General health issues
Although in the past 10 years there has been a global trend towards the democratization of political systems, the much anticipated "peace dividend" has failed to materialize. Poverty has continued, and will continue, to be a major obstacle to health development. The number of poor people has increased substantially, both in the developing world and among underprivileged groups and communities within developed as well as developing countries. During the second half of the 1980s, the number of people in the world living in extreme poverty increased, and was estimated at over 1.1 billion in 1990 - more than one-fifth of humanity.
The changing demographic picture across the world, together with the rapid shift towards urbanization, will have profound implications for the delivery of health services. The unplanned and often chaotic growth of megacities in the developing world will pose particular challenges, as poor sanitation and housing encourage the spread of infectious diseases.
Against any optimism about the global economy throughout the remainder of this century and beyond should be set a number of major uncertainties. There has been a disproportionate flow of resources from the developing to the developed world - poor countries paying money to rich ones - because of debt servicing and repayment and as a consequence of prices for raw materials that favour the latter at the expense of the former. Structural adjustment policies aimed at improving the economic performance of poor countries have in many cases made the situation worse. The words of Robert McNamara, spoken in 1980 when he was President of the World Bank, still hold true: "The pursuit of growth and financial adjustment without a reasonable concern for equity is ultimately socially destabilizing".
A further worrying global trend is growing unemployment, especially in developing countries without social security arrangements to cushion those out of work. Long-term unemployment is creating a new class of "untouchables" - by excluding a large group of people from the mainstream of development and society. The unemployed are a potent reminder of the dangers of assuming that the general prosperity of a country will trickle down to all its members. There is also considerable concern about the adverse health effects of continuing environmental degradation, pollution and the uncontrolled dumping of chemical wastes, diminishing natural resources, depletion of the ozone layer and predicted global climate changes.
Social mores are also undergoing profound changes, with a move towards shorter marriages and more divorces in many countries, leading to family breakdowns which have repercussions for individuals and for social services that may be called on to provide help for children and single parents.
Beyond any considerations for improving the health of the world must be the recognition that the growing world population will strain to the limit the ability of social, political, environmental and health infrastructures to cope. Health infrastructure - buildings and equipment, the staff, the drugs, the vehicles - is central to good health care. Services must be integrated, cost-effective and provided as close as possible to the people who need them.
With health resources unlikely to be greatly increased but with ever-growing demands for services, because of expanding populations and the advances of science which make more conditions treatable, the debate about the rationing of health care, with the attendant ethical problems, is likely to become intense. Hard choices will have to be made - and greatly enhanced mechanisms found for listening to the voice of the health consumer.