase in violence. It is one of the most glaring
features of social disintegration. In many societies, there is concern about social
disintegration stemming from the weakening of human relationships based on sharing
and caring, of the bonds sustaining and nurturing intergenerational relations, and of the
family as a social unit. Unemployment, alcohol dependence and mental disorders are
on the rise. Injuries are also likely to increase, partly as a result of increased use of
motor vehicles, urbanization and industrialization.
New trends that will influence health
Globalization
23.
National and local decisions are affected as never before by global forces and
policies. The dramatic growth in trade, travel and migration, together with
developments in technology, communications, and marketing, particularly since the end
of the Cold War, has resulted in substantial gains for some groups and severe
marginalization for others. The spread of information technologies and advances in
biotechnology worldwide will increasingly help in detecting, preventing and mitigating
the impact of disease outbreaks, famine and environmental health threats, and in
bringing health services and education to many more people. However, there is
concern that increased trade in products harmful to health and the environment
threatens the health of populations, particularly in low-income countries. Increased
transnational trade in food and the mass movement of people constitute additional
global threats to health.
12
The dramatic growth in
trade, travel and
migration, together with
developments in
technology, communica
tions, and marketing has
resulted in gains for some
and severe
marginalization for
others.
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Malnutrition: percentage of population underweight and overweight
Selected countries, around 1993
Russian Federation
United Kingdom
Sweden
Colombia
Brazil
Costa Rica
Morocco
Togo
China
Haiti
Senegal
Ethiopia
India
40
50
30
20
0
10
10
20
30
50
40
Underweight
Overweight
(Body Mass Index <18.5)
(Body Mass Index >25)
60
Percentage of population
Source: WHO.
Figure 9. Maternal mortality: pregnancy-related deaths per 100 000 live births, 1990
.1
1050
1200-r
w
£ co
_I
1000
800-
2<0 =§
2g
Oo
600-
s?
400-
0) Q.
Q_
200
§) 0
Developed market
economies
Economies in transition
Developing countries
(excluding LDCs)
Level of development
Source: WHO.
13
Least developed
countries
-I
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The health of the world's citizens is inextricably linked; it is less and less a
24.
function of events within geographical boundaries. Countries are forced to
acknowledge their interdependence because of the fragility of our shared environment,
an increasingly global economic system, and the potential for rapid spread of infectious
diseases. At the same time, there is concern that globalization will threaten the survival
of cultural and ethnic diversity in many countries and reduce public investment for
The health of the world's
citizens is inextricably
linked; it is less and less
a function of events
within geographical
boundaries.
health.
Environmental and industrial changes
25.
Global environmental hazards, such as air pollution, ozone depletion, climate
change, loss of biodiversity, and the cross-border movement of hazardous products and
wastes, have adverse impacts on health. These hazards could exacerbate the
vulnerability of poor countries and communities. In addition, national and local
environmental factors directly affect health. Unplanned and poorly controlled
industrialization, combined with inefficient use of energy in transport, manufacturing
and construction, poses threats to air quality in most rapidly growing cities. Indoor air
pollution is a major cause of morbidity and premature death. Many industrial practices
threaten health and the environment. Improper food processing is directly associated
with foodborne disease, diarrhoeal diseases and other conditions. Hazardous
occupations, unsafe working practices and conditions, and increased competitiveness in
changing economies contribute to stress and other health problems.
26.
Water supply, waste disposal and sanitation are key environmental determinants
of human health in all countries, as originally identified in the PHC approach. Despite
progress in these areas, much remains to be done. Water shortages hinder agricultural
and industrial production in many countries, contributing to soil degradation and
poverty. Substantial parts of the world's population are still at risk from diseases related
to insufficient or contaminated water. Clean water for domestic consumption is
essential to health; the lack of clean water of adequate quantity and quality can
encourage the spread of infectious diseases. Revitalized efforts and renewed
intersectoral commitment are needed to address these problems in the 21st century.
The changing role of the State
27.
There is a striking contrast between the world today and the world of 1948 when
WHO was established. The risk of conflict on a global scale has diminished sharply, but
in its place are a multitude of regional and civil conflicts. Relationships between
countries, which in the late 1940s reflected colonial practices and the Cold War, are
now influenced by a host of factors, particularly the spread of market forces and the
increasing interdependence of countries.
28.
The implications of global political, economic and social changes for the role of
the State, particularly with regard to the preservation and promotion of health, are
profound. The autonomy as well as the viability of the State is under increasing
pressure. Governments must function in a more demanding, yet constraining,
environment, and under pressures from many sources to bring national policies in line
with global and regional agreements. From within, corruption has eroded public
confidence in many governments and, in some countries, even the structure of
government has collapsed.
29.
Slow progress in implementing primary health care does not call into question
the soundness of the HFA vision. If anything, emerging threats to health reinforce the
need for an intersectoral approach, which is a key feature of PHC. PHC as originally
outlined and now adapted to address new trends (see Box 4) remains essential to the
14
Global environmental
hazards have adverse
impacts on health.
Substantial parts of the
world's population are
still at risk from diseases
related to insufficient or
contaminated water.
A51/5
achievement of HFA in the 21 st century. Adaptation needs to take account of
opportunities and pressures on health systems resulting from several factors including
decentralization and devolution of responsibilities to local government and civil society,
increased participation of the private sector in health, and the greater involvement of
people in decision-making about many aspects of health care.
Box 4
NEW TRENDS INFLUENCING HEALTH
IN THE 21 st CENTURY
* Widespread absolute and relative poverty.
♦
Demographic changes: ageing and the growth of cities.
* Epidemiological changes: continuing high incidence of infectious diseases;
increasing incidence of noncommunicable diseases, injuries and violence.
* Global environmental threats to human survival.
* New technologies: information and telemedicine services.
* Advances in biotechnology.
* Partnerships for health between private and public sectors and civil society.
♦
Globalization of trade, travel and the spread of values and ideas.
15
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SECTION II
Health for All in the
21 st century
Chapter 3. Values, goals and targets of Health
for All in the 21 st century
Chapter 3 emphasizes the need to prepare for the next century through
recommitment to HFA. The broad goals of HFA can be realized through
strengthened support for key values: human rights, equity, ethics and gender
sensitivity. These values should underpin all aspects of health policy. Specific
targets are identified to spur action.
New bases for action
A key aspect will be the
strengthening of the
participation of all
people.
30.
Evolving opportunities and the reality of an uncertain future require that HFA be
seen, not as a blueprint, but as a commitment to working together in pursuit of a shared
vision. HFA strategies in our changing world need to:
• incorporate an explicit gender perspective;
• emphasize health as central to sustainable human development (see
Figure 10);
• make use of available new technologies for health;
• recognize the expanded role of civil society in health; and
• promote global action to protect national and local health.
A key aspect will be the strengthening of the participation of people and communities in
decision-making and actions for health - a central feature of the PHC approach.
HFA: an enduring vision
The HFA vision recognizes
the oneness of humanity.
31.
HFA seeks to create the conditions whereby people everywhere, throughout
their lives, have the opportunity to reach and maintain the highest attainable level of
health. It is a vision that recognizes the oneness of humanity and, therefore, the need
to promote health and to alleviate ill-health and suffering universally and in a spirit of
solidarity. The HFA vision is based on the following key values:
17
>
ui
Figure 10 Mortality among children under five years of age in 1995-2000, by per capita gross national product in 1995
300 T
250 o
o
o
tN
in
o
o>
I
§
CO
a
L-
200 -
Central African Republic
150
Zimbabwe
§o
E
o
>
J*
o
•U
c
100
•-India
^Guyana
Fteru
I
•-Nicaragua
Z)
•-South Africa
• •-Turkey
J "Indonesia
50 • •
•
• •-'Venezuela
Costa Rica
Argentina
• • I
••
Sri Lanka
•
•
Australia
100
United States of America
Gr^ece
0 10
•
1 000
Gross national product per capita in US dollars, 1995 (log scale)
10 000
■
1
100 000
A51/5
• recognition that the enjoyment of the highest attainable standard of health is a
fundamental human right (see Box 5);
• ethics: continued and strengthened application of ethics to health policy,
research and service provision;
• equity: implementation of equity-oriented policies and strategies that
emphasize solidarity; and
• gender sensitivity: incorporation of a gender perspective into health policies
and strategies.
These values should underpin and be incorporated into all aspects of health policy,
influencing policy choices, the way those choices are made, and the interests they
serve. They are closely interlinked, serving as supports for the execution of appropriate
strategies. At the global level, WHO has the leading responsibility for the advocacy of
these values, although all members of society have a shared responsibility for their
propagation and sustainability.
Ethical principles will
have to anticipate and
guide science and
technology development
and application.
Equity requires the
removal of unfair and
unjustified differences
between individuals and
groups.
A gender perspective is
vital if equitable and
effective health policies
and strategies are to be
developed and
implemented.
32.
A strong ethical framework that includes respect for individual choice, personal
autonomy and the avoidance of harm applies to both individual and social aspects of
health care and research. Advances in science and technology, medicine, engineering,
and communications offer untold opportunities to influence health. At the same time,
scientific and technological progress is testing the boundaries of ethical norms and
challenging the very notion of what makes us human. Firm ethical principles are
therefore needed to anticipate and guide developments in science and technology and
their application, and to guide decisions about matters that influence health (see Box 6).
33.
Equity requires that care is provided according to need and that unfair and
unjustified differences between individuals and groups are removed. The measurement
of inequities is the starting-point for policy development and action. An equitable
health system ensures universal access to adequate quality care without placing an
excessive burden on the individual. Equity and solidarity should form the basis for
international technical cooperation, favouring populations and countries with the
greatest burden of poverty and ill-health. Equity and solidarity across generations
require that we maintain and protect our environment, and that work on the human
genome conforms to agreed ethical standards (see Box 7).
34.
A gender perspective is vital if equitable and effective health policies and
strategies are to be developed and implemented. A gender perspective leads to a better
understanding of the factors that influence the health of women and of men. It is not
only concerned with biological differences between women and men, or with women's
reproductive role, but acknowledges the effects of the socially, culturally and
behaviourally determined relationships, roles and responsibilities of men and women,
especially on individual, family and community health. A gender perspective, linked to
the advancement of equity, must be incorporated into health policies and programmes
(see Box 8). Specific aspects include:
• performing gender analyses and encouraging gender awareness;
• attending to the special needs of girls and boys, women and men, throughout
the life span;
• supporting the human rights, dignity, self-worth and abilities of girls and
women; and
• creating opportunities for full participation of women with men in decision
making at all levels.
