Health inequality

The recently released WHO World Health Report 2008, Now More Than Ever calls for a return to the values, principles and approaches of Primary Health Care. Globalisation, the report argues, has transformed the world and placed many countries and their health systems under particular stress with the result that many health systems are not delivering the goods and failing to provide even the most basic of health care.

Thirty years ago, the Alma-Ata Conference advanced the world Primary Care Movement, a set of broad principles designed to tackle the health inequalities in all countries, to place people at the centre of health, to stress social justice, and to place emphasis on the right to better health for all.

The sad reality is that in many ways these values have not been realised, and while access to health care for all is espoused by many world political leaders, success in actually delivering it has been profoundly disappointing and decidedly uneven.

There seems little doubt that moving towards health for all, produces challenges in an ever-changing globalised world: and while it is true that generally people are healthier and living longer lives today than 30 years ago; that many essential drugs have become commonplace; that there have been major advances in sanitation and water supply; and that the resources for health have never been better; the fact remains that inequality still reigns supreme and that there are still many health peaks to be climbed.

Certainly there have been many successes. If children still died at the rate they did 30 years ago, there would be about 16 million child deaths in the world today. In fact there are only about 9.5 million. This represents the equivalent of about 18,000 children’s lives saved every day.

So despite some important victories why has the global community failed to deliver on the promises made 30 years ago? A number of reasons seem to stand out.

First, global progress in health has been deeply unequal with some countries progressing in leaps and bounds while others have actually gone backwards. In the latter case, Zimbabwe comes to mind.

Second, many countries failed to anticipate and satisfactorily manage the impact of broad demographic and social change, particularly things like falling fertility, rapid population ageing, increasing population movements and urbanisation, and such trends have significantly changed the nature of health problems and impacted on health in a variety of unexpected ways.

Increasing population movement has, for example, transformed the health scene and raised the issue of infections, both old and new, to a new pedestal, while the burden of increasing chronic and degenerative disease concomitant on population ageing and “Westernisation” is fast taking central stage.

At the same time childhood infections, while declining in significance, still feature significantly in many developing countries.

All this has placed extraordinary strain on health systems and health care delivery. In addition, a complex web of other factors is also at work. This includes climate change, challenges to energy, water and food security, and social, economic and political tensions.

Health systems, particularly in the developing world, are not immune from such factors and are particularly sensitive to political and economic crises. The current health crisis in Zimbabwe is a good example as is the HIV-AIDS crisis and the way it was managed in the Republic of South Africa.

There also seems little doubt that the health sector remains massively under-resourced in many countries producing a substantial mismatch between broad expectations and actual performance. Globally, annual government expenditure on health varies from as little as $US20 per person to well over $US6, 000. Striking inequalities also exist throughout the world in access to health and health care and what people have to pay for care. For billions of people in low and middle income countries, more than 50 per cent of all health care expenditure must be met from personal resources.

Of approximately 136 million women expected to give birth this year in the world, 58 million will receive no medical care or assistance. Equally striking differences in life expectancy between the richest and the poorest countries continue to persist and the gap now exceeds 40 years. In Australia and New Zealand, life expectancy now exceeds 82 years. In parts of sub-Saharan Africa life expectancy remains below 45 years.

In an unequal world a return to primary health care principles would seem more relevant than ever before. Quite possibly, inequalities in health care are today much more marked than they were 30 years ago, and that is a major failing of world societies. We now live at a time of increasing polarisation of many societies where the well-off are generally healthier and have the best access to health care, while those at the other end of the socio-economic spectrum have much poorer health and are largely left to cope for themselves. Even in our own society we see evidence of this polarisation albeit on a more moderate scale.

In the final analysis, the WHO report argues that all societies must aim to diminish inequalities in health, eliminate all forms of health exclusion, develop health care systems that reflect people’s needs and expectations and become responsive to changing societal circumstances, to ultimately ensure that health care is available to all. The past 30 years suggests that we have made some progress in achieving these aims, but not nearly enough.