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“Making a difference”

The World Health Organization (WHO) has recently published its 1999 World Health Report, Making A Difference. The report is a detailed presentation of the state of human health around the world. It highlights the concerns and priority areas for future action, including discussion of the links between health and development prospects. We present here extracts from the statement by the WHO Executive Director, Gro Harlem Brundtland that prefaces the report followed by extracts from the report itself.

Statement by Gro Harlem Brundtland

The world enters the 21st century with hope but also uncertainty. Remarkable gains in health, rapid economic growth and unprecedented scientific advance — all legacies of the 20th century — could lead us to a new era of human progress. But darker legacies bring uncertainty to this vision — and demand redoubled commitment.

Regional conflicts have replaced the global wars of the first half of the 20th century as a source of continued misery. Deep poverty remains all too prevalent. The sustainability of a healthy environment is still unproved. The Universal Declaration of Human Rights, now half a century old, is only a tantalizing promise to far too many of our fellow humans. The HIV/AIDS epidemic continues unchecked in much of the world, and it warns us against complacency about other, still unknown, microbial threats.

We can make a difference. Those of us who commit our lives to improving health can help to make sure that hope will predominate over uncertainty in the century to come. Human health, and its influence on every aspect of life, is central to the larger picture. With vision, commitment and successful leadership, this report argues, the world could end the first decade of the 21st century with notable accomplishments.

Many of the world’s poor people would no longer suffer today’s burden of premature death and excessive disability, and poverty itself would thereby be much reduced. Healthy life expectancy would increase for all. Smoking and other risks to health would fade in significance. The financial burdens of medical needs would be more fairly shared, leaving no household without access to care or exposed to economic ruin as a result of health expenditure. And health systems would respond with greater compassion, quality and efficiency to the increasingly diverse demands they face. Progress in the 20th century points to the real opportunity for reaching these goals.

From the report...

A century of remarkable progress has revolutionized the health conditions of most of humanity. Among high income countries, life expectancy increased by 30 to 40 years in this period. Most of today’s low and middle income countries have experienced even more dramatic gains, gains that have transformed quality of life and contributed to economic growth.

Yet, as this report documents, over a billion people will enter the 21st century without having shared in these gains: their lives remain short and scarred by disease. Many others fail to realize their full potential for better health because health systems allocate resources to interventions of low quality or of low efficacy related to cost. Increasing numbers of people forgo or defer essential care or suffer huge financial burdens resulting from an unexpected need for expensive services. The continuing challenges to health ministries and to countries thus remain enormous. Meeting those challenges will make a major difference in the quality of life worldwide. And the difference for the poor will not only be in improving their quality of life, but also, through increasing their productivity, in addressing one of the root causes of poverty.

Global leadership and advocacy for health remain critical missing ingredients in the formula for progress. The heart of both Roll Back Malaria and the Tobacco Free Initiative is global leadership. Advocacy, a function of leadership, is required to convey evidence to prime ministers and finance ministers on how investments in the health of the poor can enhance growth and reduce poverty...

What specifically, are the main challenges?

First and foremost, there is a need to reduce greatly the burden of excess mortality and morbidity suffered by the poor. The OECD’s Development Assistance Committee has established the target of halving the number of people living in absolute poverty by the year 2015. This goal is attainable but it will require major shifts in the way that governments all over the world use their resources. It will 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, which disproportionately affect poor people, as well as malaria and HIV/AIDS, which are major constraints to economic growth.

Women and children suffer poverty more than men; there is therefore a need for greater investments in reducing maternal mortality, and finding ways of improving maternal and childhood nutrition. Reducing the burden of excess mortality and morbidity also means revitalizing and extending the coverage of immunization programmes — still one of the most powerful and cost-effective technologies available. The eradication of poliomyelitis in the Americas in the past decade, and great progress in control elsewhere, hold out the promise that poliomyelitis will join smallpox as a disease known only to history.

Second, health systems must proactively counter potential threats to health resulting from economic crises, unhealthy environments or risky behaviour. Tobacco addiction is perhaps the single most important of these threats. A global commitment to tobacco control — the goal of the Tobacco Free Initiative — can potentially avert scores of millions of premature deaths in the next half century, and its success can point the way for effective control of other threats. 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 disease threat. Beyond countering specific threats, promotion of healthy lifestyles underpins a proactive strategy for risk reduction: cleaner air and water, adequate sanitation, healthy diets and safer transportation — all are important. And all are facilitated by stable economic growth and by ensuring that females as well as males have opportunities to increase their educational attainment.

Third, there is 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 health 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...

Finally, there is a 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 — and will continue to invest — massive resources in research and development oriented to the needs of the more affluent. Much of this investment benefits all humanity, but at least two critical gaps remain. One concerns research and development relevant to the infectious diseases that overwhelmingly afflict the poor. The other concerns the systematic generation of an information base that countries can use in shaping the future of their own health systems.

These challenges provide a sense of direction — for national governments, for members of the international community and for the World Health Organization as well. Each of these diverse actors will have its own specific needs, values and capacities; and each may find some of the challenges of little relevance to its own circumstances. What is important for each, however, is to focus its resources where they can make a difference...

Concentrating technical assistance on countries with a shared strategic vision will enhance impact. Concentrating resources on poor countries, on vulnerable groups without alternative sources of finance, will also amplify impact...

The international community 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 tasks include:

  • global leadership and advocacy for health;
  • generating and disseminating an evidence and information base for all countries to use;
  • catalyzing effective global disease surveillance (e.g. as is currently done with influenza);
  • setting norms and standards;
  • targeting specific global or regional health problems where the concerted action of countries is required (e.g. eradication of poliomyelitis);
  • helping to provide a voice for those whose health is neglected within their own country or who are stateless; and,
  • ensuring that critical research and development for the poor receives finance.

Making a difference for countries entails, for the World Health Organization as for others, focusing the agenda on where the return is highest. This will sometimes be country-specific technical assistance but, more often, working with countries on an agenda of common interest will make a greater difference.

Further information

The report Making A Difference can be obtained from the World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland. Fax: 41-22-7910746. Email: It is also available in Adobe PDF format from the WHO web site.

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