19
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Box 5
THE RIGHT TO THE HIGHEST ATTAINABLE
STANDARD OF HEALTH
What does the "right to health" imply?
•
The enjoyment of the right to the highest attainable standard of health (often
referred to as the "right to health") is one of the fundamental rights of each
individual to his or her own highest potential in terms of health.
•
In interpreting the "right to health" it is accepted that:
* people's biological and genetic differences may limit their health potential;
* access to health services is a necessary but not sufficient condition for
realizing the "right to health".
The "right to health" and human rights
•
Health is a prerequisite for the full enjoyment of all other human rights.
These rights are universal, indivisible and interdependent.
International and national policies and actions to ensure the "right to health"
•
Through adoption of international and national human rights instruments
Member States assume specific responsibilities and duties to promote and
protect the health of their populations by:
* ensuring that sustainable health systems are accessible to all people;
* promoting intersectoral action to address the determinants and
prerequisites of health.
International human rights instruments
The right to a standard of living adequate for health and well-being appears in the Universal
Declaration on Human Rights (1948) and the right to the enjoyment of the highest attainable standard of
physical and mental health is protected by law in the International Covenant on Economic, Social and
Cultural Rights (1966). Other international instruments protect the "right to health" at the global and
regional levels, such as the Convention on the Rights of the Child (1989), the Convention on the
Elimination of Discrimination against Women (1979), the Additional Protocol to the American
Convention on Human Rights (San Salvador Protocol on Economic, Social Cultural Rights, 1988), the
European Social Charter (1961), and the African Charter on Human and Peoples' Rights (1981).
20
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Box 6
ETHICS: THE BASIS FOR HFA POLICIES AND PRACTICES
Ethics will guide all aspects of HFA planning and implementation
•
The conduct of health professionals:
*
*
*
*
*
•
promote health and prevent and treat disease;
provide compassionate care across the life span;
respect individual choice, confidentiality and autonomy;
avoid harm;
appreciate diverse values and needs.
Policies and priorities for health systems and services:
* work for equity and social justice in access to health care;
* involve patients and other members of the public in setting priorities for
access to health interventions;
* balance technical criteria with HFA values in allocating resources to specific
interventions;
* incorporate equity considerations into decision-making about resource
allocation within and between countries;
* educate health workers and the public about ethical principles.
•
Science, research and technology:
* monitor and update, as necessary, ethical norms for research;
* anticipate ethical implications of advances in science and technology for
health;
* apply internationally accepted codes of ethics;
♦ ensure that agreed ethical standards guide future work on the human
genome;
♦
ensure that quality in health systems and services is assessed and
promoted.
21
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Box 7
EQUITY: FOUNDATION OF HFA IN THE 21st CENTURY
Equity underpins the concept of Health for All
* The call for HFA was - and remains, fundamentally - a call for social justice.
* Equity requires the removal of unfair and unjustified differences between
individuals and groups.
New challenges to equity since the Alma-Ata Conference:
* more people living in absolute poverty;
* widening gaps between rich and poor within and between many countries,
communities and groups;
* strong evidence linking absolute and relative poverty to ill-health;
* environmental risks threatening equity across generations;
* uneven benefits of globalization;
* uneven access to health systems.
Support for equity requires specific policies and action:
(a)
National and local intersectoral action
♦
economic policies in support of equity and solidarity;
strengthened policy analysis for equity;
♦
setting of priorities based on equity;
♦
intersectoral action for achieving equity in health;
♦
priority to combating poverty;
* empowerment of women as a priority;
♦
clearly stated equity-oriented targets backed by adequate resources;
* governance systems for health that are inclusive of, and that focus
on, the poor.
♦
(b)
Health systems action
* measurement of inequities by class, sex, race, generation, age,
geography and health status;
* ensuring universal access to care of adequate quality;
* life-span approaches to health care;
* capacity-building and research on equity in health;
* health, social, and environmental services that favour the poor.
(0
Global action
* global surveillance of equity for health;
* research that addresses the needs of the poor;
* solidarity as the basis for international technical cooperation;
* transnational health and development actions that address and
prevent marginalization.
22
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Box 8
A GENDER PERSPECTIVE: RECOGNIZING THE NEEDS
OF WOMEN AND MEN
A gender perspective is essential to health policy because it:
* recognizes the need for the full participation of women and men in
decision-making;
* gives equal weight to the knowledge, values and experiences of women
and men;
♦ ensures that both women and men identify their health needs and
priorities, and acknowledges that certain health problems are unique to, or
have more serious implications for, men or women;
♦ leads to a better understanding of the causes of ill-health;
* results in more effective interventions to improve health;
* contributes to the attainment of greater equity in health and health care.
A gender perspective in relation to health is central to development because:
* gender-equality in education and decision-making will reduce poverty;
* education of girls and women will reduce infant and child mortality and the
birth rate, help eliminate gender inequalities in early childhood, and lead
to more healthy populations.
A gender perspective in relation to health systems design and implementation of
health services requires that:
* the complementary roles that men and women play in family and
community health be considered;
♦ gender-related barriers to health care be removed;
♦ surveillance and monitoring systems collect and analyse sex-specific data;
* gender balance be assured in topics of research and among the
participants, as well as in the mix of researchers;
* health care workers be trained to be sensitive to gender issues;
* financing systems take account of women's roles in the family and
community.
HFA requires:
♦
equal participation and partnerships of men and women in policy
development and decision-making;
* strong partnership with gender-sensitive NGOs and other organizations;
* systematic implementation of a gender perspective by all partners.
23
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Coals and targets of HFA
35.
Goals and targets help define the vision of HFA. Indicators assess the degree of
progress. The goals of HFA are:
• an increase in life expectancy and in the quality of life for all;
• improved equity in health between and within countries;
• access for all to sustainable health systems and services.
36.
An initial set of targets will guide the implementation of the HFA policy and
define priorities for action for the first two decades of the next century. Specific
indicators of progress will be developed for the global health targets listed below (and
elaborated in Annex A). To achieve the global targets, strategic alliances will be
established between WHO and other United Nations organizations, the World Bank,
nongovernmental organizations, the private sector and other relevant partners. Within
the framework of the global policy, WHO will define more specific targets related to its
own functions. Regional and national targets will be developed within the framework of
the global policy, and will reflect the diversity of needs and priorities. They should be
measurable, time-bound, and feasible, and will need to be supported by adequate
resources. All targets should be reviewed periodically. Indicators will be used to assess
the degree of progress being made towards the attainment of the goals and targets, as
indispensable aids to effective monitoring and evaluation of programmes.
37.
The global health targets reflect earlier HFA targets and are in line with the
development targets agreed by Member States at recent world conferences in which
WHO participated. Achievement of the global development targets is considered
essential to the successful achievement of HFA, though they are not explicitly included
in the global health targets. They include targets related to: economic well-being and
poverty reduction; social development, including primary education and gender
equality; and environmental sustainability (see Annex B for further details).
Targets should be
measurable, time-bound,
feasible and supported by
adequate resources.
The global health targets
reflect earlier HFA targets
and are in line with the
development targets
agreed at recent world
conferences.
Global HFA targets to 2020
38.
Targets related to health policies and systems need to be met if actions relating to
the determinants of health are to lead to improved health outcomes and access to care.
The original HFA 2000 targets set in 1981 were not supported by baseline data.
Considerable experience in strengthening health information systems since then means
that the targets for 2020 have been more firmly based on evidence. Achieving these
targets will ensure that the goals of HFA are met.
A.
Health outcomes
7.
By 2005, health equity indices will be used within and between countries
as a basis for promoting and monitoring equity in health. Initially, equity will be
assessed on the basis of a measure of child growth.
2.
By 2020, the targets agreed at world conferences for maternal mortality
Equity: stunting.
Survival.
rates (MMR), under-five or child mortality rates (CMR), and life expectancy will
be met.
3.
By 2020, the worldwide burden of disease will be substantially
decreased. This will be achieved by implementation of sound disease-control
programmes aimed at reversing the current trends of increasing incidence and
disability caused by tuberculosis, HIV/AIDS, malaria, tobacco-related diseases and
violence/trauma.
24
Reduced burden.
A51/5
Eradicate, eliminate.
4.
Measles will be eradicated by 2020; lymphatic filariasis will be eliminated
by the year 2020; transmission of Chagas disease will be interrupted by 2010;
leprosy will be eliminated by 2010; and trachoma will be eliminated by 2020. In
addition, vitamin A and iodine deficiencies will be eliminated before 2020.
B.
Environmental
determinants.
Healthy lifestyles.
5.
By 2020, all countries, through intersectoral action, will have made major
progress in making available safe drinking-water, adequate sanitation, food and
shelter in sufficient quantity and quality.
6.
By 2020, all countries will have introduced, and be actively managing and
monitoring, strategies that strengthen health-enhancing lifestyles and weaken
health-damaging ones, through a combination of regulatory, economic,
educational, organizational and community-based programmes.
c
Health policies.
Care and public health
Information and
surveillance.
Research.
Intersectoral action on the determinants of health
Health policies and systems
7.
By 2005, all Member States will have operational mechanisms for
developing, implementing and monitoring policies that are consistent with this
HFA policy.
8.
By 2010, all people will have access throughout their lives to
comprehensive, essential, quality health care, supported by essential public
health functions.
By 2010, appropriate global and national health information, surveillance
9.
and alert systems will be established.
10.
By 2010, research policies and institutional mechanisms will be
operational at global, regional and country level.
25
AS 1/5
Chapter 4.
Policy basis for action
Chapter 4 provides the policy basis for action. Acting on determinants of health
by making health central to human development will lead to significant overall
improvements in health and reduce inequities. The development of sustainable
health systems that will meet the needs of people is outlined.
The goals of HFA will be realized through the implementation of two policy
39.
objectives:
• making health central to human development; and
• developing sustainable health systems to meet the needs of people.
40.
These policy objectives are interrelated and are intended for application at all
levels - local, national, regional and global. Their adoption and further elaboration into
specific strategies, that are adequately financed, fully implemented and carefully
evaluated, should lead to improved health and to a narrowing of the gaps in health
status across social and economic groups. The process of adoption should harness
political, social and economic forces and engage potential partners through expanded
systems of governance for health. Investments in health will contribute to
improvements in health outcomes and will foster achievement of sustainable human
development goals.
Investments in health will
contribute to
improvements in health
outcomes and will foster
achievement of
sustainable human
development goals.
Making health central to human development
41.
It is important to recognize that health cannot be considered in isolation from
human and social development. It is a function of the social, physical, mental,
economic, spiritual and cultural environment of the communities in which people live.
