The current Context and Challenges in International Health

The international community has been collaborating over the past decades to improve the health of populations in developing countries. The significant health gains that have been achieved are encouraging and demonstrate that progress can be made. Prominent examples are the eradication of smallpox and the near eradication of polio, leprosy and guinea worm disease. Significant reduction in infant mortality in most developing countries is notable. Increase in use of modern family planning methods has resulted in reduced fertility rates in many middle and low-income countries. At the same time, progress in other sectors such as increased literacy rates and better coverage of clean water and sanitation has contributed substantially to these health improvements.

However, the inequality between the rich and the poor is increasing. There are signs that the gains are starting to be undone in certain parts of the world. In the last 10 years, the number of poor people in sub-Saharan Africa rose by more than a third. Improvements in child mortality in the 1990s gave way to actually rising infant and child mortality rates and life expectancy figures are plummeting again. HIV/AIDS has an increasingly devastating impact on health, society and economy, affecting mostly the poorest and most vulnerable countries and populations. In addition, the transition countries of Eastern Europe and Central Asia, which used to have well functioning health systems and a health status comparable to those of Western Europe, are suffering today from economic decline and the break down of the public health system. They have lost several decades of progress in terms of health status.

Besides the opportunities that globalisation could offer, the ongoing debate highlights some negative consequences of the world wide trade and financial liberalisation. This includes the roll-back of the state and the increased role played by market forces in economic and social life. Civil society organisations and advocacy groups have successfully urged the states and the international organisations to assess the health implications of the economic policies they promote. As a remarkable step, both the World Health Assembly and the WTO Ministerial Meeting reaffirmed the priority of public health over private intellectual property [4].

The last 5 years also showed the emergence of a common focus in development cooperation. In 2000, for the first time ever, the UN put HIV/AIDS as a health and development priority issue on its agenda (UNGASS AIDS). The Millennium goals, adopted in 2000, demonstrate a broad global commitment to reduce inequalities by halving the proportion of people in extreme income poverty and hunger by 2015. These goals recognise that health emerges as a key factor in reducing poverty. More than one third of the goals are directly health-related (see Annex 2). At the end of the year 2001, health became even more firmly established in the development agenda with the publication of the findings of the WHO's Commission on Macroeconomics and Health (CMH) [5]. Besides highlighting the enormous resource gap, the report demonstrated that the linkages of health to poverty reduction and the link to long-term economic growth are bi-directional, powerful and much stronger than generally understood.

Today, many challenges remain and call for a concerted and up scaled response by the international community. They include tackling poverty and key determinants that lie outside the direct influence of the health sector, as much as tackling other key challenges that are outlined in the following paragraph. There are many possible responses to these key challenges. A selection of some major and commonly agreed upon responses are subsequently mentioned.

The burden of disease: a key challenge

• Control of Communicable Diseases
A few health conditions are today responsible for a high proportion of the health deficit of the poor. In the developing world, the burden of disease is dominated by infectious diseases, all of them so-called diseases of poverty. Childhood infectious diseases are other major contributors to ill health in developing countries. HIV/AIDS has developed into a pandemic of unprecedented dimension and with major negative impact not only on health but also on the overall development situation. Already, the rate of economic growth in sub-Saharan Africa has fallen by as much as 4% because of AIDS. Labour productivity has been cut by up to 50% in the hardest-hit countries. Malaria is a preventable disease and its near eradication in the developed world is one of the successes of Public Health. But especially throughout sub-Saharan Africa, the human and economic costs of malaria are horrendous, as malaria may cost in excess of 2 million lives and 1 percentage of economic growth per year [6]. Tuberculosis is another communicable disease closely associated with poverty. Efficient control measures and treatment are available and the disease was thought to be under control towards the end of the last century. Several poverty-related factors, including the link to the HIV/AIDS epidemic, have led to resurgence of the contemporary tuberculosis epidemic, which causes 1.5 million annual fatalities [7]. The so-called neglected diseases take a heavy toll on people's health in particular geographic areas.

