Health for All by the Year 2000-Where has the WHO gone?

Enjoyment of the highest attainable standard of health is a fundamental human right of all people 2. This is seen as an important outcome as well as a goal of sustainable human development. Yet at the dawn of the 21st century massive worldwide disparities in the provision of health care continue to exist; 800 million people still lack access to health services 3. The rate of development of the first world has been greater than that of the third world so the gap between “haves” and “have nots” is greater than ever; the richest 1.2 billion people in the world account for 82.7% of the total global wealth4. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service url: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: ISSN 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, Autumn 2002 : 8-12 doi: 10.2218/resmedica.v0i0.997 Health for All by the Year 2000 Where has the WHO gone?

Enjoyment of the highest attainable standard of health is a fundamental human right of all peo ple 2. This is seen as an important outcome as well as a goal of sustainable human development.Yet at the dawn of the 21st century massive world wide disparities in the provision of health care continue to exist; 800 million people still lack access to health services 3.The rate of develop ment of the first world has been greater than that of the third world so the gap between "haves" and "have nots" is greater than ever; the richest 1.2 billion people in the world account for 82.7% of the total global w ealth4.
Even within developing countries there are major health disparities.In the past many gov ernments, in striving for very visible develop ment, have invested in building a western style medical system.As a result there are large, so phisticated hospitals often in the capital, or re gional centres capable of sophisticated proce dures.These services are life-saving, but only benefit a tiny minority of the population.All this time the same country neglects the vast ma jority who are deprived of the most basic of medical services.The traditional communist dictum of the greatest good for the greatest number is being ignored.Governments do not seem to understand that health is central to the development process.

The Road to Alma-Ata
It was in fact the aforementioned communists, in China, who first realised that the route to development was not with fast medical devel opment but in the provision of basic health care that was available to all.Chairman Mao Dezong, in 1965 as part of his cultural revolution, advo cated 'barefoot doctors' who would have only three years training but would provide inexpen sive, basic health care to all, especially the rural masses '.

WHERE THE MONEY HOW MANY PEOPLE IS SPENT ARE SERVED (as a percentage of (as a percentage of the national health budget) population)
□ p r im a r y health c a r e

Figure 1: Distribution o f health spending in developing countries
This idea lived on only to re-emerge a decade later at the 1977 World Assembly of the World Health Organisation (WHO).They decided that their main social target should be "attainment, by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life"; this target was summarised as Health for All by 2000 (HFA2000)5.Dr Mahler (the Director-General at that time) perceived the outcome of HFA -"people will use much better approaches than they do now for preventing disease and alleviat ing unavoidable illness and disability and that there will be better ways of growing up, grow ing old and dying gracefully" 6.
This was an extension of WHO's traditional role from setting normative standards and providing technical advice and assistance on medical mat ters to also include advocacy of health through HFA2000 7.This extension was a profound change for the organisation who had previously taken "the approach to health that was largely disease orientated and it studiously avoided po litical or cultural controversy" 8.

The Declaration of Alma-Ata
The conference found that the key to obtaining HFA2000 was by the worldwide implementation of primary health care (PHC).This would not be yet another externally led "add-on" pro gramme, it would form an integral and perma nent part of the health care systems from the ground up of both developed and developing countries.Thus it would be a reversal of the current hospital/institution based health care sys tem.

PHC consists of nine main areas:
-Health Education -Environmental sanitation, especially of food and water -The employment of community or village health workers -Maternal and child health programs, including immunisation and family planning -Prevention of local endemic diseases -Appropriate treatment of common diseases and injuries -Provision of essential drugs -Promotion of nutrition -Traditional medicine HFA2000 strategy is meant to operate at three levels; locally, nationally and internationally.Ideas should be initiated nationally but planned locally, therefore being most appropriate to the people it aims to serve.Internationally there should be a flow of ideas and strategies co ordinated by WHO.National self-reliance does imply national initiative but not national selfsufficiency and idea development.HFA was to encompass these five following concepts 5. 1) Equity -This is the foundation of the HFA2000 concept.Every individual must have lifelong access to comprehensive health care re gardless of how poor or remote they are.
3) Sustainability -The project must be sustain able; financially, culturally and technologically to provide health for all, as well as responsive to changing conditions.4) Community involvement -This promotes self-reliance and reduces dependence.5) Integration -Health, as a sector can not de velop in isolation; it both contributes to and is affected by other sectors such as sanitation, hous ing and education.