The purpose of human development is to permit people to lead economically
productive and socially satisfying lives. This requires progressive improvements in the
living conditions and quality of life enjoyed by all members of a society. Good health is
both a resource for, and an aim of, sustainable human development.
42.
The health of people, particularly the most vulnerable, is an indicator of the
soundness of development policies. When appropriately disaggregated, data on health
status can highlight inequities between different groups in society. The health status of
a population reflects living conditions and can provide an early warning of emerging
social problems. A human-centred approach values health and recognizes that, without
good health, individuals, families, communities and nations cannot hope to achieve
their social and economic goals. This approach places health firmly at the centre of the
development agenda, to ensure that economic and technological progress is compatible
with the protection and promotion of the quality of life for all.
Good health is both a
resource for, and an aim
of development.
The health of people is an
indicator of the
soundness of
development policies.
Developing sustainable health systems to meet the needs
of people
43.
Health systems must be able to respond to the health and social needs of people
over their life span. National and local systems need to reach out to citizens, and
engage them in improving their own health by emphasizing promotion of health and
prevention of disease. Efforts should be directed towards clearly identifying health
26
Health systems must be
able to respond to the
health and social needs of
people over their life
span.
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needs and organizing comprehensive services within a well-defined population base.
Health systems of the future must be flexible and responsive to pressures, such as:
• demographic and economic change;
• change in the epidemiological patterns of disease;
• expectations of health service users for quality and participation in decision
making; and
• advances in science and technology.
Reform of health systems should be integrally linked to broader national reforms since
many changes in economic, social and development policies will have profound
implications for health systems and for the health or people
Informed individual,
family and community
commitment to health is
the best guarantee that
improvements in health
will be realized and
sustained.
44.
Actions for good health start in the home although they are influenced by many
forces. Informed individual, family and community commitment to health is the best
guarantee that improvements in health will be realized and sustained. Health services
should complement the actions of individuals and families by providing information on
healthy living and access to quality health care, and by supporting functions that
maintain and promote public health. People's contacts with health care facilities
provide numerous opportunities at every stage of life to promote and maintain health
and prevent disease and disability.
45.
Health systems can take many forms. Primary health care services, as an
individual's first level of contact with the national health system, are designed to bring
health care as close as possible to where people live and work. Building on primary
health care, health systems should be: community-based and comprehensive, with
preventive, promotive, curative and rehabilitative components; available continuously;
adequately financed; closely linked at all levels to social and environmental services;
and integrated into a wider referral system. Further, high-quality care should be
available in all countries. The important elements of high-quality health care include:
professional expertise and knowledge of appropriate technologies, efficient utilization of
resources, minimization of risk to patients, satisfaction of patients, and favourable health
outcomes.
A socially sensitive health
system will take into
account the sociocultural
and spiritual needs of
different groups.
Political support for
health will be
demonstrated by ensuring
the financial sustainability
of health systems.
46.
A sustainable health system will actively encourage community participation in
policy development. Its employment practices will be sensitive to the needs of the
workforce, with emphasis on quality and environmental management. A socially
sensitive health system will take into account the economic, sociocultural and spiritual
values of different groups, the variety of systems of health and healing, and the potential
of those varied systems to co-exist with, and mutually enrich, one another. In drawing
fully on community resources, health systems should combine compassion with
efficiency. This must go beyond a focus on extending life and improving health; they
must relieve pain and suffering, provide compassionate care to those with incurable
disease, and try to ensure a peaceful and dignified death.
47.
There are social, political, financial, technical, and managerial dimensions to the
creation of sustainable health systems. The social aspect needs particular attention; it
requires: integration of health into daily community life, development of community
support, maximization of people's participation in maintaining the health of their
families and communities, and ensurance that the poorest have access to health
services. Governments must demonstrate unwavering political support for health by
ensuring that health systems are financially sustainable and accountable and by giving
continued attention to access and quality. Comprehensive and ongoing development of
human resources is necessary for good management practices and technical
sustainability.
27
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Essential functions of a health system
48.
The role of governments with respect to sustainable health systems is to
guarantee equity in access to health services and to ensure that essential health system
functions of the highest quality are provided to all people. These essential functions
consist of both public health activities and individual health care services,
complementing and building on existing primary health care services. Chapter 7
describes the essential functions of a sustainable health system.
28
The role of government is
to guarantee equity of
access to health services
and to ensure that
essential health system
functions are available to
all.
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Chapter 5.
The role of WHO
Chapter 5 describes the role of WHO in providing leadership to the multiple
partners involved in achieving Health for All (see Box 9).
Box 9
ROLES AND FUNCTIONS OF WHO IN THE 21st CENTURY
*
*
*
*
Serve as the world's health advocate, by providing leadership for HFA.
Develop global ethical and scientific norms and standards.
Develop international instruments that promote global health.
Engage in technical cooperation with all countries.
♦ Strengthen countries' capabilities to build sustainable health systems and
improve the performance of essential public health functions.
♦ Protect the health of vulnerable and poor communities and countries.
* Foster the use of, and innovation in, science and technology for health.
* Provide leadership for the eradication, elimination or control of selected
diseases.
♦ Provide technical support to prevention of public health emergencies and
post-emergency rehabilitation.
* Build partnerships for health.
WHO has the mandate
and the responsibility to
guide other partners
involved in global
governance of health
towards attainment of
HFA.
49.
WHO has the mandate and the responsibility to guide other partners involved in
global governance of health towards attainment of HFA (at global, regional and national
levels). It will do so by promoting international collective action that benefits all
countries, and by responding to global threats to health.
50.
As the world's health advocate, WHO will: promote global health and health
equity between and within countries; identify policies and practices that benefit or
harm health; and protect the health of vulnerable and poor communities. It will do so
by providing a facilitating and enabling environment within which the diverse range of
partners for health can work effectively together in promoting a global agenda for
health.
51.
As global interdependence increases, so will the need for global ethical and
scientific norms, standards and commitments, including some that are legally binding.
The aim will be to prevent or reduce transnational threats to health related to trade,
travel and communication. WHO will give particular attention to the development of
nationally and regionally relevant performance standards for essential health system
functions.
WHO will develop
international instruments
that promote and protect
health.
52.
In collaboration with relevant partners, including treaty bodies, WHO will
develop international instruments that promote and protect health, will monitor their
implementation, and will also encourage its Member States to apply international laws
related to health. A strong system of global governance is necessary for implementation
of existing international instruments on health and human rights as well as instruments
having health implications. These instruments include: the Universal Declaration of
Human Rights (1948), the International Covenant on Economic, Social and Cultural
Rights (1966), the Convention on the Rights of the Child (1989) and the Vienna
Declaration and Programme of Action adopted by the World Conference on Human
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Rights (1993). Health targets provide a means of monitoring the implementation of
many of these conventions. The health targets developed during the United Nations
conferences of the 1990s will be incorporated into future implementation strategies,
thus translating this policy into action.
53.
In its technical cooperation with all countries, WHO will tailor its support to the
needs of countries and, in doing so, will coordinate its efforts with other international
organizations and initiatives. It will aim to achieve policy alignment and close dialogue
between these partners. In addition, WHO will encourage countries and development
agencies to invest where the preventable disease burden among the poor remains high.
WHO will support and encourage all countries in their health development process by
providing assistance to strengthen their policy-making role, management capability and
systems of accountability. The need for strong institutional and human capacity to
support health actions will be emphasized. WHO, in collaboration with other
international agencies, will strengthen countries' capabilities to develop sustainable
health systems. WHO will seek to mobilize financial resources through a strengthened
global alliance to meet the health needs of programmes and countries. Priority will be
given to the poorest countries and communities (particularly those in sub-Saharan Africa
and south Asia), and to countries with weak institutional capabilities for health
development.
54.
The quality of decision-making for health depends upon access to health
information. WHO will work with its Member States to strengthen their capacity to
collect, analyse, interpret and disseminate health information. This will include
supporting capacity-building in epidemiology, health economics, and social sciences;
continuing to develop a global interactive health information network; and
disseminating publications on WHO's work.
55.
Global action is needed to ensure active surveillance, assessment and
anticipation of policies and actions that have a global impact on health. WHO will
ensure that global early-warning and surveillance systems provide timely information
about transnational threats to health. Existing early-warning systems for emerging
infections and for impending natural or man-made disasters will be expanded to include
other threats to health, such as legal and illegal trade in products that harm health.
Systems that connect local, national, regional and global levels and relevant
organizations will allow warnings of threats to health, even from local settings, to be
rapidly and globally amplified, thereby permitting a concerted response.
56.
WHO, in close collaboration with the international scientific and academic
community, will foster an environment in which basic and applied health research can
flourish. It will encourage scientific innovation that serves the needs of all. WHO will
use communications technologies to reach researchers who have been isolated from
global research networks because of inadequate resources. The development of a truly
global network of centres of excellence will allow local researchers to contribute to, and
benefit from, knowledge about health. WHO is committed to assisting countries to
develop their national research capacities, and to share the resulting knowledge.
57.
Global research efforts should be directed towards areas where substantial health
gains are needed. These should be complemented by country-specific research
priorities and action, through which countries will work towards improved national and
global health. WHO, its Collaborating Centres, and national and international health
research organizations, together constitute a global intellectual asset that will be fully
utilized in research. Global areas of concentration should include research that:
• informs national health policy;
30
Strengthen capacity to
collect, analyse, interpret
and disseminate health
information.
WHO will ensure that
global early-warning and
surveillance systems
provide timely
information about
transnational threats to
health.
WHO will encourage
innovation in science that
serves the needs of all.
Global research efforts
should be directed
towards areas where
substantial health gains
are needed.
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• permits cross-country comparisons of health systems, particularly in the areas
of health financing and policy development;
• identifies social, environmental and other specific sectoral policies and actions
that advance health;
• evaluates the effectiveness of interventions to reduce inequities in health;
• maximizes the efficiency of health systems and leads to sustainability;
• accelerates the reduction of childhood disease, malnutrition, and maternal
and perinatal mortality;
• identifies changing microbial threats and develops strategies for their
prevention and control;
• develops effective preventive, promotive, curative and rehabilitative
approaches to noncommunicable diseases and the health consequences of
ageing; and
• leads to control of violence and injuries.
WHO will support the
effective use of existing
technologies and
development of new
technologies.
WHO and its
international partners
must ensure worldwide
surveillance and control
of diseases of global
importance.
WHO will demonstrate
that health can be a
powerful bridge to peace.
A global framework for
action in multiple sectors
will be developed to
reinforce HFA values.
58.
