Sustainable health development – sustainable health services
Reflections and prospects
Von Marcel Tanner / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Discussing sustainable health development entails three key issues: Sustainability, health and partnership. They will be briefly reviewed and possible principles guiding the health development process and assuring it for future generations are proposed in the concluding section.
Sustainability is a key word and far too often already a buzzword in all aspects of development co-operation. We all agree that any efforts put into development processes not only aim at obtaining results within a short period, but ought to be relevant and beneficial for generations to come. Sustainable development means "…to ensure that development meets the needs of the present without compromising the ability of the future generations to meet their own needs…"(1). This definition still waits to be translated into action - fully and coherently - in the health sector. The 21 principles proposed for sustainable development by the organising group of the North/South conference (2) may well provide important stimuli and can surely guide a structured discussion of the main issues in the health sector.
While a generally agreed definition of sustainability for health development is easily established, the formulation of an operational definition, in a given social, cultural, economic and political setting is far from being achieved. A major problem that prevents effective implementation or "living" of sustainability rests already in the lack of precision or clear understanding, prevailing among most actors in the health development scene, on what needs to be sustained. Is sustainability mainly seen as a social, ecological or economical goal or as a combination of some or all these dimensions? Neglecting the careful discussion on what a comprehensive understanding of sustainability means for a given context inevitable affects sustainable development. Moreover, sustainable development is not a firm and stable state of equilibrium or harmony, but a process of change in which activities (investments, resources, institutional arrangements) must match present as well as future needs. This is of particular importance for the health sector as changes in health development issues and health sector reforms are currently frequent and also substantial: Decentralisation and health district management, cost-sharing by the population concerned, health insurance schemes, priority setting based on the assessment of disease burden (3) optimizing public-prviate mix in the service offer, sectorial funding policies….These are the key words and the concepts currently governing the discussion and being implemented within the health sector of many countries. However, they so far have hardly been coherently scrutinised in the light of our definition of sustainability, where provisions for the future and equality are underlying features.
Considering this situation, we feel that accomplishing sustainability in concrete health development activities implies focusing on the processes of decision-making based on the views and perceptions of all actors and beneficiaries. At the operational level we are therefore less interested to be guided by outcome or social and economic impact indicators such as growth, fertility, morbidity and mortality rates or gross regional or national domestic products. Accepting this view further implies substantial changes on how we approach planning in the health sector. It means a move from the prevailing, epidemiological planning concepts towards a problem-based, managerial planning approach (4).)
The understanding of health and well being is fundamental for any development process that aims at sustainability. We have readily adopted the definition of health that forms the prerequisite of the Alma Ata declaration of primary health care; health as "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity…" (5). Current day reality shows however that the views of health being the absence of disease or illness and/or health having exclusively biomedical dimensions are still far too prevalent. Clearly, in case we are really committed to assist and ensure sustainable health development, we need to adopt the comprehensive definition of health and to see health as a positive quality that one can put at risk, maintain or enhance. Adopting this view also prevents that health service provision and promotion are medicalized and that unhelpful categories such as (i) preventive and curative medicine, (ii) traditional and "modern" medicine, or (iii) clinical and social and preventive medicine continue to exist as antagonistic dichotomies that affect successful sustainable developments.
At this stage it should be noted that many bi- and multilateral governmental and non-governmental agencies have recently revised and readjusted their health development policies and promote a holistic approach to health6. The weaknesses however are clearly related to the operationalisation of the holistic approach in a given setting and, thus, to the approach used in the planning of health service provision. Health seen as a positive quality means considering measured and perceived risks, understanding of the needs and demands of the population concerned as well as an analysis of the health systems in place. This situation calls again for the problem-based planning approach mentioned above4 that includes the voices of the communities concerned. Moreover, it shows us that equality, one of the underlying principles of sustainability, means at the operational level "social equality", i.e. equity. Understanding health and health development in the terms outlined above reveals that only an interdisciplinary approach will lead us towards the transdisciplinary solution of securing sustainable health development.
