Introduction

In 1978, 134 countries along with 67 UN organizations and NGOs, affirmed their support at the International Conference on Primary Health Care held in Alma Ata, Kazakhstan for the principle that health is a human right. Building on a World Health Assembly resolution adopted in 1977 to achieve Health for All by the Year 2000, participants unanimously adopted the Alma Ata Declaration on primary health care (PHC) as the agreed framework and strategy. The eight components comprising PHC was intended to ensure that all people have access to a comprehensive range of basic health care. This commitment seemed to promise a revolution in world health development.

Almost immediately, however, debates ensued about the practicalities of the comprehensive PHC approach. If all journeys begin with a single step, it remained unclear what first steps needed to be taken. As defined in the Alma Ata Declaration (paragraph 7.3):

Primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common disease and injuries; and provision of essential drugs.

How should resource-constrained health systems begin to create such a system? More fundamentally, how could poor countries in the developing world afford to implement such a plan? How much were donors realistically expected to contribute? Perhaps most worryingly, could the world afford to provide health for all? It began to be argued that the PHC agenda was a bottomless pit (Lee, 2003).

Efforts to target specific health needs through so-called ‘vertical’ programmes soon gained popularity. Instead of pouring billions of dollars into broadly defined PHC programmes aimed at achieving healthy individuals and communities in the long term, defined in the Constitution of WHO as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity,’ it was argued that focused initiatives using proven interventions were needed that would save and improve lives immediately. In turn, it was argued that success in child immunization, infectious disease control, and oral rehydration therapy, for example, would encourage donor agencies to invest more in world health. For advocates of comprehensive PHC, however, this was a serious mistake. By ‘playing to the gallery’, the world health community risked having their priorities set by the donor-led swings of the political pendulum. It was feared that this would create distortions, inequities and a lack of sustainability.

We review how this familiar policy debate, between the ‘pit’ of comprehensive PHC and the ‘pendulum’ of vertical programmes, has been played out in more recent years amid major changes in the political landscape facing the world health community. The end of the Cold War, restructuring of the international economy and rapid technological changes have brought opportunities and constraints to both camps. Importantly, in recent years health issues have entered the consciousness of high-level decision-makers across the political spectrum. As part of a growing concern with the sustainability of current forms of globalization, it is recognized that there are serious risks in ignoring health development in an increasingly globalized world. Consequently, there are new institutional players, the reform of existing ones, and above all, a real battle for control of the health policy agenda.

The effects of globalization on human societies worldwide have already been profound and wide-ranging, and diverse efforts are underway to find better ways of managing these changes. Through emerging forms of global health governance, is there a new political space to reconcile the values of equity, social justice and human rights underpinning Health for All, with the high-profile disease-focused initiatives, evidence-based approaches and economic pragmatism demanded by political exigency?

The pit: health for all in a world of growing inequality

During the early 1990s, the prospects for achieving Health for All by the Year 2000 looked gloomy at best. Not only had the anticipated revolution in health development not occurred, its basic tenets found little companionship in the hardnosed neo-liberalism that had come to dominate the World Bank, International Monetary Fund (IMF), Organization for Economic Cooperation and Development (OECD), and many bilateral aid agencies. Downsizing of governments, privatization and decentralization became the order of the day. In the health sector, this translated into policies bent on cost recovery, the creation of a public–private mix, introduction of market forces such as managed competition, and the prioritization of cost-effective interventions. Health sector reforms advocated by the World Bank and other donors swept the world. Countries were encouraged to make their health systems leaner and meaner.

The key voice that might have spoken out against this rising tide of economic utilitarianism, WHO, was hampered by its own problems, notably weak leadership and a perceived erosion of its standing on the world stage. Some criticized the organization for trying to do too much. In an effort to fulfil its broad mandate, WHO spread itself too thin in offering a smorgasbord of health programmes from anti-microbial resistance (AMR) to zoonosis. By trying to do everything, WHO risked being seen to do nothing. This period was marked by the replacement of the Global Programme on AIDS by UNAIDS in 1996, a bitter blow to the organization's efforts to defend its turf. In a world focused on the ‘bottom line’, WHO was increasingly overshadowed by the lending (and hence political) power of the World Bank and regional development banks. In addition, initiatives to channel increased aid through NGOs to poor countries as an alternative mechanism brought ever more players into the health policy arena. Health for all was out of step, it seemed, with the political mood of the day. Despite a shrinking regular budget in real terms, donors were not wholly convinced that WHO's ‘bottomless pit’ approach offered ‘value for money’.

