The Documents Considered: Reflections and Implications
INVITATIONS TO FURTHER INQUIRY
This Synthesis has reviewed 10 reports, each of which makes a valuable contribution to health and social development. Each document presents a distinct set of concepts, methods, and strategies, and raises questions about how its recommendations are to be made operational and what factors might help or hinder those processes. Each also raises concerns that stand on their own as crucial questions in health and social development but that remain inadequately explored or essentially unresolved. We think of these as “invitations to further inquiry” and have identified 10 such ideas or themes that emerged, explicitly or implicitly, in the group of documents taken as a whole. Our premise is that these are “hinge” issues for considering the future of global health.
Changing Dimensions: New Needs in Development
At a meeting held in Ottawa in 1993 whose purpose was to start following up on the World Development Report (WDR): the World Bank and World Health Organization (WHO) advanced the position that, although generic methods and models can be enormously helpful, no universal solutions to health development are applicable to all countries. Because individual countries are proceeding along individual development trajectories, with growing diversity in their patterns of
development and needs for development assistance, those “individualities” must be recognized and solutions must be tailored accordingly. In other words, unidimensional patterns of development and development assistance are yesterday's patterns. In the view of the participants, this meant that two new “needs” must be taken into account:
A need for international agencies to change their development support strategies to include greater attention to building local capacity for policy reform and implementation, so that countries can formulate development strategies that are appropriate to their own needs; and
A need for international agencies to move their development support strategies away from independent and often isolated approaches toward closer collaborations with one another, whether on a regional or a global scale, so that whatever is done is more coherent and more effective.
Like most development ideas, neither of these is wholly new, but taken together, they are a persistent message throughout the Synthesis documents about new ways of doing development business. The broadest area of further inquiry is: How to do it?
Models and Methods: Going Beyond the Generic
The documents that we reviewed present approaches with real potential for health development, but being generic, they are hard for many countries to absorb. Overcoming this disjointedness between some generic ideal and national specifics raises questions about how to achieve the flexibility and adaptability that will be needed by those who offer these approaches and those who want to use them.
Implementing Change: What Are the Issues, and What Skills Are Needed?
Achieving better health for national populations demands the ability to analyze, formulate, and implement policy. Implementation presents especially complex challenges for the least-developed countries, where decision makers must act with resources that are limited in every respect. As concepts and methods evolve, special attention will have to be paid to how the most useful and relevant of these tools can be absorbed into the development processes of those countries best able to benefit from them. Other countries will need help in building basic capacities for both the independent and collaborative application
of new development tools; thus, the producers and promoters of such tools must be alert to what sorts of basic, country-based capacities will be required.
Defining a Country-Based Agenda
Key areas of support would include organizational, managerial, and financial innovations to support more equitable and cost-effective health systems. WHO suggests four categories in which assistance could be particularly helpful: broad policy formulation, priority setting, assessments of existing health systems, and design and implementation of system change. The first two categories have to do with improving transparency and rationality in policy making; the remaining two have to do with more adaptive and pragmatic issues of institutional assessment and improvement.
Partnership for Health System Reform: Collaboration and Networks
A pivotal question has to do with the extent to which members of the international development assistance community might join in collaborative approaches to speeding up the pace of reform, particularly in countries in greatest need. A range of possibilities is suggested, from networks for sharing information and ideas to the explicit establishment of a dedicated international forum on capacity building for health system reform. It could be asked whether the sense of mutual confidence among the international players is sufficient to warrant a strongly structured forum, especially with any one agency in the lead, or whether a more widely acceptable direction might be shared leadership and agenda setting. How this question is settled will have much to say about possibilities for new directions in development assistance.
