《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 1999 Making a Difference

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WHO Library Cataloguing in Publication Data world health report 1999: Making a difference 1. World health- trends 2. Health priorities 3. Cost of illne: 4. Health services accessibility 5. Social justice 6. Fover 7. Forecasting 8. Mortality-trends 9 Malaria- prevention and control 10. Smoking- prevention and control 11. World Health Organization I.Title: Making a difference IsBN 92 4 1561947(NLM Classification: WA 540.1) ISSN1020-331 The World Health Organization welcomes requests for permission to or translate its publications, in part or in full Applications and enquiries should be addressed to of Publications, World Organization, 1211 Geneva 27, Switzerland, which will be glad to the latest information hanges made to the text, plans for new editions, and reprints and translations already available Al orld Health Organization 1999 The designations employed and the presentation of the material in this publication, including tables and Healey do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World ountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate bor- der 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 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 blication can be obtained World Health Report 1211 Geneva 27. Switzer rland Fax(41-22)7914870 Thomson Prentice, with the a core team composed of Emmanuela Gakidou, Mie Inoue, and Michel Beusenberg Other contributors were, in alphabetical order, Howard Engers, Catherine Goodman, Emmanuel Guidon, Prabhat Jha, Kamini Mendis, David Nabarro, Jim Tulloch, Jia Wang, and Derek Yach Comments were appreciated from a number of indi- viduals including Anarfi Asamoah-Baah, David Evans, Tore Godal, Joseph Kutzin, Alan Lopez, Christopher Murray, Richard Feto and Nicholas White; additional help was gratefully received from WHO Regional Direc tors and their B dministrative support was provided by Aquilina John-Mutaboyerwa and Shelagh Probst. The report ade Guyonnet The index was prepared by Liza Weinkove and, for the French edition, by Laurent Gaiddon The report was prepared under the general direction of Jonas Store, Executive Director, Director-Gener- aI's Office, and Senior Policy Adviser; Julio Frenk, Executive Director, Evidence and Information for Pblicy; and Susan Holck, Director of Health Information Management and Dissemination African Art, Kampala, uganda, is reproduced with the kind permission of the arae zi Studio and Gallery of The cover painting"Working Woman", by Mr Nuaa Wamala-Nnyanzi, of the Nnyar by Marilyn Langfeld Layout by WHO Gr

ii The World Health Report 1999 WHO Library Cataloguing in Publication Data The world health report 1999: Making a difference 1. World health – trends 2. Health priorities 3. Cost of illness 4. Health services accessibility 5. Social justice 6. Poverty 7. Forecasting 8. Mortality – trends 9. Malaria – prevention and control 10. Smoking – prevention and control 11. World Health Organization I. Title: Making a difference ISBN 92 4 156194 7 (NLM Classification: WA 540.1) ISSN 1020-3311 The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, 1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1999 All rights reserved. The designations employed and the presentation of the material in this publication, including tables and maps, do not imply the expression of any opinion whatsoever on the part of the Secretariat 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. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland Fax: (41-22) 791 4870 This report was prepared by Dean T. Jamison, Andrew Creese and Thomson Prentice, with the assistance of a core team composed of Emmanuela Gakidou, Mie Inoue, and Michel Beusenberg. Other contributors were, in alphabetical order, Howard Engers, Catherine Goodman, Emmanuel Guidon, Prabhat Jha, Kamini Mendis, David Nabarro, Jim Tulloch, Jia Wang, and Derek Yach. Comments were appreciated from a number of individuals including Anarfi Asamoah-Baah, David Evans, Tore Godal, Joseph Kutzin, Alan Lopez, Christopher Murray, Richard Peto and Nicholas White; additional help was gratefully received from WHO Regional Directors, Executive Directors and their respective staffs. Administrative support was provided by Aquilina John-Mutaboyerwa and Shelagh Probst. The report was edited by Barbara Campanini and Angela Haden, and translated into French by Barbara Audrin and JeanClaude Guyonnet. The index was prepared by Liza Weinkove and, for the French edition, by Laurent Gaiddon. The report was prepared under the general direction of Jonas Støre, Executive Director, Director-General’s Office, and Senior Policy Adviser; Julio Frenk, Executive Director, Evidence and Information for Policy; and Susan Holck, Director of Health Information Management and Dissemination. The cover painting “Working Woman”, by Mr Nuwa Wamala-Nnyanzi, of the Nnyanzi Studio and Gallery of African Art, Kampala, Uganda, is reproduced with the kind permission of the artist. Design by Marilyn Langfeld. Layout by WHO Graphics Printed in France 99/12368 – Sadag – 20000

