GHF2006 – PL01 – Access to Health: Where Do We Stand?

Session Outline

Plenary session PL01, Wednesday, August 30 2006, 14:00-15:30
Chair(s): Fred Paccaud, Switzerland & Thomson Prentice, Switzerland
Social Determinants of Health
Eugenio Villar, WHO, Switzerland 
Healthcare for All: The True Millennium Development Goal 
Bruno Gryseels, Director, Institute of Tropical Medicine, Antwerp, Belgium
Leadership and Access to Healthcare: Global Public Goods for Local Decision-Making
Julio Frenk, Secretary of Health, Ministry of Health, Mexico 

Session document

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Session report

Submitted by: Jennie Hery-Jaona (ICVolunteers); Contributors: Marc Menichini (ICVolunteers), Tatjana Schwabe (ICVolunteers), Sarah Webborn (ICVolunteers)

Image: Viola Krebs, ICVolunteers.org

The Forum began with a welcome address by Dr. Louis Loutan representing the Organizing Committee. Dr. Loutan acknowledged the presence of over 800 participants from 80 countries encompassing Switzerland, Europe and the rest of the world and emphasized the objective of the Forum "to foster debate on access to health through the exchange of experiences, collaboration and the creation of partnerships". Following this theme, the three speakers raised the key issues of social determinants of health, health care for all (3 of the 8 Millennium Development Goals focus on health) and leadership and access to health care.

The first speaker, Eugenio Villar, Coordinator of the Department of Equity, Poverty and Social Determinants at the World Health Organization (WHO), Switzerland, discussed the recent initiatives of WHO about social determinants of health (SDH). It is paradoxical to treat people in poor countries only to send them back to the social reality that made them sick.

Social determinants must be emphasized, he said, because: they have a direct impact on health; they predict the greatest variation in health; they influence and structure health behaviours of individual and institutions; and they interact with each other. Socio-economic, cultural and environmental conditions thus have a great impact on health.

The importance of Europe's achievement of a welfare system was illustrated with the case of Sweden which from the XIXth century has adopted a two stage approach: content (addressing health inequalities and social determinants of health instead of individual diseases); and process (the objectives and including the relevant participants). "Health policy should focus on the need to reduce health inequity", he said.

Other case studies were presented, illustrating the fact that social reforms in health or access to education are achievable even within a short-time period. For instance countries such as Sri Lanka and South Africa have made important progress in only seven years.

A second issue addressed by Dr. Villar was "WHO and Equity". Referring to the late Dr. Lee's WHO Commission on Social Determinants of Health, Dr. Villar emphasized the need for realizing goals through "action, learning, advocacy and leadership". He also mentioned the importance of nine knowledge network themes, among which are health systems and child development, in order to build health and health equity.

The second speaker, Bruno Gryseels, Director of the Institute of Tropical Medicine in Antwerp, Belgium, looked backwards in time to the 1976 WHO World Assembly's agenda on the need for primary health care, and the 1978 WHO and UNICEF conference at Alma Ata (see outcome declaration), which set the ambitious goal of "Health for all by the year 2000". By the year 2000, however, on the one hand progress had been made on mapping the human genome, while on the other hand unprecedented health crises took place in some developing countries, with a breakdown of access to health care resulting in a requirement for major health sector reforms. There was also a shift in the key role played by WHO with the emergence of organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM - www.theglobalfund.org), Bill & Melinda Gates Foundation (BMGF - www.gatesfoundation.org) and Private Public Parternships (PPP). In addition, the Millennium Development Goals (MDGs - www.un.org/millenniumgoals) then replaced the 'Health for All' agenda.

Dr. Gryseels also mentioned the World Bank's 2006 publication on Disease Control Priorities in Developing Countries (www.dcp2.org/pubs/DCP). He highlighted the fact that input from developing countries was limited to only 1 out of 9 editors and 42 out of 346 contributors. On a lighter note, the top-down approach of priority-setting at a global level and the difficulties in integrating the numerous health-care programmes which resulted were illustrated by cartoons.

Most importantly, Dr. Gryseels emphasized that access to health care is a universal human right and claimed that: "Healthy people have many dreams... the sick have only one".  A graph comparing life expectancy and child mortality in the Northern and the Southern hemispheres illustrated a continuing lack of equity despite the declaration of universal human rights.

Among the themes related to quality of health care, Dr. Gryseels noted that research remains useless if there is no health care system to implement any innovation. Striving for accessible health care was hence "the mother of intervention" (paraphrased from F. Zappa).

Reiterating his key point, Dr. Gryseels stated that in order to have efficient international health policies, there is a clear need to curb the top down approach. He discussed the alternative between vertical approaches based on specific campaigns and the horizontal approaches centered on primary health care. He shared an illustration showing the advantage of the 'verticalist' over the 'horizontalist' in that the former is "standing up". He suggested a synthetic or 'diagonal approach', able to combine selective actions with the need to develop community-based health care, since the last is a "strong motor for political empowerment and democratization", he concluded.

The final speaker, Julio Frenk, Minister of Health in Mexico, shared his reflections on real life experience as a minister of health. He focused his lecture on instrumental value of knowledge in improving health, as knowledge is essential in everyday behaviour and produces the evidence necessary for correct decision making. Each innovative move must be tried because it is an experiment for increasing knowledge.

Dr. Frenk mentioned the global consensus that health plays a key role in development and highlighted the importance of scientific knowledge. He argued that these two issues are the "driving force for health progress", as they change individual behaviour by "empowering people to promote their own health". Describing Mexico's case, Dr. Frenk said that half of the total expenditure in Mexico was 'out of pocket' because half of the population lacked insurance and social protection. Reform was therefore badly needed in order to provide universal or popular health insurance (in Spanish "seguro popular". Democratic financial reform thus took place at the macro level, in addition to which there was managerial reform. The reform was put in place in 2003 and provides seven years of public funding for the "seguro popular". Dr. Frenk emphasized the need for integrating vertical and horizontal approaches so as to form a 'diagonal', but also the requirement to define priorities to drive overall improvements in health systems, so as to serve the poor more successfully. Moreover, he noted that a well-functioning health system will be helpful to fight HIV/AIDS. On balance, he described the 'hallmarks' of Mexico's reform as: the investment in research, the evaluation of resources and decision-making. Emphasizing the importance of knowledge, he said that "reform is inform or else deform". There is thus the need to share knowledge through international collective action and the transformation of countries' self-interest into common interest. In this manner, the creation and dissemination of knowledge remain the most important issue, according to Dr. Frenk. Everyone will win: the knowledge-producers, the translators, the citizens and more. In summary, this forum's objective should be to "bridge divides", such as the vertical-horizontal, analysis-advocacy and national-global divides. There is a need for a more integrated approach on global public health, based on three components: exchange, evidence, empathy, "as we all are members of the same human species", he concluded.

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