WDR Methodologies: Contributing to Global Mechanisms
The emergence and reemergence of infectious diseases as major epidemiologic players, on the global stage have raised the need for global mechanisms very explicitly. A multidonor-sponsored meeting in Bellagio, Italy, in 1993 and a growing number of meetings since then have centered on elaborating mechanisms for bringing the research, disease control, and donor communities into coordinated action around these problems. More generally, the Bellagio meeting also pressed for ways that the methods and analytical framework of the WDR might be used in the fashioning of national and global action
agendas. The basic premise was that the content of the WDR is too important to be left to find its own way to where it is needed most, yet its applications are too complex for developing countries to absorb easily. The urgency of a shift toward global coordination among donor agencies is fully expressed here, with the suggestion that the coordination be among the research, control, and donor communities and between essential national health research and global health research activities. The meeting then focused on how applications of the WDR could lead to global strategies and methods for coordinating international resources and recommended the following:
that the international health community take WDR as the basis for formulating national and global action agendas and that the conceptual and analytic frameworks of that document be used as the foundation for the creation of a global health system dedicated to objectively identified priorities;
that a global health information network be established to help collect, analyze, and interpret data on the absolute and relative burdens of threats to health at the local, national, and global levels and on the effectiveness and costs of interventions and systems intended to reduce those threats;
that national and global mechanisms be put in place for formulating research priorities according to the burden of disease, adequacy of response, and risk factors for multiple infectious diseases, since there is no mechanism for setting global health research priorities that could complement national health research efforts;
that there be mechanisms for strengthening coordination among the research, control, and donor communities to increase the efficiency of resource allocation and return on investment; and
that an initiative funded by the World Bank, WHO, the United Nations Children's Fund (UNICEF), and the United Nations Development Programme be put into place to carry out and oversee the recommendations of the WDR and the Bellagio meeting and to take responsibility for leading the implementation of the WDR recommendations.
Work has advanced since the Bellagio meeting. Articles describing the methodologies and preliminary results of an implementation team comprising representation from the WHO, World Bank, and the Rockefeller Foundation have been published. The Pew Charitable Trusts is pursuing an endeavor entitled Foundations for Global Research. Several countries are attempting applications of the burden-of-disease methodologies in their own national settings, and there is an informal network that is sharing the findings and evolving ideas
emerging from these applications. Networks of various sorts are also coalescing around the subject of emerging diseases.
The Health Transition: Waiting for Attention
The question of what has come to be called the “health transition” that is occurring as a consequence of demographic and epidemiologic changes is widely recognized internationally as a dominant theme in development processes, since countries and agencies alike must characterize these transitions and readjust policies, technologies, and programs to accommodate them.
Because of the changes in population structures as more of the world 's populations survive to live longer and experience the disabilities and chronic diseases of greater age, the study of the health of adults in developing countries makes the shifts in the determinants of disease and the consequent changes in epidemiologic patterns plain to see. It also points to the extent of the shortfall in the responses to those changes. The study of flows of overseas development assistance to the health sectors in developing countries and their relationships or lack of relationshipsto some of the realities of disease burden reveals major gaps between resource allocations and significant epidemiologic needs.
These authors point to a research and policy vacuum at many points along the continuum from the collection and analysis of fundamental data through every stage of program implementation. There is the intimation that these matters are urgent: With rising demand for care emanating from vulnerable and politically vocal adult populations, there is a distinct risk that choices will be made, under pressure, in ways that are erratic and perhaps unwise and that these choices will sometimes be difficult to reverse.
There are at least three critical questions: How can existing health care arrangements be modified to incorporate responses to the problems of transition rather than creating new and separate mechanisms? How can this be done without prejudicing the unfinished agendas for the care of mothers and children and the control of communicable diseases? And to what extent can the handling of these transitional problems be facilitated by stronger mechanisms for international coordination?
Coping with Violence: Rising Problem, Complex Response
Violence is a new topic for health sector attention and it is mentioned in virtually every document that we reviewed as an area of
mounting concern. Violencein the home, in communities, on the streetsis rising in frequency, variety, and virulence and is one of the most complex public health problems that the world faces. No setting or level of society appears immune, yet the social, economic, and political impact of violence, its prevalence, and its determinants are not well understood. The documents which address the topic of violence point to poverty, marketing of drugs and arms, social instability, discrimination, hopelessness, abrogation of human rights, population displacements, and lack of opportunity. The classical public health approachdefine the problem, identify risk factors, develop interventions, take action, evaluatemay be as valid here as with any public health problem, but the social, economic, cultural, environmental, political, psychological, and educational parameters are different. Because understandings here are so indeterminate, diverse kinds of science and partnerships with real communities would seem to be essential. Because developed countries are in no way free of violence, understanding and addressing it is an area apt for international sharing and interdependency.
