The World Health Report 2003 Shaping the Future World Health Organization
The World Health Report 2003 Shaping the Future World Health Organization
o World Health Organization 2003 Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health bookorders@who. int). Requests for permission to reproduce or translate WHO Publications- whether for sale or for noncommercial distribution-should be addressed to Publications, at the above address(fax: +41 22 791 4806: The designations employed and the presentation of the material in this publication do not imply the expression of any pinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, ty or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers'products does not imply that they are endorsed or commended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Information concerning this publication can be obtained from: World Health Report 1211 Geneva 27. Switzerland Fax:(+4122)7914870 Copies of this publication can be ordered from: bookorders@whoint The full report was produced under the overall direction of Tim Evans (Assistant Director-General) and Robert Beaglehole(Editor-in-Chief). The principal authors were Robert Beaglehole, Alec Irwin and Thomson Prentice The other main contributors to chapters were: Chapter One: Colin Mathers, Kenji Shibuya and Claudia Stein. Chapter Two. Andrew Cassels and Michel Thieren. Chapter Three. Paul Farmer. Chapter Four, Bruce Aylward. Chapter Five: David Heymann and Mary Kay Kindhauser. Chapter Six. Ruth Bonita and Srinath Reddy (cardiovascular diseases section): Sarah Galbraith and Douglas Bettcher(tobacco control section): Margaret MacIntyre, Margaret Peden, Mark Rozenberg and Christie Vu(road traffic hazards section). Chapter Seven. Rafael Bengoa, Ties Boerma, Marie-Andree Diouf, David Evans, William Savedoff, Alaka Singh, Barbara Stilwell, Wim Van Lerberghe and Eugenio Villar Montesine Other contributors to the report were: Prerna Banati, Michel Beusenberg, Sandro Colombo, Carlos Dora, Joan Dzenowagis, Helga Fogstad, Elangovan Gajraj, Gauden Galea, Claudio Garcia Moreno, Yusuf Hemed, Alan Hinman, Alex Kalache, Rania Kawar, Michele Levin, Alan Lopez, Abdelhay Mechbal, Lembit Rago, Shekhar Saxena, Philip Setel, Cyrus Shahpar, Hans Troedsson and Alice Yang Contributors to statistical tables were: Dorjsure Bayarsaikha, Steve Begg, Christina Bernard, Dan Chisholm, Steve Ebener, Emmanuela Gakidou Yaniss Guigoz, Patricia Hernandez, Mollie Hogan, Kim Iburg, Chandika Indikadahena, Mie Inoue, Karsten Lunze, Doris Ma Fat, Takondwa Mwase, Fanny Naville, Jean-Pierre Poullier, Chalapati Rao, Darryl Rhoades, Hossein Salehi, Joshua Salomon, Angelica Sousa, Ruben M. Suarez-Berengue U Than Sein, Niels Tomijima, Nathalie Van de Maele, Sven Volkmuth, and Hongyi Xu dalo valuable input was received from Assistant Directors-General, policy advisers to the Director-General at WHO headquarters, and many techni- aff. Additional help and advice were kindly provided by Regional Directors and members of their staff. The report was edited by Barbara Campanini, assisted by Leo Vita-Finzi. Translation coordination and other administrative and production pport was provided by Shelagh Probst, assisted by Laura Pearson and Gary Walker. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Front cover photographs(top row, left to right): reproduced with permission of Ming Pao, China, Hong Kong Special Administrative Region; WHO/P. Viros: PhotoDisc; (bottom row, left to right: WHO/P. Virot; Photo Disc; Digital Stock/Corbis. Interior design: Steve Ewart and Marilyn Langfeld yout: Steve Ewart and Reda Sadki Printed in france 2003/15424- Sadao-4500
2 The World Health Report 2003 © World Health Organization 2003 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland Fax: (+41 22) 791 4870 Copies of this publication can be ordered from: bookorders@who.int Cover design: Marilyn Langfeld Interior design: Steve Ewart and Marilyn Langfeld Layout: Steve Ewart and Reda Sadki Printed in France 2003/15424 – Sadag – 4500 The full report was produced under the overall direction of Tim Evans (Assistant Director-General) and Robert Beaglehole (Editor-in-Chief). The principal authors were Robert Beaglehole, Alec Irwin and Thomson Prentice. The other main contributors to chapters were: Chapter One: Colin Mathers, Kenji Shibuya and Claudia Stein. Chapter Two: Andrew Cassels and Michel Thieren. Chapter Three: Paul Farmer. Chapter Four: Bruce Aylward. Chapter Five: David Heymann and Mary Kay Kindhauser. Chapter Six: Ruth Bonita and Srinath Reddy (cardiovascular diseases section); Sarah Galbraith and Douglas Bettcher (tobacco control section); Margaret MacIntyre, Margaret Peden, Mark Rozenberg and Christie Vu (road traffic hazards section). Chapter Seven: Rafael Bengoa, Ties Boerma, Marie-Andrée Diouf, David Evans, William Savedoff, Alaka Singh, Barbara Stilwell, Wim Van Lerberghe and Eugenio Villar Montesinos. Other contributors to the report were: Prerna Banati, Michel Beusenberg, Sandro Colombo, Carlos Dora, Joan