Introduction

For many reasons, this decade is a time of rethinking many things. There is the impending turn of the millenium, an event packed with meaning. There is recent political history, which has changed the global structure of power in ways few could foresee, and there is an economic fluidity worldwide that makes every day unpredictable and the future uncertain. There are movements of people and surges of violence that seem unparalleled, and well may be. We are awash in change, and people everywhere are trying to understand that and read its implications. It is a time that provokes soul-searching: backward, into the lessons and achievements of the past, and forward, into ways for the future to be better.

The fields of health and social development are no exception. More specifically, events and conditions in the health sector point to the need to rethink some large issues. Nations everywhere are grappling with the economic and ethical dilemmas of achieving and maintaining healthy populations, since these are both cause and consequence of true development. Increasingly, the thinking is global, because there are comparisons to be learned from, connections that have implications, obligations to fulfill, and costs that are somehow shared.

As part of this dynamic, there has been an explosion of analytic documents, published since the start of this decade, that deal mainly, though not exclusively, with health in developing countries. Although these documents have various authors and institutional provenance, and although not all are formally published volumes in the public



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Global Health in Transition: A Synthesis: Perspectives from International Organizations Introduction For many reasons, this decade is a time of rethinking many things. There is the impending turn of the millenium, an event packed with meaning. There is recent political history, which has changed the global structure of power in ways few could foresee, and there is an economic fluidity worldwide that makes every day unpredictable and the future uncertain. There are movements of people and surges of violence that seem unparalleled, and well may be. We are awash in change, and people everywhere are trying to understand that and read its implications. It is a time that provokes soul-searching: backward, into the lessons and achievements of the past, and forward, into ways for the future to be better. The fields of health and social development are no exception. More specifically, events and conditions in the health sector point to the need to rethink some large issues. Nations everywhere are grappling with the economic and ethical dilemmas of achieving and maintaining healthy populations, since these are both cause and consequence of true development. Increasingly, the thinking is global, because there are comparisons to be learned from, connections that have implications, obligations to fulfill, and costs that are somehow shared. As part of this dynamic, there has been an explosion of analytic documents, published since the start of this decade, that deal mainly, though not exclusively, with health in developing countries. Although these documents have various authors and institutional provenance, and although not all are formally published volumes in the public

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Global Health in Transition: A Synthesis: Perspectives from International Organizations domain, they comprise a fair spectrum of opinion about issues of global health, though surely not a complete one. Each document advances understanding of specific challenges to health in the development process, and each raises further questions, explicitly in its content or implicitly by work that it has left undone. Each assesses the current status of the areas of health or social development with which it is most concerned; expands on the ideas and methods its authors wish to advance; proposes strategies; and then reflects on their likely impacts, shortfalls, and policy implications. Each document acknowledges that much more needs to be done to bring key ideas to fruition in terms of developmental effects than is specified in its own strategies. Finally, and importantly, each document intimates that what we have been calling “international health” may need, somehow, to be rethought in a more comprehensive way as “global health.” Two aspects of these documents commanded the attention of the Institute of Medicine's Board on International Health. One was the broad range of constituencies and points of view drawn upon in producing them. The other, all the more striking because of this breadth of representation, was the degree to which the documents appeared to converge on what seemed to us a significant number of goals, values, and principles, as well as on some key development themes. Whether this reflects real and mounting consensus on what is important in health development or whether it is just a coincidental uncovering of related ideas and experiences is an interesting question. More interesting to the Board was the fact of convergence, which, in itself, would serve to make the collection greater than the sum of its parts. We do not mean to give an impression of total harmony. That would be naive and wrong. The titles alone reflect variations in emphasis and scale, and there are differences in geographic and sectoral foci and in the priorities assigned to kinds of assistance. Still, after years of grappling intellectually and practically with the problems of health and illness in the developing world, the fact that there is some core of agreement among major actors is not trivial. At a minimum, it is a reasonable point for new departures. This is a body of thought from a voyage of discovery by hundreds of individuals around the globe. Our purpose was to distill the essential elements from those efforts, discuss the major ideas they share and the thoughts they prompt, ask what those might mean for a next agenda in global health, and comment on the shifting context in which our current concepts of the ideal will proveor not provetheir adequacy for the future.

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Global Health in Transition: A Synthesis: Perspectives from International Organizations THE DOCUMENTS REVIEWED: AN ANALYSIS The first part of this Synthesis is an analysis that summarizes 10 documents in a common format. Each summary starts with a brief background note and then analyzes the document in terms of its objectives, conclusions, and main recommendations for policy and action, hewing as closely as possible to its original language. All presentations end with a brief commentary highlighting issues that we consider pivotal and locating them in the larger contexts of health and social development. The following 10 documents were reviewed: Disease Control Priorities in Developing Countries (World Bank, 1993); World Development Report 1993: Investing in Health (World Bank, 1993); The Health of Adults in Developing Countries (World Bank, 1992); Human Development Reports, 1993 and 1994 (United Nations Development Programme, 1993, 1994); Ninth General Programme of Work, 1996–2001, and Intensified Cooperation with Countries in Greatest Need (World Health Organization, 1994); The State of the World's Children, 1994 and 1995 (United Nations Children's Fund, 1994, 1995); Health Research: Essential Link to Equity in Development (Commission on Health Research for Development, 1990); Global Comparative Assessments in the Health Sector (World Health Organization/World Bank, 1994); Partnerships for Global Development: The Clearing Horizon (Carnegie Commission on Science, Technology, and Government, 1992); and Strategies for Sustainable Development (U.S. Agency for International Development, 1994). THE DOCUMENTS CONSIDERED: REFLECTIONS AND IMPLICATIONS Invitations to Further Inquiry The second approach to the Synthesis documents is a set of reflections on their implications. We first extract 10 themes, ideas, or concerns that are explicit in at least some of the documents or implicit in

