Learning from the past, preparing for tomorrow’s realities 23

Progress towards achieving health for all

Note:The original draft had, as its first section, a summary of epidemiological and other trends related to the attainment of the targets adopted in 1984 and 1991, highlighting priorities for action if the goal of better health for all in the Region were to be attained. This foreshadowed the substantive content of the policy chapters of HEALTH21.

A conceptual model of the macro influences on health

The pursuit of progress towards the achievement of health for all has focused on determinants of health and disease. Development is the major underlying factor or determinant. It is a difficult and complex task to foresee development over the next

decades. Only selected factors or aspects of development are highlighted here, conscious as we are that these are highly interrelated: economic, social, political, scientific and

technical. These have been chosen on the basis that they cover the principal concerns that shape public policy.

In anticipating future events, we know that strategic decisions taken in different fields can have a long lead time before the effects become visible; various trends are now firmly

established and the course is set for at least the medium term, as in the case of population age structure. It is also important to recognise the possibility of chance happenings, or

unanticipated events of significance, such as the collapse of regimes in the east of Europe at the end of the 1980s.

23. Extracts from the original internal draft of 1997, with annotations.

Health on the international community’s development agenda

Note:This section argues that the essence of a development agenda that addresses health issues has been fashioned by the United Nations summits of the 1990s.

Although it is its efforts in maintaining peace and security that attract public attention, in recent years the United Nations has been building an agenda that could become a powerful vision of human development.

Throughout the series of United Nations conferences and summits involving heads of state and government, issues linking the themes of health and human development have been put on the policy agenda. This is not an occasion to review them all extensively;

the citations in Table 1 (opposite page)of principles and desired objectives, presented at various international conferences, illustrate that these themes have been woven into events at the highest level.

Member States have in fact adopted a set of resolutions and plans of action at these meetings, which can be seen to respond to trends and assumptions such as those outlined above. Some of these resolutions and action plans have attracted media attention. This has usually been because of specific controversial proposals, mostly related to the field of reproductive health, rather than the general thrust of the action plans.

The Copenhagen Declaration on Social Development²⁴warrants particular attention. It

includes a commitment to promoting and attaining the goals of the highest attainable standard of physical and mental health, and the access of all to primary health care, making particular efforts to rectify inequalities relating to social conditions and without distinction as to race, national origin, gender, age or disability. Associated actions at the international level included a request to specialised agencies, including specifically the World Health Organisation, to give greater emphasis to the overriding goals of eradicating poverty, promoting full and productive employment and fostering social integration.

Interrelationships between health and the economic, political and social environments Note:This section takes the first steps towards presenting a coherent picture of the likely or possible future environment for health, by focusing on the objective of development strategy and the criteria by which the outcomes of public policy and the quality of life created should be judged.

For the United Nations family as a whole, the twin goals of development are the improvement of people’s material conditions or level of livingand the maintenance of social cohesion. At the macro level, there is a tension between optimistic and pessimistic views of trends and

possibilities within the European Region. The evidence on progress in the European Region in recent years is mixed, and for quite obvious reasons.

In terms of equity, the fundamental United Nations ethic, severe challenges are now posed by evidence of gaps between population groups in income distribution, access to

employment, access to resources, and freedom from threat of war or social disturbance. But there are also a number of positive signs, linked inter aliawith changing perspectives on participation and governance and the still untapped potential in the use of technology in tackling problems.

24. http://www.visionoffice.com/socdev/wssdco-0.htm

1992 United Nations Conference on Environment and Development

Rio de “Human beings are at the centre of concerns for sustainable development.

Janeiro They are entitled to a healthy and productive life in harmony with nature.”

“The right to development must be fulfilled so as to equitably meet

developmental and environmental needs of present and future generations.”

“In order to achieve sustainable development, environmental protection shall constitute an integral part of the development process and cannot be

considered in isolation from it.”

(Rio Declaration on Environment and Development, Principles 1, 3 and 4)

“... to coordinate the involvement of citizens, the health sector, the health-related sectors and relevant non-health sectors (business, social, educational and religious institutions) in solutions to health problems.”

“... to minimise hazards and maintain the environment to a degree that human health and safety is not impaired or endangered yet encourage development to proceed. Specific objectives are: to incorporate appropriate environmental and health safeguards as part of national development programmes in all countries; ...”

1992 International Conference on Nutrition

Rome “Healthy and properly nourished people are both the result of successful development and contributors to it. Nutritional well-being should be adopted as a key objective in human development and must be at the centre of

development strategies, plans and priorities.”

1994 International Conference on Population and Development

Cairo “... to increase the accessibility, availability, acceptability and affordability of health care services and facilities to all people in accordance with national commitments to provide access to basic health care for all.”

1995 World Summit for Social Development

Copenhagen “Support progress and security for people and communities whereby every member of society is enabled to satisfy his or her basic human needs and to realise his or her personal dignity, safety and creativity.”