Dzenowagis, Helga Fogstad, Elangovan Gajraj, Gauden Galea, Claudio Garcia Moreno, Yusuf Hemed, Alan Hinman, Alex Kalache, Rania Kawar, Michele Levin, Alan Lopez, Abdelhay Mechbal, Lembit Rago, Shekhar Saxena, Philip Setel, Cyrus Shahpar, Hans Troedsson and Alice Yang. Contributors to statistical tables were: Dorjsure Bayarsaikha, Steve Begg, Christina Bernard, Dan Chisholm, Steve Ebener, Emmanuela Gakidou, Yaniss Guigoz, Patricia Hernández, Mollie Hogan, Kim Iburg, Chandika Indikadahena, Mie Inoue, Karsten Lunze, Doris Ma Fat, Takondwa Mwase, Fanny Naville, Jean-Pierre Poullier, Chalapati Rao, Darryl Rhoades, Hossein Salehi, Joshua Salomon, Angelica Sousa, Ruben M. Suarez-Berenguela, U Than Sein, Niels Tomijima, Nathalie Van de Maele, Sven Volkmuth, and Hongyi Xu. Valuable input was received from Assistant Directors-General, policy advisers to the Director-General at WHO headquarters, and many technical staff. Additional help and advice were kindly provided by Regional Directors and members of their staff. The report was edited by Barbara Campanini, assisted by Leo Vita-Finzi. Translation coordination and other administrative and production support was provided by Shelagh Probst, assisted by Laura Pearson and Gary Walker. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Front cover photographs (top row, left to right): reproduced with permission of Ming Pao, China, Hong Kong Special Administrative Region; WHO/P. Viros; PhotoDisc; (bottom row, left to right): WHO/P. Virot; PhotoDisc; Digital Stock/Corbis
Message from the Director-General Todays global health situation raises urgent questions about justice. In some parts of the world there is a continued expectation of longer and more comfortable life, while in many others there is despair over the fail ure to control disease although the means to do so exist This contrast is starkly evident in lack of access to HIVIAIDS treatment, which led me, earlier this year, to declare a global health emergency. WHO decided to take this rare measure after evaluating the global situation and finding that only 5% of those in the developing world who require LEE Jong-wook antiretrovirals(ARVs)are getting them. In sub-Saharan Africa, only 50 000 of the 4 million people in need have access to ARVs. This spells catastrophe, not only for the societies hardest hit but for the world as a whole. Our first step to respond to this crisis must be to reach 3 by 5-3 million people in developing countries on antiretrovirals by 2005 Major disparities also exist in areas such as child mortality. Of the more than 10 million children under 5 years old who die every year, almost all are in developing countries A world marked by such inequities is in very serious trouble. We have to find ways to unite our strengths as a global community to shape a healthier future. This report on the world's health, my first since taking office, gives some initial indications of how to do it. A message that runs throughout these pages is that progress in health, including rapid and sustainable expansion of emergency treatments, depends on viable national and local health systems. Scaling up ARv therapy in resource-poor settings has to be done in such a way as to strengthen health systems based on primary health care. In most countries, there will be only small and short-lived advances towards acceptable standards of health without the develop- ment of health care systems which are strong enough to respond to current challeng To lend impetus to this process WHO is now making results in countries its main objective. Effective action to improve population health is possible in every country but it takes local knowledge and strength to turn that possibility into reality. We have learnt this through suc cesses such as controlling the SARS epidemic and major advances in the polio eradication campaign, and we have learnt it through setbacks as well, such as the continuing rise of AIDS, TB and malaria. All of these lessons have prepared us for the task ahead
Message from the Director-General Today’s global health situation raises urgent questions about justice. In some parts of the world there is a continued expectation of longer and more comfortable life, while in many others there is despair over the failure to control disease although the means to do so exist. This contrast is starkly evident in lack of access to HIV/AIDS treatment, which led me, earlier this year, to declare a global health emergency. WHO decided to take this rare measure after evaluating the global situation and finding that only 5% of those in the developing world who require antiretrovirals (ARVs) are getting them. In sub-Saharan Africa, only 50 000 of the 4 million people in need have access to ARVs. This spells catastrophe, not only for the societies hardest hit but for the world as a whole. Our first step to respond to this crisis must be to reach “3 by 5” – 3 million people in developing countries on antiretrovirals by 2005. Major disparities also exist in areas such