Globally, there has been in recent years some improvement in the world’s health. . . . Yet a new-born child in some African countries has only a 50–50 chance of surviving through adolescence, four-fifths of the world’s population have no access to any permanent form of health care and only one in three persons in developing countries has reasonable access to safe water and adequate sanitation. . . .
THE IMPERATIVE FOR CHANGE
The scope for improving the human condition is therefore great and the action required is urgent. . . . Nations cannot extend their existing health services to cover the entire population at a price they can afford. Health for all, therefore, remains a dream, and it will remain so as long as the dream is formulated in purely technocratic terms—drugs, nurses, vaccines, hospitals, doctors, and X-ray equipment. If the dream is to be turned into a reality, existing health care strategies will have to be vigorously transformed. . . .
Firstly, there are too few resources being invested in the health sector. The public health services of the 67 poorest developing countries, excluding China, spend less in total than the rich countries spend on tranquilizers. The total expenditure on health services in the Third World, including China and including the private health sector, is just over half the sum that the world spends every year on cigarettes. . . . The 2%–3% of GNP that most developing countries spend on health care, represents as little as $4–6 per capita. If these countries were to increase their health spending in real terms by as much as 10% per annum, in the year 2000 they would still be spending only about US $40 per capita, or less than 5% of the amount spent in the USA in 1979–80.
Secondly, the few resources that are available are usually spent on meeting the needs of only 10%–15% of the population.
Thirdly, the richer countries are attracting doctors from the poorer ones. Over three-quarters of the world’s migrant physicians can be found in just five countries—Australia, Canada, the Federal Republic of Germany, the United Kingdom, and the USA. Though it is 8 times more expensive to train a physician than a medical auxiliary, many countries still continue to stress the training of the former. . . .
WHAT IS “HEALTH FOR ALL”?
“Health for all” means that health is to be brought within reach of everyone in a given country. And by “health” is meant a personal state of wellbeing, not just the availability of health services—a state of health that enables a person to lead a socially and economically productive life. “Health for all” implies the removal of the obstacles to health—that is to say, the elimination of malnutrition, ignorance, contaminated drinking-water, and unhygienic housing—quite as much as it does the solution of purely medical problems such as a lack of doctors, hospital beds, drugs and vaccines.
“Health for all” means that health should be regarded as an objective of economic development and not merely as one of the means of attaining it. . . .
“Health for all” depends on continued progress in medical care and public health. The health services must be accessible to all through primary health care, in which basic medical help is available in every village, backed up by referral services to more specialized care. Immunization must similarly achieve universal coverage.
“Health for all” is thus a holistic concept calling for efforts in agriculture, industry, education, housing, and communications, just as much as in medicine and public health. Medical care alone cannot bring health to hungry people living in hovels. Health for such people requires a whole new way of life and fresh opportunities to provide themselves with a higher standard of living. . . .
THE MULTISECTORAL APPROACH
Health does not exist in isolation. It is influenced by a complex of environmental, social, and economic factors ultimately related to each other. The health of the poor is largely the result of a combination of unemployment (and underemployment), poverty, a low level of education, poor housing, poor sanitation, malnutrition, and lack of the will and initiative to make changes for the better. It would be unrealistic to expect any substantial health improvements in these populations unless these constraints are first removed or alleviated.
Thus health management has to be considered along with such things as producing more or better food, improving irrigation, and marketing products. Even where infant mortality is high, diarrheal and respiratory diseases rampant, and no organized health service available, health and disease may come low on the list of perceived needs, following an equitable system of laws, land tenure reforms, improved agricultural production and marketing, family planning programs, good nutrition, and health education. . . . Action undertaken outside the health sector can have health effects much greater than those obtained within it. . . .
COMMUNITY INVOLVEMENT
. . . The approach that is being adopted to attain health for all is based on the fundamental understanding that it is there, where people live and work, that health is made or broken. People must therefore understand what health is all about, and it is the duty of those who know to help others to understand. . . . But to gain such an understanding a minimum level of health is essential. So health and social awareness must go hand in hand, the one leading to the other and each progressively reinforcing the other. The process briefly described is known as community involvement. . . .
