EDITORIALS
Shaping the future of global health
Andy Haines
Dean, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England (email: andy.haines@lshtm.ac.uk)
"Today's global health situation raises urgent questions about justice" says Dr Jong-wook LEE as he introduces The world health report 2003 Shaping the future, the first World health report to be published during his term as Director General (1). The report begins with an overview of the stark and growing inequalities in health on a global scale. Although the average life expectancy at birth has increased by almost 20 years during the last half-century, in parts of sub-Saharan Africa current adult mortality rates now exceed those of 30 years ago. More than 10 million children die of preventable causes each year (2). In 16 countries, the under-5 mortality rate is higher than it was in 1990.
Governments have committed themselves to address the challenges posed by poverty and its consequences, by agreeing to work towards the Millennium Development Goals (MDGs) (3). Progress is falling short of that needed to achieve the MDGs by 2015. WHO will focus on working with countries in order to help them tailor MDGs to their needs; to ensure that disadvantaged groups within countries share in benefits of the progress; and to urge developed countries to live up to their part of the contract. Trade, development assistance and debt are particularly important areas. WHO will also continue to advocate an increase in health assistance to reach a total of US$ 27 billion annually by 2007 (4).
WHO has committed itself to the ambitious 3-by-5 target for anti-retroviral therapy which aims to ensure that 3 million HIV-infected people in developing countries will have access to antiretroviral therapy by the end of 2005. Two of the crucial challenges are to ensure that access to high quality HIV care strengthens prevention efforts and health systems. The world health report documents some salient success stories. Brazil, for example, became one of the first countries to give free universal access to HIV care, in the context of a strong political commitment to prevention strategies. Recent figures suggest that the incidence of HIV in Brazil declined between 2000 and 2001. However, Brazil has better infrastructure than many countries with a high HIV burden. In order to reach the 3-by-5 target, successful local programmes, such as the HIV equity initiative in rural Haiti, need to be implemented on a larger scale (5).
The world health report includes an important piece of good news; polio eradication. The number of countries with endemic polio has now fallen from over 125 to 6. One key lesson was the need to deploy substantial numbers of technical and support staff in areas where formal health systems were weakest. Polio eradication is a comparatively straightforward public health task, and more complex solutions will be needed to tackle the diseases which currently claim lives and affect livelihood, particularly in least-developed countries.
WHO, through its Global Outbreak Alert and Response Network (GOARN), also played a key role in the rapid containment of the severe acute respiratory syndrome (SARS) outbreak in 2003. However, we cannot be complacent that these measures would be equally effective in other circumstances and resources need to be allocated to improve surveillance systems around the world. Better disease surveillance can only be developed with due consideration of both local and international priorities.
The world health report concludes with a discussion of how it is imperative to improve prevention and management of noncommunicable diseases (NCDs) in many countries. Diabetes, obesity, cardiovascular disease and trauma contribute to the heavy toll exacted by NCDs; five of the top 10 risks worldwide are specifically noncommunicable, (6) and 60% of deaths worldwide are attributable to NCDs. By the 2020s road traffic injuries are likely to be the third leading cause worldwide of disability-adjusted life years (DALYs) lost. Injury prevention will require intersectoral collaboration, political commitment, and an improved evidence base for interventions in low income countries.
The world health report argues persuasively that there is an urgent need for increased primary health care provision. However, the workforce crisis in many countries is likely to delay progress. Education and in-service training need to be made readily accessible to more health care professionals of all grades. Doctors and nurses are particularly likely to emigrate to wealthier countries, but assistant medical officers and other mid-level professionals are also a valuable human resource. With adequate training and support these health care workers can fill many of the roles necessary for progress towards the MDGs.
The challenges and potential responses outlined in The world health report have major implications for WHO. The emphasis on developing national capacity means that more staff will need to work in regional and country offices, a move to which Dr LEE is already committed. Country representatives will need extra support to assist countries in the process of improving their health systems. WHO has an important role as an advocate for health policy and systems research to address gaps in the evidence for action (7). The world health report outlines clear priorities and maps a way forward; the challenge now is to implement the vision. Effective action to address injustice will require collaboration with a range of partners including governments, NGOs, academic institutions, international agencies, the private sector, public private partnerships, and funding bodies. If WHO can foster and sustain a truly collaborative global coalition for health then real progress will be made towards the MDGs. 
References
Web version only, available at: http://www.who.int/bulletin