Strengthening Health Systems: The Necessary Pathway
Some of the documents reviewed give limited attention to health system development, yet the health care system is a necessary pathway for bringing health care interventions to populations in need. A key challenge for every health system is how to address the matter of equity and how it is to be defined, an issue raised in both the 1993 WDR and the WHO Ninth General Programme of Work. The WHO definition emphasizes the output side of equity and defines it essentially in terms of inequity, that is, as objective differences in health status that are unnecessary, avoidable, and therefore unjust. “Equity” may also be applied conceptually to the input side, for instance, universal coverage, health care according to need, or provision of equal access to health care. It may refer to some process of bringing health care to the most fundamental level, which implies a basic set of preventive and curative health services and referral processes that reach every community and, ideally, every household. It may be considered relative to cost and quality, or it may be scrutinized in connection with specific system components; for example, Health Research: Essential Link to Equity in Developmentstresses the centrality of research in equity-oriented health systems in each of these components.
However elusive the concept of equity and its achievement may be in the health sector, it generally includes some notion of health system components that can embrace defined populations, identify those in
greatest need, and extend care to them in an appropriate context of financing, quality assurance, and cost containment. In the discussions of health system reform that appear in most of the documents analyzed, cost containment is a dominant theme, always with a caveat about the risk of compromising other qualities of care. Thus, the point can be made that issues of equity become more and more complex as health systems differentiate. Health care reform in various shapes changing government roles, greater privatization, and a more active independent sectorwill have to be monitored not only for effectiveness and efficiency but also for equity, since pressures for reform can overwhelm concerns for the last of these.
Universities and Nongovermental Organizations: Essential Partners
A theme pervading all the Synthesis documents is the urgency for collaborative partnerships. Governments and international organizations are obvious partners, and the private sector receives increasing encouragement, but universities and nongovernmental organizations (NGOs) receive less attention. Many universities are serious players in health and social development and have traditionally contributed to the health sector, in health system research and education, research on health problems that governments have been unable to contain such as infectious diseases, and training programs to support specific health care programs. In each of these roles, universities have worked with governments or with NGOs in the capacity building that is repeatedly emphasized in all of the documents.
Nongovernmental organizationsinternational and indigenousare also traditional players, committed to working at the grass roots, and are generally seen as trusted partners. As governments realize that they cannot do all that is developmentally necessary, they have turned outside the public sector for complementarity. The Human Development Report singles out NGOs for special mention and points to their clear impact in advocacy on behalf of the disadvantaged, the empowerment of marginalized groups, reaching the poorest, and providing emergency assistance. All will be highly relevant, if not essential, as development agendas shift and as governments increasingly decentralize services and emphasize community involvement and capacity development.
Ethics and Human Rights: Expanding Concerns
Issues of ethics and human rights surface in different ways in the
Synthesis documents, for the most part indirectly, in the context of the meaning of equity in relation to health care and, possibly, its “rationing ”; in connection with ideas about community participation, including community participation in research; relative to differential values placed on human lives in quantifying burdens of disability and mortality; and in the context of human rights violations as determinants of disease and injury, notably issues concerning the status of women, such special disease conditions as human immunodeficiency virus (HIV) infection and AIDS, and the generation and consequences of violence. Extension of these issues will eventually involve bioethical concerns emerging outside the developing world, for example, decisions on patient care and patient autonomy; truly informed consent; and the tension among the moral rights of individual carriers of infectious disease, disease screening, partner notification, and the safety of communities.
These questions and intimations are proliferating, and some already command international attention. A Global Bioethics Agenda was proposed at the 1994 World Health Assembly, and collaborative approaches to such issues as the ethical ramifications of policy choicesunthinkable a decade agoare edging to the forefront.
External Assistance: Magnitude and Directions
Part of the burden-of-disease exercise was to group the many components of burden into categories, which could then be used for various comparative purposes. When the burden was sorted into categories of communicable disease, maternal and perinatal causes, noncommunicable diseases, and injuries and these were then matched with resource allocations, it became apparent that, at least according to the best data available as of 1990, some health problems seemed to be receiving disproportionate shares of external assistance compared with their potential contribution to reducing the overall burden. In other words, diseases afflicting a relatively small number of individuals seemed to be getting relatively large allocations, with others getting allocations that were quite small compared with the sizes of the afflicted populations. There were also great disproportions in the structure of external health sector assistance relative to the growing proportions of the global disease burden attributable to noncommunicable diseases and injury. The proportion of all external assistance in 1990 for noncommunicable diseases and injuries combined was just 1.8 percent (1.6 and 0.2 percent, respectively). This amounts to less than $0.05 per Disability-Adjusted Life Year, although those two categories
accounted for 50 percent of all disease in developing countries as of that year.
