Global Health in Transition: A Synthesis: Perspectives from International Organizations (1996)

United Nations Development Programme. 1993 and 1994. Human Development Reports. New York: Oxford University Press. The purpose of these reports, published yearly since 1990, has been to contribute to the larger development debate and to track and update the Human Development Index (HDI). HDI is a measure, analytically applicable to regional, national, or subnational groups, that combines three equally weighted indicators: life expectancy at birth, educational achievement (adult literacy rate and mean years of schooling of individuals over age 25), and a modified measure of per capita income. Each report has a special focus. In 1993 the focus was on people's participation in markets, governance, and community organization and on five core concepts for a new, people-centered world order. The 1994 report enlarged on those concepts as the framework for the 1995 World Summit for Social Development. All reports reflect the contributions of practical experience, research results, and statistical information from a large number of organizations and individuals worldwide. Report preparation is the charge of an independent United Nations Development Programme team with the support of a consultant panel and an extensive external drafting and review process. The following summary comprehends both reports.

• To explore the key dimensions of participation of peoplethrough markets, government, and community organizationsas a central theme in human development.

• The democratic transition in many developing countries, the

collapse of socialist regimes, and the worldwide emergence of people 's organizations are part of historic change, not isolated events.

• Unless the full context of the dynamics of development is kept in view, development perspectives become narrow and are likely to miss critical issues that bear importantly on health.

• Analysis of countries ranked according to the HDI found that:

  • There is no automatic link between income and human development; poor distribution of income, however, does have a major impact on human development.

  • Improvement in a country's HDI is as meaningful as its absolute level: Starting at similar levels, some countries have advanced their HDIs far more than others.

  • When the HDI is adjusted for gender disparity, no country improves its ranking; that is, no country treats its women as well as it treats its men.

  • Startling divergences from averages are revealed when the HDI is disaggregated for purposes of intraregional and intranational comparison so that, simultaneously, there may be great progress and great persistent deprivation.

• Given major cuts in global military expenditures, the numbers of nuclear warheads, and the sizes of armies and defense industry workforces, there needs to be a significant redefinition of the concept of national securityas in food, employment, and environmental security.

• Despite the assumption that pursuing economic growth would necessarily increase employment, there is a new and disturbing economic phenomenon growth that does not generate new jobs, that is, “jobless growth.”

• Concentration and centralization of power and resources are still more the rule than the exception because of the centralization of nation building derived from the colonial experience, weak democracy, low levels of social spending, urban bias, and the composition and directions of foreign aid.

• Nongovernmental organizations are effective in advocating for the disadvantaged, empowering marginalized groups, reaching the poorest, and providing emergency assistance. Still, they reach only one-fifth of the 1.3 billion people living in absolute poverty in developing countries and receive only 2.5 percent of the total resources that flow to those countries.

The central concept for development should be societies built around people's genuine needs, a perspective that calls for five new pillars of a people-centered world order:

1. New concepts of human security, for nations and for peoplefood, employment, environmental securityas functions of

   • defense cuts to finance human development and the transition from defense to civilian production;

   • accelerated disarmament in the developing world; and

   • new regional and international alliances for peace.

2. New models of sustainable human development that enable full use of human potential through

   • investment in basic education, relevant skills, and worker retraining;

   • support for small-scale enterprises and informal employment through fiscal incentives and credit system reform;

   • creation of an efficient service economy by investing in new skills;

   • encouragement of labor-intensive technologies, especially through tax incentives;

   • extension of employment safety nets in times of major economic distress through labor intensive public works programs; and

   • sharing of limited employment opportunities through adjustments to the work week.

3. New partnerships between the state and the market that

   • combine market efficiency and social compassion;

   • empower people to exert more effective influence;

   • allow many more people to capitalize on the advantages that markets offer by providing the preconditions for participationeducation, health, productive assets, physical infrastructure, information, liberal trade, and supportive legal and regulatory systems;

   • provide the accompanying conditions for participation stable macroeconomic environment and comprehensive and predictable incentive systems; and

   • maintain a social safety netemployment, pensions for the

elderly, feeding programs for malnourished children and mothers, and free basic health and education for all low-income groups.

4. New patterns of national and global governance that accommodate the rise of people's aspirations and the decline of the nation-state through

   • the decentralization of power, with genuine democracy at the local level; and

   • broader and more participatory institutions of global governance.

5. New forms of international cooperation built on a new motivation for aid and a global war on poverty based on the needs of people rather than the preferences of nation-states through

   • tripling current allocations to 20 percent for health, basic education, environmental security, and reducing population growth;

   • basing aid allocations on poverty levels;

   • linking aid with mutual concerns of recipients and donors, the interdependence of developed and developing countries, and the sharing of global market opportunities;

   • establishing a new people-centered policy dialogue; and

   • using technical assistance for national capacity building.

The Human Development Report (HDR) contrasts with the other nine documents reviewed in our Synthesis. It deals largely with a vision of development; the others deal with methods and strategies. The HDR builds a context of concern for people as the central feature of development; the others address health problems and analytical and policy approaches to grappling with them. Both are necessary. Indeed, an interesting aspect of the Synthesis documents is that duality: attention to the methodologic details of development on the one hand, and attention to the context in which those methods are made operational on the other.

For years there have been calls for greater participation of people in the development process, but those calls have often been muted by an insistence on economics as the primary determinant of development progress. It is increasingly clear, however, that other parameters of development share central positions with economics. For example, the thesis underlying the World Development Report is that

investing in health itself is essential to development. There are other indications that economics cannot be treated as the sole measure of development: The HDR points out that employment opportunities have not expanded with economic growth, as had been expected, so that other routes to employment security for people must be sought. In questioning traditional concepts of development, the HDR also puts forward notions of security that go far beyond customary definitions of national security to a definition of the security of people. It goes on to state that sustainable human development cannot depend on economics alone, but must be built on people's capacities, which can be enhanced only through participation in the development processes.

Health is integral to the social imperatives put forward in the HDR. The health sector has approaches to assessing risks and needs, setting priorities, planning interventions, and monitoring outcomes that can bring both concern and methodologic rigor to social development. The principles of social development that are expressed in the HDR can also bring to the health sector an insistence on shared decision making and respect for individuals and communities. Viewed this way, there is a complementarity between the health and social sectors of development.