The Role of WHO "WHO knows everything but does nothing" 9
The role of WHO is not to provide the primary health care for HFA2000 but to inspire and as sist countries to do so themselves as well as co ordinating the non-governmental organisations (NGOs) such as UNICEF (who incidentally "knows nothing but does everything" 9).In this there is a problem, WHO itself is in crisis.It is an underfunded (biennial budget for 1994-5 just $1.8billion compared to the annual NHS budget of $60billion), bureaucratic, overspread organi sation 7.
Over the last decade there has been mounting criticism o f the lack o f strong leadership and clear strategy; there have even been rum ours o f cor ruption 7. The fact that pharm aceutical repre sentatives are present at m any policy-form ing m eetings has long been considered inappropri ate 3. W H O can not afford to loose its credibil- M any o f the problem s have been contributed to by the poor leadership o f the recent directorgeneral Dr Hiroshi N akajim a who held the posi tion from 1988-1998.Seen by m any as a re served and a poor com m unicator, he him self con fe s se s to n o t b e in g a s tro n g le a d e r 10.D r N akajim a attem pted to establish "a new para digm for health" but he em barrassingly failed to explain w hat this was.
The international loss in confidence, especially by donor countries led to a dem and for greater accountability.To gain m ore control over their donations there has been an increase in the so called 'extra budgetary contributions' for 'spe cial program m es', accounting for 50% o f W H O 's incom e, which are outside the direct control of the m anagem ent.Donors can exert political pres sure by threatening to w ithdraw these funds11.This leads to another problem for W H O: spe cial p ro g ram m e s are g e n e ra lly p e rfo rm an c e driven, judged by short-term outputs (such as per centage im m unity ac h ie v ed )11.They also by-pass W H O 's com m itm ent to only w orking through governm ents and are generally non-integrated.The program m es are forced to com pete with each other for funds so focus on the glam orous, at tention-grabbing causes rather than the grass root developm ent so essential for the im plem entation o f HFA2000.
The problem s o f global initiatives are neatly sum m arised by B anerji: Firstly, how can one have a 'prefabricated' initiative given the extrem e variations am ong and often within poor coun tries?Second, selection o f health problem s for action conform ed m ore to the special interests o f the rich co untries that the poor.T hird, a technocentric approach to problem solving was adopted.Fourth, there is an obvious contradic tion in the scientific basis o f the claim that the suggested globe-em bracing program s are costeffective given the profound variations am ong and within countries.Fifth, by their very nature, international initiatives cannot prom ote com m u nity self-reliance.Sixth, there is the key ques tion o f dependence and sustainability; 'donors' have used their trem endous influence on the pli able ruling classes o f the poor countries to en sure that the ill-conceived, ill-designed, ill-managed global initiatives are given priority over the ongoing w ork o f health organisations.Finally, and above all, these program s are the very an titheses o f the A lm a-A ta D eclaration.

Future of WHO
M uch hope was placed on D r B runtland the cur rent D irector-G eneral.She is originally from a m edical background and was Prim e M inister of N orw ay for 10 years 12. H er main im m ediate aim s as stated in her initial address in July 1998 w ould be to "pull W H O together by focusing on our core business" , "reconnect the organisation through flatter structure, better com m unication, m ore transparency and a clearer distribution of roles", and "create an organisational structure not driven by bureaucratic rules but one that pro m otes p e rfo rm a n c e and re s u lts " 13.All this so u n d s g re at and is d e sp e ra te ly n eed ed fo r This is a tragic state of affairs; the premises on which HFA2000 was launched over twenty years ago still exist.There is still a huge unmet need for provision of basic health care for all people, regardless of how poor or how remote.The in dividual special programmes are valid but intrin sically focused on a particular population, be it those with H IV /A ID S, or m other and child health.W H O is at risk from losing sight of its philosophy of equity and becoming an organisa tion of parallel programmes.

Conclusion
The principle of Alma-Ata was to develop PHC to become an integral and permanent part of the health care systems.To establish HFA2000 was hugely ambitious and although it was not ob tained it does not mean it is not possible given time and enthusiasm ; developm ent occurs in small steps rather than great leaps17.It has been estimated that $27 billion would save 8 million lives per year; this seems like a colossal amount o f money but it is still $13 billion less than America's Congress appropriated for its "War on Terrorism" only three days after the Septem ber 11th attacks; alternatively it could be looked at as being only $25 per rich-county citizen each year 18.WHO is in a unique position to influence the governments of developing countries to raise the status of health on national agendas and to re structure health systems to focus on primary health care 19.WHO will always be faced with problems of political instability and conflicts of interest but with perseverance governments will eventually realise that having a healthy popula tion is the only way of obtaining long-term, sus tainable, economic and social development.
HFA needs to be separated from WHO's Glo bal Health Targets, maybe even renamed Health by All so it is not considered a passive process 20.It must be re-established as a major global initiative that operates locally, nationally and in ternationally involving individuals, communi ties, NGOs and governments.It may even be ap propriate to separate WHO into two sister or ganisations; one dealing with the shorter-term specific "special programmes", the other striv ing for the fulfilment of HFA through develop ment of primary health care systems.

"
Tell the Ministry o f Public Health it only works fo r 15% o f the entire population.Furthermore, this 15% is made up o f mostly the privileged.The broad ranks o f the peasants can not obtain medical treatment and also do not receive medicine.The Public Health Ministry is not a people' s ministry.It should be called the Urban Public Health Ministry, or the Public Health Ministry o f the Privileged, or even the Urban Public Health Ministry o f the Privileged".Chairman Mao Dezong, June 26, 1965 1

Figure 3 :
Figure 3: Dr Bruntland -current Director-General 12 revitalising the W HO. but what has happened to HFA2000?In Dr Bruntland's 16 page opening address in July 1998 she referred to HFA only once in reference to "keeping our long term ob jective of H F A ..." I3.She seems more interested in highlighting the importance of the special pro grammes especially relating to HIV/AIDS, which are more inclined to by-pass governments and be a "global initiative" .W H O has to re-estab lish its two main roles; firstly to encourage gov ernments and NGOs to work towards health for all.and secondly, to stress the need for partner ships between health and other sectors 3.