WHO will support the effective use of existing technologies and the development
of new technologies in different countries and settings by: disseminating knowledge as
widely as possible; supporting improved technology forecasting; investing in education
and human resources development; building partnerships with the private sector and
between countries; working towards policies that make technologies more affordable
and available; and promoting the use of essential technologies for health.
59.
WHO will lead efforts to eradicate, eliminate or control diseases that are major
threats to public health. For certain conditions, global consensus and action for
eradication or elimination are both feasible and desirable (see Annex A for details). The
global pandemics of human immunodeficiency virus (HIV) infection, malaria, and
tuberculosis, as well as tobacco-related diseases, trauma and violence, are likely to
become increasingly important in the first quarter of the next century. Several
infectious diseases may continue to threaten all countries and, therefore, require global
attention. For many of the poorest countries and communities, the burden of
childhood infectious diseases, maternal mortality and undernutrition remains a priority
demanding global support.
60.
In many areas, civil conflicts, wars, and natural and man-made disasters have
prevented the establishment of sustainable health systems and have significantly
retarded health development. WHO's response to such public health emergencies will
be primarily in the form of prevention and the setting of norms. It will give emphasis to
preparedness, prevention, reconstruction and humanitarianism, with interventions
carried out in close collaboration with international, national and local bodies. During
post-emergency reconstruction, WHO will support governments in restoring their health
and social systems, and in addressing the long-term human adjustment problems.
WHO aims to demonstrate that health can be a powerful bridge to peace, and will
document the public health impact of weapons as a basis for preventive action.
61.
WHO will provide leadership, example and direction to organizations and
institutions working for better world health. WHO will emphasize and demonstrate that
policy changes require properly financed functional and structural changes if action is to
follow. It will promote more integrated approaches to capacity-building, policy
development and resource mobilization for health in countries. Further, it will strive for
greater policy alignment between international and intergovernmental agencies whose
work has an impact on health. Together with these partners, WHO will emphasize the
Vafa - too...
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need for a global framework for action in multiple sectors to promote economic, trade,
and social policies and programmes that reinforce HFA values.
62.
In addressing the broad determinants of health WHO will work closely at global,
regional and national levels with international and regional intergovernmental agencies,
including the regional development banks. Effective means of harmonizing WHO's
programme of work with those of other intergovernmental organizations, such as regular
interagency consultations focusing on key areas of mutual concern, will be emphasized
in implementing the HFA policy. In some areas of multisectoral collaboration, such as
global disease surveillance, WHO will take the lead role. However, in other areas of
cooperation, for instance food security and structural unemployment issues, other
agencies may be better placed to assume the leadership position. Effective interagency
and intersectoral collaboration requires clearly defined roles and responsibilities, and
will provide the foundation for successful implementation of the HFA policy.
Collaboration should aim to make optimum use of all resources available for health and
development within the United Nations system and among other international agencies.
Effective interagency and
intersectoral
collaboration requires
clearly defined roles and
responsibilities.
Accountability and commitment
63.
Accountability for achieving Health for All in the 21 st century is widely shared.
WHO at the international level, and health workers at the national and local levels,
must ensure that all partners fulfil their roles and responsibilities in implementing the
HFA policy. Their combined actions will help to build a world in which HFA values and
supportive actions lead to all people being able to enjoy the highest attainable level of
health. Committed action at all levels is critical to transforming the HFA vision into a
practical and sustainable public health reality.
32
Committed action at all
levels is critical to
transforming the HFA
vision into a practical and
sustainable public health
reality.
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SECTION III
Fulfilling the vision: actions
for implementation of the
policy
Chapter 6. Actions needed to make health
central to development
Chapter 6 describes four strategic lines of action: to combat poverty, to promote
health in all settings, to align sectoral policies for health, and to include health in
sustainable development planning.
64.
Four lines of action are required to address the determinants of health and to
make health central to human development. They aim to:
• combat poverty,
• promote health in all settings,
• align sectoral policies for health,
• include health in planning for sustainable development.
Combating poverty
Integrated development
plans are needed to
break the vicious spiral of
poverty and ill-health.
65.
Accelerated human development and economic growth in both the public and
private sectors are needed to lift the poorest people and communities out of poverty.
Such growth must be backed by substantive and sustained international support for
healthz education and appropriately strengthened government institutions in the poorest
countries. Integrated development plans, that include debt reduction and provision of
credit, are needed to break the vicious spiral of poverty and ill-health. The long-term
health of populations depends on many factors, particularly on the maintenance of
peace, equitable economic growth, the empowerment of women, the provision of
sustainable livelihoods and improved education. For all countries, ethical economic
policies that enhance equity are essential for sustainable economic growth and human
development.
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66.
Health interventions must be linked to improved education of girls and the
provision of a basic public health infrastructure and essential health services. Such a
linkage can help break the cycle of poverty and ill-health, reduce child mortality and
slow population growth. In particular, the provision of child health care and nutrition
services can have a lasting positive effect on entire populations. Ready access by the
poor to quality health care services, through outreach to their homes if required, should
be supported as an essential component of future poverty-reduction programmes.
67.
As poverty is multidimensional, the combined efforts of many sectors will be
required for its sustained alleviation. The health system can play a vital role in reaching
poor households and regions by focusing on problems that disproportionately affect the
poor. Collaboration is thus essential between health systems and agricultural, trade,
financial, food and nutrition, education, and industry sectors. In addition to broad
based approaches, people's health and education must be protected during periods of
temporary economic hardship. Ensuring food security is closely aligned to combating
poverty.
Health interventions can
help break the cycle of
poverty and ill-health,
reduce child mortality
and slow population
growth
The health system can
play a vital role in
reaching poor households
and regions.
68.
Disease-control programmes that operate across large geographical regions or
within specific settings may have a considerable impact where one or a few diseases
make a major contribution to poverty. For example, the control of onchocerciasis in
West Africa led to the opening up of vast areas to new agricultural development.
Similarly, the control of malaria and other endemic communicable diseases has
contributed significantly to food and cash crop production and employment generation
in many areas. Combined food aid and deworming programmes can lead to significant
gains in children's scholastic performance and in school attendance.
Promoting health in all settings
69.
Individuals, families and communities can act to improve their health when they
are given the opportunity and the ability to make appropriate choices. People,
therefore, need knowledge, awareness and skills - as well as access to the possibilities
offered by society - to cope with changing patterns of vulnerability, and to keep
themselves and their families healthy. To succeed, health promotion must take into
account the social, cultural, political, legal and spiritual environments in which people
live, work, play, and learn. Social action can help to protect the young from violence
and substance abuse, ensure that working conditions are conducive to health, promote
healthy diets and recreation, and create a school environment that is supportive of
learning, good health and personal growth.
People need knowledge,
awareness and skills to
keep themselves and their
families healthy.
70.
Communications technology, including interactive methods, has become an
important means of sharing images and messages for health promotion to support
individuals and communities in improving the quality of their lives. The media can play
a greater role in advocating health and health practices. They can help to raise public
awareness of health by discussing health issues. Health information and entertainment
that reach into every community and home can allow even the most remote families to
benefit from current knowledge.
Aligning sectoral policies for health
71.
In government, diverse authorities take decisions that affect health including, for
example, those in the sectors of agriculture, housing, energy, water and sanitation,
labour, transport, trade, finance, education, environment, justice and foreign affairs.
The policies of all sectors that affect health directly or indirectly need to be analysed
and aligned to maximize opportunities for health promotion and protection. This will
require health professionals to be more responsive to the primary motivations of
professionals from these other sectors and to be willing to negotiate for policies that are
34
The policies of all sectors
that affect health directly
or indirectly need to be
analysed and aligned to
maximize opportunities
for health promotion and
protection.
AS 1/5
mutually beneficial. Further, multidisciplinary research is required to identify new
opportunities for health promotion and protection through intersectoral action.
Stronger joint action by
health systems and the
education sector could
contribute substantially
and rapidly to the overall
improvement of health
status.
72.
Stronger joint action by health systems and the education sector could contribute
substantially and rapidly to the overall improvement of the health status of populations
and to a long-term reduction in health and economic inequalities between groups.
Economic and fiscal policies can significantly influence the potential for health gains and
their distribution in society. Fiscal policies that contribute to health - for instance, those
that discourage use of harmful products and stimulate consumption of nutritious foods
and the adoption of healthy lifestyles - should be encouraged. Such policies, when
combined with appropriate legislation and health education programmes, can retard
and even reverse negative trends, particularly increases in noncommunicable diseases
and trauma.
73.
Agricultural policies can incorporate specific disease prevention measures in
irrigation schemes, actively promote integrated pest management to minimize the use
of toxic chemicals, establish land-use patterns that facilitate - rather than discourage human settlements in rural areas, encourage substitution for crops that harm health, and
ensure the production of safe and sufficient foods. An energy policy that favours health
should support the use of cleaner energy sources. It should ensure that less hazardous
and toxic waste is produced, that cleaner and more energy-efficient transport is
available and that buildings are designed to be energy-efficient. The cumulative impact
of such policies can be substantial. Their enactment can ensure that health is not
sacrificed for narrow short-term sectoral or economic gains.
74.
National policies to address population growth will integrate strategies to improve
the status of women, particularly through their access to education and primary and
reproductive health care programmes, and their equal participation in decision-making.
The social, economic and ethical implications of reproductive technologies will be
considered by national and international organizations.
including health in planning for sustainable development
Health considerations
must receive the highest
priority in sustainable
development plans.
75.
For development to be sustainable, its benefits must accrue to present and future
generations. If health is to be central to human development, health considerations
must receive the highest priority in sustainable development plans. In particular,
promotion and protection of human health and well-being should be a primary reason
for all aspects of development.
76.
Non-renewable resources have been dangerously over-exploited, while
renewable resources are being consumed on a non-sustainable basis. The adoption of
conventions and actions that discourage or prevent severe environmental degradation
will benefit the health of future generations.
Health professionals have
a leading responsibility to
ensure that the linkages
between health, health
systems and services, and
other sectors are clearly
identified.
Introduction of health
indicators into
environmental impact
assessment will improve
decision-making.
77.
Health professionals have a leading responsibility to ensure that the linkages
between health, health systems and services, and other sectors are clearly identified.
They must ensure that the overall health impact of development activities, and
consequences for equity, are measured or anticipated. Appropriate policies must be
developed and actions taken in support of HFA. This includes taking advantage of
opportunities to improve health presented by development programmes.
78.
The introduction of health indicators into environmental impact assessment will
improve decision-making in the health and environment sectors. An increased
understanding of the long-term cumulative effects of chemicals, the depletion of the
ozone layer, climate change, low-dose radiation, and genetic manipulation of plants
and animals used for food is crucial for anticipating future threats to health and for
taking timely remedial action. The health consequences of environmental changes must
be quantified and used to assess progress towards sustainable development. This will
create incentives for both environmental improvement and health protection.