Annex Table 8 Malaria: magnitude of the problem by age, sex and WHO Region, Annex Table 9 Tobacco: magnitude of the problem by sex and WHO Region, estimates for 1998 Annex Table 10 Tuberculosis: magnitude of the problem by sex and WHO Region, 116 INDEX TABLES Table 1.1 Life expectancy at birth, selected countries, around 1910 and in 1998 Table 1. 2 Sources of mortality reduction, 1960-1990 Table 2.1 Health status of the poor versus the non-poor in selected countries, around 1990 19 Table 5.1 Tobacco: cigarette consumption, mortality and disease burden by WHO Region 67 Table 5.2 The ten largest tobacco companies, 1997 71 Table 5.3 Goals and principles of tobacco control policies 72 Table 5.4 Principles to guide tobacco control policies in different countries FIGURES Figure 1.1 Age distribution of deaths in Chile, females, 1909 and 1999 cohorts Figure 1.2 Declines in fertility by WHO Region, 1950 and 1998 Figure 1.3 Distribution of the population of the South-East Asia Region, by age and sex, 19502000and2050 2345 Figure 1.4 The role of improvements in income in reducing infant mortality rates Figure 1.5 Links between health and income Figure 2.1 Distribution of deaths by cause for two cohorts from Chile, 1909 and 1999 Figure 2.2 The emerging challenges: DALYs attributable to noncommunicable diseases 134 in low and middle income countries. estimates for 1998 Figure 2.3 The emerging challenges: DALYs attributable to injuries in low and middle ountries. estimates for 1998 Figure 2.4 Distribution of the probability of death, selected countries, around 1990 Figure 2.5 DALYs attributable to conditions in the unfinished agenda in low and middle income, countries, estimates for 1998 Figure 2.6 Infant mortality rate related to income Figure 2.7 Reductions in wild poliovirus transmission between 1988 and 1998 Figure 3.1 Infant mortality rate relative to income, China, 1962-1992 Figure 3.2 Global immunization coverage, 1987-1997 Figure 3.3 Who bears the risk of health care costs? The impact of different financing schemes and provider payment systems Figure 3.4 Health insurance status of China's population, 1981 and 1993 Figure 3.5 Funding, risk pooling and coverage pattems Figure 3.6 Alternatives for moving towards prepaid health services Figure 4.1 Malaria risk across sub-Saharan Africa according to population density Figure 4.2 Comparative cost-effectiveness of selected malaria control interventions in a typical low income African country, US$, 1995 Figure 4.3 Comparative affordability of selected malaria control interventions total cost of full coverage as a percentage of a public sector health care budget for a typical low income African country Figure 5.1 Premature deaths from tobacco use, projections for 2000-2024 and 2025-2049 66 Figure 5.2 Trends in per capita cigarette consumption, 1971, 1981 and 1991 Figure 5.3 Age at which nicotine addiction starts, USA, 1991