• Reproductive and Child Health
Maternal and perinatal complications are to a large extent avoidable. Yet, half a million women die each year of pregnancy or childbirth, 99% of them in developing countries. Much the same is true for the perinatal and infant deaths. Reproductive rights are today considered an essential human right that should be equally valid for the populations in the poorest countries. Children are our future and any effort to improve their health development will be an investment into the development of a society.

• Control of Non-Communicable Diseases
Non-communicable diseases, such as cardiovascular diseases, diabetes, cancer or mental health problems, are on a steep increase, also in transition and developing countries. Changing smoking and diet/nutrition habits, urbanisation, social disruption and unhealthy lifestyles - often linked to poverty- are just some of the explaining factors. Accidents and violence are of increasing concern in causing injuries, disabilities and deaths.

Options for an adequate response

• Empowerment of the Civil Society and the Users of Health Services
Ownership in terms of health and health services is not only of concern to governments, but particularly also to communities. Decentralisation, the diversification of services to meet the health needs of all population subgroups, and higher transparency will increase accountability and allow for a stronger participation of the civil society in shaping health systems. The challenge for international development cooperation in health consists in linking and adopting a mix of solutions to community expressed needs that consider modern, folk and traditional medicine alike.

• Addressing the Determinants of Health
Health is undoubtedly a very complex outcome, influenced by many determinants. Not only health care delivery systems, but also the socio-economic situation (e.g. poverty, education, nutrition), environmental factors (such as water, sanitation, environmental and in-door air pollution or traffic) and social stability and security (social justice, gender relations, societal and domestic violence, political instability) have a great external impact on health status. It is evident that, in addition to the crucial contribution of the health sector, the activities of the other sectors contribute in an important way to the goal of better health for the poor and most vulnerable populations.

• Investing in Knowledge
With the current state of funding, the majority of research studies address problems of developed countries and focus on their burden of disease. Even if scientific evidence exists for problems common both in the developed and developing countries, this evidence may not be directly applicable in developing and transition countries without further feasibility and cost-effectiveness analysis. The gaps in research concerning the most pertinent health issues of developing countries are huge. Less than 10% of the spending for research and development is directed at the health problems of 90% of the world's population. Global research initiatives were initiated to address these shortcomings. They complement ongoing academic basic research and country specific operations research.

• Closing the Resource Gap
According to WHO's Commission of Macroeconomics and Health, low-income countries will need to commit additional domestic financial resources to improve the health of their populations. Existing scarce resources should be used more efficiently and those countries concerned may need to revise spending patterns. However, to solve the most burning problems, they will need increased donor support which the CMH estimated at an additional $22 billion per year by 2007, compared to the $6 billion of current official development assistance. There are other attempts to close this gap; e.g. donor coordination is increasing at all levels, joint global initiatives, such as the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) are created and health is increasingly dealt with as a global public good (e.g. vaccine development or investment in research of neglected diseases).

• Developing new Aid Modalities
Taking account of the lessons of the past, aid modalities of multilateral and bilateral agencies are changing. Based on principles such as partnership, ownership, country leadership, broad-based participation, development effectiveness and accountability, a shift away from the classical project approach to a more centralised sector and government support has been observed. Recent developments have resulted in the partial privatisation of health care provision and public private partnerships (PPP) in order to respond more effectively to the most pressing challenges. New actors, such as large private foundations, have emerged in the field of development cooperation.

• Strengthening Health Systems
The burden of disease can only be efficiently addressed by tackling its determinants and by assuring adequate performance of health systems. Unacceptably low quality of services, financial and geographical inaccessibility and cultural barriers are major factors explaining poor access to and a low level of utilisation of health care by the poorest and most vulnerable populations. The public health system in most poor and transition countries is facing major constraints. Existing scarce resources are often badly managed or not used appropriately. In recent years, many countries, both in the developed and in the developing world, have introduced reforms to improve efficient leadership, good governance and performance of their health system. Today, the private sector is an important provider of services, but coverage, quality of services and coordination by the public sector are often weak. In addition, where health systems remain centralised, they usually are not responsive to local needs and locally defined priorities.