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Chapter 7. Essential functions of sustainable
health systems
Chapter 7 describes the essential functions of sustain able health systems. These
include:
• making quality health care available across the life span;
• preventing and controlling disease, and protecting health;
• promoting legislation and regulations in support of sustain able health
systems and development;
• developing health information systems and ensuring active surveillance;
• promoting research and fostering the use of, and innovation in, science
and technology for health;
• building and maintaining human resources for health; and
• securing adequate and sustainable financing.
These functions include both essential public health functions and individual
health care services (see Box 10).
Box 10
ESSENTIAL PUBLIC HEALTH FUNCTIONS
These functions are a set of fundamental and indispensable activities to protect the
population's health and treat disease, targeted at the environment and the
community. They are vital for maintaining and improving health. Countries at all
levels of development should ensure that these functions are performed at least to
minimum standards, and that their implementation should be monitored by
government agencies. Functions are considered essential if they promote health
and prevent or protect the population from major health hazards. The execution of
these functions requires strong partnerships.
Making quality health care available across the life span
79.
A life-span approach to health acknowledges the complex and interrelated effects
of many factors on the health of adults and children. Life-span care emphasizes
interventions with a preventive and caring potential that can extend from birth to death.
The life-span approach is based on evidence of intergene rational effects, and on
80.
linking early factors - present from before birth to childhood - with health in
adolescence and later life. There are many examples of conditions and behaviour that
could be prevented by investment in early childhood development, leading to
important improvements in health later in life. A life-span approach to health
promotion, prevention and care has the potential to reduce disabilities and enhance the
quality of life in later years.
36
A life-span approach to
health acknowledges the
complex and interrelated
effects of many factors on
the health of adults and
children.
AS 1/5
81.
Health care settings in the 21 st century will differ from those of today. A greater
focus on incorporating scientific evidence into clinical practice, combined with an
emphasis on quality of care, should reduce variations in diagnoses and outcomes. A
wider range of care and services in community settings should be available directly or
indirectly, such as through the use of communications technology. Hospitals should
focus increasingly on providing ambulatory, technology-intensive, curative and
diagnostic services. Long-term care would be primarily provided in the community
through non-hospital institutional care and home-based services. This will require
community solidarity and multigenerational support within families.
Close integration of
health, social and
environmental services,
including school health
and workers' health
programmes, will be
required.
82.
Life-span care should be available in local communities, within a health system
that emphasizes quality of prevention, diagnosis, treatment and rehabilitation. Local
and district health services must be able to provide essential drugs and other services to
meet community needs. They should be linked electronically, and by permanently
available transport, to referral centres. The relationship between the local health service
and the State will be defined in terms of the degree to which authority, responsibility
and initiative are devolved. For quality health care, a balance must be found that
reflects the community structure, resources, and needs. Close integration of health,
education, social and environmental services, including school health and workers'
health programmes, will be required.
Preventing and controlling disease, and protecting health
Community-based
population-oriented
disease prevention and
control and health
protection services
benefit all.
83.
Disease prevention for populations, across the life span, is crucial to human
development. Community-based population-oriented disease prevention and control
and health protection services benefit everyone, and their implementation requires little
individual participation. Priority should be given to endemic and commonly occurring
infections, noncommunicable diseases, injuries and violence. Maintenance and
extension of the ability to promote such services should be decentralized, as much as
possible, recognizing that successful decentralization requires competent local
authorities.
84.
Environmental services that help to protect and maintain health are the
responsibility of national and local governments. They include services to ensure access
to safe water and sanitation, clean air and safe food, manage hazardous chemicals and
wastes, and control vectors and pollution. Further, incorporating health needs and
concerns into town planning, and developing adequate inspection and monitoring of
environmental health hazards, are mainly local authority functions. While these
services are often provided outside of health systems, health professionals should be
responsible for ensuring their coordination and should advocate their implementation.
85.
Disease prevention and health protection services in the workplace are essential
components of an integrated approach to improving the health of workers. The current
emphasis on preventing exposure to specific agents and on promoting safety at work
should be extended to cover all preventable conditions that affect adults in the
workplace. Where people work at home, their occupational health needs should be
met by local or district health services.
Promoting legislation and regulations in support of
sustainable health systems
National laws should set
the basis for collective
action for health.
86.
National laws should set the basis for collective action for health, protect
vulnerable and disadvantaged people from adverse economic effects, and define the
boundaries and expectations of government with respect to its partners. Legislation and
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regulations need to strike a balance between individual freedoms and public needs and
interests. People entrust their governments with the development of health systems that
meet their needs. Health ministries and departments are responsible for developing
policies and priorities that reflect people's needs: by setting standards and norms, by
ensuring that supportive legislation and regulations are adopted, and by informing the
public about their rights and responsibilities.
87.
Regulation and oversight are vital to achieving an appropriate balance between
the public and private sectors. With globalization and privatization of the economy, the
need for legislation is increasing. Legislation that promotes health includes measures
relating to: environmental standards, food safety, bans on tobacco advertising and
sponsorship, restrictions on alcohol promotion, bans on access to certain weapons,
measures for consumer protection, and the entitlements of people to health care.
Environmental health legislation can protect the public against exposure to a wide range
of hazardous products. Legislation is also needed to: help control violence and injury;
ensure that ethical practices are followed in medical care and research; provide a
regulatory framework for private-sector health care and intersectoral action for health;
ensure the safety of pharmaceuticals and foods; and protect consumers and providers
of health care. The success of these approaches will depend on political commitment,
capacity-building in public health law, public support and effective enforcement.
Regulation and oversight
are vital to achieving an
appropriate balance
between the public and
private sectors.
Developing health information systems and ensuring
active surveillance
88.
National and local health information systems are a prerequisite for the
development of effective, efficient, equitable and quality health systems. National
health information systems should be capable of providing, analysing, evaluating,
validating and distributing information needed for active surveillance, decision-making,
health management, clinical practice and public education. National and local
monitoring, surveillance and evaluation systems are needed to provide timely
information to decision-makers that will facilitate evaluation and management of health
systems and the best use of resources.
89.
A hallmark of a sustainable health system is its emphasis on active surveillance
and monitoring. Global, regional, national and local surveillance, monitoring and earlywarning systems will alert the public to impending threats to health, thus allowing
appropriate action to be taken. By appropriate disaggregation of data, these systems
will also allow identification of differences in health, related to social class, sex, location
or age. Better information and communications technologies will improve linkages
between local settings, national organizations, and WHO.
Health information
systems are a prerequisite
for the development of
quality health systems.
Global, regional, national
and local surveillance,
monitoring and earlywarning systems will alert
the public to impending
threats to health.
90.
An integrated system of active surveillance and monitoring for health will focus
on at least the following areas: infectious diseases; health status and trends, including
birth and death rates; implementation of international norms, standards and
regulations; progress in reducing health inequities; performance of essential public
health functions; the impact of various lifestyles on health status; the health impact of
the abuse of human rights; transnational health problems; and sectoral impacts on
health.
Fostering the use of science and technology
91.
Advances in science and technology have made substantial contributions to
health in the past. They are likely to yield even greater benefits for all in the 21st
century. In particular, rapid progress in several fields over the coming decades should
38
Rapid progress should
allow poorer countries to
take maximum advantage
of developments in
technology and benefit
from the experiences of
other countries.
AS 1/5
allow poorer countries to take advantage of developments in technology and benefit
from the experiences of other countries.
92.
The scope of technologies for health extends from those that provide a direct
benefit to health, such as "genomics" (the study of the structure and function of the
genome), biologicals, pharmaceuticals and medical devices, to those that support health
system functions, such as telecommunications, information technologies and
environmental protection and food technologies. Closer partnerships between science
and technology research and development, between users and innovators, and between
the private and public sectors will increase the chances of innovations in science
contributing to improved health worldwide. Researchers and research funding agencies
working in a diverse range of geographical and development settings must be
encouraged to share expertise and resources, in a spirit of international solidarity.
93.
In assessing and promoting new technologies for health, the following should be
considered: the ability to contribute to quality of life and health; the potential to
promote equity; the respect for privacy and individual autonomy, and the degree of
focus on determinants of health. An effort must be made to adopt a long time-frame
and wide view with respect to technology transfer, as the benefits and applications of
technology are not always immediately understood, realized, or affordable.
Building and maintaining human resources for health
A well-trained and
motivated workforce is
essential for health
systems to function well.
Institutional and
individual leadership by
health personnel should
emphasize Health-for-All
values.
Health workers' clinical,
public health and
management knowledge
and skills need to be
constantly upgraded.
94.
A well-trained and motivated workforce is essential for health systems to function
well. Support by the State, WHO and their partners in training institutions should
reflect the need for ongoing and comprehensive capacity-building for health. The
health workforce of the 21st century and the working conditions of all health workers
must be capable of providing quality services based on HFA values. A culture of health
that respects and supports the right to health, ethics, equity, and gender sensitivity is
fundamental. This applies to all health care providers, including members of the
community, who will increasingly provide care for people at home and in the
community.
95.
Educational institutions for health personnel should constantly review their
curricula in the light of new knowledge, with a view to meeting the needs of people. A
greater responsiveness to society's needs would be achieved through expanding
community-oriented medical and health education and research. Institutional and
individual leadership by health personnel should emphasize Health-for-All values. For
health care providers, this requires explicit attention to respect for individuals' rights to
confidentiality, dignity and self-respect; appreciation of individuals' diverse spiritual
and cultural values and needs; and an understanding of the need for equitable,
affordable, and sustainable health care. Professional codes of conduct should be
consistent with HFA values.
96.
Human resource planning should recognize the need to consider changing mixes
of health care providers working in a multidisciplinary and collaborative fashion. The
mix would include public health providers, technicians, therapists, doctors and nurses
among others. Technical cooperation and national and international training
opportunities have to be strengthened in order to fill gaps in the supply of public health
professionals. The boundaries of existing developmental, environmental, social, public
health and medical disciplines need to be extended and community-development skills
strengthened. The combination of new technologies and different demographic,
epidemiological and social challenges requires that health workers' clinical, public
health and management knowledge and skills be constantly upgraded. To serve the
need of the public for better information about all aspects of health, greater attention
should be given to training in communications, health promotion skills, care giving and
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community assessment. Telecommunications linkages offer new opportunities for
distance-learning and diagnostic support in many settings. These links will break down
the barriers of distance and promote accelerated development of human resources in
poor countries and communities.