The Synthesis documents that apply the WDR DALY metric illustrate its potential not only for measuring the burdens of disease and the cost-effectiveness of interventions but also for illuminating mismatches between those burdens and values and international investments in particular disease entities. The question that remains is how that metric can be made operational in guiding policy formulation and resource allocations nationally and internationally, since its utilityand utilizationwill necessarily vary among countries, and, indeed, is still a matter of probing debate. Some countries may be able to apply the DALY measure quite literally; others may see it as primarily of heuristic value; still others may use it as a point of departure toward better ways of focusing and organizing national-level data collection.
Health Research: Large Returns, Small Investment
The 10th idea has to do with global investment in research and development (R&D) for health, a theme in all of the documents reviewed, subdued in some and a focal point in others. The basic contention in all instances is that research pays off in terms of human health in a large and compelling fashion.
Amidst concerns about the hypermedicalization of health and, increasingly, the impact of high technology on the costs of health care, it is easy to forget that it was the R&D investment in vaccines, diagnostics, preventive and curative therapies, contraceptives, medical devices, and drug delivery systems that spurred quantum advances in human health status. It is hard to imagine that these advances would have occurred without that investment. Further, many of these technologies have proved to be, more often than not, cost-effective. It is also true that the discoveries of medical science have evoked powerfully efficacious public policy responses to such general health needs as environmental sanitation and safety, as well as somewhat wiser management of high-risk behaviors by individuals and population groups. Another crucial consequence of health R&D in both the developing and established market economies has been the formalization of a culture of inquiry, the basis in any society for the human and institutional ability to address threats to the health of its population.
There is justifiable concern about the potential of health care reform and cost containment for inhibiting the pace of innovation and its adoption. Still, the momentum of discoveries in genetic research, computer and communications technologies, combinatorial and synthetic peptide chemistry, and recombinant DNA techniques, as well the wid
ening spectrum of diagnostic possibilities, seems to be well and irreversibly established. The remaining questionswhich are large have to do with how much, how far, how fast, and to whose benefit.
Yet, despite the high past and potential returns to health R&D, the amounts and proportions of external assistance devoted to the health problems of developing countries are erratic; in some cases poorly correlated with the size of disease burdens and the real needs of health systems; and, for the well-being of the global commons, seriously inadequate. This is most unfortunate, for even limited external funding, which may be quite marginal in terms of overall national budgets, can pay off significantly when it is allocated wiselyto building local research capabilities and executing nationally relevant research. It is this sort of capacity that becomes the receptor for the transfer of health technologies, as well as the generator of indigenous solutions to indigenous health problems. Absent such capacity, it is hard to imagine how the world will deal with the enduring challenges of infection, undernutrition, and unintended fertility; threats of emerging and reemerging diseases; epidemics of noncommunicable disease and injury in industrializing societies; the violence that is shaking so many societies; and the nearly ubiquitous inefficiencies and inequities in health systems.
A NEXT AGENDA: CONVERGENCE, DIVERGENCE, AND CHANGE
This Synthesis was motivated in large measure by the perception of an intriguing concordance of thought in a set of documents that were appearing as the Board on International Health of the Institute of Medicine was considering preparation of a report on the state of affairs in world health and the role of the United States in those affairs. In a field fractionated by divergent institutional agendas and intellectual premises, it seemed to us that it might be especially worthwhile to call attention to what was not divergent. After all, these documents had evolved from an iteration between theory and practice over several decades through the efforts of many individuals who cared deeply about the furtherance of what we have been calling “international health.” As a compendium of collective wisdom and thought about the role, importance, and principles of international health, the documents could be expected to reflect ideas about what had proved to be desirable and effective, as well as ideas about what had been thought to be feasible and appropriate but proved to be less so. Reflections on the full range of these experiences would be essential to any contemplation of what should happen next.
