Organisation mondiale de la santé (OMS) · Technical Documents

Health for all in the 21st century

31 décembre 1997 Organisation mondiale de la santé

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WPRlRC48/8 INI!"l)OC. 1

World Health Organization Organisation mondiale de la Same

PPE/PAC/97.5 Dim.: Limited Original:Engli,h

Health for All in the 21st Century

This draft policy has been prepared in accordance with resolutions WHA48.16, ED 99.R15 and ED99.RI6. for review by WHO's Regional Committees

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Disu.: Limited Original: English

. 9~ World Health Organization Organisation mondiale de la Sante

Health for All in the 21st Century

This draft policy has been prepared in accordance with resolutions WHA48.16, EB 99.RIS and EB99.R16 for review by WHO's Regional Committees. - ".:(~~,

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Contents Ex'i!cuttve . summary .. ,... II •••••••••••••••••••••••••••••••••••••••••••••• II •••••• t •••

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Health For ALL' Origins and Renewal... .................................................. 1 Reflections on a Changing World ................................................................... 3

Towards Health for All ............................................................................. 13 Embracing Health for All ~lues ................................................................. 13 Making Health Central to Dwelopment .. ............................................... ..... 15 Building Sustainable Health Systems ........................................................... 18 ,:8) . \',

From Policy to Action ................................................................................ 27 The Role o/WHO in the 21st Century ...................................... 35

© World Health Organization 1997 This document is not issued to the general public. and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed. abstracted. quoted. reproduced or trans· lated. in part or in whole. without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic. mechanical or other - without the prior wrinen permission of WHO. The views expressed in documents by named authors are solely the responsibility of those authors.

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Executive Summary Health for AlL' Origins and Renewal • Health for All (HFA) seeks to create the conditions where people have - universally and throughout their lives - as a fundamental human right, the opportunity to reach and maintain the highest attainable level of health. The call for HFA was, and remains, a call for social justice. The vision ofHFA outlined in this document builds on the experience of the past and the promise of the future.

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The world has seen tremendous gains in health in the past 50 years. Preven tion of several diseases has greatly reduced childhood mortality. People arc living longer: the gap in life expectancy between rich and poor nations has narrowed. However, the number of people living in absolute poverty is growing steadily. Increased life expectancy, lower birth rates and lower rates ofinfectious diseases, combined with exposure to new threats, define the challenges for the future. The rate of globalization of trade, travel and migration, technology, communication and marketing has accelerated over the past two decades, resulting in gains for some groups and marginalization for others. The consequence of this for the role of the nation State in relation to health will be profound.

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Over the past two decades there has been the growing acceptance of HFA and the primary health care strategy. Despite this, public health services are often underresourced and poorly maintained. The lack of health policy and management expertise in many countries has impeded progress in building sustainable health systems.

Towards Health for All • The goals of HFA are to achieve an increase in healthy life expectancy for all people, universal access to quality health care, and health equity between and within countries. These goals will be realized through the implementation of three interrelated policy directions: embracing the values of HFA, making health central to development, and developing sustainable health systems.

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Health for All is based on the recognition of the universal right to health; the application of ethics to health policy, research and service provision; the implementation of equity-oriented policies and strategies; and the incorporation of a gender perspective into health policies and strategies. Embracing these values will influence the choices made when selecting among policy options, the way they arc made, and the interests they serve.

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Accelerated human development and economic growth must occur if the poorest people and communities are to emerge from poverty. This must be backed by substantive and sustained international support for health. education and strengthened government institutions among the poorest countries. For all countries. economic policies that enhance equity are not only ethically sound but are essential for economic growth and sustainable human development. Health interventions. especially when linked to improved education of girls. can help to break the poverty/ill-health cycle. The health sector has a vital role to play in targeting poor households and regions by focusing on problems that disproportionately affect the poor.

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Individuals. families and communities can act to improve their health given the opportunity to make choices for health. The settings where people live. work. play. and learn provide a host of opportunities for promoting health. Government can facilitate concerted action for health by creating an environment that stimulates and facilitates partnerships for health. The policies of all sectors that affect health can be aligned to promote and protect health. The centrality of health to development demands that health considerations receive ~e highest priority in sustainable development plans.

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Health systems in all countries must be able to respond to the health and social needs of people over their life span. To accomplish this. national and local systems need to engage citizens in improving their own health through an emphasis on promotion of health. The role of government with,regard to sustainable health systems is to guarantee equity of access and to ensure that essential health system functions are maintained. Such functions include guiding sustainable health systems by developing policies that reflect people's needs. by setting standards and norms. by ensuring that supportive legislation is adopted. and by informing the public about their righu and responsibilities. It includes ensuring active surveillance at global. regional. national and local levels; making care available across the life span; preventing and controlling disease. and protecting health; encouraging scientific and technological progress; building and maintaining human resources for health; and securing an adequate level of financing to support susrainable health s y s t e m s ' ' ' ' i

From Policy to Action • There is a continuing need for strong policy capacity £0

address the major challenges

confronting governments. Policy development is a deliberative process that should proceed from assessment £0 the development of policy options, to decisions and actions in relation £0 specific policy enactments. For the process to be successful, attention should be given to building consensus at each stage. • Four operational principles guide the successful implementation of the HFA policy. These are: emphasizing health promotion and disease prevention by acting on the determinants of health, pursuing a human-centred approach to health development, ensuring that strategies are sustainable, and devising policies and actions using the best available scientific evidence. • While the range of strategies available to improve health is wide, the availability of resources is constrained. This requires that governments set priorities for action. Targets guide the implementation of the HFA policy and define priorities for action. Regional, national and local targets should complement global targets and reflect local diversity of needs and priorities. Global action and cooperation between countries provide the essential underpinning for national health. Global public health action must strive to be universally relevant.

Tbe Role ofWHO in the 21st Century • WHO - its Member States, its Secretariat and its governing bodies - has a unique mandate and a responsibility £0

guide other partners involved in global governance of

health towards attainment ofHFA. As the world's health conscience, WHO will advocate for global health, for health equity between and within countries, and identify policies and practices that are beneficial or harmful to health. WHO will continue systems for transnational threats £0:

develop global ethical and scientific norms and standards; establish global surveillance £0

health; foster innovation in science and technology;

facilitate technical cooperation and mobilise resources for the poorest countries and communities; provide leadership for the eradication, elimination or control of selected diseases; support public health emergency prevention and rehabilitation; and provide leadership to a global alliance for health to address the determinants of health. WHO at the international level and the health sector at the national and local levels must ensure that all partners for health, at all levels of society, are able to

fulfil their roles and

responsibilities in implementing the HFA policy. Committed action by all is critical to transforming the HFA vision into a practical and sustainable public health reality.

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II Health for AllOrigins and Renewal Section J highlights the extent ofglobal progress lowards Healt" for Ail ill the past

50 yean Despite this progress, gains in health are 110t shared eqllally. This section identifies emerging threats and opportunities for health ill the twenty-first cmtllry. 1. Health for All (HFA) seeks to create the conditions where people have - universally and throughout their lives - as a fundamental human right, the opportunity to reach and maintain the highest attainable level of health. Health for All in the 21st Century presents the values and principles to guide action and policy for health at global, regional, na....

tional and local levels. Governmental and nongovernmental organizations and other sectors committed to these principles can find common ground to bring a visionary idea to fruition. Health for All in the 21 st Century suggests global priorities and targets for the first two decades of the next century. These will be periodically updated, taking into account progress achieved and new constraints and opportunities.

