A century of remarkable progress has revolutionised health conditions the world over. Among high income countries, life expectancy has increased by 30 to 40 years. Most of today's low and middle income countries have experienced even more dramatic gains that have transformed quality of life and contributed to economic growth. That is sadly where the goods news ends. The bad news is that over a billion people will enter the 21st century without having shared in these gains: their lives will continue to be short and scarred by disease. Many others fail to realise their full potential for better health because health systems allocate resources to interventions of low quality or low efficacy related to cost. Increasing numbers of people forego or defer essential care or suffer huge financial burdens resulting from an unexpected need for expensive services. The continuing challenges to health ministries will be enormous.
The World Health Organization (WHO) feels there is a need to reduce greatly the burden of excess mortality and morbidity suffered by the poor. The Organization of Economic Cooperation and Development (OECD)'s Development Assistance Committee has established a target of reducing to half the number of people living in absolute poverty by 2015. This would mean focusing more on interventions that can achieve the greatest health gain possible within prevailing resource limits. It will mean giving renewed attention to diseases like tuberculosis as well as malaria and HIV/AIDS.
What must also be done, WHO suggests, is to proactively counter potential threats to health resulting from economic crises, unhealthy environments or risky behaviours. A global commitment to tobacco control, for instance, can potentially avert scores of millions of premature deaths in the next 50 years. Preparing effective responses to emerging infections and countering the spread of resistance to antimicrobials will help insure against the prospect of a significantly increased infectious diseases threat.
There is also a need to develop more effective health systems. In many parts of the world, health systems are ill-equipped to cope with present demands, let alone those they will face in the future. The institutional problems which limit sector performance are often common to all public services in a country. But despite their importance, they have been relatively neglected by governments and development agencies alike. Dealing with issues such as pay and incentives in the public sector, priority setting and rationing, and unregulated growth in the private sector constitute some of the most challenging items on the international health agenda.
Another must is the need to invest in expanding the knowledge base that made the 20th century revolution in health possible, and that will provide the tools for continued gains in the 21st century. Governments of high income countries and large, research-oriented pharmaceutical companies now invest massive resources in research and development oriented to the needs of the more affluent. Much of this investment benefits all humanity, but two gaps remain. The first about research and development is relevant to the infectious diseases that overwhelmingly afflict the poor. The second is about the systematic generation of an information base that countries can use in shaping the future of their own health systems.
The international community, WHO advocates, should avoid using its resources for what individual countries can do for themselves. International resources should, instead, concentrate on functions where international collective action is required. These include: global leadership and advocacy for health; generating and disseminating an evidence and information base for all countries to use; catalysing effective global disease surveillance; setting forms and standards; targeting specific global or regional health problems where the concerted action of countries is required.
Review: World Health Report 1999