At the outset of this report, we commented that two aspects of the documents commanded particular attention. One was the broad spectrum of constituencies and points of view that they represented; the other was an apparent convergence on what seemed to be key principles and development themes. The latter raised the interesting possibility that the fact of this convergence could, in effect, make the collection greater than the sum of its parts. With this possibility in mind, we proceed here to examine the nature of that convergence, as well as the character of the environment in which it has unfolded.
Zones of Convergence
Principles, Values, and Goals
The Alma-Ata Legacy Although the goal of Health for All has not been accomplished, it has achieved intellectual and practical prominence as an ideal. It was at the International Conference on Primary Health Care sponsored by UNICEF and WHO in 1978 that Health for All was expressed in the key principles of the Alma-Ata Declaration:
Universal access to health services, with priority assigned to those most in need, to be pursued mainly through basic health services and a strong emphasis on prevention, usually referred to as “the primary health care approach”;
Effectiveness and affordability of services;
Community involvement, self-reliance, and self-determination in the development of services; and
Intersectoral action on health-related matters.
In subsequent implementation of these principles, the concept of equity came to be seen as a cornerstone of their central intent. As that concept crystallized, it grew beyond the fundamental notions of equality of access to a focus on those most in need and to the incorporation of some sense of fairness and justice, an orientation applicable in both developed and developing countries. Two later meetingsin Riga, Latvia, in 1988, and again in Alma-Ata, Kazakhstan, in 1993reviewed progress toward the Health for All goals. Each meeting provided an opportunity for a recommitment to the Alma-Ata Declaration 's principles, and at each meeting, participants made it clear that those principles were not a passing exercise in rhetoric destined for policy oblivion but, instead, were permanent fixtures in international health policies and programs. At the same time, equity remains a complex and labile concept with many definitions. A cur
rent WHO effort to clarify the concept so that equity can be monitored focuses first on the reduction of unfair and modifiable disparities by providing the most vulnerable groups some minimal level of health and social services and second on striving to reduce the size of the gaps in health status and access to health services between more and less privileged groups and areas.
Over the years, the streams of thought from Alma-Ata have been joined by others. Each successive iteration of the Human Development Reports and The State of the World's Children has called attention to notions of empowerment and people-centered development. The World Bank documents reviewed here repeatedly emphasize equity and propose methods and policy reforms for pursuing it. The WHO, as noted above, is shaping a New Global Health Policy predicated on concepts of equity and solidarity. Throughout all of the Synthesis documents runs a theme of health as more than just a function of medicine and as something to be ensured by other sectors and such crucial externalities as education, employment, women's participation in development, safe water and sanitation, and environmental protection. Other organizations and agencies have come to accept these principles and values as synonymous with appropriate development and to incorporate them into development-related programs as a matter of course. All in all, it is hard to remember that, not so long ago, the principles of Alma-Ata were matters of hot and lengthy debate.
Although these principles endure generally unchallenged, there are large changes in the kinds of problems to be addressed through health care and how those are to be responded to in different settings. The Synthesis documents make it clear that the Alma-Ata Declaration's principles alone are not the answer: While a system not founded on those principles may fail in its impact, without a system to make them appropriately operational, those principles are empty. The present challenge is to find ways in which the Health for All principles are retained at the same time that the health sytems that they inform must adapt to new societal and epidemiologic requirements. There will be more and more instances in which linking principles with practice will require dramatic departures, well beyond the familiar forms of primary health care, to innovations in policy, finance, and management that can somehow merge the concepts of equity, efficiency, cost-effectiveness, affordability, and sustainability.
Finally, there is the growing momentum around the need to pay attention to matters of biomedical ethics and human rights as imperatives, including such principles as the right to informed consent, protection from harm, the right to beneficial care, and distributive justice,
so that human rights language is more and more prominent in formulations of health and social development.