Coinciding with this crisis of confidence within WHO were worrying signs that all was not well for the world's health. While the major institutions comprising the so-called Washington Consensus (i.e. the World Bank, IMF, US government, USAID) continued to stand behind neo-liberal policies, there were growing doubts that sufficient attention was being paid to the social and environmental consequences of economic globalization. While development economists argued over methodology (whether absolute numbers or proportion of the world's population was the most important indicator), it was very clear that huge numbers of people remained impoverished worldwide. Indeed, the gap between the rich and poor, both within and across countries, was widening. One billion people continued to lack access to clean water and sanitation. HIV/AIDS continued its seemingly inexorable march, decimating parts of Africa and spreading in Asia and the former Soviet Union. Tuberculosis was declared a global emergency by WHO in 1993 and fears of growing drug resistance emerged. AMR and emerging diseases began to preoccupy the minds of policymakers.

Moreover, the emergence of a global economy was throwing up new challenges because of the potential for crisis in one part of the world to have far reaching consequences elsewhere. The break-up of the former Soviet Union, the Asian economic crisis and economic instability in Latin America have all been followed by adverse social impacts. The creation of the World Trade Organization (WTO) in 1995 signalled new efforts to push the boundaries of trade liberalization. However, there are widespread fears concerning the wider ‘adjustment’ effects of implementing multilateral agreements on intellectual property rights, services and agriculture, especially when trade liberalization is given priority over other policy needs such as health.

The election of Gro Harlem Brundtland in 1997 as Director-General of WHO was greeted with high hopes that WHO would reassert its leadership in world health. Just as economic globalization was accelerating, the world needed a ‘health conscience’. Many called for clear priorities that the health community could rally round. Donor fatigue had reduced many bilateral aid budgets and there was a need to reinvigorate interest in the developing world. During the last years of the Hiroshi Nakajima era, WHO had tried to renew Health for All. Could the new Director-General turn the commitment into a strategy that donors could finally buy into?

The pendulum: health—what is it good for?

The legacy of Gro Harlem Brundtland, who stepped down in 2003 after only five years as Director-General of WHO, was not only to reignite familiar debates within the world health community, but to put health at the centre of high-level debates about globalization. Armed with considerable political experience, she found herself in the middle of a battlefield of ideas and ideologies, in many cases backed by powerful vested interests. Her first task was to unite WHO internally—the organization seemed to be structurally fragmented and lacking in a shared vision. She believed that what was needed was a corporate identity, complete with core values and leading brands, and a clear strategy for marketing them in the highly competitive world of development assistance. Like UNICEF's child immunization programmes, WHO needed initiatives that people could identify with the organization. The reforms adopted at headquarters were aimed at achieving this through rationalizing the programme structure into ‘clusters’, and pruning excessive senior posts along the way. A cabinet of executive directors and high-level advisers was formed to enable the Director-General to maintain close control over operations.

Perhaps most prominently, WHO adopted two flagship initiatives: Roll Back Malaria (RBM) and the Tobacco Free Initiative (TFI). In the development world, the competition for scarce resources was never more intense. With more players becoming increasingly active in health development, the organization needed to woo back donors by focusing on major global health challenges. Malaria and tobacco control were sound choices. Malaria eradication had eluded the organization since the 1950s, and by the late 1990s the disease was killing one million people annually, including 3000 children per day. In addition, the disease represented a substantial burden of disease for affected countries. Worryingly drug resistant forms of malaria were spreading and global climate change threatened to extend the reach of the mosquito vector. Working with the World Bank and UNICEF, RBM sought to develop new anti-malarial drugs.

Tobacco consumption had been woefully neglected under Nakajima despite its alarming toll in death and disease. Globalization was proving to be the tobacco industry's friend, opening up new and lucrative markets in low- and middle-income countries through economic restructuring, trade liberalization and global communications. By the late 1990s, tobacco was responsible for almost five million deaths annually, with projections of double this figure by 2030 if concerted action was not undertaken. Brundtland's launch of the TFI was an ambitious and courageous move. The process of negotiating the first international health treaty—the Framework Convention on Tobacco Control (FCTC)—was fraught with political minefields. And it moved WHO into direct confrontation with a hugely powerful industry.

A third focus of WHO's work during this period, and a core part of the strategy for making a stronger argument for world health, was evidence. Given stiff competition from other sectors, the health community needed to ‘up its game’ in international politics to grab a bigger share of the ‘peace dividend’. This required ‘hooks’ to attract high-level policymakers and a strong evidence base to put the case convincingly for increased resources. Economic arguments, led by such concepts as disability adjusted life years (DALYs) and basic health packages, were the prevailing paradigm. Hence, Brundtland recruited prominent individuals involved in the Global Burden of Disease project from Harvard University, the World Bank and elsewhere. Then in 2000 she formed the Commission on Macroeconomics and Health (CME), led by former Harvard economist Jeffrey Sachs, to undertake studies on ‘how concrete health interventions can lead to economic growth and reduce inequity in developing countries’. The phrase ‘health as good economics’ was effectively deployed to influence hard-nosed policy makers into investing greater sums in health development (Banta, 2002).