REORIENTATION OF EXISTING HEALTH SYSTEMS
These, then, are the absolute prerequisites to reach health for all by the year 2000: multisectoral approach, community involvement, appropriate health technology, and total health services coverage, including the remotest parts of the country and the poorest members of society. . . .
COOPERATION NOT CONFRONTATION
The goal of health for all was certainly originated in a climate of political optimism, and that was only a few years ago. At that time there was still a feeling that in spite of ideological differences, in spite of economic enigmas, somehow our world was muddling its way out of an impasse and was going to substitute cooperation for confrontation. Now we can detect unmistakable signs that this is beginning to change, and the world is once again tending to become divided. But we have to continue to find points of cooperation even in areas of confrontation. All the actors in the existing health drama—the governments of the North and the governments of the South, their medical, scientific, and industrial establishments, and the international health bureaucracy—will have to work hard toward reducing the areas of friction and enlarging the areas of cooperation. . . .
Halfdan Mahler (1923–Present). Photo printed with the permission of the World Health Organization/Erling Mandelmann/1980.
If we want a system which is accessible to all members of the community, which is concerned with the promotion of health in the whole community, and in which major decisions concerning health are taken and implemented by the community, the doctor will have to become only one component of a team whose every member does what he or she has been trained for and which is oriented toward identifying and solving the priority health problems of the community. . . .
THE SCIENTIFIC COMMUNITY
To achieve our world health target, we shall have to work closely with the scientific community. Scientists are becoming concerned about social relevance and social equity. There is growing disillusion with research that leads not to action but to the need for further research. Take the one million children dying every year in Africa from tropical malaria. It is possible to mobilize enough social commitment among those involved in health research to say that this cannot be tolerated when we have such fantastic scientific tools at our disposal, but many of these tools need sharpening and in this the scientific community has an essential role to play. . . . We have started to strengthen biomedical research capabilities in the developing countries. . . . To be really useful their work must be oriented to practical problem-solving. . . .
THE CONFRONTATION WITH INDUSTRY
The confrontations with industry are the most difficult to resolve. The pharmaceutical industry, the infant foods industry, the tobacco industry, the medical equipment industry—all affect the health of the people, whether negatively or positively or in both ways.
. . . Look, for instance, at drugs. Developing countries found it very difficult to formulate national drug policies because of the resistance of the medical specialists or the general physicians, who were often influenced by the international drug industry. . . . Essential drugs, which can cope with the overwhelming majority of the problems even in relatively sophisticated societies, number around 200. But for the villager and urban slum dweller great miracles can be achieved with fewer than 30 well-chosen drugs. Without these drugs the primary health care program cannot work. . . .
We shall undoubtedly have to face many political problems. Some of them will derive from commercial and professional interests, where they are touched, for example, by the generation of appropriate technology for health, by the adoption of drug policies aimed at providing essential drugs for all and establishing drug industries in developing countries, and by the preferential production of vaccines in certain countries on behalf of the region concerned. Most of all, there will be the political pressures deriving from any attempt to change a planning process from one that aims to meet the needs of a few into one that aims to meet the needs of all. . . .
IS “HEALTH 2000” REALISTIC?
How much will it cost? Are the costs exorbitant? Recent small-scale studies in developing countries have shown that considerable improvements in people’s health can take place for an extra expenditure of as little as 0.5–2% of the per capita gross national product—or what amounts to a few dollars a year. This is by any standard a reasonable cost—a hundredth of what is spent on health by people in many rich countries. So cost factors should not hinder governments when they consider their plans for meeting their commitment to the target of health for all by the year 2000. . . .
Change is coming and I am sure we shall succeed. We must succeed. The children of today, and those who have not yet been born but will comprise more than a third of the people living in the year 2000, will never forgive us if we do not.