as child mortality. Of the more than 10 million children under 5 years old who die every year, almost all are in developing countries. A world marked by such inequities is in very serious trouble. We have to find ways to unite our strengths as a global community to shape a healthier future. This report on the world’s health, my first since taking office, gives some initial indications of how to do it. A message that runs throughout these pages is that progress in health, including rapid and sustainable expansion of emergency treatments, depends on viable national and local health systems. Scaling up ARV therapy in resource-poor settings has to be done in such a way as to strengthen health systems based on primary health care. In most countries, there will be only small and short-lived advances towards acceptable standards of health without the development of health care systems which are strong enough to respond to current challenges. To lend impetus to this process WHO is now making results in countries its main objective. Effective action to improve population health is possible in every country but it takes local knowledge and strength to turn that possibility into reality. We have learnt this through successes such as controlling the SARS epidemic and major advances in the polio eradication campaign, and we have learnt it through setbacks as well, such as the continuing rise of AIDS, TB and malaria. All of these lessons have prepared us for the task ahead. LEE Jong-wook Overview 3
The World Health Report 2003 Twenty-five years ago, the Declaration of Alma-Ata challenged the world to embrace the prin ciples of primary health care as the way to overcome gross health inequalities between and within countries. Health for all" became the slogan for a movement. It was not just an ideal but an organizing principle: everybody needs and is entitled to the highest possible standard of health. The principles defined at that time remain indispensable for a coherent vision of global health. Turning that vision into reality calls for clarity both on the possibilities and on the obstacles that have slowed and in some cases reversed progress towards meeting the health needs of all people. This entails working with countries-especially those most in need-not only to confront health crises, but to construct sustainable and equitable health systems I urge the global health community to set its sights on bold objectives. All countries of the world have pledged to reach the Millennium Development Goals set at the United Nations Summit in 2000. These include ambitious targets for nutrition, maternal and child health, infectious disease control, and access to essential medicines. With this support we have a real opportunity make progress that will mean longer, healthier lives for millions of peo ple, turn despair into realistic hope, and lay the foundations for improved health for genera- tions to come To reach our goals, increased resource commitments and intensified collaboration among partners will be required. The following report describes the challenges we face and points the way for a united response from WHO and the global health communit LEE Jong-wook October 2003
4 The World Health Report 2003 LEE Jong-wook Geneva October 2003 Twenty-five years ago, the Declaration of Alma-Ata challenged the world to embrace the principles of primary health care as the way to overcome gross health inequalities between and within countries. “Health for all” became the slogan for a movement. It was not just an ideal but an organizing principle: everybody needs and is entitled to the highest possible standard of health. The principles defined at that time remain indispensable for a coherent vision of global health. Turning that vision into reality calls for clarity both on the possibilities and on the obstacles that have slowed and in some cases reversed progress towards meeting the health needs of all people. This entails working with countries – especially those most in need – not only to confront health crises, but to construct sustainable and equitable health systems. I urge the global health community to set its sights on bold objectives. All countries of the world have pledged to reach the Millennium Development Goals set at the United Nations Summit in 2000. These include ambitious targets for nutrition, maternal and child health, infectious disease control, and access to essential medicines. With this support we have a real opportunity now to make progress that will mean longer, healthier lives for millions of people, turn despair into realistic hope, and lay the foundations for improved health for generations to come. To reach our goals, increased resource commitments and intensified collaboration among partners will be required. The following report describes the challenges we face and points the way for a united response from WHO and the global health community