1995 World Conference on Women

Beijing “... providing appropriate social services to enable vulnerable people and people living in poverty to improve their lives, to exercise their rights and to participate fully in all social, economic and political activities and to

contribute to social and economic development.”

1996 United Nations Conference on Human Settlements, Habitat II

Istanbul The Conference identified as its seven priorities: unsustainable consumption and production patterns, particularly in industrialised countries; unsustainable population changes; homelessness; unemployment; lack of basic infrastructure and services; growing insecurity and violence; and increased vulnerability to disasters. These are all factors that are connected to levels of health in populations.

Table 1. Selected United Nations international conferences and summits

Level of living (material wellbeing)

In today’s Europe, there is a rising proportion of people living in poverty. Lack of income and job insecurity prevent them from accessing the potential benefits afforded by

technology, and limit their participation in civil society and even their ability to use health services. Increasing numbers of people are living in absolute or extreme poverty, unable to cover the cost of basic needs such as food and shelter and thus facing direct threats to their health.

Levels of (particularly long-term) unemployment combine to create a situation whereby a growing proportion of the workforce earn extremely low wages. Low wages dominate in most parts of the informal economy and also disproportionately affect women, migrants and the disabled. The structure of the welfare benefit system and limited opportunities for paid employment combine to keep certain groups in a poverty trap.

Recent changes in many welfare systems have removed certain categories of people from eligibility for benefit, such as some types of migrant, political refugees or asylum seekers, and those deemed to have intentionally made themselves homeless. The real level of many benefits has often not been maintained against inflation.

Social cohesion

In terms of the social structure of European societies, there are a number of new issues to address. One is change in family structure (single-parent families, divorce, commuter families, etc.) and the fragile social and family support networks that are a continuing reality in most countries in Europe.

The rediscovery of poverty in the midst of affluence is an important factor that fuelled the growing interest in the influence of the social and economic structure. The importance of social support, the ability to cope and maintain dignity and the sense of control over one’s life are now more fully recognised.

There is general concern at the growth in all parts of the European Region of violence at home and in the streets as a result of deteriorating social and economic conditions and dislocation;

and at the growth of organised violence.

There is a spectrum of social consequences of violence. At worst it would mean social

disintegration and breakdown of infrastructure. There is also the sense of perceived threat that may be engendered by the awareness of interpersonal violence, even though it may not have been directly experienced or witnessed. In political and policy terms, this can be translated into demands for increased surveillance and policing aimed at the manifestations, rather than more positively oriented preventive programmes aimed at the causes of social breakdown.

Equity

Poor economic growth together with rising unemployment, job insecurity and poorly paid work lead to widening income gaps and rising social inequality. Increased inequality imposes economic, social and psychological burdens that reduce the wellbeing of society and threaten social cohesion and solidarity.

There is a clear relationship between economic performance, income distribution and the health status of a nation. Inequity in health is strongly associated with social position,

occupational status, ethnicity, gender and generation. The major improvements in mortality that have occurred in the developed world are strongly linked to social and economic development. The earlier reductions in infectious disease mortality were brought about by changes in the environment, improved lifestyles (e.g. better nutrition), improved living

conditions (e.g. better housing and sanitation) and other factors related to social and economic development.

Above a certain level of wealth, it is not the richest societies that have the best health but those that have the smallest difference in income between rich and poor. Health improvements are more rapid in countries with smaller income differentials, and this greater equity is also associated with faster economic growth. Improvements in the population’s health are predicated on widely shared economic prosperity, on the development of a supportive community life and on investment in people.

Education is a key factor, not only in promoting greater equity but also in greater personal fulfilment and health for individuals.

It is important to examine the implications for equity of different policy directions. These may include, for example, how to ensure that trends in the use of new technology do not

selectively benefit only certain groups in society, and how to gain political acceptance of the need to take action to move towards a more equal distribution of income and access to resources.

There is thus no reason for making the false choice between greater equity and economic growth; investment in “social capital” increases efficiency by lubricating the economy and society.

Scenarios for European health policy development

Note:This section consolidates the issues into a challenge to policy-makers through the device of scenarios. First, an explanation and justification for the use of scenarios is offered (to draw attention to the range of possibilities facing policy-makers). Then the material previously presented is reworked into two coherent, strongly contrasting pictures of the future that subsume two contrasting policy responses.

The build-up of an international agenda for economic and social development is only one, albeit vital, preliminary step. An equally demanding task is to stimulate policy-making at all levels in a way that encourages decision-makers and stakeholders not only to articulate their views of the desired future but also to think through the implications of various trends and possible courses of action. Herein lies the value of the “scenario” as a picture of the future and the need to prepare different scenarios.

