Eleventh WHO General Programme of Work, 2006-2015
A Global Health Agenda
"The analysis of the past and our understanding of the key challenges and gaps in the response, show that future progress, with less health inequity, requires strong political will, integrated policies and broad participation. Any significant progress towards the health-related Millennium Development Goals will require action in many sectors and at all levels – individual, community, national, regional and global."
The global health agenda outlined here is for all stakeholders, not just the World Health Organization. It highlights seven priority areas. The first three refer to broad areas closely related to health: investing in health to reduce poverty; building individual and global health security; and promoting universal coverage, gender equality, and health-related human rights. The other four focus on more specific tasks: tackling the determinants of health; strengthening health systems and equitable access; harnessing knowledge, science and technology; and strengthening governance, leadership and accountability.
To deal with some of the underlying determinants of health, a global framework for a health promotion strategy is needed. This is a responsibility of all government ministries at all levels, as well as communities and corporate and civil society. To take up this challenge, action in line with the Ottawa Charter is recommended: to build healthy public policies, create supportive environments, strengthen community action, develop personal skills, and reorient health services.
1. Investing in health to reduce poverty
“Eradicate extreme poverty and hunger” is the first and most important Millennium Development Goal. In all countries, poverty is associated with high childhood and maternal mortality, and increased exposure to infectious diseases, malnutrition and micronutrient deficiency. The link with poverty goes both ways: improvement in health is indispensable for reduction of poverty, and vice versa.
Improvement in the health of the poorest will maximize the effectiveness of these poverty reduction efforts. To achieve this, health systems have to become more equitable. This can be achieved, for instance, by designing fairer financing systems. This entails aligning contributions with ability to pay, and use of services with degree of need, thereby protecting people from being exposed to poverty because of health-related expenses. Such measures are linked to security: those at risk of absolute poverty need “safety nets” to protect them from catastrophic expenditure and further impoverishment. Cash transfers, food-subsidy programmes, public works and micro-credit are among the means of providing such protection. Ensuring that people have access to services essential for health may entail the use of such devices as vouchers, fee waivers for health care services, social health insurance, and fuel allowances for cooking and heating.
The role of government is central. Poverty reduction strategies, where they exist, enable policy-makers to define programmes across departments such as education, environment and health in one coherent policy process. Their success, however, depends on government ownership, and public sector capacity to focus on outcomes and track progress. Some of the most useful and accurate indicators for this are on health status. The contributions of partners such as the World Bank, the United Nations, the European Commission, and bilateral aid agencies, together with the private sector, play an important role in these coordinated efforts to reduce poverty. New forms of financing, such as the International Financing Facility, are being introduced to complement and scale up existing efforts.
2. Building individual and global health security
Global health security has become a prominent item in the international agenda. Conflicts, natural disasters, disease outbreaks and zoonoses, are increasing in number. The risk of a pandemic in humans arising from avian influenza and the associated human cases is an example. The continued increase in trade in food across borders, as well as the large numbers of people travelling between countries, can accelerate the transmission of disease to a widely dispersed population. The spread of HIV/AIDS, which has become a disaster in many countries, is an example.
At the household level in poorer communities, prevention and
control of infectious diseases is a priority, but equally important are the
health risks pertaining to food and water insecurity. Across many parts of the
world, sexual violence against women and rape is widespread and deeply ingrained.
Such causes of ill-health and premature death can be minimized by awareness,
preparedness and preventive measures.
“This Eleventh General Programme of Work covers a 10-year period from 2006 to 2015, coinciding with the time-frame for achieving the Millennium Development Goals. It reviews and restates our understanding of the determinants of health and the measures required to improve the health of populations, communities, families and individuals. It recognizes health as a shared resource and a shared responsibility. It outlines the priority problems, and says how the world must tackle them.” Foreword by Dr Lee Jong-Wook, WHO Director-General (1945-2006)
Within communities, health risks are linked to broader factors such as education, gender equality, income, and availability of food, water, fuel, and land. Further afield, trade, taxation and farm subsidies are also involved. Government plays a decisive role in all these areas, both in protecting those most at risk and in collaborating with other countries.
The United Nations system will continue to work with national authorities to build capacity to respond to health needs in times of crisis. When conflict or disasters occur, resources have to be mobilized quickly to support recovery and the transition to a sustainable health system. To the extent possible, safe and dependable primary health care, immunization, and hospital services must continue to be available in times of crisis. As the threat from pandemics such as avian influenza increases, the international community should work with national and international authorities to provide a rapid, equitable and cost-beneficial response.
