The world health report

Global health improvement and WHO: shaping the future

A world torn by gross health inequalities is in serious trouble. The global health community can do much to reduce suffering and death among vulnerable groups. WHO is changing its way of working, alongside member states and financial and technical partners, to reach key national health goals and strengthen equity. The most urgent objectives include the health-related Millennium Development Goals, the 3 by 5 target in HIV/AIDS treatment (to provide 3 million people in developing regions with access to antiretroviral treatment by the end of 2005), and addressing the growing epidemics of non-communicable diseases. The key to achieving these objectives is strengthening of health systems guided by the values of Health For All.

Core values for a global health partnership

Effective public health action needs an ethical position as well as technical skills. To shape a healthier future, we need to be clear about our values, as well as our science. WHO's core values are those stated in its constitution, drafted in 1946. In the 1940s, as today, the world was deeply concerned with questions of security. Indeed, "to maintain international peace and security" was the primary purpose assigned to the newly-created UN.2 But the founders of WHO and the UN system clearly saw the relationship between security and justice. The preamble to the UN charter says security depends on "conditions under which justice . . . can be maintained". The authors knew that security without justice is unsustainable. We must rediscover this truth today-and act upon it. The founders of these international institutions also realised the close connection between health-understood as "a state of complete physical, mental and social wellbeing" -and the core values of justice and security. The WHO constitution identifies the "enjoyment of the highest attainable standard of health" as "one of the fundamental rights of every human being without distinction". A crucial part of justice in human relations is promotion of equitable access to health-enabling conditions. The constitution warns that the non-respect of some people's right to health may put the security of all at risk. "The health of all peoples is fundamental to the attainment of peace and security"; whereas, "Unequal development in different countries in the promotion of health and the control of disease... is a common danger" for humankind as a whole.3

During the last decades of the 20th century, health and security were often separated in national and international debates. At the national level, these two areas were assigned to different branches of governance, specifically ministries of health and the military, whose objectives and activities were seen as unrelated.4 Increasingly, however, the connections are reemerging. The UN Security Council and national bodies acknowledge the growing effect of HIV/AIDS on security.5 The threat of new infections, arising naturally or as a result of human action, demands new forms of cooperation between security and public health.

Questions of health equity and the empowerment of the poor have a personal relevance for me. As a Korean born in 1945, I grew up in a country impoverished and torn by war. Our people suffered the afflictions known to many other poor countries then and now. Koreans of my generation have not forgotten the lessons of that earlier time. We know what it means to face conflict, poverty, and widespread sickness. We know what it means to suffer injustice and to lack security. This formative experience has spurred my determination to place the health needs of the most vulnerable at the heart of WHO's agenda. I began working for WHO in 1983, during the early years of the Health For All movement. Like many colleagues, I was inspired by the commitments to equitable health improvement outlined in the 1978 declaration of Alma-Ata.6 The declaration challenged gross inequalities in health status between and within countries as "politically, socially and economically unacceptable". Setting 2000 as the ambitious target year, signatories pledged to pursue the attainment by all peoples of a level of health that would enable a dignified and productive life. Strengthening primary health care was identified as the way to attain this objective.

Much was accomplished in the decades following the Alma-Ata conference, but progress toward Health For All was slow in many countries. Reasons included insufficient political commitment, the constraints of persistent poverty, difficulty in achieving intersectoral action for health, continuing disempowerment of women, weaknesses in human resources and health information systems, and demographic and epidemiological changes including the assault of HIV/AIDS and the expanding burden of non-communicable diseases and injuries in lowincome and middle-income countries.7

The scope and content of primary health care generated frustrating debates. In some places, primary health care became a euphemism for cheap, low-quality care- second-rate health services for poor people. Meanwhile, the economic and institutional context of health-service delivery changed swiftly. The delegates at Alma-Ata could not have anticipated today's complex service delivery landscape, in which non-governmental organisations and the private sector operate in the gap left by states' withdrawal from health-care provision-a withdrawal often encouraged by international financial institutions and interests uncritically supportive of health-care privatisation.

The Alma-Ata goal of Health For All was right. So were the basic principles of primary health care: equitable access, community participation, and intersectoral approaches to health improvement. These principles must be adapted to today's context. Recent World Health Assembly resolutions show enduring commitment to Health For All and primary health care in the worldwide health community, as confirmed by the results of a WHOled global review of primary health care, involving inclusive consultations at national, regional, and international levels.8 To attack worldwide health inequalities and meet goals for today and tomorrow, we must carry forward the primary health care experience and the commitment to health equity and social justice that inspired Health For All.9,10