WHO's constitutional mandate 2. Over a half century ago, the Member States of the World Health Organization defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". The Constitution of WHO proclaimed "the health of all peoples ... fundamental in the attainment of peace and security and ... dependent upon the fullest cooperation of individuals and states". This was the vision and the commitment in post-War 1946, an era in which the spirit of building a safe and sane world gave health a central place. In the closing years of the 20th century, our challenge is to build on the achievements of the past to shape a world where ethical principles underpin our knowledge and technology to create a healthy and secure world.

Health for all' origins and renewal 3. The concept of Health for All as a goal for all societies was initiated in 1977 and launched at the Alma Ata Conference in 1978. Primary health care was defined and proclaimed as the strategy to attain this goal. Health for All advanced a vision of the universai attainment by the year 2000 of a level of health that would permit all people to lead socially and economically productive lives. The call for HFA was - and remains, fundamentally - a call for social justice.

HFARenewal The HFA renewalproctSswas initiated in 1995 to ensure that individuals. countries and organizations will be pr~p~ed ~o ~~et the chall~~ to health that the twentyfirst cenrury will bring. The HFA renewal has followed a process of consultation with and within countries. Arrange of partners co~mitted to health. including nongovernmental organizations. academic and research communities. the private sector. theUnited Nations. Bretton Woods Bodies and the World Trade Organiza• . I· .'

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cion have been consulted. All participants in theproccss have emphasised that Health for All ie~ the'~tral visio~ for h~thin ,

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New opportunities for action 4. The vision of HFA oudined in this document builds on the experience of the past and the promise of the future. The changing world is reflected in the incorporation of a gender perspective and in the centrality of health to sustainable human development. The expanding role of civil society in governance for health reveals opportunities for alliances not foreseen 20 years ago. Acting globally to protect national and local health is pivotal. The importance of strengthening both local participation and structures for health - central features of the primary health care approach - is highlighted. 5. Evolving opportunities and the reality of an uncertain future require that HFA be seen not as a blueprint. but rather as a means to come together in pursuit of a shared goal. We must imagine the future as we wish it to be and work with dedication and inspiration to make that vision a reality. The achievement ofHFA in the twenty-first century unquestionably poses a global challenge to re-commit to

the purpose and goal of health.

On the verge of the new millenium, the availability of powerful new technologies and methods in a dynamic. resourceful and interconnected world offer a unique opportunity to make a profound difference in the lives and health of millions of people.

Reflections on a Changing World Substantial health gains 6. The world has seen tremendous gains in health in the past 50 years. These gains have been due not only to advances in science. technology and medicine. but also opportunities for women. The impact of infectious diseases has declined in many countries and smallpox has been eradicated. Prevention of a range of diseases such as measles. poliomyelitis. diphtheria and tuberculosis has greatly reduced childhood mortality. People are living longer: the average life expectancy at birth of 46 years in the 1950s has increased to 65 years in 1995. Although a gap in life expectancy between rich and poor nations remains. it has narrowed from 25 years in 1955 (Q

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panded infrastructures. rising incomes. and improved nutrition. sanitation. literacy and

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Demographic and epidemiologic changes 7. Improvements in health status throughout the world, associated with economic growth, have led to a number of demographic and epidemiological changes. Increased life expectancy, lower birth rates and a rise in noncommunicable diseases, combined with exposure to new threats, define the challenges for the future. Rapid population growth has turned a relatively "small" world into one where sheer population numbers in some countries and high consumption of resources in others compromise our chances of meeting the needs of the world's people.

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All populations are ageing: The rate of increase in the number of people older than 65 years is occurring faster in middle-and low-income countries than in advanced industrialized countries. Although the elderly in many countries enjoy better health than before, population ageing is often accompanied by an increase in noncommunicable diseases and mental health problems. This trend is already placing significant pressure on social support systems as well as requiring a shift in health services. In some countries, the medium-term impact of the demographic transition will also be fdt in terms of an absolute increase in the number of young people. The pressures of this trend on health and educational services, as well as the employment sector, are likely to continue for decades. ". ) 6 ""."

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There has been substantial progress in disease prevention and con trol and a worldwide decline in the impact of communicable diseases. Despite this, new and old infectious diseases will remain important threats to global health in the next century. There is considerable uncertainty in projections for the future because of the potential for travel and trade, urbanization, migration and microbial evolution to amplifY these diseases and create condi dons for their re-emergence. Microbial evolution, including the development of drug resistance - for example, in hospital-acquired infections, malaria, tuberculosis and sexually-transmitted diseases - further increases the risk. The potential also exists for the emergence of pathogens such as HIV and the re-emergence of diseases

such as yellow fever and dengue haemorrhagic fever that carry severe mortality. Progress in reducing malnutrition in children has stagnated. Maternal deaths are still unacceptably common. For many low-income countries. the majority of deaths still occur in children under the age of five, largely due to conditions that are preventable, or are amenable to early intervention. In many of the poorest parts of the world, these diseases and others associated with poverty will remain major contributors to the burden of disease. 10. Today, noncommunicable diseases - a heterogeneous group that includes major causes of death such as ischaemic heart disease and cancer, and major causes of disability such as mental disorders - contribute significantly to the global burden of disease. Tobacco use, consumption of a high-fat diet and other health risks will make noncommunicable diseases the dominant causes of death. disease and disability worldwide by the 2020s. Tobacco use is a risk factor for some 25 diseases. While its effects on health are well known. the sheer scale of its impact on disease now and in the future is still poorly appreciated. Injuries and violence are also likely to increase in importance. in part as a result of increased use of motor vehicles. urbanization and industrialization.

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Poverty and growing inequities . 11. Between and withi~·~~uies. certain health gaps have widened. There are alarming uends in ~ n~ber ~f diseases. rod projections for the future raise the possibility that what has be~n achieved for many cannot be maintained. Health has suffered most where economies have b~en unable to secure adequate income levels for all, where social systems hav~'collapsed and wh~e environmental resources have been poorly managed. A host of global and local environmental and social problems continue to add to the burden of disease and ill-health . • I

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The poor experience a disproportionate share of the global burden of ill-health and suffering. They often live in unsafe and overcrowded housing. They are more likely to be exposed to pollution and other health risks at home, at work and in their communities. They are more likely to consume insufficient food and food of poor quality, to

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ing to health. This reduces their opportunities in every sphere and hence their ability to lead full and productive lives. The inequities and increasing gaps between rich and poor in many countries and communities, even as economic growth continues, threaten social cohesion and are strongly related to excess mortality, violence and psychological and social stress.

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Urbanization 14. The overall impact of urbanization has meant an improvement in the quality of life and health in many countries. However, urbanization affects the social environment in a negative way when it outstrips the capacity of the infrastructure to meet people's needs. There are well-documented links between uncontrolled urban growth and the spread of infectious diseases. In addition, overcrowding and poor working conditions can lead to anxiety, depression and chronic stress, and have a detrimental effect on the quality of life of families and communities. Changes in family structure and living arrangements have had a significant impact on people's health and their capacity to cope with health and social problems. Disruption of traditional rural cultures has, in many circumstances, been accompanied by the erosion of social support systems.

