WHO's World Health Report 2003

The overall message of this year's World Health Report, “Shaping the future,” from the World Health Organization is clear. Strengthen health systems, otherwise there will be no progress in meeting a vast and growing array of health inequalities. Furthermore, the report says firmly that strengthened health systems must be based on primary health care. “Shaping the future” is actually about going back to basics.

Justice is seen as both a moral imperative and an aspect of wise security. The message of the new director general, Dr Lee Jong-wook contrasts the injustice of parts of the world where there are expectations of longer and more comfortable lives, with other parts where there is despair over the failure to control disease, even though the means to do so exist. A child in Japan can not only expect to get reasonable access to health care throughout her life, but also to receive medicines worth, on average, $550 (£312; €443) per year (and more if necessary). In contrast, a child in Sierra Leone—if she survives the diseases of childhood—will have little access to treatment for illness and will receive, on average, medicines worth about $3 per year.¹

These inequalities must be confronted by strengthening health systems, building on the values and practices of primary health care, the core principles of which remain as relevant in 2003 as they did at Alma Ata in 1978: universal access to care and coverage on the basis of need; commitment to health equity; community participation; and intersectoral collaboration.² This is no rhetorical or nostalgic journey back to the 1970s, but a restatement of enduring principles in a very changed and much more complex environment. The many references to partnership in the report show that WHO is well aware that it is no longer the only player in health, but must collaborate with others. Many will welcome this return to basics and will agree with the thrust of the report: that there is no point in throwing masses of funds at diseases such as HIV/AIDS, tuberculosis, and malaria without paying close attention to the health systems that will deliver the interventions that will impact on those diseases.

The report is refreshing in its attempt to offer an integrated approach to improving health. Three chapters focus on particular diseases, but emphasise how health systems will play a part in meeting overall health goals. Although it does not evade the urgent need to confront the havoc caused by HIV/AIDS, and reminds readers of WHO's own “3 by 5” commitment (getting 3 million people onto antiretroviral therapy by the year 2005) the report keeps coming back to the health systems that will deliver the necessary prevention and treatment. It gives examples of countries such as Brazil where prevention and care have been part of a successful approach to HIV/AIDS policy. Universal and free access to HIV care, among other policies, led to a drop of new registered HIV infections from over 17 000 in 2000 to 7361 in 2001.³ Another chapter champions the polio eradication campaign as a disease oriented initiative, which has successfully brought together both public and private groups to immunise 575 million children against polio, reminding us that the encouraging success could be undermined if the last endemic areas of the world are not included, and the funding gap not bridged.⁴,⁵ And just one of the lessons from the SARS epidemic is that weaknesses in health systems, especially in infection control practices, play a key part in permitting emerging infections to spread. The report does not neglect other determinants of health, drawing on three examples—tobacco control policies, road traffic injuries, and cardiovascular disease—to remind us of the need for integrated action across different sectors, to combat these growing threats to health worldwide.

In 2000 the World Health Report was entitled “Health systems: improving performance.” It received a great deal of media coverage, largely because it ranked countries' overall health systems' performance, resulting in some rather surprising league tables, for example, the United States scored highest in terms of responsiveness to expectations of the population. The report was strongly criticised for the criteria used to judge health systems, methods for ranking systems, and shortcomings in the data, although it had some interesting conceptual ideas about stewardship and responsiveness.⁶,⁷ While the 2003 report does not have health systems in its title it draws on notions of responsiveness and stewardship. It asks what needs to be done in order to ensure health systems are able to be responsive to the needs of populations, and how can stewardship steer towards pro-equity health systems. It draws attention to the crisis in the global health workforce—recognising that human resources are the fount of health care, and without them there is no health system. It also acknowledges the importance of information and evidence to inform policy. How heartening it would be to see this World Health Report receiving the high level of attention it deserves—and moving the lens from specific diseases to supporting the health systems which will deliver the interventions.