Tools and Mechanisms
The second zone of convergence is around the demand, relentlessly reiterated in every Synthesis document, for building the capacity in developing and developed countries for taking charge of their own development goals and processes. Part of the generation of capacity has to do with transferring the tools, mechanisms, and operational perspectives that make the most sense in terms of their potential for rethinking and recrafting approaches to health development. These candidates are offered:
The concepts of the global burden of disease and the DALY, for defining changing patterns of disease and related resource allocations to adjust key targets for policy change and action;
The nurturing of health research, for clarifying those problems that are most pressing and shaping the design and evaluation of interventions in shifting environments;
Strengthening of capacities for policy making and management and for integrating epidemiology, economics, and the behavioral sciences with newer management methods, information systems, and organizational innovations, to set the stage for grappling with local challenges to health and social development;
Formation of training “chains” and teams of health personnel, including professional, paraprofessional, and community resources, to bridge the span from technologically advanced facilities to local settings where people's needs are most strongly expressed and where returns on health investments may be realized most effectively;
Partnerships between the public (government), private (corporate), and independent (universities, NGOs) sectors as critical tools for strengthening a range of national capacities and, most importantly, for grappling with problems beyond the reach of government and in overseeing policies and programs that ensure equitable coverage of populations; and
Global networks for a range of ad hoc and longer-term activities that could profit from collaboration, for example, research, setting research priorities, expanding information systems, and professional education and practice, to enhance intranational and international capacities for dealing with change.
Each, and therefore all, of these considerations is presented as being essential to a well-balanced and effective approach to health and social development in a changing world. They are organizing devices or, at a minimum, integral parts of capacity building, not as something held by any single organization or nation but as tools to be shared and accessed through different sorts of partnerships.
The third zone of convergence has to do with priorities among diseases, hazards to health, and obstacles to development. Although priority setting is most acutely difficult under conditions of instability and scarcity, and although priority setting must vary according to local circumstance and preference, the Synthesis documents suggest that there is still a cluster of what might be called “generic priorities,” which will likely matter in virtually every situation:
The utility of applying the global burden-of-disease methodologies to priority-setting processes, defining magnitudes of disease, cost-effectiveness of interventions, and related allocation of resources;
The importance of the health and well-being of females throughout their life span;
The concern for the health and well-being of children in particularly volatile environments where mortality is surging, as in areas with high prevalences of malaria, AIDS, tuberculosis, acute nutritional deprivation, and mass displacement of populations;
New disease patterns associated with the health transition, most particularly the health of adults and the diseases of chronicity;
The public health significance of violence, a problem long present but increasingly recognized in most countries and requiring deeper understanding in all of them;
The persistence of AIDS, with its devastating impacts on many populations and its defiance so far of virtually every effort in health and development research, policy, and action;
The urgency of reforming health systems and their financing and the associated reallocation of resources and restructuring of the systems themselves;
The requirement for paying special attention to Africa, where the need to reduce suffering and strengthen development is of global concern;
The need to incorporate ethical guidelines into assigning priorities and choosing those priorities that best respond to criteria of equity and justice; and
The inseparability of poverty, population growth, and environmental degradation.
This admittedly redundant list is not intended as a formal analysis of priority issues. It is meant to express the fact that contributions to a major body of literature, generated by a variety of agencies and individuals with disparate mandates and disciplinary orientations, coincide in some fundamental view on what areas must not be left untended. That multiple actors have independently come to similar conclusions so that it was even possible to make such a list suggests that the selection of priorities for health and social development might now profit from international dialogue and some shared policy making.
Divergence: A World Awash with Change
We could be lured by our perceptions of convergence into concluding that the future of what we have been calling “international health ”. is now straight and clear. This would be an incomplete and inaccurate interpretation both of the Synthesis documents and of the current environment. Each Synthesis document refers to great changes in the climate around international health and notes that in some way those changes motivated and shaped it.
At the same time, the documents do not react to that recognition at the same level. Some urge modifications in analytical and policy approaches to health problems stemming from that altered climate and in the strategies for implementing those approaches. Others insist on radical shifts in the fundamental vision of development and in the factors of change themselvesthe very context in which any fresh strategies would be made practice. Yet, none of the documents states that all that is needed is modest retrofitting of what is already being done. All at least intimate that the entire health development endeavor may need to be pursued, in substance and in process, in new ways.
One reason for engaging in the Synthesis exercise was to gather up the strands of current thought in the field as a basis for asking “What next?” To answer that, we will first have to challenge the meanings and authenticities of the convergences that we have identified. If the global health agenda is to be reconceptualized, are those areas of convergence adequate as a point of departure and might they constitute a platform for the rethinking process? Or, are the extent and depth of change so great that the past is not particularly instructive as prologue and the value of the Synthesis is largely as a picture of where we
have been? How do we preserve what remains pertinent and focus energy on what must be totally redone?
