Chapter VIII: Health, morbidity and mortality - A. Primary health care and the health-care sector

Basis for action

8.1. One of the main achievements of the twentieth century has been the unprecedented increase in human longevity. In the past half century, expectation of life at birth in the world as a whole has increased by about 20 years, and the risk of dying in the first year of life has been reduced by nearly two thirds. Nevertheless,these achievements fall short of the much greater improvements that had been anticipated in the World Population Plan of Action and the Declaration of Alma Ata, adopted by the International Conference on Primary Health Care in 1978. There remain entire national populations and sizeable population groups within many countries that are still subject to very high rates of morbidity and mortality. Differences linked to socio-economic status or ethnicity are often substantial. In many countries with economies in transition, the mortality rate has considerably increased as aresult of deaths caused by accidents and violence.

8.2. The increases in life expectancy recorded in most regions of the world reflect significant gains in public health and in access to primary health-care services. Notable achievements include the vaccination of about 80 per cent of the children in the world andthe widespread use of low-cost treatments, such as oral rehydration therapy, to ensure that more children survive. Yet these achievements have not been realized in all countries, and preventable or treatable illnesses are still the leading killers of young children. Moreover, large segments of many populationscontinue to lack access to clean water and sanitation facilities,are forced to live in congested conditions and lack adequate nutrition. Large numbers of people remain at continued risk of infectious, parasitic and water-borne diseases, such as tuberculosis, malaria and schistosomiasis. In addition, the healtheffects of environmental degradation and exposure to hazardous substances in the workplace are increasingly a cause of concern inmany countries. Similarly, the growing consumption of tobacco,alcohol and drugs will precipitate a marked increase in costly chronic diseases among working age and elderly people. The impact of reductions in expenditures for health and other social services which have taken place in many countries as a result ofpublic-sector retrenchment, misallocation of available health resources, structural adjustment and the transition to market economies has pre-empted significant changes in lifestyles, livelihoods and consumption patterns and is also a factor in increasing morbidity and mortality. Although economic reforms areessential to sustained economic growth, it is equally essential that the design and implementation of structural adjustment programmes incorporate the social dimension.


8.3. The objectives are:

  1. 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;
  2. To increase the healthy life-span and improve the quality of life of all people, and to reduce disparities in lifeexpectancy between and within countries.


8.4. All countries should make access to basic health care and health promotion the central strategies for reducing mortality and morbidity. Sufficient resources should be assigned so that primary health services attain full coverage of the population. Governments should strengthen health and nutrition information, education and communication activities so as to enable people to increase their control over and improve their health. Governments should provide the necessary backup facilities to meet the demand created.

8.5. In keeping with the Declaration of Alma Ata, all countries should reduce mortality and morbidity and seek to make primaryhealth care, including reproductive health care, available universally by the end of the current decade. Countries should aimto achieve by 2005 a life expectancy at birth greater than 70 years and by 2015 a life expectancy at birth greater than 75 years. Countries with the highest levels of mortality should aim to achieve by 2005 a life expectancy at birth greater than 65 years and by 2015 a life expectancy at birth greater than 70 years. Efforts to ensure a longer and healthier life for all should emphasize the reduction of morbidity and mortality differentials between males and females as well as among geographical regions,social classes and indigenous and ethnic groups.

8.6. The role of women as primary custodians of family healths hould be recognized and supported. Access to basic health care,expanded health education, the availability of simple cost-effective remedies, and the reappraisal of primary health-careservices, including reproductive health-care services to facilitate the proper use of women's time, should be provided.

8.7. Governments should ensure community participation in health policy planning, especially with respect to the long-term care ofthe elderly, those with disabilities and those infected with HIVand other endemic diseases. Such participation should also be promoted in child-survival and maternal health programmes, breast-feeding support programmes, programmes for the early detection and treatment of cancer of the reproductive system, and programmes for the prevention of HIV infection and other sexually transmitted diseases.

8.8. All countries should re-examine training curricula and thedelegation of responsibilities within the health-care delivery system in order to reduce frequent, unnecessary and costly relianceon physicians and on secondary- and tertiary-care facilities, while maintaining effective referral services. Access to health-careservices for all people and especially for the most underserved and vulnerable groups must be ensured. Governments should seek to makebasic health-care services more sustainable financially, while ensuring equitable access, by integrating reproductive health services, including maternal and child health and family-planning services, and by making appropriate use of community-based services, social marketing and cost-recovery schemes, with a view to increasing the range and quality of services available. The involvement of users and the community in the financial management of health-care services should be promoted.

8.9. Through technology transfer, developing countries should be assisted in building their capacity to produce generic drugs for the domestic market and to ensure the wide availability and accessibility of such drugs. To meet the substantial increase in demand for vaccines, antibiotics and other commodities over the next decade and beyond, the international community should strengthen global, regional and local mechanisms for the production, quality control and procurement of those items, where feasible, in developing countries. The international community should facilitate regional cooperation in the manufacture, quality control and distribution of vaccines.

8.10. All countries should give priority to measures that improve the quality of life and health by ensuring a safe and sanitary living environment for all population groups through measures aimed at avoiding crowded housing conditions, reducing air pollution, ensuring access to clean water and sanitation, improving waste management, and increasing the safety of the workplace. Special attention should be given to the living conditions of the poor and disadvantaged in urban and rural areas. The impact of environmental problems on health, particularly that of vulnerable groups, should be monitored by Governments on a regular basis.

8.11. Reform of the health sector and health policy, including the rational allocation of resources, should be promoted in order to achieve the stated objectives. All Governments should examine waysto maximize the cost- effectiveness of health programmes in order to achieve increased life expectancy, reduce morbidity and mortality and ensure access to basic health- care services for all people.

© 2001 by Ulrich Schmitthenner • Bildschirm-Version