Global Health in Transition: A Synthesis Perspectives from International Organizations (1996) / Chapter Skim
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II: The Documents Considered: Reflections and Implications
II: The Documents Considered: Reflections and Implications
Pages 61-82
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II The Documents Considered: Reflections and Implications
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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)
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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.
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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.
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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)
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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.
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"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.
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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)
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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)
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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.
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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 -- wisely -- to building local research capabilities and executing nationally relevant research.
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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.
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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,
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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)
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Priorities 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, costeffectiveness 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
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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.
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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.
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In this connection, perhaps the harshest reality is that the most powerful levers for achieving durable improvement in human health status in any country -- that is, poverty, education, demographics, and domestic and community environments -- lie 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
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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 restructuring -- conceptually, organizationally, and financially -- of its directions in foreign aid; and • Changing configuration of the world health system toward greater pluralism, with less emphasis on bilateral cooperation, greater
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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.
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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.
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