Scenario writing is a well tried and proven means of addressing complex issues and coping with the inherent uncertainties in policy-making. The term “scenario” is used in various senses, but these only reflect levels of sophistication and detail, especially in the quantification and analysis of the different factors that are taken into account. The basic idea is that a

scenario, as “a picture of the future”, is a synthesis of evidence, ideas and assumptions whose nature should be immediately apparent to any reader. Scenarios are notpredictions, but products of imagining what the future might or could be.

Note:The implication of the last observation is that there is no such thing as a “correct” or

“incorrect” scenario. It may also be argued that there is no objectively “plausible” or

“implausible” scenario: plausibility is in the mind of the reader or receiver. This is not an insignificant point. There is always the risk that the receiver will reject a scenario that does not accord with what he or she would like to hear, however well the scenario is presented. This could present the writer with a dilemma: to present only a scenario that supports the policy status quo or to find some new, imaginative way of drawing less welcome possibilities to the receiver’s attention. This would be particularly urgent if the writer felt obliged to draw attention to circumstances when the costs (to the policy-maker) of inaction would be greater than any costs incurred in a change of policy direction.

For purposes of demonstration, the present text proceeds as though gaining the policy-maker’s attention through scenarios is not a problem.

The crafting of a set of scenarios provides policy-makers with a sense of the range of possible futures. These scenarios would have different emphases and sets of assumptions.

One mode of presentation is to consciously write a scenario as if it were history, by

projecting forward in time, and developing an imaginative account of how history unfolded from the present time.

The simplest approach, which for purposes of demonstration will be adopted in this paper, is to present just two strongly contrasting scenarios that – we can assume here – have been drawn from a more extensive set that has been considered. Contrasting scenarios underline the spread of possibilities. They serve to focus policy-makers’ attention and to provoke a response in terms of action to be taken, either to create what is desirable or to prevent what is

undesirable.

A picture of the desired future that mobilises people to work together to bring it about can have great political power. In some organisations and settings it is presented as the “vision”.

Among policy-makers it is also referred to as the “preferred scenario”. The current work within WHO to launch the renewal of health for all could be understood as the preparation of the Organisation’s “preferred scenario” for health and development.

The rationale for selection of scenarios

Health is not an end in itself but a necessary condition for human development. At the individual level, it is the means for enabling all people to lead productive and fulfilling lives.

At the policy level of collective benefits, it is instrumental in achieving society’s social and economic goals. Policy-making within the framework of health for all identifies the

contributions of various measures to promote, protect and restore health in the individual and in communities.

People-centred development adheres to and reflects the basic values of the United Nations family: everyone is of equal worth, everyone’s autonomy is to be respected, and everyone should be enabled to meet their basic needs. This suggests that certain assumptions about society underpin the pursuit of the goal of health for all. The quality of life in that society can be assessed in terms of its achievements – in terms of the level of equity, material wellbeing (level of living) and social cohesion or sense of security. Those achievements can be assessed using levels of health as a benchmark: the greater the level of achievement, the higher the level of health enjoyed by the population.

Below are two simplified fragments of “history scenarios”: alternative futures (in which people will use whatever health potential they have in attempting to lead satisfying lives) that reflect these three dimensions of equity, level of living and social cohesion. They are written from the vantage point of 2030, far enough into the future for the effects of trends to have become clear and for the benefits of policy shifts and changes in culture to have come through.

The contrast between them happens to reflect the tension found in the mass media and in public debate between optimistic and pessimistic views of trends and possibilities. They can be depicted as taking the United Nations seriously as the voice of the world community versus muddling on in a reactive, passive mode to trends and pressures.

Scenario 1. Business as usual – “muddling on”

In the early years of this 21st century, continuing migration, urbanisation, chronic unemployment and falling birth rates further eroded family structures and established

communities. Meanwhile, the informal economy flourished and violence was endemic, despite strong private security and public law enforcement agencies.

Politicians were unable or unwilling to envisage any alternative to the existing economic and social order. A continuing lack of confidence in the ability of governments and the responsible international financial institutions to manage economic development ensured that the already existing momentum for globalisation, privatisation and deregulation not only continued but accelerated. Capitalism’s basic law of obligation to protect and enhance shareholder value determined that decisions on productive capacity would be governed by opportunities to automate and to relocate to where labour costs could be minimised.

Virtually all controls on health hazards, whether in the environment or in the sale of goods known to be harmful to health, were relaxed under pressure to remove “unnecessary”

production costs or restraints on trade. In health care, the profit motive replaced the public service ethic: technology development was skewed in favour of innovations that offered the most promising returns on investment rather than health gain for the population.

The fleetingly fashionable concept of an enterprise having responsibility for, or accountability to, multiple stakeholders was rejected – by governments, industrial pressure groups and think tanks alike – as self-defeating and unworkable. It was deemed to be against individual

The fleetingly fashionable concept of an enterprise having responsibility for, or accountability to, multiple stakeholders was rejected – by governments, industrial pressure groups and think tanks alike – as self-defeating and unworkable. It was deemed to be against individual