97.
The health sector should develop national policies that contribute to selfsufficiency in human resource development, appropriate career development and
deployment of the health workforce and the working conditions of all health workers.
Such policies should: address the long-term needs for a health workforce; develop
institutional and individual leadership; strengthen managerial capacity; and improve
the management, infrastructure and institutional environment. In addition, global and
regional policies must address broader human resource issues, such as the transnational
movement of health professionals, the provision of training, the need for international
harmonization of education and service standards, and the use of appropriate regulatory
and financial mechanisms to maintain and strengthen national capacity.
The health sector should
develop national policies
that contribute to selfsufficiency in human
resource development
and deployment of the
health workforce.
Securing adequate and sustainable financing
98.
Government action and regulations are needed to secure an adequate level of
financing (through public or private sources), to promote cost containment and fiscal
discipline, to provide lists of essential drugs and technology, and to ensure that national
resources are used equitably to meet health needs. Close collaboration between health,
finance, planning and other departments in government is required to achieve these
objectives. When the government has the major mandate for, or is the main funder of,
health systems, there is more likely to be equity of access, cost containment, and a
strong emphasis on preventive and promotive services.
Government action and
regulations are needed to
ensure that national
resources are used
equitably to meet health
needs.
99.
Approaches required to secure adequate levels of financing for sustainable health
systems vary between countries. In many of the poorest countries, additional financing
from community sources and international donors is required to support essential health
system functions, particularly those that benefit poor people. In middle-income
countries, ensuring that a large share of financing derives from a pre-paid source of
revenue improves the chances of achieving equitable and efficient health services. In
high-income countries, increased health care costs may not yield health gains. In all
countries, containment measures should be considered in order to maximize cost
effectiveness. All countries are encouraged to improve their analytical capabilities to
allow a more equitable and efficient use of financial resources.
All countries are
encouraged to improve
their analytical
capabilities to allow a
more equitable and
efficient use of financial
resources.
100. In an equitable health care system, there would be universal access to an
adequate level of care throughout the life span. Over time, the State would be able to
expand and improve the level of care made available. The costs of ensuring access to
essential health care, as well as the effects of rationing, will be distributed fairly across
the population, according to need. However, shifting health care costs from the public
sector to individuals and families should be done with caution. Solidarity-based financial
mechanisms and insurance systems can be used to advance equity by ensuring that the
sick and the poor are supported by the healthy and employed members of society.
These approaches should be designed to secure investment in health and social services
for future generations.
The costs of ensuring
access to essential health
care, as well as the effects
of rationing, will be
distributed fairly across
the population.
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Chapter 8. Keys to successful implementation
of Health for All in the 21 st century
Chapter 8 describes the progress from policy to action, a deliberative and
consensus-building process through which the ideals of policy will be translated
into concrete achievements by countries. The process starts with an assessment
and identification of core values, goals and targets, followed by the development
of policy options, decisions and actions, and finally, by evaluation. Keys to
successful implementation are good governance, a mechanism for setting
priorities, strong partnerships and evaluation.
Strengthening capacity for policy-making
Progress from policy to
action requires dynamic
leadership.
Governments need to
have a strong policymaking capacity to
address the major
challenges confronting
them.
Ethical considerations
must guide the use of
scientific evidence.
101. Progress from policy to action requires dynamic leadership, public participation
and support, a clear sense of purpose and resources. Translation of the HFA policies
into action must be considered in the context of the overall economic and social
situation of a country or locality; the decisions needed are not easy, given the multiple
pressures and uncertainties of a complex policy environment. Each country will select
the best mix of policies to achieve Health for All. The mix will vary according to
national needs, capacities and priorities.
102. Governments need to have a strong policy-making capacity to address the major
challenges confronting them. They will have to overcome several obstacles to the
implementation of their policies. In many countries, health personnel are able to
conceptualize policy, but cannot translate it into action. Governments need to develop
strategic management expertise, minimize outmoded bureaucratic procedures and
rules, and establish a legislative and regulatory framework that provides a sound basis
for reform. Above all, they must develop a supportive organizational culture that
encourages health workers to innovate and move steadily towards clearly defined policy
goals and targets. More attention must be given to policy analysis, particularly as it
relates to intersectoral action, to ensure that the policies of different sectors are aligned
for health. Decisions should be assessed for their short-, medium-, and long-term
implications, with the ultimate goal of achieving sustainable outcomes. Public support
for policies that will yield long-term benefit is strengthened when health improves
perceptibly in the short term.
103. For policy to be based on scientific evidence, a solid research base in health and
epidemiology is needed, together with related information on public preferences as well
as on the availability of resources. This requires the strengthening of the scientific and
technological infrastructure (particularly in developing countries), the promotion of
health policy and systems research, and methodological innovation in measurement,
analytical techniques and resource allocation models. Ethical considerations must guide
the use of scientific evidence.
Good governance
Governance is the system
through which society
organizes and manages
the affairs of diverse
sectors and partners in
order to achieve its goals.
104. Health for All depends on the will and action of diverse sectors and partners at all
levels. Governance is the system through which society organizes and manages the
affairs of these sectors and partners in order to achieve its goals. Only with the
collaboration of the many interests and sectors that have an impact on health can the
HFA vision be realized. The participation of civil society, particularly nongovernmental
organizations, increases the likelihood that all those responsible for health will assume
ownership and accept accountability for their actions.
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105. Hallmarks of good governance for health - at all levels - are transparency,
accountability, and incentives that promote participation. Good governance will result in
the promotion and maintenance of peace and stability between and within countries conditions that are essential for health. With good governance, criteria used for
decision-making, from priority-setting to allocation of resources, are made public and the
results of monitoring and evaluation of implementation are widely distributed. Within
such a system, each contributor's role and responsibilities need to be acknowledged.
106. National governments have an obligation to ensure that health is explicitly
considered in the development of public policy (see Box 11). Decentralized decision
making for health, within a broad development framework in which partnerships in the
provision of services are encouraged, will help to ensure that local needs are considered.
Local participatory planning, full use of local capacity and resources, and more effective
collaboration in bringing environmental, social and economic services closer to people
will strengthen community ownership of those services and increase their utilization.
Good local governance of health systems, supported by national, regional, and global
action, will promote healthy living and working conditions, as well as access to health
care throughout the life span. To succeed, those involved in local governance must be
trained in managerial skills.
107. International and foreign policy must be broader-based, with greater emphasis on
international health security and its contribution to sustainable peace. Foreign policies
should include public health approaches to disease prevention and health promotion.
Policy should acknowledge and address threats to human security, including the health
consequences of the abuse of human rights; transnational threats of disease; trade in
products and technologies harmful to health; environmental degradation; health and
economic disparities between and within countries; migration; and population growth.
Countries must collaborate to develop strategies that ensure sustainable human security.
Local participatory
planning will strengthen
community ownership of
services.
Foreign policies should
include public health
approaches to disease
prevention and health
promotion.
108. Regional economic, political and development alliances, as well as new bilateral
and multilateral bodies, should be formed with a view to creating new opportunities for
regional governance for health. Cooperation between countries at similar levels of
economic development will allow a common approach. It will be important to ensure
that policies and actions are targeted at the level at which they can be of greatest benefit
to health.
Setting priorities for action
109. There are a wide range of strategies available to improve health, but resources are
limited. This means that governments must set boundaries for action and select priorities
within those boundaries. The process of setting priorities will differ according to whether
the choices relate to national, local or individual levels. Five possible levels of financial
decision-making for health systems are:
• macro-level of funding for health systems and services;
• distribution of the budget between different geographical areas and services;
• allocation of resources to particular forms of treatment;
• choices concerning which patients should receive treatment;
• decisions on how much to spend on individual patients.
Setting priorities to make health central to human development is complex and requires
careful consideration at the highest levels of government. In doing so, a socially caring
government will emphasize the long-term needs of people, especially those of the poor
and women.
42
As resources are limited,
governments need to set
boundaries for action,
and select priorities
within those boundaries.
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Box 11
ROLE OF GOVERNMENTS IN IMPLEMENTING HFA
Demonstrate commitment to underlying values:
* develop policies that support HFA;
♦
advocate Health for All;
♦ implement international instruments that promote and protect health;
♦ strengthen national capacity to ensure ethical standards in health and
health care;
♦
incorporate equity and gender considerations into health and development
policies;
* promote good governance for health;
♦
facilitate the development of partnerships for health.
Make health central to human development:
*
*
*
*
*
ensure that economic policies promote health;
invest in health and education systems and services;
combat poverty through multisectoral and targeted programmes;
align government policies in all sectors to promote health;
require environmental- and health-impact assessments for development
projects.
Build sustainable health systems:
♦
implement an effective legal and regulatory framework for HFA;
ensure equal access to essential quality care across the life span;
implement national and local surveillance and monitoring systems;
ensure that major endemic diseases are controlled;
exert efforts to eradicate or eliminate selected diseases;
invest in health-related science and technology;
* ensure that institutional and human capacity for public health and health
care is developed and maintained;
* secure adequate and sustainable financing for health systems.
*
*
*
*
*
110. Technical considerations, particularly the health situation and the needs of
populations, must be taken into account in setting priorities. Priorities for action in a
given population will be determined by the relative importance of the different health
problems, in terms of: epidemiological measures of the burden of disease or suffering,
the effectiveness (and cost-effectiveness) of interventions to improve health and reduce
inequity, the likely trends in the absence of action, the capacity of the health sector to
act or promote intersectoral action and public support. In addition specific sectoral
contributions as well as financial feasibility and institutional capacity, will need to be
considered.
Priorities should be set
using an open,
consultative approach
involving the public and
key partners for health.
111. Priorities should be set using an open, consultative approach involving the public
and key partners for health. An appreciation of the values that should underpin
decisions will need to be fostered. Regular dialogue and the exchange of views
between the groups will lead to the development of a shared understanding of the
major problems and options for action. The views of marginalized groups, patients and
disabled people are essential if equitable and sustainable policies are to be developed.
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Priorities should be reviewed regularly. The role of governments is important in
facilitating this process. A well-defined policy and solid analytical capabilities are
required to ensure that national needs take precedence when negotiating with
international donors.
Partnerships for health
112. The growing pluralism affecting the governance of the health sector is evident.
Partnerships are needed between the multiple levels and sectors concerned with health,
and will be a primary component of HFA implementation. Productive partnerships will
enable different ideologies, cultures and talents to come together in a way that creates
energy and stimulates the imagination in working towards improved health. Working in
partnership involves defining roles, demonstrating accountability, critically assessing the
impact of joint actions, and above all, developing trust.