Sustainability in health development cannot be discussed without addressing the crucial driving force of the process – the nature and dynamics of partnership. We have all moved from the concept and strategies of aid towards committed co-operation. It is noteworthy that this move in conceptual and strategic thinking, also at governmental and international agency level, was clearly based on and driven by the significant experience and expertise of non-governmental organisations (NGO). The sound experience of NGOs in priority setting on the basis of participatory approaches involving actors and beneficiaries and by respecting local needs and demands was of particular importance for this change. Partnership became the cornerstone of joint responsibility and driving force for joint action. However, we often forget how much the nature and pattern of partnership needs to be tailored to the changing socio-economic climate and the socio-political anatomy of a country or a region. We have to accept and tackle the challenges that partnerships and the institutional change face in a time when so many new concepts (see above) are brought into the discussion of health reform processes. Unfortunately, many actors in the health development scene lack the sensitivity for these crucial issues which may be partly explained by their less comprehensive understanding of sustainability and health as defined above.
A further point - related to the latter discussion - rests in the nature of interactions between providers and users of health services. Traditionally, providers offer a service and users consume the "products" of that specific offer. Health and health services understood in a holistic way do no longer allow to maintain this type of hierarchy but call for a partnership in which users are also providers and vice versa. Clearly, all partners of a partnership need to engage in a learning process through which problems and potential solutions are identified and related to concept and possibilities at national and international level. This concept may appear grossly visionary and/or highly unrealistic. However, we have already a wealth of convincing experience emerging from the participatory approaches (originally called "recherche-action-formation", RAF) activities in the field of agriculture, urbanisation and health generated by the NGO ENDA-Graf-Sahel in West-Africa over many years. (6) It therefore appears that all actors in health development cannot be satisfied with partnership once created, but that the nature and dynamics of partnerships may require readjustment or even new paradigms. At least we are challenged to review our partnerships. More concretely, classical formats of co-operation such as "the project" or "the programme" will require critical assessment against the background of the need for growing networks of south-south exchange, mutual assistance and collaboration. The RAF-approach offers attractive options and concrete steps towards partnerships for sustainable developments at individual and population level, i.e. partnerships of solidarity, i.e. that combine and respect the principles of equity and caring for future generations.
Based on the short review of the three key factors entailed in the theme of this paper, the following principles as theoretical and also practical guide towards sustainable health development are offered for discussion:
- Sustainability can be achieved and lived provided we become actively engaged in introducing equity and caring for the future in our health service and health promotion activities at individual, community and institutional level.
- Health and well being can be assured provided we consider health as a positive quality in any given socio-cultural and socio-economic setting where we are actively engaged in health development activities.
- Firm and committed partnerships are created and maintained provided we base them on and drive them by (i) a mutual exchange of expertise and experience and (ii) a joint analysis of problems and potentials for solutions at the individual, community and institutional level.
Input by Marcel Tanner, Director of the Swiss Tropical Institute Bael, at the MMS Workshop on Sustainable Health Cooperation as part of the North/South Conference on Sustainable Development "No future without solidarity", 25-29 May 1998, Berne, Switzerland
1. Aus "Our Common Future", Bericht der Kommission über Umwelt und Entwicklung, Oxford University Press 1987.
2. Summarised in: Working Group Swissaid/Fastenopfer/Brot für alle/Helevtas/Caritas "Was heisst nachhaltige Entwicklung", Süd-Magazin 2, 1997.
3. We refer to the assessment of disease burden DALYs (Disability Adjusted Life Years) as first introduced in the World Development Report 1993 (Investing in Health, World Bank 1993).
4. A more comprehensive discussion on this issue is provided in: Lorenz N., Kilima P., Tanner M., Garner P: "The right objectives in health care planning", World Health Forum 16, 280-282, 1995.
5. For example well presented in: WHO: "Primary Health Care", Health for All-Series # 1, Geneva 1978.
6. Comprehensive discussions of the RAF approach as well as detailed references can be found in: ENDA Graf Sahel "La ressource humaine, avenir des terroirs – recherches paysannes au Sénégal" Editions ENDA Dakar & Karthala, Paris 1993 und ENDA Graf Sahel "Réinventer le présent, quelques jalons pour l'action" Editions ENDA, Dakar 1994.