Overview Global health is a study in contrasts. While a baby girl born in Japan today can expect to live for about 85 years, a girl born at the same moment in Sierra Leone has a life expectancy of 36 years. The Japanese child will receive vaccinations, adequate nutrition and good schooling. If she becomes a mother she will benefit from high-quality maternity care. Growing older, she may eventually develop chronic diseases, but excellent treatment and rehabilitation services ll be available; she can expect to receive, on average, medications worth about US$ 550 per year and much more if needed. Meanwhile, the girl in Sierra Leone has little chance of receiving immunizations and a high probability of being underweight throughout childhood. She will probably marry in adoles cence and go on to give birth to six or more children without the assistance of a trained birth attendant. One or more of her babies will die in infancy, and she herself will be at high risk of death in childbirth. If she falls ill, she can expect, on average, medicines worth about US$ 3 per year. If she survives middle age she, too, will develop chronic diseases but, without access to adequate treatment, she will die prematurely These contrasting stories reveal much about what medicine and public health can achiev and about unmet needs in a world of vast and growing health inequalities. The World health Report 2003 affirms that the key task of the global health community is to close the gap be- tween such contrasting lives. Building on past experience and achievements, the report pro poses solid strategies to shape a healthier, more equitable future. A key message of this report is that real progress in health depends vitally on stronger health systems based on primary health care. In most countries, there will be only limited advances towards the United Nations Millennium Development Goals and other national health pri orities without the development of health care systems that respond to the complexity of current health challenges. Systems should integrate health promotion and disease prevention on the one hand and treatment for acute illness and chronic care on the other This should be done across all levels of the health care system, with the aim of delivering quality services equitably and efficiently to the whole population. The lessons from SARS and poliomyelitis eradication programmes shape strategies for an urgent health system response to HIV/AIDS in turn, scaling up the attack on HIVIAIDS will do much to strengthen health care systems
Overview Global health is a study in contrasts. While a baby girl born in Japan today can expect to live for about 85 years, a girl born at the same moment in Sierra Leone has a life expectancy of 36 years. The Japanese child will receive vaccinations, adequate nutrition and good schooling. If she becomes a mother she will benefit from high-quality maternity care. Growing older, she may eventually develop chronic diseases, but excellent treatment and rehabilitation services will be available; she can expect to receive, on average, medications worth about US$ 550 per year and much more if needed. Meanwhile, the girl in Sierra Leone has little chance of receiving immunizations and a high probability of being underweight throughout childhood. She will probably marry in adolescence and go on to give birth to six or more children without the assistance of a trained birth attendant. One or more of her babies will die in infancy, and she herself will be at high risk of death in childbirth. If she falls ill, she can expect, on average, medicines worth about US$ 3 per year. If she survives middle age she, too, will develop chronic diseases but, without access to adequate treatment, she will die prematurely. These contrasting stories reveal much about what medicine and public health can achieve, and about unmet needs in a world of vast and growing health inequalities. The World Health Report 2003 affirms that the key task of the global health community is to close the gap between such contrasting lives. Building on past experience and achievements, the report proposes solid strategies to shape a healthier, more equitable future. A key message of this report is that real progress in health depends vitally on stronger health systems based on primary health care. In most countries, there will be only limited advances towards the United Nations Millennium Development Goals and other national health priorities without the development of health care systems that respond to the complexity of current health challenges. Systems should integrate health promotion and disease prevention on the one hand and treatment for acute illness and chronic care on the other. This should be done across all levels of the health care system, with the aim of delivering quality services equitably and efficiently to the whole population. The lessons from SARS and poliomyelitis eradication programmes shape strategies for an urgent health system response to HIV/AIDS; in turn, scaling up the attack on HIV/AIDS will do much to strengthen health care systems. Overview 5