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Violence is one of the most glaring features of social disintegration. It is manifest in different ways in different societies: tribal or ethnic conflict, gang warfare, and family violence. In some countries, exposure to violence in the media, combined with the ease of access to weapons and the use of alcohol and illicit drugs, has contributed to an increase in violence. In many societies there is concern for social disintegration stemming from the weakening of human relationships based on sharing and caring, the bonds sustaining and controlling intergenerational relations, and the family as a social unit.

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Environmental changes 16. Global environmental changes such as air pollution. O1.one depletion. climate change. and biodiversity loss. the cross border movement of haz.ardous products and wastes ultimately impact health. In addition to these. national and local environmental changes directly affect health. Unplanned and poorly-controlled industrialization combined with inefficient energy use in transport. manufacturing and construction pose threats to air quality in most rapidly growing cities. Indoor air pollution is a major cause of morbidity and premature death. Many industrial practices threaten health and the environment. Practices such as food processing, when done poorly. are directly associated with food poisoning. diarrhoeal diseases and other ill-defined health effects. Haz.ardous occupations, unregulated safety practices and working conditions. and increased competitiveness in changing economies contribute to occupational stress and health problems. 17. Water supply. waste disposal and sanitary conditions are key environmental determinants of human health. Water shortages hinder agricultural and industrial production in many countries. contributing to soil degradation and poverty. Clean water for domestic consumption is essential to health. and the lack of an adequate quantity and quality can further exacerbate the spread of infectious diseases. Nearly half of the world's population are affected by diseases related to insufficient and contaminated water. -::':1

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Globalization 18. National and local decisions are affected as never before by global forces and policies. The rate of globalization of trade, travel and migration, technology, communication and marketing has accelerated dramatically over the past twO decades, resulting in huge gains for some groups and severe marginalization for others, The spread of information and new technologies hold potential worldwide to help detect, prevent and mitigate the impact of disease outbreaks, famine and environmental health threats and to bring health services and education to many. The health of the world's citizens is inextricably linked and is increasingly independent of geography. The countries of the world are forced to acknowledge their interdependence by the fragility of our shared environment, an increasingly global economic system, and the potential for rapid spread of infectious diseases. There is concern for the survival of cultural and ethnic diversity with the rush to globalization in many countries.

Changing role ofthe State 19. There is a striking contrast between the world today and the world of 1948 when WHO was established. The risk of conflict on a global scale has diminished sharply, but in its place are a multitude of regional and civil conflicts. Relationships between countries, which in the late 1940s reflected colonial patterns and the Cold War, are now open to influence by a host of factors, particularly the spread of market forces and the increasing interconnectedness of countries. 20. The consequence of global political and social changes for the role of the State in general, and in relation to the preservation and promotion of health in particular, is profound. The autonomy as well as the viability of the State is under threat. Governments must function in an increasingly demanding - yet constraining - environment, with many entities imposing pressures to bring national policies in line with global and regional institutions and agreements. Governments are decentralizing and devolving responsibilities to local government and civil society. From within, corruption has eroded public confidence in governments, and in some countries even the structure of government has collapsed.

Response ofhealth systems 21. Over the past two decades there has been the growing acceptance of HFA by governments and nongovernmental organizations as a framework for improving health. A majority of countries have adopted the primary hcalth care strategy. The population's access to the elements of primary health care defined at Alma Ata has steadily increased, albeit with wide variation within populations and between countries. Primary health care, together with economic, educational and technological advances, has contributed significantly to the declines in infant and child mortality and morbidity worldwide and to the profound increases in life expectancy at birth seen over the past 20 years. Millions of children have lived [0 adulthood as a result of early health interventions. 22. Unfortunately, these gains are not universal. Public health systems and services are underresourccd and poorly maintained in many countries. Following Alma Ata, a long period elapsed before human and financial resources began to be reoriented toward primary health care. As a result, decision-making in the health sector is still dominated by professional interests that favour curative clinical medicine over preventive and promotive public health. Care for the disabled, terminally ill and frail aged is, on the whole, poorly supported. 23. In many countries, development and economic policies combine with demographic and epidemiological changes to increase the burden of disease with which health systems have to contend. The health sector is paying the price for the negative health consequences of certain economic policies and for the failure of governments in long-term measures to promote and protect health. [0

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24.

A lack ofhealrh policy and management expertise has impeded progress in defining and implementing appropriate policies and actions to build flexible and responsive health systems. The impact of this varies widely between countries. In the pooresr counrries, an absolute lack of investment in health and social services and an inability of government to raise domestic and international funds for healrh seriously hampers progress towards HFA. In other counties, failure to establish or maintain essential services has led to sragnation or deterioration in the health status of populations. Rapid growth of private health care in many middle-income countries has had a varied impact on public sector services, in some cases contributing to unsustainable cost escalation, to ineffective and inefficient care, and to inequities in access to

health care. In advanced industrialized

countries, cost control in the face of population ageing and rapid increases in the price and demand for new technologies is the basis of health care reforms.

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Towards Health for All Section 11 prollides the policy b(/sis for He(/Ith for All by addressing tbe emerging global. I"rgional and nfltiollti/ challenges find opportunities described in Section 1. This section emphasizes the /leed to focus olllhe determilltlllts ofbealth whife building slIStailiaMe health systems.

Health for All goals and policy directions 25. The goals ofHFA are to achieve: • an increase in healthy life expectancy for all people; • access for all to adequate health care of good quality; and • health equity between and within countries. 26. These goals will be realized through the implementation of three policy directions: • embracing the values of HFA; • making health central to development; and • developing sustainable health systems. 27. These policy directions are interrelated and are intended for alllevds: local. national. regional and global. Their adoption and further elaboration into specific strategies that are adequately financed. fully implemented and carefully evaluated can lead to improved health and to narrowing the gaps in health status across social and economic groups. The process of adoption should harness political, social and economic forces and reach potential parmers through expanded systems of governance for health.

Embracing Health for All Values 28. The HFA vision is people-centred and gender conscious. HFA values underpin all aspects of health policy, influencing the policy choices made, the way these choices are made, and the interests they serve. Health for All is based on the following key values: • the recognition of the universal right to

healch;

• the application of ethics to health policy, research and service provision: • the implementation of equity-oriented policies and strategies; and • the incorporation of a gender perspective into health policies and strategies.

29.

The WHO Constitution calls· the enjoyment of the highest attainable standard of health ... one of the fundamental rights of every human being... n The right to health is the right of everyone to a standard of living adequate for health and well-being. This includes food, water, clothing, housing, medical care, reproductive health and social services, and the right to security in the event of unemployment, sickness, disability, old age or lack of livelihood in circumstances beyond their control. Respect for human rights and the achievement of public health goals are complementary.

30.