113. Community partnerships and the development of skills, with the aim of increasing
both the options available to individuals and countries, and the control they exercise
over those options, constitute the essence of HFA. Partnerships between people and
institutions at all levels allow for the sharing of the experience, expertise and resources
necessary for the attainment of Health for All. The need for community participation
was stressed at Alma-Ata. People's direct and indirect participation in the promotion
and maintenance of their health, and that of their families and communities, lies at the
core of people-centred approaches to development. Such approaches require the
implementation of sustainable development programmes, based on self-reliance, that are
managed and owned by the community. Increased commitment by all is urgently
needed to ensure full implementation.
114. Governments should aim to create an environment that stimulates and facilitates
partnerships for health. Both formal partnerships and community-based informal
networks at different levels are needed. WHO and governments should consider
developing guidelines with the private sector, aimed at ensuring that new partnerships
are mutually beneficial and always benefit health. Partnerships can draw upon the
energy and vitality of civil society, particularly nongovernmental organizations, to
develop environments that support health. Informal networks are important, but are
often absent in areas undergoing rapid urbanization or migration, in refugee
communities and in post-conflict situations. Establishment (or re-establishment) of
cultural, sports, religious and women's groups through a system of local governance can
enhance social cohesion and a social environment conducive to health.
Productive partnerships
will enable different
ideologies, cultures and
talents to come together
in a way that creates
energy and stimulates
imagination.
People's direct and
indirect participation lies
at the core of peoplecentred approaches to
development.
Both formal partnerships
and community-based
informal networks at
different levels are
needed.
Global action in support of national health
115. Regional, national, and local action in isolation cannot ensure that the highest
level of health can be universally attained, or that inequities in health are reduced.
Global action and cooperation between countries are also necessary. This action should
aim at securing the benefits of globalization for the health of all on an equitable basis
and at preventing or minimizing threats. For this to be successful, the full mobilization
and support of international and intergovernmental organizations involved in health and
development for HFA will be decisive. Priorities for global action will be directed
towards addressing:
• the global burden of preventable disease;
44
Global action should aim
at securing the benefits of
globalization for the
health of all on an
equitable basis.
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• the increasing disease burden, particularly in the poorest countries and
communities;
• global diseases and health problems that transcend national borders, and for
which there are known health-sector or intersectoral solutions that require
transnational approaches;
• situations where the performance of public health functions is hampered by
natural or man-made disasters (including conflict) or where the institutional
and human capacity for action remains weak.
Global public health
action must be universally
relevant.
116. Global public health action must be universally relevant, constituting a global
public health good. While the benefit to an individual country may be low, the overall
benefit is high. Such global public health action includes active surveillance, support for
research on poverty and health, and development of global ethical and scientific norms
and standards. It includes the prevention, control, eradication or elimination of diseases
and their risk factors that constitute transnational threats to health and are amenable to
interventions. In addition, liberalization of trade calls for greater compatibility in policy
objectives to be developed between international and intergovernmental agencies and
multinationals involved in trade and health.
Evaluation and monitoring
Evaluation is a critical
management tool and the
basis for shaping new
policies and programmes.
117. Evaluation is a critical management tool to assess the value of a programme,
based on measurement of programme performance against objectives. As the basis for
shaping new policies and programmes, evaluation must be tied to policy analysis and
recommendations. Evaluation should play a key role in strengthening the policy
process, and should serve as the ultimate test of the success of policies. Policies will be
revised every 10 years, based on the evaluation of global progress towards achieving
HFA. The process of evaluation should be integrated with goal-setting and the
development of targets and indicators.
118. National and local targets based on HFA policy should reflect country situations
and priorities. Evaluation and monitoring systems, enhanced by communication and
information technologies, will determine whether objectives are being met and which
ones require extra attention. They will also assess their level of impact and contribute
to the development of new approaches, using existing resources, that will be of greatest
benefit. The aim will be to provide the information needed to assess policy impact at
all levels. Explicit attention will be given to evaluating the extent to which HFA values
have been incorporated into strategies at all levels.
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ANNEX A
Explanatory remarks about
global health targets
Global health targets
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Health equity: childhood stunting
Survival: MMR, CMR, life expectancy
Reverse global trends of five major pandemics
Eradicate and eliminate certain diseases
Improve access to water, sanitation, food and shelter
Measures to promote health
Develop, implement and monitor national HFA policies
Improve access to comprehensive essential, quality health care
Implement global and national health information and surveillance systems
Support research for health
General remarks
*
Health information systems should report on all relevant subgroups of the population, disaggregating data
according to age, socioeconomic class, sex, race/ethnicity, geographical location and health status.
*
Indicators should be developed and used at appropriate levels of the health system to measure progress
towards the achievement of the targets.
*
The achievement of all targets requires strong collaborative actions at all levels by many partners for health.
The mix of partners and their individual contributions will vary.
Specific remarks
Target 1: By 2005, health equity indices will be used within and between countries as a basis for
promoting and monitoring equity in health. Initially, equity will be assessed on the basis of a measure of
child growth.
*
The initial quantitative target utilized for equity will be: the percentage of children under five years who are
stunted1 should be less than 20% in all countries and in all specific subgroups within countries by the year
2020.
1 Defined as height-for-age more than two standard deviations below the reference value.
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Annex A
♦
Linear growth retardation has been recommended by the WHO Expert Committee on Physical Status: the
Use and Interpretation of Anthropometry1 as an ideal indicator for determining priorities for allocation of
resources to improve equity in health care.
♦
The best indicator for monitoring child growth is height-for-age, because it measures cumulative deficient
growth associated with long-term factors, including chronic insufficient daily food intake, frequent infection,
poor feeding practices, and possibly, the low socioeconomic status of households.
*
On the basis of current trends and levels (38% in developing countries and 34% in the world), the global
target of 20% of under-five-year-olds is achievable. However, in consideration of the different contexts at
the regional, national and local levels, countries are encouraged to set their own targets.
*
It is recommended that a clear distinction be made between formulating an equity target with a given
indicator and a generic target. The following example illustrates what is meant by a generic and an equity
target for child mortality rate:
• a generic target; by the year
z reduce child mortality rate to x% (refers to overall, aggregate);
• equity target; by the year
, reduce child mortality to x% overall and reduce the disparities in child
mortality between the highest and the lowest income quintiles by z%.
Target 2: By 2020, the targets agreed at world conferences for maternal mortality rates (MMR), under
five or child mortality rates (CMR), and life expectancy will be met.
*
The quantitative targets for MMR, CMR and life expectancy, in line with targets set at recent world
conferences, are: MMR - less than 100 per 100 000 live births; CMR - less than 45 per 1000 live births;
life expectancy at birth - over 70 years for all countries.
*
In setting a target of CMR less than 45 per 1000 live births, the health community undertakes to give priority
to providing resources to IMG (integrated management of childhood illness), and to ensure that
interventions that are now available, affordable and known to be effective are fully implemented in all
countries. This approach would reduce the impact of the five major causes of death in children: acute
respiratory infection, diarrhoea, malaria, measles and malnutrition.
*
Current trends for MMR, CMR and life expectancy suggest that the targets set are achievable in a global
context. However, regions and countries are encouraged to set their own targets.
♦
Infant, neonatal and adult mortality rates may be considered optional indicators. The infant mortality rate
(IMR) is widely monitored and provides additional information on survival in early childhood.
*
The maternal mortality rate is a particularly sensitive indicator of the performance of health systems. A
reduction in maternal deaths depends upon functioning links between primary health care services and
referral centres, as well as the availability of midwifery skills throughout the health system.
1 WHO Technical Report Series, No. 854, 1995.
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Annex A
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Target 3: By 2020, the worldwide burden of disease will be substantially decreased. This will be
achieved by implementation of sound disease-control programmes aimed at reversing the current trends of
increasing incidence and disability caused by tuberculosis, HIV/AIDS, malaria, tobacco-related diseases and
violence/trauma.
*
This target highlights the importance of addressing five pandemics, which are cumulatively responsible for
over 20% of all deaths. Effective control programmes based on current knowledge, often requiring
intersectoral action, can reverse the rising trends and significantly reduce the impact on health.
*
The impact will be quantified in terms of both premature death and disability.
*
Although these diseases have a global impact, regions and countries may want to give particular attention to
certain aspects and are encouraged to set targets for these.
*
Specific indicators will be set at all levels of action. These may include:
• tuberculosis: disease-specific mortality, morbidity, notification rate, cure rate, countries implementing
DOTS;
• HIV/AIDS: disease-specific mortality, morbidity;
• malaria: disease-specific mortality, morbidity;
• tobacco-related diseases: mortality, morbidity, the percentage of smokers in certain age categories;
• violence/trauma: mortality, morbidity, disability.
Target 4: Measles will be eradicated by 2020; lymphatic filariasis will be eliminated by the year 2020;
transmission of Chagas disease will be interrupted by 2010; leprosy will be eliminated by 2010; and
trachoma will be eliminated by 2020. In addition, vitamin A and iodine deficiencies will be eliminated
before 2020.
*
It is expected that by the year 2000 poliomyelitis will have been eradicated, and that by the year 2005 the
transmission of dracunculiasis will have been interrupted. Post-eradication surveillance and further
measures of certification will continue after the year 2000. Specific targets for a number of diseases are
given in paragraph 38 of this document.
*
The main focus of the elimination of leprosy will be at the district level, i.e., to have a prevalence rate of
below one per 10 000 in each district.
Target 5: By 2020, all countries, through intersectoral action, will have made major progress in making
available safe drinking-water, adequate sanitation, food and shelter in sufficient quantity and quality.
Specific indicators will be set, such as:
• proportion of households/people with regular access to sufficient and safe drinking-water;
• proportion of households/people with adequate sanitation facilities;
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Annex A
• proportion of households/people living in shelter that is structurally safe and sited on safe land;
• proportion of households/people with access to sufficient and safe food.
Target 6: By 2020, all countries will have introduced, and be actively managing and monitoring,
strategies that strengthen health-enhancing lifestyles and weaken health-damaging ones, through a
combination of regulatory, economic, educational, organizational and community-based programmes.
♦
This target builds on the Ottawa and Jakarta Charters concerning healthy public policy, supportive
environments, community action, personal skills and health services. It reflects the importance of acting on
the underlying personal, social and economic determinants of health and disease.
*
Indicators will be used that relate to health-enhancing lifestyles (for example physical activity, nutrition,
personal relationships) and health-damaging ones, such as substance use, violence and unsafe sex.