The proliferation of global public–private partnerships as the governance mechanism of choice can be seen as part of the above efforts to move health onto centre stage. It was argued that health development should no longer be seen only as a social cost under the sole responsibility of governments, or as the grateful recipient of charitable aid. To the extent that sustainable governance of globalization required greater attention to poverty reduction, the economic development of countries could not progress without attention to their health needs. Conversely, without healthy and therefore prosperous populations, the spread of economic globalization would falter. If health was a good economic investment, this called for resources by both the public and private sectors. Brundtland thus encouraged the forging of links to the private sector, notably but not exclusively working cooperatively with the pharmaceutical industry to develop new drugs. Recognizing the scientific and commercial expertise of the private sector, she sought to harness these unique resources to further the public good.

The redefinition of the world health agenda has, in many ways, been successful at heightening interest in selected health issues among high-level policymakers. This interest has been peaked further by fears of emerging and re-emerging diseases, especially those that potentially threaten populations in high-income countries such as HIV/AIDS, tuberculosis and SARS (severe acute respiratory syndrome). The risk of bio-terrorism has also served as a useful policy link to the influential foreign policy and security communities.

While political exigency may have required WHO and others to grab the world's attention by playing the nasty bugs and bio-terrorism cards, backed by shrewd economic rationalism, there has been considerable concern that the price for this utilitarian approach will be too high. Health is clearly on the radar screens of policymakers across the political spectrum, resulting in an increase in overall resources. The creation of the Global Fund to Fight HIV/AIDS, malaria and tuberculosis; the rise of new charitable foundations such as the Bill and Melinda Gates Foundation; the proliferation of global public–private partnerships for health; the commitments to health development made at meetings of the World Economic Forum and Group of Seven Summits; and the increased attention to health at ministerial meetings of the WTO all seem to herald a new era of world health. Globalization has focused the mind. Advocates of vertical programmes appear to have been vindicated.

Politicizing world health in the 21st century: moving the agenda forward

Efforts to attract greater political attention on world health have been hard won and have not come without criticism. While it is difficult to deny that additional resources for health development are long overdue and highly welcome, the familiar challenge of setting appropriate priorities lies not far below the surface. For many the return to vertical programmes aimed at selected diseases or conditions fragments efforts at improving population health. By being forced to be in synch with the pendulum swings of donor preferences, local priorities are potentially distorted. It is argued that many of the priorities set, such as bio-terrorism and acute epidemic infections, reflect the self-interests of the powerful few rather than the real needs of the world's majority.

Perhaps most importantly, by focusing efforts on selected health needs, many believe that only the symptoms of a larger malaise are being addressed. Report cards on globalization, and particularly economic globalization, are mixed at best. While economic growth has occurred in some developing countries over the past decade, others are being left further and further behind. More accurately, the delineation between the winners and losers of globalization cut across national boundaries and can become invisible when concentrating on aggregated data or national averages. Even research published by the World Bank (Milanovic, 2000) demonstrates a need for more sophisticated understanding of the complex distribution of impacts caused by globalization. This is supported by evidence of widespread poverty within a context of growing global inequality (UNDP, 1999). The anticipated ‘trickle down’ effect is not happening fast enough or, in some places, not at all. There are clear cracks in the policy strategies of the Washington Consensus and the mass demonstrations of the so-called ‘anti-globalization’ movement since the late 1990s have jolted many out of their complacency.

In WHO, Brundtland soon confronted these differing perspectives. After an initial honeymoon period, discontent with her centralized management style began to be expressed. Her efforts to embrace the global burden of disease work dismayed many public health experts who felt uncomfortable with the need to rationalize health development by economic criteria. It was recognized that new forms of global health governance involving a wider range of actors was needed. However, many were concerned with her flirtation with the private sector, without the equivalent nod towards civil society. It was feared that this might risk WHO's ability to speak independently as the world's ‘health conscience’. Indeed, the NGO community called for WHO to take a more decisive stance on such key issues as access to medicines, multilateral trade agreements and health inequalities (Kapp, 2002).

It is in this context that Brundtland announced in 2002 that she would step down from leading WHO after five years, and that a new Director-General would be elected to take forward these challenges. Familiar debates ensued in the run-up to the elections, many published in prominent medical journals such as The Lancet, on what the priorities of the new Director-General should be. Many prominent individuals lent their voices. Most called for WHO to retain a lead role in any emerging form of global health governance.