A strong ethical framework that includes respect for individual choice, personal autonomy and the avoidance of harm applies to both individual and social aspects of health care and research. Advances in science and technology, engineering, communications and medicine have brought us untold opportunities to influence health. If everyone is to share in the progress and promise, ethical principles will have to anticipate and guide science and technology development and use. Scientific and technological progress are testing the boundaries of ethical norms and challenging the very notion of what makes us human. Therefore, there must be firm ethical principles on which to base decisions about matters that influence health. ,:(:1 .. ~,

31.

An equitable health system ensures universal access to adequate quality care without an excessive burden on the individual. The attainment of equity requires the reduction of unfair and unjustified differences berween individuals and groups. The measurement of inequities is the starting point for policy development and action. Equity should form the basis for international technical cooperation with countries. favouring populations and countries with the greatest burden of poverty and ill-health.

32.

A gender perspective is vital to the development and implementation of equitable health policies and strategies. It goes beyond a concern for women's reproductive role and acknowledges the effects of men's and women's socially, culturally and behaviourally determined roles and responsibilities in addition to biological differences. A gender perspective is part of the advancement of equity and includes: • gender analysis and awareness; • attention to the special needs of both women and men; • creation of opportunities for the participation of women in decision-making; and • promotion of an environment that supports the dignity. self-worth and abilities of women.

Making Health Central to Human Development Health as an indicator ofhuman development 33. Making health central to development implies that greater emphasis will be given and to to

identifying and acting on the determinants of health, in order to reverse negative trends promote health. Human development implies progressive improvements in the living conditions and quality of life enjoyed by members of a society. The purpose of development is to permit people to lead economically productive and socially satisfying lives. Health - in the sense of complete physical, mental and social well-being, as well as the absence of disease - is a fundamental goal as well as an engine of development. 34. The health of people, particularly the most vulnerable, is an indicator of the soundness of development policies. When examined by economic and social strata, sex and race, data on health status highlight disparities between different groups in society. Health reflects living conditions, it may point to inequity; and it can provide an early warning of emerging social problems.

Combatting poverty 35. Accelerated human development and economic growth in both the public and private sectors must occur if the poorest people and communities are to emerge from poverty. Such growth must be backed by substantive and sustained international support for health, education and strengthened government institutions in the poorest countries. Integrated development plans that include debt reduction and provision of credit are needed to break the vicious cycle of poverty and ill-health. The long-term health of populations depends on the provision of opportunities for sustainable livelihoods. For all countries, economic policies that enhance equity are ethically sound - as well as essential- for economic growth and sustainable human development. 36. Health interventions, especially when linked to improved education of girls and the provision of a basic public health infrastructure, can help break the povertylill-health cycle, reduce childhood mortality and lower population growth. In particular, the provision of child health and nutrition services can have a lasting positive effect on entire populations. Ready access by the poor erty reduction programmes. to

quality health care services, by outreach to

their homes if required, should be supported as an essential component of future pov-

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37.

The health sector has a vital role to play in targeting poor households and regions by focusing on problems that disproportionately affect the poor. As poverty is multidimensional, the combined efforts of many sectors will be required for the sustained alleviation of poverty. Collaboration between the health, agricultural, trade, financial, food and nutrition, education, and industry sectors is thus essential. In addition to broadbased approaches, people's health and education must be protected during periods of temporary economic hardship. Ensuring food security is closely aligned to combatting poverty.

38.

Disease control programmes that operate across large geographic regions or within specific settings may have a great impact where one or a few major diseases are contributing to poverty. For example, the control of onchocerciasis in West Mrica opened up vast new areas to agricultural development. Similarly, the control of malaria and other endemic communicable diseases has contributed significantly to food and cash crop production in many areas. In the school setting, combined food aid and deworming programmes can lead to significant gains in scholastic performance and attendance. .

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Promoting health in all settings 39. Individuals. families and communities can act to improve their health given the opportunity and the ability to make choices for health. People therefore need knowledge. awareness and skills - as well as access to the possibilities offered by society - to cope with changing patterns of vulnerability and to keep themselves and their families healthy. The settings where people live. work. play and learn provide a host of opportunities for promoting health. Social action can help to protect the young from violence and substance abuse. ensure that working conditions are conducive health and personal growth. 40. Communications technology. including interactive methods. has become an important means of sharing images and messages for health promotion to support individuals and communities in improving the quality of their lives. Health information and entertainment that reach into every community and home can allow even the most rcmote families to benefit from current knowledge. The media can playa greater role in advocating for health and health practices. They can help to raise the public profile of health and make it a topic of public debate. to

health. promote healthy

foods and recreation. and create a school environment that is supportive of learning,

Aligning sectoral policies for health 41. In government. diverse authorities take decisions that affect health including. for example. those in the sectors of agriculture. housing. energy. water and sanitation, labour. transport. trade. finance. education. environment. justice and foreign affairs. The policies of all sectors that have major direct or indirect effects on health can be analysed and aligned to

maximize opportunities

promote and protcct health. Economic and fiscal

policies can significantly influence the potential for health gains and their distribution in society. Fiscal policies that contribute to health can be encouraged; for instance. those that discourage production of harmful products and encourage consumption of nutri-

·-

tious foods and the adoption of healthy lifestyles. These policies. when combined with appropriate legislation and health education programmes. can retard and even reverse negative trends. particularly the increases in noncommunicable diseases and trauma. 42. Agricultural policies can incorporate specific disease prevention measures in irrigation schemes. actively promote integrated pest management to minimize the use of toxic chemicals. establish land usage patterns that facilitate. rather than discourage. human settlements in rural areas, encourage substitution for crops that harm health. and ensure the production of safe and sufficient foods. An energy policy that favours health should support the use of cleaner energy supplies and ensure that less hazardous and toxic waste is produced. that cleaner and more energy-efficient transport is available and that buildings are designed to be energy-efficient. The cumulative impact of such policies is substantial. Their enactment can ensure that health is not sacrificed for narrow short-term sectoral or economic gains.

Health in sustainable development 43. Health, environmental and social sustainability are inextricably linked. For development to be sustainable, its benefits must accrue to present and future generations. The centrality of health to development demands that health considerations receive the highest priority in sustainable development plans, which should aim to ensure that the opportunities for health arc equitably distributed. 44. Non-renewable resources have been dangerously over-exploited and renewable energy and natural resources are being consumed on a non-sustainable basis. The adoption of conventions and actions that discourage or prevent severe environmental degradation will benefit the health of future generations. 45. The health sector has a leading responsibility to ensure that the linkages between health and orher sectors are clearly identified, that the health impact of development activities is measured or anticipated, and that appropriate policies are developed and actions taken in support of HFA. This includes taking advantage of opportunities to improve health presented by development programmes. 46. The introduction of health indicators into environmental impact assessment will improve decision-making in the health and environment sectors. An increased understanding of the long-term cumulative effects of chemicals, the depletion of the ozone layer, climate change, low-dose radiation, and genetic manipulation of plants and animals used for food is crucial if we are to anticipate future threats to health and take timely remedial action. The health consequences of environmental changes must be integrated into accounting systems needed for sustainable development in order to create incentives for both environmental improvement and health protection.