Monitoring will be focused on changes in:
*
(1)
health behaviour (e.g. smoking prevalence in different social groups);
(2)
health determinants (e.g. healthy food supply, social isolation);
(3)
regulatory, fiscal, economic and environmental policy (e.g. regarding alcohol restriction);
(4)
capacity-building programmes (e.g. health promotion, infrastructure, information, leadership
development);
(5)
participation (e.g. individuals, communities, schools, workplaces, media and other sectors).
In addition, selected "tracer" studies will be used for monitoring and evaluating this target, with a special
focus on equity and access issues.
Target 7: By 2005, all Member States will have operational mechanisms for developing, implementing
and monitoring policies that are consistent with this HFA policy.
*
The national HFA policies will incorporate the values of HFA: the enjoyment of the highest attainable
standard of health as a fundamental human right, equity and solidarity, ethics and gender sensitivity.
*
The policies should be developed in an open and participatory way: be reflected in the allocation of
resources; and be implemented through a coherent institutional and legal framework.
♦
Indicators should be applied to measure:
• the quality of community involvement in development of the policy;
• the existence of a policy as reflected in terms of national legislation;
resource allocation in line with the policy;
• technical cooperation;
• sustainability of policy/resource allocation.
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Annex A
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Target 8: By 2010, all people will have access throughout their lives to comprehensive, essential, quality
health care, supported by essential public health functions.
♦
*
♦
Comprehensive essential care should comprise, as a minimum, the elements defined in PHC as adapted to
emerging needs and new opportunities for sustainable health care. The sustainability, affordability and
quality of such care are underpinned by essential public health functions (see Box 2).
This target acknowledges the notion of a life-span approach. Factors early in life, or even before birth, can
have a lasting impact on the health of people.
Indicators of the quality of care, including its accessibility, effectiveness, utilization and the degree of
integration into a broader referral system, and performance indicators for essential public health functions
will be developed.
Target 9: By 2010, appropriate global and national health information, surveillance and alert systems will
be established.
♦
*
Health information systems should enable countries to monitor and evaluate their health situation, the
performance of their services and the impact of their policies. These systems are the basis for surveillance
and decision-making.
Emphasis will be given to developing systems to collect data of use at the local level. Further, decisions
about the extent of data collected will take into account the capacity of the local level to analyse, interpret
and use data for decision-making. These considerations need to be balanced against the data requirements
at national and global levels.
♦
Health information systems should generate data in areas such as drug availability, food safety, quality
assessment, auditing, financial administration and technology assessment.
*
Appropriate global and national surveillance and alert systems, supported by the use of communications
technology, will permit rapid and wide dissemination of information about current and impending local,
national, regional and transnational threats to health. The target also emphasizes the importance of an
adequate response to such threats.
Target 10: By 2010, research policies and institutional mechanisms will be operational at global,
regional and country level.
♦
Research policies and institutional mechanisms should support capacity-building, innovation in research,
partnerships between stakeholders and science-based decision-making, and should explicitly include ethical
review processes.
*
All countries need to define their research priorities, ensure that research is funded and managed, that
ethical principles are applied, and that capacity development is supported. Specific indicators will be
developed relevant to these issues.
*
A global indicator will be developed to monitor trends in expenditure on health research between countries
and areas of concentration.
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ANNEX B
Selected targets related to development
and poverty endorsed at world conferences
in the 1990s
i.
Economic well-being: The proportion of people living in absolute poverty in developing countries should be
reduced by at least one-half by 2015.
2.
Social development: There should be substantial progress in primary education, gender equality, basic
health care and family planning, as follows:
3.
(a)
There should be universal primary education in all countries by 2015.
(b)
Progress toward gender equality and the empowerment of women should be demonstrated by the
elimination of gender disparity in primary and secondary education by 2005.
(c)
The death rate for infants and children under the age of five years should be reduced in each
developing country by two-thirds the 1990 level by 2015. The rate of maternal mortality should be
reduced by three-fourths during this same period.
(d)
All individuals of appropriate ages should have access through the primary health care system to
reproductive health services (including safe and reliable family planning methods), as soon as possible
and no later than the year 2015.
Environmental sustainability and regeneration: There should be a national strategy for sustainable
development being implemented in every country by 2005. This is necessary to ensure that current trends
in environmental degradation and the loss of natural resources - forests, fisheries, fresh water, climate, soils,
biodiversity, stratospheric ozone, the accumulation of hazardous substances and other major indicators - are
reversed, at both global and national levels, by 2015.
_______
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ANNEX C
Further reading
Ad Hoc Committee on Health Research Relating to Future Intervention Options. Investing in health research and
development. Geneva, World Health Organization, 1996 (Document TDR/GEN/96.1).
Commission on Population and Quality of Life. Caring of the future: making the next decades provide a life worth
living. Report of the Commission on Population and Quality of Life. New York, Oxford University Press, 1996.
De Ferranti D, Feachem RGA, Preker AS. Sector strategy paper: Health, nutrition and population. World Bank,
Washington, D.C., June 1997.
ECOSOC. Mainstreaming the gender perspective into all policies and programmes of the United Nations system
(Document E/1997/L.30 dated 14 July 1997).
Global Advisory Committee on Health Research. Research policy agenda: science and technology in support of
global health development. Presented to ACHR, Geneva, World Health Organization, October 1997 (Document
ACHR35/97.13).
Murray CJL, Lopez AD, ed. The global burden of disease: a comprehensive assessment of mortality and disability
from diseases, injuries, and risk factors in 1990 and projected to 2020. Published by the Harvard School of Public
Health on behalf of the World Health Organization and the World Bank. Cambridge, MA, 1996.
Our planet, our health. Report of the WHO Commission on Health and Environment. Geneva, World Health
Organization, 1992.
Reports on the WHO Working Groups on Health for All: Essential public health functions; Technology for health for
the future; Health status and determinants; Partnerships for health; Human resources for health in the 21st
century. Geneva, World Health Organization, 1997 (Unpublished WHO documents).
Tarimo E, Webster EG. Primary health care concepts and challenges in a changing world. Alma-Ata revisited.
Geneva, World Health Organization, 1997 (Current Concerns ARA paper number 7, document
WHO/ARA/CC/97.1).
United Nations Development Programme. Human development report, 1996. Oxford University Press,
New York, 1996.
United Nations Development Programme. Human development report, 1997. Oxford University Press,
New York, 1997.
WHO. A new global health policy for the twenty-first century: an NGO perspective. Outcome of a formal
consultation with nongovernmental organizations held at WHO, Geneva, 2 and 3 May 1997. Geneva, World
Health Organization, 1997 (Document WHO/PPE/PAC/97.3).
WHO Advisory Committee on Health Research. Development of a research agenda for science and technology to
support the Health for All strategy. Geneva, World Health Organization, 1997 (Document ACHR35/97.13).
52
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Annex C
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WHO. Alma-Ata 1978: primary health care. Geneva, World Health Organization, 1978.
WHO Constitution. In: Basic documents, 41st ed. Geneva, World Health Organization, 1996.
WHO. Equity in health and health care: A WHO/SIDA initiative. Geneva, World Health Organization, 1996
(Document WHO/ARA/96.1).
X
I
WHO. Formulating strategies for health for all by the year 2000. Geneva, World Health Organization, 1979.
WHO. Global Strategy for Health for All by the Year 2000. Geneva, World Health Organization, 1981.
WHO. Health and environment in sustainable development. Five years after the Earth Summit. Geneva, World
Health Organization, 1997 (Document WHO/EHG/97.8).
WHO. Interagency Consultation on the New Global Health Policy. Geneva, 9-10 July 1997. Summary Report.
Geneva, World Health Organization, 1997 (Document WHO/PPE/PAC/97.4).
WHO. Intersectoral action for health: addressing concerns in sustainable development. Geneva, World Health
Organization, 1997 (Document WHO/PPE/PAC/97.1).
WHO. Intersectoral action for health: a cornerstone for health-for-all in the twenty-first century. Report of the
International Conference, 20-23 April 1997 Halifax, Nova Scotia, Canada.
WHO. New challenges for public health. Report of an interregional meeting, Geneva, 27-30 November 1995.
Geneva, World Health Organization, 1996.
WHO. Renewing the Health-for-AlI Strategy: elaboration of a policy for equity, solidarity and health. Geneva,
World Health Organization, 1995 (Document WHO/PPE/95.1).
WHO. Resolution WHA37.13. The spiritual dimension in the Global Strategy for Health for All by the Year 2000
(In document WHA37/1984/REC/1, p. 6).
WHO. The African Economic Community: a framework for action by WHO. Geneva, World Health Organization,
1995 (Document WHO/INA/95.2).
WHO. The Jakarta Declaration on Leading Health Promotion into the 21st Century. Adopted at the Fourth
International Conference on Health Promotion. Jakarta, Indonesia, 21-25 July 1997. Geneva, World Health
Organization, 1997 (Document WHO/HPR/HEP/4ICHP/BR/97.4).
WHO. The world health report 1995: bridging the gaps. Geneva, World Health Organization, 1995.
WHO. The world health report 1996: fighting disease, fostering development. Geneva, World Health
Organization, 1996.
*
WHO. The world health report 1997: conquering suffering, enriching humanity. Geneva, World Health
Organization, 1997.
WHO. Think and act globally and intersectorally to protect national health. Geneva, World Health Organization,
1997 (Document WHO/PPE/PAC/97.2).
WHO. WHO Global Partnerships Initiatives for Health Development. Geneva, World Health Organization, 1997
(Document WHO/INA/97.2).
WHO. WHO/World Bank Partnership: recommendations for action for health development. Geneva, World
Health Organization, 1995 (Document WHO/INA/95.1).
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ANNEX D
Acronyms
?
I
AIDS
ACQUIRED IMMUNODEFICIENCY SYNDROME
CMR
CHILD MORALITY RATE
DOTS
DIRECTLY OBSERVED TREATMENT, SHORT COURSE (FOR TUBERCULOSIS)
EB
EXECUTIVE BOARD (OF THE WORLD HEALTH ORGANIZATION)
ECOSOC
ECONOMIC AND SOCIAL COUNCIL (OF THE UNITED NATIONS)
HFA
HEALTH FOR ALL
HIV
HUMAN IMMUNODEFICIENCY VIRUS
LDCs
LEAST DEVELOPED COUNTRIES
MMR
MATERNAL MORTALITY RATE
NGO
NONGOVERNMENTAL ORGANIZATION
PHC
PRIMARY HEALTH CARE
UNICEF
UNITED NATIONS CHILDREN'S FUND
WHA
WORLD HEALTH ASSEMBLY
WHO
WORLD HEALTH ORGANIZATION
■
b
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