3. Promoting universal coverage, gender equality, and health-related human rights
The Constitution of WHO states that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. In recent years, the scope and content of healthrelated human rights have been further clarified in international law. They oblige governments to work for the progressive realization of these rights.
One of the problems that has to be solved all over the world is the lack of access by the poor and other marginalized groups to essential health services. To achieve universal coverage, health systems characterized by adequate and equitable financing and distribution of reliable health care are required, with marginalized groups receiving priority attention. Ensuring everyone’s right to the enjoyment of the highest attainable standard of health entails expanding access to sexual and reproductive health care for all. All groups have the right to participate in the design, implementation and monitoring of health policies, programmes and legislation. In some settings it will be necessary to stress that these include people with physical or mental disabilities, refugees and displaced or migrant populations, indigenous and tribal communities, ethnic and religious minorities, people living with HIV/AIDS, widows, children, adolescents, and older people. For participation to be successful, elimination of stigma and discrimination also has to be at the forefront of the global public health agenda. Other key health-related human rights in this context include the right to benefit from scientific progress and the right to access to health information and education.
The Millennium Development Goals acknowledge that women’s empowerment and gender equality are prerequisites for development, and all the health-related goals require action in this area if they are to be achieved. Women’s health is adversely affected by the prevalence among them of poverty, lack of employment, violence and rape, limited power over their sexual and reproductive lives, and lack of influence in decision-making. Expanding access to sexual and reproductive health care is essential. Those working with governments and public health authorities must actively promote a gender perspective in the design and implementation of health policies and programmes. Monitoring and evaluation should routinely use sex-disaggregated data.
Many countries are working to expand coverage with essential
health services, by renewing their primary health care systems. This provides
an opportunity to focus on people who are marginalized or the object of discrimination,
to promote population-based and personal care services, to orient the private
sector to public health goals, and to improve access to reliable hospital care.
International public health initiatives that aim to strengthen essential health
services will do so through strengthening primary care services, and enabling
health workers to locate and help those most in need. Collaboration efforts
facilitated by WHO and its partners, such as the Global Fund to Fight AIDS,
Tuberculosis and Malaria, and the Global Alliance for Vaccines and Immunization,
will build on recent successes in disease control, such as polio eradication
and measles reduction, combining forces in new ways as the need and the opportunity
arise. Ownership at country level is a key to success. With such initiatives,
and with increases in investments from governments and international agencies,
all countries can develop their own innovative ways to reach marginalized populations,
and make plans for universal coverage in areas such as immunization; sexual
and reproductive health; continuum of care from pregnancy through motherhood,
newborn care and beyond; outbreak surveillance and response; and prevention,
treatment and care services for protection against infectious diseases such
as HIV/ AIDS, tuberculosis and malaria.
4. Tackling the determinants of health
Any serious effort to improve the health of the world’s most vulnerable people and reduce health inequities must tackle the key determinants of health. Some of these, such as income, gender roles, education, and ethnicity, are related to social exclusion; others, such as living conditions, work environment, unsafe sex and the availability of food and water are more related to exposure to risks. Broader economic, political and environmental determinants include urbanization, intellectual property rights, trade and subsidies, globalization, air pollution and climate change.
Unhealthy lifestyles, once considered a problem mainly for richer countries, have been exported throughout the world and exacerbated by increasing urbanization. The nutrition transition and the global marketing of foods high in sugar, fat and salt are driving forces in the growing epidemic of chronic noncommunicable diseases. Harmful use of alcohol is a further cause of chronic disease and mental disorders. These health problems can be reduced by a lifecourse approach to prevention and control, which includes maternal health, exclusive breast-feeding for six months, health promotion in schools and in the work-place, sex education, a healthy diet, and regular physical activity from childhood into old age. Engagement with industry is also required. Actions on some of these fronts could require government regulatory functions including law and improved enforcement capacity.
The health effects of a rapidly changing climate are likely to be negative, particularly in poorer communities. The increase in heatwaves, threatened water supplies, flooding, reduced food production, and longer transmission seasons for vector-borne diseases are likely to affect poorer communities the most. Growing urbanization is bringing with it inadequate sanitary facilities and water supplies, poor housing, overcrowding, and unhealthy working environments. Much can be done to mitigate these problems. For example better insulation of houses can lead to lower fuel consumption and reduction of indoor air pollution.