Buildi1lg Sustainable Health Systems Meeting the needs ofpeople 47. Health systems must be able to respond to the health and social needs of people over their life span. To accomplish this, national and local systems need to reach out and engage citizens in improving their own health through an emphasis on promotion of health and prevention of disease. Health systems of the future must be flexible and responsive to pressures such as: • demographic and economic change; • change in the epidemiological patterns of disease; • expectations of health service users for quality and involvement in decision-making; and • fundamental developments in science and technology.

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48.

The creation of health starts at home and is influenced by a multitude of forces. Informed individual, family and community commitment to health is the best guarantor that improvements in health will be realized and sustained. Health services complement the actions of individuals and families by providing information to facilitate healthy living and access to quality health care and by supporting functions that maintain and promote public health. People's I;ontact with health care settings provide innumerable opportunities at every stage oflife to promote health and prevent disease and disability.

Access to primary health care

49.

Health systems can take many forms. Primary health care, as an individual's the first level of contact with the national health system, is designed to bring health care as close as possible to where people live and work. Building on primary health care, health systems should be: community-based and comprehensive, including preventive, promotive, curative and rehabilitative components; available continuously; closely linked at all levels to social and environmental services; and integrated into a wider referral system. o Souru:WHO 20 60

100

50.

A sustainable health system will actively encourage community participation in policy development. Ie will establish employment practices in the health system that are sensitive to the needs of the workforce and give priority to quality and environmental management. A socially-sensitive health system will take into account the sociocultural and spiritual needs of different groups, the variety of understandings of health and healing, and the potential of those varied understandings to exist peacefully with and mutually enrich each other. In drawing fully on community resources, health systems should combine compassion with efficiency. This must go beyond a focus on extending life and improving health, to include the relief of pain and suffering and a provision for a peaceful death.

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Essential health system functions 51. The role of government with respect to sustainable health systems is to guarantee equity of access and to ensure that essential functions are performed at the highest level of quality for al\ people. In view of the changing roles of state institutions, there is a need to give greater emphasis to ensuring that essential public health functions are maintained and that individual health care services are made universally available. Such functions complement and build on existing primary health care services. 52. These essential functions include: • guiding sustainable health systems; • ensuring active surveillance; • making care available across the life span; • preventing and controlling disease, and protecting health; • fostering the use of, and innovation in, science and technology; • building and maintaining human resources for health; and • securing adequate financing for sustainable health systems.

Guiding sustainable health systems 53. The people entrust their government with the development of a health system that meets their needs. The health sector is responsible for developing policies and priorities that reflect people's needs: by setting standards and norms, by ensuring that supportive legislation and regulations are adopted, and by informing the public about their rights and responsibilities. National laws set the basis for collective action for health, protect the vulnerable and disadvantaged from adverse economic effects, and define the boundaries and expectations of government with respect to its partners. 54. Legislation that promotes health includes measures to ensure environmental standards, the safety of food, bans on tobacco advertising and sponsorship, restrictions on alcohol promotion and access to weapons, measures to protect consumers and the entitlements of people to health care. Environmental health legislation can protect the public against exposure to a wide range of hazardous products. Legislation is required to help control violence and injury, to ensure that ethical practices are followed in medical care and research, to provide a regulatory framework for private sector health care and intersectoral action for health, and to ensure the safety of pharmaceuticals. Regulation and oversight are vital to achieving an appropriate balance between the public and private sectors. With globalization and privatization of the economy, the need for such legislation is increasing. The success of these approaches will depend on political commitment, capacity in public health law, public support and effective enforcement.

Active surveillance 55. A hallmark of a sustainable health system is its emphasis on active surveillance and monitoring. Global, regional, national and local surveillance, monitoring and early warning systems will alert the public to impending threats to health, thus allowing appropriate action to be taken. Enhanced linkages between local settings, national organizations and WHO will be made possible by improved information and communications technologies. Complementary mechanisms that monitor States' implementation of agreed obligations will be part of global surveillance. 56.

An integrated system of active surveillance and monitoring for health will focus, at least, on the following areas: infectious diseases; health status and trends, including birrh and death rates; implementation ofinternational norms, standards and regulations; progress in reducing health inequities; performance of the essential public health functions; the impact of various lifestyles on health status; transnational health problems and sectoral impacts on health.

,........,

57.

National and local information systems for health are a prerequisite for the development of effective, efficient, equitable and quality health systems. National and local monitoring, surveillance and evaluation need to provide timely information to decision-makers and the public that will facilitate evaluation and management of health systems and facili tate the best use of resources.

Quality care across the life span 58. A life span approach to health care acknowledges the complex and interrelated effects of many factors on the health of individuals and their children. Life span care emphasizes interventions with a preventive potential that extends from birth to death. 59. The life span approach is based on evidence of intergenerational effects, and on linking early facrors - present from before conception to childhood - with health in adolescence and later life. There arc many examples of conditions and b~haviour whose early prevention is important for later health. A life span approach to health promotion, prevention and care has the potential to limit disability and enhance the quality of/ife in later years. 60. Health care settings in the twenty-first century will differ from today's. A greater focus on incorporating scientific evidence into clinical practice, combined with an emphasis on quality of care, should reduce variations in diagnoses and outcomes. A wider range of care and specific services in community settings should be available directly or indirectly, such as through the use of communications technology. Hospitals should focus increasingly on providing ambulatory, technology-intensive, curative and diagnostic services. Long-term care should be primarily provided in the community through nonhospital institutional care and home-based services. This will require community solidarity and multi generational support within families.

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61.

Life span care should be available in local communities, within a health system that emphasiz.es quality of diagnosis, treatment and rehabilitation. Local health services must be able to provide essential drugs and other services to meet community needs. They should be linked electronically and by permanently-available transport ro referral centres. The relationship berween the local health service and the State will be defined ill terms of authority, responsibility and initiative. In all three of these areas, maximum freedom should be sought for local services. For quality health care, a balance must be found that best reflects community structure, resources, and needs. Close integration of health, social and environmental services, including school health and workers' health programmes will be required.

Prevmting disease and protecti11g health 62. Disease prevention for populations is crucial to human development. Disease prevention across the life span benefits individuals and communities. Community-based disease prevention and health protection services benefit all, with implementation demanding minimum individual participation. Maintenance and extension of such services, where needed, should be a priority of local government. 63. Maintaining environmental services that protect health is the responsibility of national and local governments. This includes ensuring safe water and sanitation, clean air and safe food, and managing haz.ardolls chemicals and wastes. While provision of these services often occurs outside the health sector, ensuring their implementation is the health sector's responsibility. 64. Preventive and protective services in the workplace are essential components of an integrated approach to improving the health of workers. The current emphasis on preventing exposure to specific agents and on promoting safety at work should be extended to cover all preventable conditions that affect adults in the workplace. 65. Diseases of global importance require worldwide efforts for surveillance and control, through collaboration with WHO and its international partners. For certain conditions, global eradication or elimination is feasible and desirable. The decision ro eradicate or eliminate a disease requires global consensus and action and is taken only after consideration of the likely direct and indirect benefits. Global pandemics of human immunodeficiency virus (HIV) infection, malaria, tuberculosis, tobacco-related diseases and trauma/violence are likely ro become even more important in the first quarter of the next century. The emergence oHood and water-borne infectious diseases in all countries requires global attention. For many of the poorest countries and communities, the burden of childhood infectious diseases, maternal mortality and undernutrition remains a priority demanding global support.