The response to such questions is conditioned by the kinds of changes that we are talking about and whether those are specific to the health sector or are driven by larger, more commanding realities that lie primarily outside of that sector. A look at those realities with the most immediate relevance suggests that the latter case prevails:
Changing states of development, as some countries, like many of the countries of Southeast Asia and Latin America, vault ahead, whereas others, such as those in Africa, fall sadly behind; as formerly socialist states struggle with rocky transitions; and as inequalities, among and within countries, abound and intensify;
Changing status and meaning of the “nation-state,” with proliferation in the sheer number of states; much internal fragmentation and, in some cases, actual failure; and the rising importance of what might be called “non-national actors,” that is, class strata and interest groups that have more affinity across national boundaries than they do within them;
Changing political and ethnic relationships, leading to strife, violence, discrimination, massive displacements and migrations of people, and abrogation of a wide range of human rights;
Changing access to information through an explosion of new and expanding communications media, with many more people having greater and easier access to information but multitudes still left out; and
Changing health problems and epidemiologic patterns proceeding from changing global demographic and environmental dynamics, with the aging of populations and the accelerated transfers of all sorts of risks across permeable and fluid national frontiers.
Among the consequences of these contextual shifts are shifts in basic perspectives that have special relevance to the health sector, though they are hardly limited to it. The following are the most important:
Changing concepts of “development” with challenges to the notion that it necessarily leads to progress and stability or that there is some imperative economic model on which it should be based, or that the notion of sustainability is an essential defining component;
Changing ideas about development processes, for instance, people-centered development and other responses to democratization
and the tension between such ideas and more market-centered orientations;
Changing organizational structures and management approaches in both the corporate and public sectors, often entailing radical downsizing and decentralization for greater efficiency and competitiveness, resulting in the restructuring of bureaucracies and the larger labor force within the health sector and outside it;
Changing roles for government in relation to the private and independent sectors, with government accepting that others will have a larger place in health development, not only in financing but in risk sharing and all aspects of the delivery of health care;
Changing approaches to the financing of health care, for example, greater privatization, more managed care and fewer fee-for-service arrangements, and movement away from the concept of universal coverage;
Changing concepts and tools emerging from the laboratory such as new vaccines, therapies, diagnostics, and drug delivery systems; wide-access information systems and friendlier software; and freshly conceptualized methods for building and analyzing databases, measuring disease burdens, and guiding allocationswhich remain, nonetheless, largely unassessed for their cost-effectiveness in producing better health outcomes for more people; and
Changing views on the connections among ill health, poverty, and social pathology, with more disposition to see ill health as a consequence of poverty and inequity, irreconcilable with authentic development and often requiring both social policies and health policies for any resolution. Although there is ongoing debate about what are fundamentally social problems and what are health problems, as well as about how and when both social and health policies should address them, few are totally prepared to resist the conclusion that many of the major social problems of our time have immense health outcomes and that many of our major health problems have social origins and social consequences. In this connection, perhaps the harshest reality is that the most powerful levers for achieving durable improvement in human health status in any countrythat is, poverty, education, demographics, and domestic and community environmentslie outside the health sector.
Implications for the United States
Until recently, the vision in the United States of where the country stood and where it had come from with regard to international development was based on what is, historically, an atypical sampling: the
period from 1945 to 1975, a time of great prosperity when the United States was enormously dominant in the world and could, in effect, write the story of what social and economic development should be all about.
That picture is much altered. The collapse of the communist regimes in the Soviet Union and the Eastern Bloc opened a huge zone of political instability, uncertainty, chaos, and civil war and shook the systems that had stabilized international relations for some 40 years. The weakening of the nation-state as an unquestioned political force, shifts in the center of economic gravity, and a series of socioeconomic and political events have made it clear that the development story is not always written in the same fashion, nor is any story immutable or complete. At best, “development” is a complex, various, elusive, and difficult notion, particularly in a new, confusing, and unpredictable multipolar world.
