Urgent work needed to rebuild health care systems

GENEVA -- Health care systems must be strengthened through focused action in countries if global health goals agreed by the international community are to be met, according to a new report published by the World Health Organization (WHO). The health care services of most developing countries require urgent investment and international support, says The World Health Report 2003 - Shaping the Future.

The renewed focus on health systems and services involves all areas of WHO work: the "3 by 5" initiative to increase the availability of antiretroviral treatment for HIV/AIDS; a newly refocused drive to reduce maternal mortality; and work on chronic diseases and mental health. All of these initiatives contribute to the development of better health care in countries - and all require stronger health systems to succeed.

The urgency of the challenge faced today is illustrated by the contrasting prospects of baby girls born at the same moment in Japan and Sierra Leone. While the baby born in Japan can expect to live for about 85 years, life expectancy for the child in one of Africa's poorest countries is just 36 years. The Japanese girl will receive some of the world's best health care whenever she needs it, but the girl in Sierra Leone may never see a doctor, nurse or health worker.

Health for all remains the goal

"These global health gaps are unacceptable," said Dr LEE Jong-wook, Director-General of WHO. "Twenty-five years ago, the Declaration of Alma-Ata on Primary Health Care challenged the world to embrace the principles of health for all as the way to overcome gross health inequalities between and within countries," said Dr Lee.

"The principles defined at that time remain indispensable for a coherent vision of global health. Turning that vision into reality calls for clarity both on the possibilities and on the obstacles that have slowed and in some cases reversed progress towards meeting the health needs of all people. This means working with countries - especially those most in need - not only to confront health crises, but to construct sustainable and equitable health systems."

"To lend impetus to this process WHO is now making the achievement of results in countries its main objective", Dr Lee said.

Lessons learned from tackling major health challenges including SARS, HIV/AIDS, polio eradication and tobacco use demonstrate that millions of people could be saved from premature death and years of disability through a combination of financial aid and targeted improvements in health services, says The World Health Report 2003.

The report confirms that HIV/AIDS has cut life expectancy by as much as 20 years for many millions of people in sub-Saharan Africa. Every day in the poorest African countries, 5,000 men and women and 1,000 children die from HIV/AIDS.

Today only 5% of all those people living in the developing world who require antiretroviral treatment for HIV/AIDS actually receive it: a treatment gap which WHO declared a global health emergency in September 2003.

"The WHO goal of universal access to HIV/AIDS treatment, with the concrete target of providing treatment to three million people in the poorest countries by the year 2005 is a clear demonstration of how the principle of equitable access can be put into practice," said Dr Lee. "Working with our partners, we will show that investments we make in treating people with AIDS can help to build up health systems for the benefit of all."

"To meet the major health challenges facing the world, WHO is fundamentally changing the way we work. We are committed to combining new technologies with proven approaches to provide better health care for all."

Global health gaps in life expectancy growing

Today's global health situation raises urgent questions about justice. In some parts of the world there is a continued expectation of longer and more comfortable life, while in many others there is despair over the failure to control disease although the means to do so exist.

The report points out that even without the impact of HIV/AIDS, millions of children born in African countries today are at greater risk of dying before their fifth birthday than they were a decade ago.

In developing countries, communicable diseases still represent seven out of the ten major causes of child deaths. Some of the leading killers in 2002 were:

-HIV/AIDS, 2.3 million deaths
-Heart disease, 1.3 million deaths
-Tuberculosis, 1 million deaths
-Road traffic injuries, 0.8 million deaths
-Stroke, 0.8 million deaths.

The gap between developed and developing countries is also made starkly clear in the shocking statistics on maternal mortality. The risk for women of dying in childbirth is 250 times higher in poor countries than in rich ones. More than 500,000 women die each year as a result of complications during pregnancy.

Chronic diseases are the biggest killer of adults

The report also highlights the spread in developing countries of epidemics of heart disease, stroke and other chronic diseases, which in addition to communicable diseases create a "double burden" of premature death and ill-health. The report proposes a "double response" to this burden by integrating prevention and control of both communicable and noncommunicable diseases within a comprehensive health care system.

Of the 45 million deaths among adults worldwide in 2002, almost three-quarters were caused by noncommunicable diseases. These are the main cause of death in all regions, except Africa where HIV/AIDS has become the leading cause of mortality among adults aged 15-59 years. In this age group, the leading killers in 2002 were:

-Respiratory infections, 1.9 million deaths
-Diarrhoeal disease, 1.6 million deaths
-Malaria, 1.1 million deaths.

Neglect of health systems has international consequences

The continuing HIV/AIDS epidemic, deadly outbreaks of diseases such as SARS and the challenge of completing the eradication of polio are all symptoms of a failure to invest in health systems. This failure can have rapid and devastating international consequences, the report says. "Even before I took office, I travelled to China to view the impact of SARS and appreciated the importance of stronger health systems to deal with this latest epidemic. There will be more to come, hence the urgency of strengthening our ability to respond to and prevent epidemics, whether they be local or global," said Dr Lee.

The lessons learnt from such health emergencies are helping to shape strategies for an urgent health system response to the prevention and care of HIV/AIDS. This will involve complex health interventions that WHO recognizes as being not only feasible in resource-poor settings, but precisely what is needed. "The experience we will gain in responding to HIV/AIDS will eventually be applicable to the full range of chronic conditions, from diabetes to stroke," said Dr Lee.

The report suggests ways in which international support can counter some of the main health care systems weaknesses, including critical shortages of health workers, inadequate health information, a lack of financial resources and the need for more government leadership aimed at improving the health of the poorest members of society. The report calls for rapid increases in training and employment of health care workforces, and stronger government-community relationships.

"Effective action to improve population health is possible in every country but it takes local knowledge and strength and sustained international support to turn that possibility into reality. We have learned this through successes such as controlling the SARS epidemic and major advances in the polio eradication campaign, and we have learnt it through setbacks as well, such as the continuing rise of AIDS, TB and malaria. All of these lessons have prepared us for the tasks ahead," said Dr Lee.

The World Health Report 2003 - Shaping the Future, published December 18 2003 in English, French and Spanish, available through bookorders@who.int and on the Internet here.