Fostering the use of, and innovation in, science and technology 66. Advances in science and technology have yielded substantial dividends to health in the past. Scientific and technological progress is likely to yield even greater benefits for all in the twenty-first century. Rapid progress in several fields over the next decades should allow poorer countries to take maximal advantage of developments in technology and benefit from the experiences of other countries. Communications and electronic information technologies, for instance, offer opportunities for the most remote researchers to participate fully and contribute to scientific progress. 67. Global research priorities should be directed towards areas where substantial gains are needed for health. These are complemented by Country-specific research priorities and action, through which countries will work towards improved national and global health. Global research priorities include research that: • informs health policy and improves health equity; • evaluates the effectiveness of interventions to reduce inequities in health; • identifies social, environmental and specific sectoral policies and actions that advance health: • leads to sustainable health systems: • accelerates the reduction of childhood disease, malnutrition, and maternal and perinatal mortality; • addresses changing microbial threats and develops strategies for their prevention and control: • identifies effective preventive, promotive and curative approaches to noncommunicable diseases and health consequences of ageing; and • leads to control of violence and injuries. 68. Closer partnerships between science and technology, between user~ and innovators, and between the private and public sectors will increase the chances that innovations in science will contribute to improved health worldwide through the development of technology and the implementation of research. The scope of technologies for health extends from those that provide a direct benefit to health such as genetic modification, biologicals, pharmaceuticals and medical devices to those that arc supportive of health system functions, such as telecommunications, information technologies, devices for environmental protection, and food technologies.

69.

In assessing and promoting new technologies for health, the following will be considered: their ability to contribute to life and health: to promote equity: to respect privacy and individual autonomy and their focus or diversion of attention from the determinants of health. At the same time, an effort must be made to adopt a long timeframe and wide view, as the benefits and applications of technology are not always immediately understood, realized, or affordable.

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Human resources for health 70. A well-trained and motivated workforce is essential for health systems to function well. Support by the State. WHO and their partners in training institutions should reflect the need for ongoing and comprehensive capacity-building for health. The hc:alth workforce of the twenty-first century must be capable of providing quality hc:alth services based on HFA values. A culture of health that respects and supports the right to health. ethics, equity, and gender sensitivity, and analysis in protecting and promoting public health is fundamental. This applies to personnel in public health as well as to members of the community who will increasingly provide care for people at horne and in the community. 71. In human resources planning, the current emphasis on medical and nursing personnel would be complemented by a cadre of people capable of working in a multidisciplinary and collaborative fashion. Existing gaps in the supply of public health professionals will be addressed at global and national levels through technical cooperation and international training and education. There is a need to extend the boundaries of existing developmental, environmental. social, public health and medical disciplines. The combination of new technologies and different demographic and epidemiological challenges requires that hc:alth workers' skills are constantly upgraded. To serve the public need for better information about all aspects of health. greater attention will be given to training in communications and hc:alth promotion skills. Telecommunications linkages offer new opportunities for distance learning and diagnostic support in many settings. These links will eliminate distance and allow accelerated development of human resources in poor countries and communities'. 72. The hc:alth sector should develop national health workforce policies that contribute to human resource development and deployment. National policies: address the long-term needs for a health workforce; develop institutional and individual leadership; strengthen managerial capacity; and improve the management, infrastructure and institutional environment. In addition, global and regional policies will address broader human resource issues, such as the transnational movement ofhc:alth professionals, the availability of training. and the need for international harmonization of education and service standards. ,,)

Securing adequate financing 73. Government action and regulation are needed to secure an adequate le~el of financing (through public or private sources), to promote cost containment and fiscal discipline, to provide essential drug and technology lists, and to ensure that national resources are utilized equitably to meet health needs. Close collaboration between health, finance and planning departments in government is required to achieve these objectives. When the government is the main funder of health systems, it follows that equity of access, efficiency, and cost containment are more likely.

74.

Approaches required to secure adequate levels of financing for sustainable health systems vary between countries. In many of the poorest countries, additional financing from communiry sources and international donors is required to SUppOrl essential health system functions, particularly those that benefit the poor. In middle income countries, ensuring that a large share of financing derives from a pre-paid source of revenue improves the chances of achieving equitable and efficient health services. In upper-income countries, where increased health care costs may not yield health gains, cost containment measures should be considered. All countries are encouraged to improve their analytic capabilities to ensure the equitable and efficient use of financial resourccs.

75.

In an equitable health care system, there is universal access to an adequate level of care throughout the life span. The State would have the capaciry over time to expand and improve the level of care it makes available to all. The costs of ensuring access to

essento

tial health system functions, as well as the burden of rationing, will be distributed fairly across the population. Financial mechanisms and insurance systems can be used .~

ad-

vance equiry by ensuring that the sick and the poor are supported by the healthy and employed members of sociery and designed to secure investment in health and social services for future generations.

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.11 From Policy to Action Section III describes the movement from policy to action, a deliberative and consensus-building process oftranslating the ideals ofpolicy to what is achievable il1 countries. Policy development proceeds from an assessment (Section I) to the development of options (Section II), to decisions and actiom, followed by evaluation. Key to a successful process are good govemance, a mechal1ism for developing priorities, and action guided by targets.

Strengthening policy capacity in health 76. To achieve a successful translation of policy to action, HFA policies must be relevant to the lives and health of people and to the interests of communities. Translation of these policies to action must be considered in the context of the total economic and social siruation of a country or locality; these decisions are not easy, given the multiple pressures and uncertainties of a complex policy environment. 77. Governments require a strong policy capacity to address the major challenges confronting them. Greater attention is needed in policy analysis, particularly as it relates to intersectoral action, to ensure that policies are aligned for health. Decisions should be assessed for their long-term implications, with the goal of achieving sustainable outcomes.

Good governance: a foundation for action 78. r~,

Health for All depends on the will and action of diverse sectors and partners at all levels.

Gov~rnance is

the system through which society organizes and manages the affairs of

these sectors and partners in order to achieve the goals of the people. Only with the collaboration of the many interests and sectors that impact on health can the promise of the HFA vision be realized. The participation of civil society, particularly that of nongovernmental organizations, increases the likelihood that all responsible for health will be held accountable for their actions. 79. Hallmarks of good governance for health - at all levels - are transparency,

acco~ntabil

ity and incentives that promote participation. Good governance implies that crite~ia used for decision-making. from priority-setting to allocation of resources, are publtc. Results of monitoring and evaluation of implementation are widely distributed. Within such a system, each contributor's role and responsibilities are acknowledged.

80.

National governments are obligated to ensure that health is explicitly considered when all aspects of public policy are developed: in this the health sector has a leading role. Decentralized decision-making for health. within a broad development framework in which partnership models of service provision are encouraged. will help to ensure that local needs are considered. Local participatory planning. full use of local capacity and resources. and more effective collaboration in bringing environmental. social and economic services closer to people will increase their use and strengthen community ownership of those services. Local governance of health systems, supported by national. regional. and global action. will promote healthy living and working conditions as well as access to life span care.

81.