The election in 2003 of Dr Jong Wook Lee as Director-General of WHO was accompanied by renewed calls for the organization to navigate between ‘health for all’ and donor-led initiatives. So far both have been given a verbal nod. Upon taking office, Lee confirmed that communicable diseases, especially HIV/AIDS, tuberculosis and malaria would be among his ‘highest priorities’. A long-time staff member of WHO, he has sought to build on experience as head of the WHO Global Programme for Vaccines and Immunizations and Director of Stop TB. A new cluster has been formed and Jack Chow, former Special Representative of the US Secretary of State for HIV/AIDS, has been appointed to lead it (Ahmad, 2003). Lee also declared an ‘all out assault’ on polio, aiming for its eradication during the period of his tenure.

Support for WHO's unique role in communicable disease control has received a further boost by the successful international effort on SARS. As well as jumpstarting efforts to revise the International Health Regulations, the value of such initiatives as the Global Outbreak Alert and Response Network was effectively demonstrated. This success has come at a time when support by the US government for multilateralism has been at its lowest point since before the Second World War. Hence, there remains much to be done to convince major donors to cough up sufficient resources such as the need to combat endemic infections—US $27 billion annually by 2007 and US $38 billion by 2015 as calculated by the Commission on Macroeconomics and Health (Waitzkin, 2003). Targets, such as the Millennium Development Goals and ‘3 by 5’ (three million people on anti-retroviral therapy by the end of 2005), have been affirmed to provide donors with clear products to buy into.

At the same time, Lee has been careful to acknowledge calls to address the broader determinants of health. As the editor of The Lancet Richard Horton (2002) wrote:

Brundtland's successor will have to translate the emerging political commitment to diseases of the poor into workable country-level public-health programmes. Those priorities mean that far greater attention will have to be paid to the causes of the causes of disease—malnutrition, unsafe sex, unsafe water, indoor smoke, and tobacco. The scope of public health needs to be widened in the face of mounting evidence about the broader determinants of health.

In response to such calls, Lee launched the World Health Report 2003 by describing WHO's reason for existence as ‘to promote justice and security by making available to everyone the best health possible. Health is arguably the most fundamental human need and right in every society’.Footnote 1 In his address to the 113th session of the Executive Board, he hoped for ‘the real possibility of reclaiming and reinventing the vision of health for all for the specific challenges we now face.’Footnote 2

There are concerns, however, that Lee's interpretation of health for all will focus too heavily on high profile initiatives. In celebrating the 25th anniversary of the Alma Ata Declaration, Lee agreed that Health for All had ‘achieved a great deal’ but that ‘progress has slowed and, in many cases, even been reversed by the upsurge of AIDS and the resurgence of tuberculosis and malaria. It is time for another global effort.’Footnote 3 Where he has sought to take a broader approach, the spectre of the bottomless pit has threatened to loom. The long list of challenges outlined to the Executive Board—communicable diseases, child immunization, family and reproductive health, public health emergencies, non-communicable disease prevention including tobacco control and a Global Strategy on Diet, Physical Activity and Health—all read comfortably like a familiar public health textbook. It would be difficult to challenge any of these as worthy of support but the overarching vision to tie it all together has yet to be articulated. This may reflect the fact that it is still early days and Lee is finding his feet at the helm of a notoriously diverse organization. He is also on less familiar political territory than Brundtland who was clearly comfortable with rubbing shoulders with world leaders. To an infectious disease man, issues such as trade, poverty and inequality may seem too politically charged and nebulous.

Conclusions

Today, it would seem that the world health community has made limited progress in reconciling the political debates over how best to achieve good health. Two philosophical approaches continue to vie for policy influence. The first argues that all people have a basic right to good health and that health lies at the heart of commitments to social justice. To achieve health for all, the world must first tackle, for example, inequalities in socio-economic status, basic needs and ultimately political power. Others continue to argue that there is an unavoidable need to set priorities in the ‘real world’. Given scarce resources, good health can only be practically pursued as an entitlement to the extent that individuals and societies can afford to pay.

How globalization has impacted on this now familiar debate remains unclear. The number of institutional actors involved in world health has proliferated, and we are facing a transition period towards emerging forms of global health governance. If governance is defined as how a society organizes itself to achieve agreed goals (Fidler, forthcoming), then many questions remain to be confronted. How should the world organize itself to identify and set agreed health priorities? What collective resources are available and how should they be used? How can the world community, in all its diversity, be appropriately represented in any process to answer these questions?

While there is now a recognized need for a ‘post-Washington consensus’, the political will to move the debate forward has been slow in coming. Some reflection has been prompted by the events of 9/11, for example, and the SARS outbreak in 2002–2003. Further impetus has been provided by anti-globalization protests which demonstrate the extent of dissatisfaction with current forms of global governance. It is accepted that more socially and environmentally sustainable forms of globalization must be found. The potential contribution of the world health community to this larger challenge could be profoundly important. In a world increasingly bound together by mobile populations, interdependent economies, environmental change and mass communications, we can only be as healthy as our neighbours in the emerging global village. The question is how big a shock will it take for us to realize this?