HEALTH; a Precious Asset

Dr John Martin

Progress in fulfilling the commitments made in 1995 has not been what was hoped for. Universal access to basic health services has not been achieved and in some countries access has deteriorated, particularly for the poorest populations. At the same time major communicable diseases, notably HIV/AIDS, malaria and TB, as well as malnutrition and maternal mortality disproportionately affect the poor.

But tangible progress has been achieved in international consensus on the essential elements of human development and the need to better integrate economic, environmental and social concerns. This includes recognition of the centrality of health - as a critical input to development; as an outcome of development, which must be consciously pursued; and as a fundamental human right with a value in and of itself.

The wealth of poor people is their capabilities and "assets". Of these assets, health is the most important to the poor. A fit, strong body is an asset, while a sick, weak, disabled body is a liability, both to the person, as well as to those who must support them. Enjoyment of good health, or even mediocre health, is key to productivity. When breadwinners experience episodes of ill health, long-term disability or death, the results can be disastrous - the entire household suffers due to loss of income combined with the cost of medical care. This is a common cause of impoverishment itself.

From this perspective protecting and promoting health are central to the entire process of poverty eradication and human development. As such they should be goals of development policy shared by all sectors - economic, environmental and social. Leaving health to the health sector, alone, will not work. The major determinants of health, including poverty itself, are beyond the control of health services.

Today's reality remains that health components of poverty reduction programmes are largely absent or marginal. On the one hand health authorities limit their responsibility to the production of publicly funded health services. On the other the architects of poverty reduction policies neglect the human and social capital contributions of health to sustainable livelihoods.

It is WHO's contention that development policy needs to be put on a new, more effective track by recognizing the value of good health status as one of the most important assets of the poor. On that basis the protection and improvement of health status of poor and vulnerable populations should become a core international development strategy to be shared by all actors in the development process - social, economic and environmental.

As its particular contribution to the development of such a strategy WHO has proposed that the following areas of action be pursued as integral components of the follow-up to Copenhagen Plus Five. They require action at global, regional and country levels, in close collaboration with a range of development partners.

1. Global Policy for Social Development

WHO is engaged in the UN-wide effort to help take forward the process of global policy development. WHO's particular contributions will include:

• Working with other agencies of the UN system to integrate health into their policies and programmes, recognizing that beneficial influences on health are often found outside the health sector. This work builds on initiatives in the following areas: employment, education, macroeconomic policy, environment, transport, nutrition, food security, housing, developing equitable health financing systems, trade in health goods and services.
  
  
• building country capacities to assess the impact and design responses to economic, technological , cultural and political aspects of globalization on health equity and the health status of poor and vulnerable populations
  
  
• strengthening governance for social development through development and advocacy of health protection norms and standards for the guidance of the international and national business sectors

2. Integrating Health Dimensions into Social and Economic Policy

Macroeconomic policy has a major impact on countries' abilities to protect and improve the health status of their citizens, particularly the poor and vulnerable. Human migration, rapid urbanization, increased road traffic, are both results of macroeconomic policy and, through their effects on the environment and on human health, are also massive drains on public expenditure.

(a) Health in Macroeconomic Policy
WHO is preparing the evidence for elaborating technical options and costs as the basis for more informed macroeconomic decision-making to improve the health of the poor by 2015 by governments, the World Bank, IMF, and Regional Development Banks. This draws on the work of the WHO Commission on Macroeconomics and Health.

(b) Trade in Health Goods and Services
Increasing trade in drugs, biological agents and health services, including private health insurance, have important implications for health equity, particularly access by the poor.

WHO is working with UNCTAD and WTO in order to help strengthen capacities of developing countries, especially the least developed, to analyse the consequences of agreements on trade in health services for health equity and the ability to meet the health needs of people living in poverty.

WHO is also working with other agencies to monitor and analyse the therapeutic and public health implications of relevant international agreements, including those on trade, so that governments can develop appropriate policies and regulatory measures.

(c) Health and Promotion of Full Employment
Millions of people are unable to access livelihoods or compete for employment due to chronic ill health, undernutrition and disability. For those who are employed, particularly in the informal sector, lack of occupational health and safety protection can lead to death, permanent disability and destitution.

WHO is working with ILO and other agencies to promote health protection measures in future international and national policies for full and productive employment. These measures include:

• Improving and protecting the health status of poor and vulnerable people, including the disabled, as one means of improving their employability and access to livelihoods
  
  
• Promoting safe and healthy settings for work, particularly for women in informal employment
  
  
• promoting social insurance and solidarity mechanisms, formal and informal, to protect households from the burden of health care costs arising from occupational causes, including in the informal sector
  
  
• Promoting the employability of women by creating community-based health and social services for sick and dependent family members.

3. Develop health systems that meet the needs of poor and vulnerable populations

WHO urges the international community to join forces to develop sustainable, pro-poor health systems by focusing on the following three areas.

(a) Substantial reduction in mortality due to the diseases affecting the poor disproportionately

• Resources for prevention and treatment must be redirected to focus on cost-effective interventions for the diseases and conditions that disproportionately affect the poor. These include the Expanded Program on Immunization, the Integrated Management of Childhood Illness, the Adult Lung Health Initiative, Integrated Management of Pregnancy and Childbirth, and targeted interventions for HIV/AIDS, malaria and TB.
  
  
• Health systems must better target the poor and vulnerable by directing funds, staff and supplies to facilities that are located near where they work, live and learn; by designing insurance systems to protect the poor from out-of-pocket costs; and by linking the delivery of these services to other poverty reduction programs, such as microcredit and employment training.
  
  
• More resources must be mobilised for the purchase of cost-effective medicines and supplies. These can be considered global public goods to the extent that they are directed to benefit low-income countries.

(b) More Equitable Health Financing Systems

WHO endorses the following key principles of health system financing to increase financial risk protection of the poor:

• increase levels of pre-payment for health care via general taxation or mandated social health insurance contributions,
  
  
• subsidise the poor by expanding the pool of contributors widely, so that the rich are not able to "opt-out",
  
  
• set progressive taxes or contributory rates

Many low-income countries have institutional constraints - high levels of informal work and weak revenue collection systems -- that make it difficult to develop pre-payment systems (taxes or social insurance). In the short-term, community-based pre-payment schemes can be promoted by WHO, ILO, and other UN agencies. But, in the long-term, health officials must work closely with other sectors in developing the financial infrastructure to promote greater social solidarity in health financing.

(c) Promote Responsible Health Stewardship.

Health systems have grown to encompass multiple actors, agencies, and institutions. This has made it critical for states to build new capacities to ensure achievement of societal goals. Ministries of Health require to undertake a radical change of roles - from directly providing health services to broad oversight, setting rules for financing and delivering health care by multiple providers, creating strong partnerships across diverse interests and sectors, and undertaking cross-sectoral advocacy to influence policy on the wider determinants of the health of the poor. They must be able to hold all actors accountable for country performance on agreed-upon national and international health goals.

Fulfilling this vision of strengthened health stewardship will require strong international political, financial and technical support, especially in sub-Saharan Africa and South Asia.