A broader basis for international relations requires that international/foreign policy give greater emphasis to international health security and its contribution to lasting peace. Policy should acknowledge and address threats to human security. These include the health consequences of the denial of human rights. transnational threats of disease. trade in products harmful to health. environmental degradation. global inequity. migration and population growth. Countries must collaborate to develop strategies that assure mutual human security.

82.

The formation of regional economic. political and development alliances and the establishment of new bilateral and multilateral bodies should be undertaken with a view to creating new opportunities for regional governance for health. Governance within countries at similar levels of economic development allows for a common approach based on similar levels of resources and threats to health. It will be important to ensure that policies and actions occur at the level at which they have the greatest benefit for health.

Operational principles for implementation 83. Based on the HFA policy directions. four operational principles guide the implementation of the HFA policy. These are: • emphasizing health promotion and disease prevention by acting on the determinants of health: • pursuing a human-centred approach to

health development:

• ensuring that strategies are sustainable: and • devising policies and acting on the basis of the best available scientific evidence.

84.

To act on the determinants of health requires a recognition that health is attained in the context of human and social development and is a function of the social, physical, economic and cultural environment of the communities in which people live and grow. Good health is both a resource for development and an aim of development in a mutually reinforcing cycle. Consequently, it is possible to adopt a "healthy development policy'·. whereby programming in all sectors is undertaken in such a way as to maximize the opportunity to improve health, whether directly or indirectly. Promoting the creation of an enabling environment for health is one of the most imporranr strategies for the prevention of disease and disability.

85.

A human-centred approach values health and recognizes that, without good health, individuals, families, communities and nations cannot hope to achieve their social and economic goals. In this approach, health is firmly placed at the centre of the development agenda to ensure that economic and technological progress is compatible with the protection and promotion of the quality of life for all.

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86.

The sustainability of health systems has social, political, financial, technical, and managerial dimensions. Socialsustainability should be given explicit attention: by integrating health into daily community life, by developing community support, by maximizing people's participation in maintaining the health of their families and communities, and by ensuring that the poorest have access to health services. Government accountability and unwavering political support for health will be expressed by ensuring the financial sustainability of health systems and through continued attention to access and quality. Comprehensive and ongoing human resources development is a priority for ensuring that good management practices arc implemented and technical sustainability achieved.

87.

An approach based on scientific evidence requires that the values and assumptions applied are made explicit, as policy-making involves choices based on values. Evidence to

support health policy depends on a solid health research base, epidemiological research and related information on public preferences and on availability of resources. This is turn requires strengthening of scientific and technological infrastructure (capacity-building, particularly in developing countries), the promotion of health policy and systems research, and methodological innovation in measurement, analytical techniques and resource allocation models. In using the best scientific evidence, ethical values must be respected.

Setting priorities for national health action 88. While the range of strategies available to improve health is wide. the availability of resources is constrained. This requires that governments set boundaries for action and. within these boundaries. select priorities. Priority-setting requires an open. consultative approach involving key partners for health. Dialogue and the exchange of views between these groups over time will lead to the development of a shared undersranding of the major problems and options for action. Priorities should be regularly reviewed. The role of governments is important in facilitating this process. A well-defined policy and a solid analytic capacity are required to ensure that national needs take precedence when negotiating with international donors. 89. The health situation and the needs of populations must be considered in setting priorities. Epidemiological measures of the burden of disease or suffering. the effectiveness (and cost-effectiveness) of interventions. the likely trends in the absence of action. the capacity of the health sector to act or advocate for intersectoral action. and specific sectoral contributions to the burden together define the importance of the health problem. The priorities for action in a given population are defined by the impact of the problem. the benefit of interventions on reducing inequity and improving health. public suppOrt. and financial and institutional feasibility. Priority-setting should be carried out in a transparent manner. within the overall principles and approaches of the global policy.

Establishing targets 90.

An initial set of targets guides the implementation of the HFA policy and defines priorities for action for the first two decades of the next century. Targets should be measurable. reviewed periodically. and supported by the resources required for their attainment. Regional. national and local targets should be developed within the framework of the global policy and targets. reflecting the diversity of needs and priorities.

91.

The global targets will be elaborated with specific indicators of progress. The global targets reflect continuity with earlier HFA targets and those agreed in recent United Nations conferences. Not included in the global health targets. but regarded as essential to the successful achievement of HFA. are global development targets supported by Member States. In particular. these include targets for school enrolment. adult literacy. poverty reduction. gender equality and environmental sustainability.

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Health outcomes • Health equity indices. initially based on child growth measures. will be used within and between countries as a basis for promoting and monitoring equity in health by 2008. .• Maternal mortality. child monality and life expectancy targets agreed to in

UN conferences will be met by 2015 (CMR less than 45 pei 1000 population; life expectancy greater than 60 years for all countries). • The percentage of stunted children less than five years of age will be below

20% by 2010.

• The eradication ,or elimination of. the following diseases will have been achieved by 2020: polio. measles, Chagas disease, trachoma and leprosy. o

Global control programmes will substantially reduce the impact of pandemics , , • , • •r

ofTB, H1:v. malari~. tobac~ and vi~lence/traumaby 2020.

Determinants ofhealth " " • I.

• Safe drinking water. proper sanitation and food in sufficient quantity and quality will bea~i1able to ali by 2015. o

All countries will have introduced measures (legal and fiscal) an4 programmes (school. community and ~edia health education) that promote health and reduce the occurrence 'of the m~st important h~rmfullifestyles that affect their country by 2010.

Health system policies andfunctions o

All member states

will have d~el~p~d. and be implementing and monitor-

• All people will h~~e' ~~~sthroughou~their Iive~ [oquality, essential. comprehensive care, U:;cl~ding child and reproductive health services, by 2010. .~.

ing' policies consistent with thisHFA p~licy by 2005.

• Global surveiILmce ~d alert sYstems' ~upported by the use of communica, , ';"'>.," '"' '-;,.'"

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tions technology will rapidly and widely disseminate information about current and pending transnational threats to health by 2010 . • Policies and institutional mechanisms;' including ethical review processes, that support innovation in science·and appropriate use of technology for health will be ~perational at global ana country levels by 2010. 1" . '_ ,I. I,

, °10

be finalized afier duansion in, the &gional Commiltees

G~balacrioninsupportoJfnarionalheakh 92. Regional, national, or local action in isolation cannot ensure that the highest level of health will be universally attained, or that inequities in health will be reduced. Global action and cooperation between countries are also required. The following criteria will be used to select global health priorities for action: • preventable global burden of disease; • increasing disease burden, particularly in the poorest countries and communities; • diseases and health problems that transcend national borders; • global diseases and problems for which there are known health sector or intersectoral solutions that require transnational approaches; • countries where the performance of public health functions is hampered by natural or man-made disasters (including conflict) or where the institutional and human capacity for action remains weak. 93. Global public health action must be universally relevant, constituting a global public health good, where the benefit to individual countries might be low, but the benefit to all is high. Such global public health action includes active surveillance, suppOrt for research especially to address the problems of the poor, development of global ethical and scientific norms and standards. It includes the prevention, control, eradication or elimination of selected diseases or their risk factors. In addition, trade liberalization requires that greater compatibility in policy objectives be developed between international intergovernmental agencies and multinationals involved in trade and health.