Global food insecurity is being monitored by the United Nations, which assists in providing direct access to food, and social safety nets in extreme cases. The Codex Alimentarius Commission will continue to implement the Joint FAO/WHO food standards programme to protect consumers and to facilitate trade in food.
The action required to tackle most of these determinants goes beyond the influence of ministries of health, and involves a large number of government and commercial responsibilities. If these determinants are to be dealt with effectively, therefore, the boundaries of public health action have to change. Governments, especially health ministries, must play a bigger role in formulating public policies to improve health, through collective action across many sectors. It is the responsibility of WHO to keep governments informed of the situation, raise awareness, and advocate policies to tackle the determinants when opportunities arise. This has been illustrated by the WHO global strategy on diet, physical activity and health, the reproductive health strategy and the global strategy for prevention and control of sexually transmitted infections; the Framework Convention for Tobacco Control; and findings of the Commission on Intellectual Property, Innovation and Public Health. Such policy options are expected to increase after the Commission on Social Determinants of Health publicizes its findings. For many areas, governments, with assistance from WHO, will need to engage with industry around a commonly agreed public health agenda.
5. Strengthening health systems and equitable access
Without sustained and serious investment, health systems will not be able to progress towards universal coverage, and gaps in implementation will not be closed. Strengthening health systems will be linked to broader processes of government, such as civil service reform, public expenditure reviews and reform, decentralization, and poverty-reduction strategies. All of these processes have an impact on health, yet historically health professionals have contributed little to them.
Systems in need of strengthening at all levels include leadership and governance, knowledge production, facilities and management capacity for better health service delivery, and technologies, including interventions and medicines. The work on strengthening these systems should be focused on such objectives as: increased provision of effective services to everyone who needs them, improved patient safety and financial protection, greater efficiency, expanded capacities, and policy-making that is better coordinated, more participatory, more accountable, and more fully implemented. Building up managerial skills at all levels and accommodating reform is critically important, as is the delivery of primary health care. Better national and district-level health information systems will increase the variety and effectiveness of strategies and interventions possible. Fully functional referral processes must be put in place so that people can have access to hospital or specialist care when they need it.
The problem of inequitable health outcomes for rich and poor people is an issue in all countries. This is often exacerbated by the private sector providing more care for the better off. The private sector has an important role to play, but government must show stewardship in its engagement, encouraging the business community to work towards public health goals. Social protection and financial risk sharing are needed to protect individuals from economic ruin because of their expenditure on health care.
The current crisis of human resources for health management, which includes shortages and mal-distribution of health workers, is a problem for many countries and is getting the attention of policy-makers worldwide. Demographic and epidemiological transitions, financing policies, technological advances and consumer expectations are also driving forces of change that affects health systems and workforce demands. Workers seek job opportunities in expanding international labour markets, resulting in accelerated professional migration from the poorer to the richer parts of the globe. Within countries, government leadership is necessary to foster health worker productivity by means of a national policy based on a well-informed understanding of problems such as retention difficulties, and on the views of the workers themselves. Educational activity will need to increase to prepare for the future, and financing of the health workforce should be coordinated and predictable enough to encourage equity and increases in volume. National and international efforts must be aligned to ensure adequate fiscal space for increasing investment in the workforce and to negotiate policies shaping migration and international labour markets, taking fully into account the adverse impact on developing countries of the loss of health personnel.
Many groups in civil society make essential contributions and should be part of any consultative process for major change in the health system. These groups include private providers, traditional practitioners, community-based organizations, nongovernmental organizations and home-based care providers. Communities and individuals must be involved in decision-making which affects their health, and incentives are required to enable this to happen.
6. Harnessing knowledge, science and technology
The world’s present burden of premature death and disease could be significantly alleviated by using relatively inexpensive and tested solutions within a more coherent and coordinated set of public health measures. Further scientific breakthroughs and new knowledge are also needed, however, as new knowledge and technology might provide effective treatments. For example, new technologies are required to control tuberculosis, malaria, HIV/AIDS, chronic diseases, and the health problems associated with ageing populations.
More research is required for a better understanding of the links between determinants and their consequences, and for how governments, in particular ministries of health, can best influence other government sectors. Research has not yet focused sufficiently on interventions most urgently needed by the poor, such as antibiotic delivery mechanisms for children with pneumonia, access to perinatal care, and access to treatment for neglected tropical diseases such as leishmaniasis, human African trypanosomiasis, schistosomiasis, Buruli ulcer, and Chagas disease. Opportunities provided by traditional medicines and other indigenous knowledge are also overlooked. The generation and evaluation of new technologies is an important area for the future.