The traditional yardstick of an exceptional period of stability for the United States serves only poorly in understandingand affecting today's powerful intersections among politics, economics, and health. The current drive toward fiscal austerity, the ongoing redefinition of the role of the federal government vis-à-vis the states and municipalities, and the relative roles of the public and the private sectors have contributed to particular instability in the health sector, where de jure efforts at reform have given way to de facto free market adjustments. That picture is likely to remain fluid, with considerable repercussion and little sign of imminent reversal. Such changes and the larger issues of how to sustain appropriate levels of investment in the social sectors are not solely U.S. phenomena; they are questions of capacity, choice, and political will for all countries.
The economic participation of the United States in bilateral and multilateral assistance to other countries is also much in flux, mostly because of internal preoccupations and political differences. What seems to be a trend toward reduced funding is likely to continue. This has contributed to and in the future will be affected by two other substantial changes that have much to do with the character of the U.S. role:
Changing global patterns of external assistance, with some countries and their aid agencies receding and others advancing in the amounts and patterns of their contributions, as the United States engages in a radical review and probable restructuringconceptually, organizationally, and financiallyof its directions in foreign aid; and
Changing configuration of the world health system toward greater pluralism, with less emphasis on bilateral cooperation, greater
presence of multilateral agencies, and more attention to involvement of the corporate sector.
What is striking about the Synthesis documents is that although only some of them directly address the role of the United States in global development processes, they contain little that is irrelevant to U.S. development policy. Their critical messages are that the consensus that can be found in them is no less applicable to the United States than it is to any other country disposed to participate in external assistance and that, overall, the meaning of that consensus for the health sector is much the same as it is for any other sector. The United States, like other nations, is caught in the tension between the practical realities of living in a “global neighborhood” and whatever dispositions there may be toward inwardness. Despite struggles with defining the whether and why, the major question for the United States about external assistance remains: how to be engaged?
The most compelling of the implications for the United States that can be drawn from the Synthesis deal with content, financing, partners, methods, values, and risks of noninvolvement and are essentially statements about ways in which things simply cannot stay the same.
The first implication is simply that older development emphases must yield to newer onesthe push for growth better balanced with equity, management with participation, efforts large in scale with those smaller in scale, and global orientations with local exigencies. Some of the documents point to the immense capacities of the United States to do this because of its relevant experience, technological knowhow, and sector-specific resources, as well as its ability to harness the power of its own pluralism across the lines of its own institutions its federal, state, and local governments and its large private, for-profit, and independent sectors.
The second implication has to do with funding. The Synthesis documents that address this topic make the point that almost no developed country invests a proportion of its gross national product in the area of global development that is commensurate to the needs of the less developed countries. For example, less than 1 percent of the federal budget of the United States goes for all of its foreign assistance, that is, economic, military, bilateral, and multilateral; no member country of the Organization for Economic Cooperation and Development spends more than 2 percent of its gross domestic product on such assistance. An even smallerand ever more minisculeportion of that assistance is dedicated to research in areas of keenest rel
evance for developing countries and, most important of all, in fostering an indigenous capacity for understanding and resolving indigenous needs.
The third implication pertains to recognition of the simultaneous marginality and importance of external assistance. Economic assistance may be critical for the lowest-income countries, where it can constitute a significant proportion of national budgets. For other countries, the value of economic assistance is at the margin, where it can nevertheless affect national policies, the generation of new knowledge, and the building of indigenous capabilities for understanding and resolving indigenous needs.
The fourth implication has to do with acknowledgment that all approaches to development must shift, if only partially and incrementally, away from focused development projects and toward integrated development strategies that are the products of shared planning among cooperating countries.
The fifth implication goes toward affirmation of a basic principle of development cooperation as fostering creative interactions among the public (government), private (corporate), and independent (NGOs, foundations, universities) sectors, an implication of notable importance for the United States, where the corporate and nongovernmental sectors are so prominent.
The sixth implication relates to crediting the importance of measures of disease burdens and their use in guiding policy formulation and resource allocations, especially as constrained resources and shifting priorities promote the urgency of greater allocative efficiency.
The seventh implication is for understanding that science and technology are crucial enabling tools for national and global development and that the United States has particular (though not exclusive) strengths for sharing scientific advances and helping countries build research capacities relevant to their own development needs.
The eighth implication addresses appreciation of the critical role of the United States, in partnership with other countries, in addressing the serious problems of health and social development on a global scale with, again, special (though not exclusive) concern for those countries and populations that are most vulnerable and deprived.