Partnerships for health 94. The growing pluralism affecting the governance of the health sector is evident. Partnerships are needed between the multiple levels and sectors concerned with health, and will be a primary component of HFA implementation. Partners create a common ground where different ideologies, cultures and talents come together in a way that creates energy, unleashes imagination, and results in mutually beneficial change. Working in partnership requires that roles are defined, accountability is demonstrated and the impact of parmership actions is critically assessed. 95. Governments can Iilcilitate concerted action for health by creating an environment which stimulates and Iilcilitates partnerships for health. Both formal partnerships and community-based informal networks in different settings are needed. Such partnerships can draw upon the energy and vitality of civil society to

develop environments that are

supportive to health. Informal networks are important, but are often absent in areas undergoing rapid urbanization or migration, in refugee communities and in post-conflict situations. Establishment (or re-establishment) of cultural, sports, rdigious and women's groups through a system of local governance might enhance social cohesion and the social environment conducive to health.

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Evaluation and monitoring 96. Evaluation is a critical management tool. providing a means to assess programme performance against objectives. and the basis for shaping new policies and programmes. It is indispensable that evaluation be tied to policy analysis and recommendations. Evaluation should playa key role in a strengthened policy process and serve as the ultimate test of the success of policies. The process of evaluation should be incorporated with goal-setting in the shorr. medium and long term. 97. National and local targets based on HFA policy should reflect COUntry situations and priorities. Evaluation and monitoring systems will determine where objectives are being met or where they require attention. their level of impact. and contribute to the development of new approaches that will be of greatest benefit. using existing resources. The aim will be to provide the information needed to assess policy impact at all levels. Explicit attention will be given to evaluation of the extent to which HFA values have been incorporated at all levels into strategies and the resulting impact.

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The Role of WHO in the 21 st Century Section IV describes the role of WHO and the health sector in providing leadership to tIle multiple partners involved and committed to achieving Health for All. 98. WHO - its Member States, its Secretariat and its governing bodies - has a unique mandate and a responsibility to guide other partners involved in global governance of health towards attainment of HFA. As the world's health conscience, WHO will advocate for global health, for health equity between and within coumries; and identifY policies and practices that are beneficial or harmful to health. 99.

As global interdependence increases, so will the need for global ethical and scientific norms, standards and commitments, including some that are legally binding. WHO will give specific attemion to the developmem of performance standar~s for essemial public health functions.

100. In collaboration with relevant partners, WHO will develop international instruments that advance global health and will monitor their implementation. A strong system of global governance will allow the full implementation of existing international conventions and legally binding agreements, including the Universal Declaration of Human Rights (1948), the Imernational Covenant on Economic and Social Rights (1966), the Convention on the Rights of the Child (1989) and the Vienna Declaration and Programme of Action adopted by the Working Group on Human Rights (1993). Health is a benchmark in the monitoring of the implementation of many of these conventions. The health targets developed during the United Nations conferences of the 1990s will be incorporated into future implementation strategies in bringing this policy to action. 101. Active surveillance, assessment and anticipation of policies and actions with a global impact on health is the starting point for global action for health. WHO will ensure that global early warning and surveillance systems provide timely information about transnational threats to health. Existing early warning systems for emerging infections and for impending famine will be expanded to include other threats to health, such as legal and illegal trade in products that harm health. In addition, WHO will be particularly vigilant with respect to the attainment of equity in health, to early signs of new threats to health, and to implementation of international instruments that promote health or prevem disease. Systems that connect local, national, regional and global levels and relevant organizations will allow voices from local settings warning about threats to health or human rights to be rapidly and globally amplified, to enable concerted action.

102. WHO, in close collaboration with the international scientific and academic community, will foster an environment in which basic and applied health research can flourish and will encourage innovation in science that serves the values and needs of all. WHO will use communication technologies to connect researchers who have, by virtue of inadequate resources, been isolated from global initiatives. The development of a truly global network of centres of excellence will allow local researchers to contribute to, and benefit from, globally distributed knowledge. WHO is committed to assisting countries to develop and share their national research capacities. 103. WHO will suppOrt the effective use of existing technologies and development of new technologies in diverse countries and settings by: sharing knowledge as widely as possible, supporting improved technology forecasting, investing in education and human resources, building partnerships with the private sector and between countries, working towards policies that make technologies more affordable and available, and promoting the use of essential technologies for health. 104. Technical cooperation between WHO and countries will be integrated with other international efforts to strengthen the overall performance and sustainability of health systems. WHO will advocate for countries and development agencies to invest where the preventable disease burden among the poor remains high. WHO will support and encourage governments to strengthen their policy-making role, their management capability and systems of accountability. In doing so, WHO will support countries as they direct their health development process. The need for Strong institutional and human capacity to support health actions will be emphasized. WHO will work for the mobilization of financial resources through a strengrhened global alliance to meet the health needs of programmes and countries. Priority will be given to the poorest countries and communities, and to countries with weak institutional capabilities in health. 105. As sustainable health systems become universally established, WHO's response to public health emergencies will be primarily preventive and normative. This framework emphasizes preparedness, prevention, reconstruction and humanitarianism, with interventions carried out in close collaboration with international, national and local bodies. During post-emergency reconstruction, WHO will support governments in restoring their health systems. 106. WHO will lead efforts to eradicate, eliminate or control diseases of global importance. 107. WHO will provide leadership in strengthening the global linkage of organizations and institutions working for better health. It will strive for greater policy alignment between international and intergovernmental agencies whose work has an impact on health, as well as more integrated approaches to capacity-building, policy development and resource mobilization for health in countries. Through such an alliance, a global framework for action in multiple sectors will be developed that will promote economic, trade. and social policies and programmes that reinforce HFA values. •

The role ofWHO in the 21st Century • Act as the world's health conscience. • Develop global ethical and scientific norms. standards and commitments. • Develop international instruments that advance global health and monitor their implementation. • Establish active global surveillance and alert systems. • Foster the use of and innovation in science and technology. • Facilitate technical cooperation and mobilize resources for the poorest countries and communities. • Provide leadership for the eradication. elimination or control of selected diseases. • Provide primarily normative support to public health emergency prevention r'.....

and rehabilitation • Provide leadership to a global alliance for health to address the determinants of health.

Reaching for Health for All lOB. The pursuit of health requires courage to overcome many impediments. Healthauthorities need competence and support to implement strategies that will improve the quality oflife and health. Progress towards HFA goals will be measured in terms of the degree to which the major directions. policies and actions identified above have been implemented. In particular. this implies that: health policies will be based on HFA values. measures will be taken to combat poverty; health will be incorporated into sustainable development plans and actions. health will be promoted in all settings and sectors. and that health systems will be sustainable. 109. Accountability for achieving Health for All in the twenty-first century is widely shared.

WHO at the international level. and the health sector at the national and local levels. must ensure that all partners for health are able to fulfil their roles and responsibilities in implementing the HFA policy. Their combined actions will help to build a world in which human rights are respected. health equity is achieved and all people are able to enjoy the highest attainable level of health. Committed action on all levels is critical to transforming the HFA vision into a practical and sustainable public health reality.

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Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 31 décembre 1997

Source Organisation mondiale de la santé