In principle, the Millennium Development Goals relating to health make sense. Unfortunately, however, they remain disconnected from overarching approaches to health care or social policy in general. The donors’ global agenda threatens to undermine local participation and self-determination. What is required is an integrated concept geared towards the needs of the poor. It should address the affected individuals as decisive actors.
By Andreas Wulf
In 1982, the United Nations Children’s Fund, UNICEF, presented “super-weapons” for a “Child Survival and Development Revolution”. The key points were: 1. growth monitoring, 2. oral rehydration, 3. breastfeeding and 4. immunisation. At the time, similar hopes were pinned on that programme as are today on the current health care packages of the WHO Commission on Macroeconomics and Health (Sachs, 2001) or the 23 health interventions of the Bellagio Study Group on Child Survival (2003), which have proven to be effective. These instruments are expected to help achieve the health-related Millennium Development Goals (MDGs – goal 4: reduce child mortality by two thirds; goal 5: reduce maternal mortality by three quarters, goal 6: halt and begin to reverse the spread of HIV/AIDS, tuberculosis and malaria by 2015).
However, the fundamental, conceptual revolution in international health affairs occurred back in 1978. At a conference held by UNICEF and WHO in Alma-Ata, delegates from 134 member states rewrote the fundamentals on how to attain the highest possible level of health for all people. This approach (WHO 1978) deviated radically from the World Health Organisation’s previous agenda, which had relied on a largely technical understanding of health evident in eradication programmes in the 1950s and 1960s (combating malaria with DDT and chloroquine, smallpox vaccinations).
Insights from Alma-Ata
The experiences of countries that had undergone radical social change (People’s Republic of China, the State of Kerala in India, Sri Lanka, Costa Rica and Cuba) formed the basis for this reorientation. They led to a reassessment of the social determinants of health. These countries, after all, had succeeded in fundamentally improving health care and the health situation of their poor and long-neglected population strata.
The key insights of Alma-Ata were:
- Political and socio-economic conditions must be taken into account. In more concrete terms, this means that the abolition and prevention of war, poverty and hunger are necessary preconditions for health.
- Improving health requires multisectoral efforts and cannot be achieved by the health system alone. Safe drinking water, sanitary systems, housing conditions, food security and the prevention of violence are central to health promotion. All these issues require cooperative efforts by highly diverse actors.
- The affected people must be involved as actors in improving health conditions and setting up health care services. This implies reliance on local resources and decentralised decision making.
On the one hand, the Declaration of Alma-Ata clearly pointed out the responsibility of civic and governmental actors to create the basic frameworks required for “health for all people”. On the other hand, the declaration called for the affected persons to become involved in solving their problems. Both aspects conflicted with the conventional understanding of the public health service being the prime producer of health. The idea was that health professionals should re-consider their role and no longer view themselves as fighting ignorance (in terms of prevention and cure) on their own.
In addition, the re-orientation to “the highest possible level of health for all” required a massive political commitment to redistribute resources and to devolve decision making to the periphery of society. It meant creating infrastructures for poor rural regions and neglected urban slums, making intersectoral efforts, and providing better living conditions for impoverished as well as excluded segments of the population.
This approach was applauded at the international conference and spelled out in non-binding documents. Reality turned out differently. The implementation of concepts with the potential to transform society was blocked by emerging economic recession in the early 1980s as well as the Cold War’s surrogate conflicts.
In order to demonstrate an ability to act and deliver results, it seemed more promising to pursue individual health programmes. UNICEF’s “super weapons” did in fact result in declining death rates of young children, in line with increased protection given by vaccination. According to WHO/UNICEF estimates of 2003, the worldwide rates of immunisation with the six standard vaccinations (tuberculosis, measles, polio, tetanus, whooping cough and diphtheria) increased during the 1980s from 40 to 70 percent. Moreover, the mortality rates of young children (0-5 years) sank by 20 percent worldwide (UNICEF, 2001). However, living conditions did not really improve – and definitely not on a sustainable basis. This was, after all, the era in which the World Bank and the International Monetary Fund slashed the health and education budgets of many developing countries and insisted on privatising state-run institutions (Global Health Watch, 2005: 59ff).