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Global Health in Transition: A Synthesis: Perspectives from International Organizations what they suggest as work remaining to be done. There are surely more than 10 ideas in this considerable group of documents. We chose those that we believe lie at the heart of what needs to be asked about what is useful, appropriate, and possible in the field of health development in today's changed and changing circumstances, ideas that will be critical to any reconceptualization of that field. Because at least some of these concepts require moresometimes much moretheoretical or practical attention, we deal with them as invitations to further inquiry. They are outlined below. Changing dimensions: new needs in development. As countries proceed along their individual development trajectories, patterns of development and needs for assistance are becoming far more diverse. This means that unidirectional, unidimensional patterns of development and development assistance are yesterday's patterns. Models and methods: going beyond the generic. Given each country's particular needs, there is also a need to find ways to build local capacity and to adapt evolving models and methods so that they are attentive to the uniqueness of local settings. WDR methodologies: contributing to global mechanisms. The World Development Report (WDR) framework offers a basis for shaping collaboration and action agendas that is both more expansive and more precise, including measurement of the world's burden of disease over time; a global health information network; and ways to vitalize coordination among the research, disease control, and donor communities. All remain to be realized. The health transition: waiting for attention. The policy and research vacuum around the health of adults in developing countries is a consummate example of the tardy response to the realities of the demographic and epidemiologic transitions and of the substantial costs that they will inevitably exact virtually everywhere. Coping with violence: rising problem, complex response. Violence exemplifies the problems that emerge and spread in marginalized populations, problems whose determinants are complex; deeply embedded in the nature of family and community life; and exacerbated by poverty, ethnic differences, population displacement, societal discrimination, and political instabilities. There are no simple solutions for any of these. Strengthening health systems: a necessary pathway. The strengthening of health systems through various approaches, including research, improved management, and enhanced human resources for health, appears in most of the documents. Yet, how to do this effectively is largely unstated and undersupported in many health

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Global Health in Transition: A Synthesis: Perspectives from International Organizations development strategies, though it is central to realizing many health development recommendations. Universities and nongovernmental organizations: essential partners. The public, private, and independent sectors are essential partners in development cooperation. Governments are obvious partners, and the private sector receives growing encouragement, but two crucial actors receive but modest attention: universities and nongovernmental organizations. Ethics and human rights: expanding concerns. In many parts of the world, the impact of bioethics on patient care is noteworthy, as is its focus on the moral criteria for decisions about that care. The question now is how to bring comparable concerns to the care of populations, communities, and, indeed, the world itself. External assistance: magnitude and directions. Assessments of the global burden of disease and funding flows by categories of health problems suggest some dissonances in priorities that call for fresh scrutiny of allocative processes, worldwide and within individual countries. Health research: large returns, small investment. Pay-offs to investment in health research have proven to be high in several ways, notably in fostering indigenous capacity for resolving indigenous problems. Yet, in proportional terms, investment in creating such capacity has not been commensurate with its potential rewards. A NEXT AGENDA: CONVERGENCE, DIVERGENCE, AND CHANGE We next examine the nature of the consensus that we identified among the Synthesis documents and explore three zones of convergence, the first having to do with principles, values, and goals; the second with tools and mechanisms; and the third with priorities. We then talk of change and the uncertainty that it is provoking. As heartening as it is to see commonalities in a field that, understandably, has been driven by particular institutional agendas, a stern eye is required nonetheless. The documents themselves call attention to the fact that the context for what we have considered “development ” is shifting, in many respects tectonically. This means that some areas of convergence may be more fragile than they seem. Others may need bolstering if they are to survive and, like the most technically advanced earthquake-proof buildings, will require deeply thoughtful engineering, great structural flexibility, and ample creativity. A whole new architecture, and perhaps even a new language to describe it, may be needed.

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Global Health in Transition: A Synthesis: Perspectives from International Organizations The Synthesis documents contribute a distinct set of concepts, methods, and strategies for promoting and protecting health in developing countries, contributions of much potential interest to all countries engaged in development assistance. The documents suggest a framework within which countries notably including the United States and this Institute's Board on Internaitonal Healthmight rethink the character and directions of their participation in global health. A FINAL NOTE The “Final Note” of our Synthesis turns to three large questions: Will this distillation of the best ideas, common themes, and principles that animated a decade's worth of good, hard thinking about what we have been calling “international health” be an adequate foundation for a new architecture; will the foundation have to be entirely rebuilt to serve good purpose in a world awash with change; and who will do it?