To bridge the gap between knowing what to do and actually doing it, more effective national and global mechanisms are needed which apply existing knowledge and technology, and increase local capacity to conduct research. As new technology leads to more effective treatments, countries need to know how to make them affordable so as to prevent them from causing new inequities and ethical dilemmas. International finance mechanisms such as the Global Fund and Global Alliance for Vaccines and Immunization provide some guarantee for manufacturers of a secure market that allows the necessary investment to scale up production. New international support for technology development, such as grants from the Bill & Melinda Gates Foundation and the work by the International Task Force on Global Public Goods, is contributing significantly to the production of new interventions for the poor. Such initiatives are a powerful instrument for change, and require increasing efforts by WHO and other partners to establish a common agenda, with reference to national and globally agreed priorities.
Global experience continues to expand on the use of media to raise awareness of health issues such as sexual and reproductive health in adolescents and young adults. Advances continue in the use of information and communication technology to provide health care for people in remote areas or who are otherwise hard to reach, to collate health data and research findings, and to distribute information and advice. These advances are beginning to benefit poorer communities. A clear understanding of how best to use the internet to achieve public health goals is increasingly needed. Direct marketing by the private sector is likely to increase, leading individuals to choose care and some treatments without professional support. This will require further work by WHO – Member States and Secretariat – to help set standards that ensure quality and inform users.
7. Strengthen governance, leadership and accountability
At national level there is a need for strong political will, good governance, and wise leadership. Governments must have the population’s health as one of their central concerns. All public policy-making is an opportunity to bring more coherence to the delivery of health outcomes. The ministry of health must show leadership in promoting policy dialogues and intervention strategies across sectors, both public and private. This means dealing not only with health sector issues but with broader ones, such as civil service reform, macroeconomic policy, gender equality and health-related human rights.
The evidence showing the influence of health on economic growth and reductions in poverty means that health should feature prominently in national strategies for development, economic growth and reduction of poverty and inequities. The macroeconomic dialogue between the health ministry and ministries of finance and planning should focus on providing more predictable, stable and long-term financing linked to agreed objectives.
Ministries of health play the central role in shaping, regulating and managing health systems and clarifying the respective responsibilities of government, society and the individual. In considering the scaling up of interventions and services, national authorities and those that work with them should develop robust and realistic plans, based on equity, costeffectiveness and financial analyses, local commitment, and knowledge of what works locally. Pilot projects and islands of excellence do not usually lead to expanded coverage unless this is planned from the outset.
Where there is significant health sector investment by international partners, government needs the capacity to plan, manage and coordinate the cooperation. Governments, with WHO support, should persist in harmonizing and simplifying donor policies, and aligning them with commonly agreed priorities and management systems, as agreed in the 2005 Paris Declaration on Aid Effectiveness, which rightly states the five essential needs: ownership, harmonization, alignment, results, and mutual accountability. International donors, the United Nations and the global health partnerships need to follow through and ensure collective action on this declaration.
At the international level, governments will need to engage effectively with negotiated agreements such as TRIPS and the General Agreement on Trade in Services, given their increasing importance for health goods and services. Engagement with industry in general, covering areas such as food, pharmaceuticals and insurance, should continue, focusing on commonly agreed public health agendas. WHO has a responsibility to keep governments informed and engaged in the process.
Finally, the participants in public health outside government, whether they be activists, academics or business people, need forums through which they can contribute in a transparent way to global and national debates on health-related policies. Formal agreements on international health matters are generally adopted by governments in forums such as the Health Assembly. Given the growing role of non-government actors, and their importance in ensuring good governance and accountability, additional global mechanisms and forums are required that bring the broader public health community together on issues of common concern.
*Reproduction of Chapter C, “A Global Health Agenda”, of:
Engaging for Health. 11th General Programme of Work, 2006-2015. © World Health
Organization, May 2006, www.who.int/gpw/en/index.html.
All rights reserved. The Programme of Work was adopted by the World Health Assembly
in May 2006. It was presented at the MMS Symposium of 2 November 2006 by Dr.
Daniel López-Acuña, Director of Recovery and Transition Programs, Health Action
in Crisis, at WHO Headquarters in Geneva. Contact: LopezAcunaD@who.int.