Access to health
services in the developed countries has been largely complete for
many years, and a few developing countries report 80 to 100 per
cent coverage. Maternal and child health services have increased in
most developing countries, but care for children under five years
of age is still very limited. Availability of essential drugs and
treatment for common diseases and injuries are quite widespread,
but lack of resources and poor transportation and communications
are still major obstacles in rural areas.
In all countries,
demand for more sophisticated health services has increased.
Overcrowded, costly hospitals in urban areas and poorly equipped
intermediate health facilities cannot satisfy the demand.
Economically sound approaches are needed to clear this bottleneck
in the health-care delivery system. Very few countries have
incorporated health goals into the revised national budgets that
have been compelled by the severe economic problems in the 1980s.
These goals can minimize the impact of disease and protect high-
risk groups most vulnerable to adverse effects of recent austerity
measures. Increased access to food and primary health care is
needed, especially for women and children, working populations at
high risk and the poor and underprivileged.
Projections of life
expectancy indicate that current inequalities in women's health
between developed and developing regions will remain largely
unaltered by the year 2010. Policies to improve female health care
in developing countries in childhood and the reproductive years
should remain a priority, especially in rural areas where maternal
mortality rates are highest. Medical examinations and basic medical
care should be brought to the village, the school, the farm, and
other places of employment.
In 1977, the
Thirtieth World Health Assembly decided that the main social goal
of Governments and WHO in the coming decades should be worldwide
attainment by the year 2000 of a level of health that would permit
all people to lead socially and economically productive lives. The
key to attaining this goal is availability of primary health care:
essential health care made accessible at a cost the country and
community can afford, with methods that are practical,
scientifically sound and socially acceptable. Everyone in the
community should have access to it and be involved in it. Primary
health care should include community education on prevalent health
problems and methods of preventing or controlling them; the
promotion of adequate food supplies, proper nutrition, sufficient
safe water and basic sanitation, and maternal and child health
care, including family planning; the prevention and control of
locally endemic diseases; immunization against the main infectious
diseases; appropriate treatment of common diseases and injuries;
and the provision of essential drugs.
In the early 1980s,
WHO estimated that primary health care could be provided in the
developing countries for $10 to $15 per person per year (excluding
food, water and sanitation). This amount is more than most
Governments spent for health during the early 1980s (among the
developing countries with data), especially in Africa and South and
Southeast Asia. Total governmental and private expenditures
combined would be sufficient to provide primary health care in many
countries, however, if the services were priced and distributed
more equitably than they are now. In the poorest countries—
mainly in South Asia and sub-Saharan Africa—the total
expenditures would have to increase by $5 or $10 per capita
(roughly 3 to 4 per cent of GDP per capita), along with development
of a wider delivery system to reach more of the rural and
low-income urban population. But as little as $1 to $5 per capita
could significantly reduce child mortality in many low income
countries, if allocated to the most cost-effective means of primary
health care and delivered by health care workers paid according to
national per capita income levels.
The mobilization and
management of financial resources for health have been identified
by WHO as critical for achieving the long-term goal of "Health for
All by the Year 2000" through primary health care. While financial
cutbacks present major problems in the short run, the best long-run
options are to tap additional and new sources of domestic
resources, and to make more efficient use of all available
resources. In many countries, national health plans have been found
to be too expensive to fund and implement. A greater mobilization
of domestic resources is possible: employers and employees could
contribute to health insurance plans; employers could provide
health services directly; public or private institutions might be
created to attract voluntary insurance contributions;
other types of community financing might be
developed; and consumers might be required to pay direct fees for
some of the health services they use. Recent studies suggest that
it would be both equitable and efficient to charge middle-income
and upper-income groups for curative services, thus preventing
excessive consumption of free services and allowing limited
government funds to provide health care to more of the low- income
population. Even if it is necessary to charge user fees to
low-income groups, this can provide better health to more people
than systems that rely on inadequate government funds. Even if
health, broadly conceived, is accorded very high priority, national
development planners face complex trade-offs. They must try to
estimate the relative effectiveness of allocating limited resources
among investments and operating expenses for primary health care
facilities, high- technology hospitals, modern and traditional
medical training, public health education, nutrition programmes,
safe water supply and sanitation, shelter, etc. Focusing on
specific goals and timetables, such as reducing the infant
mortality rate below 50 by the year 2000, helps to mobilize the
necessary resources.
The recent rise in
concern with cost-containment in many countries is likely to
continue throughout the early 2000s. Determining the appropriate
mix of public and private services, providers and funding sources
will call for considerable research and public policy debate. There
is substantial room for improvement in the cost-efficient
allocation of resources among drugs, surgery and other methods of
health care. A strong case can also be made for a reorientation of
health services towards primary health care and rural
areas.