How did this situation come about?
The global health discussion for the past fifty years has pivoted about two alternative strategies: either to concentrate on a limited number of cost-effective health interventions targeting the diseases that in quantitative terms cause the greatest suffering and mortality, or to build up a holistic system with a balance between preventive and curative treatment, based on a well developed primary health care service. In the 1950s, the health sector was very largely a medical matter, and health did not rank very high on the political agenda. Emphasis was placed on curative treatment at medical centres.
But towards the end of the 1960s there was growing recognition that a high proportion of disease was related to poverty, and not caused by biology alone. At the same time, public sector investment increased. Market mechanisms functioned poorly in developing countries and, in the economic thinking of the time, this legitimised governmental intervention to correct the market (6). The priority given to health and social development created an optimism that grew into a global movement, culminating in the Alma-Ata Declaration in 1978 (7). The declaration promoted a holistic approach with strong emphasis on building health systems on a foundation of primary health care (Box 1).
Box 1
Main points of the Declaration of Alma-Ata, 1978
The Declaration of Alma-Ata of 12 September 1978 urges all authorities, all health and development workers and the world community to protect and promote the health of all the peoples of the world.
Health is physical, social and mental wellbeing, not merely the absence of disease
Health is a fundamental human right and an important social goal that requires action across all sectors
The gross differences in health between different countries are politically, socially and economically unacceptable, and therefore of concern to all countries
Health for all is fundamental to sustainable economic and social development, quality of life and world peace
The people have the right and duty to participate in the planning and realisation of their health service
Governments have a responsibility for the health of their people which can be fulfilled only by the provision of good and fair health and social programmes through primary health care
The goal is that by the year 2000, all the citizens of the world should attain a level of health that permits them to live a socially and economically productive life
The primary health-care service shall be available where people live and work. It shall be based on both research and experience, and shall contribute to promotive, preventive, curative and rehabilitative services. Health-care work demands full participation from the local community
Health-care workers shall cooperate to meet local health needs, and the primary health service shall be the first element of a continuing health-care process
The government must demonstrate a political will to mobilise the country’s resources to develop and maintain the primary health service as part of a comprehensive health system
All countries must cooperate in an equitable partnership to provide health services for all because the health of one country directly concerns every other country
Health for all by the year 2000 can be achieved through better use of the world’s resources
Considerable resources are spent today on armaments and military conflict. A policy of peace will release resources that can be used for peaceful purposes as a part of social and economic development
However, with the advent of Margaret Thatcher (1979) and Ronald Reagan (1981), neo-liberal economic thinking gained ground. Developing country debt, instability and inefficiency were interpreted as failed economic policy. Because of their central role as lenders to developing countries, the World Bank and the International Monetary Fund (IMF) could demand economic and political reforms (6). In the health sector, this was reflected in large budget cuts, the emergence of private services and out-of-pocket payments for the patients. The public health sector in many low- and middle-income countries withered through the 1980s and 1990s. In these difficult times, the AIDS epidemic hit Africa like a thunderbolt.
But the rapid spread of HIV/AIDS also acted as a wake-up call, and in due course mobilised the world community into a concerted effort for global health. The Millennium Development Goals were established in the year 2000, and in the following years a number of high-profile global disease-specific initiatives were launched. Between 1990 and 2007, resources allocated to global health increased from USD 5.6 billion to USD 21.8 billion annually. So far, only a very small proportion of these funds has been earmarked for developing health systems (8), and the global health initiatives have received considerable criticism for overriding and undermining the existing health service. On the other hand, health has been awarded a central place on the global agenda during this period, and valuable new knowledge has been developed about the implementation of health measures.
Today the discussion is again tending towards the more comprehensive approach to global health. With the Paris Declaration of 2005, the international community undertook to arrange aid in such a way that the individual country can prioritise and plan public sector development (9), and in 2008 the WHO launched its report on the social determinants of health (10). This is to be followed up in autumn 2011 with the planned Rio Declaration, which is intended to secure global commitment to action.