In a peculiar way, the UN Millennium Agenda is related both to the Alma Ata principles and the “super-weapons” approach. The health-related MDGs outlined above are indeed supported by other relevant MDGs (goal 1: halving hunger, goal 2: universal primary education, goal 3: gender equality in primary and secondary schools, goal 7: environmental sustainability including access to safe drinking water and goal 8: a global partnership for development including a fair global trade system). Nonetheless, the various health-related MDGs are juxtaposed without any clear connection. While they all seem plausible in their own right, the priorities are arbitrarily set – precisely in the UNICEF tradition of 1981.
Dubious actionism
Experts from target countries and elsewhere, with good reason, ask whether we are dealing with yet another attempt to achieve good looking statistics fast, rather than tackling the daunting, overarching challenges. What is actually required is the establishment of reliable health care systems with an ability to act. They must be committed to taking care of all people’s problems and supporting these clients in emergencies. Quick success stories that satisfy financiers and make politicians look good are not to be expected. While focussed special programmes may indeed lead to isolated cases of triumph, they unfortunately also foster fragmentation. After all, they pit programmes dealing with particular health problems against one another in competition for limited resources, personnel and attention.
This is evident presently in countries such as Kenya or Tanzania, where up to 28 different health programmes are to be implemented with international funding alongside one another – including large global public-private partnerships such as “Roll back Malaria”, “Stop TB” and the “Global Alliance for Vaccines and Immunisation” (WEMOS, 2004). Even more problematic, perhaps, is the fact that the programmes’ priorities are generally prescribed from outside. This does not correspond at all to the idea of developing a culture of participation, of having a say, of ownership by health care staff as well as current and future patients – in other words, by all the relevant local actors.
It is, however, precisely such a sense of ownership that allows individuals to assume responsibility for their personal health. It is a rarely expressed paradox that this attitude can only be promoted by embedding persons in their social context, even though it is far more common to depoliticise health issues as purely private matters and then making calls for individual responsibility. In comparison, the Guatemalan village community, which concerns itself with paying their local “dental healers” fairly, is a promising model. The same could be said of voluntary First Aid groups supplying medication for the chronically ill in Palestinian towns, despite curfews during the Intifada. Indian villagers choosing the most reliable candidates from their community to be trained as health professionals are similarly pointing the right way.
The success of such commitments cannot be depicted with statistics. But they matter far beyond the individual success. They prove that health does not revolve around the activities of experts and professionals or procedures (whether they be medication, operations or even the “right” health behaviour). All summed up, health results from a collective effort in search of “good life”.
Supporting such creative processes, as is the policy of Medico International, should form a significant part of any international assistance to health promotion. This way of “investing in health” differs from what the World Bank and the WHO Commission for Macroeconomics and Health have in mind. It is not primarily about increasing the economic performance of impoverished people in Asia, Africa and Latin America, but rather about cooperating on fair terms with partners capable of setting their own health priorities.
Of course, such local processes are neither harmonious nor non-hierarchical. There are evident trends of women’s and children’s status often remaining weak, of local power politics dominating affairs and of unpleasant issues being suppressed (as is seen in the example of AIDS). It is therefore essential to support, in a focussed manner, those whose voices traditionally fall on deaf ears. Decisions imposed from outside, however, tend to trigger resistance rather than to lead to intelligent solutions.
The health-related MDG agenda is running precisely this risk. None of the goals is fundamentally wrong, but the MDGs are not embedded in any comprehensive concept. This lack of context is likely to direct attention to well expressed lip service in the debating societies of multilateral politics, while fundamentally flawed global trends (concerning, for instance, resource distribution, world trade or privatisation) remain unchallenged.
Dr. Andreas Wulf is a doctor. He works as a project coordinator for the Frankfurt-based organisation Medico International. wulf@medico.de
More Information
Sources
The Bellagio Study Group on child survival. Knowledge into action for child survival. Lancet 2003, 362: 323-27,
Global Health Watch, 2005/6: An alternative World Health Report (www.ghwatch.org)
Sachs, JD, 2001: Macroeconomics and Health: Investing in Health for Human Development. Geneva: World Health Organisation
UNICEF, 2001: Progress since the World Summit for Children: A Statistical Review, New York.
Unicef: Who we are:www.unicef.org/about/who/index_history.html
WEMOS: Risky Remedies for the Health of the Poor, 2005,
WHO. 1978: Primary Health Care, A Joint WHO-UNICEF Report, Geneva, New York, 1978