Message from the Director-General v Annex Table 8 Malaria: magnitude of the problem by age, sex and WHO Region, estimates for 1998 115 Annex Table 9 Tobacco: magnitude of the problem by sex and WHO Region, estimates for 1998 115 Annex Table 10 Tuberculosis: magnitude of the problem by sex and WHO Region, estimates for 1998 116 INDEX 117 TABLES Table 1.1 Life expectancy at birth, selected countries, around 1910 and in 1998 2 Table 1.2 Sources of mortality reduction, 1960–1990 5 Table 2.1 Health status of the poor versus the non-poor in selected countries, around 1990 19 Table 5.1 Tobacco: cigarette consumption, mortality and disease burden by WHO Region 67 Table 5.2 The ten largest tobacco companies, 1997 71 Table 5.3 Goals and principles of tobacco control policies 72 Table 5.4 Principles to guide tobacco control policies in different countries 73 FIGURES Figure 1.1 Age distribution of deaths in Chile, females,1909 and 1999 cohorts 2 Figure 1.2 Declines in fertility by WHO Region, 1950 and 1998 3 Figure 1.3 Distribution of the population of the South-East Asia Region, by age and sex, 1950, 2000 and 2050 4 Figure 1.4 The role of improvements in income in reducing infant mortality rates 5 Figure 1.5 Links between health and income 11 Figure 2.1 Distribution of deaths by cause for two cohorts from Chile, 1909 and 1999 13 Figure 2.2 The emerging challenges: DALYs attributable to noncommunicable diseases in low and middle income countries, estimates for 1998 14 Figure 2.3 The emerging challenges: DALYs attributable to injuries in low and middle income countries, estimates for 1998 18 Figure 2.4 Distribution of the probability of death, selected countries, around 1990 20 Figure 2.5 DALYs attributable to conditions in the unfinished agenda in low and middle income, countries, estimates for 1998 21 Figure 2.6 Infant mortality rate related to income 23 Figure 2.7 Reductions in wild poliovirus transmission between 1988 and 1998 24 Figure 3.1 Infant mortality rate relative to income, China, 1962–1992 34 Figure 3.2 Global immunization coverage, 1987–1997 38 Figure 3.3 Who bears the risk of health care costs? The impact of different financing schemes and provider payment systems 39 Figure 3.4 Health insurance status of China’s population, 1981 and 1993 40 Figure 3.5 Funding, risk pooling and coverage patterns 41 Figure 3.6 Alternatives for moving towards prepaid health services 42 Figure 4.1 Malaria risk across sub-Saharan Africa according to population density and climate 52 Figure 4.2 Comparative cost-effectiveness of selected malaria control interventions in a typical low income African country, US$, 1995 57 Figure 4.3 Comparative affordability of selected malaria control interventions: total cost of full coverage as a percentage of a public sector health care budget for a typical low income African country 58 Figure 5.1 Premature deaths from tobacco use, projections for 2000–2024 and 2025–2049 66 Figure 5.2 Trends in per capita cigarette consumption, 1971, 1981 and 1991 67 Figure 5.3 Age at which nicotine addiction starts, USA, 1991 70

Message from the Director-General MESSAGE FROM THE DIRECTOR-GENERAL n May of this year, health ministers and leaders from around the world will gather in eneva for the final World Health Assembly of the century. This years World health report-Making a difference reviews the accomplishments and challenges in world health nd highlights their implications for WHOs approach, priorities and work in the years to come The world enters the 21st century with hope but also with uncer- tainty. Remarkable gains in health, rapid economic growth and unprecedented scientific advance -all legacies of the 20th century could lead us to a new era of human progress. But darker legacies bring uncertainty to this vision-and demand redoubled commitment. Regional conflicts have replaced the global wars of the first half of the 20th century as a source of continued misery Deep poverty remains all too prevalent. The sustainability of a healthy environment is still unproved.The Universal Declaration of Human Rights-now half a century old -is only a tantalizing promise for far too many of our fellow humans. The HIVIAIDS epidemic continues unchecked in much of the world and it warns us against complacency about other, still unknown, We can make a difference. those of us who commit our lives to improving health can help to make su Dr Gro harlem brundtland that hope will predominate over uncertainty in the century to come. Human health -and its influence on every aspect of life- is central to the larger picture. With vision, commitment and successful leadership, this report argues, the world could nd the first decade of the 21st century with notable accomplishments. Many of the worlds poor people would no longer suffer todays burden of premature death and excessive dis- ability, and poverty itself would thereby be much reduced Healthy life expectancy would increase for all Smoking and other risks to health would fade in significance. The financial burdens of medical needs would be more fairly shared, leaving no household without ac- cess to care or exposed to economic ruin as a result of health expenditure. And health systems would respond with greater compassion, quality and efficiency to the increasingly diverse demands they face. Progress in the 20th century points to the real opportunity for reaching these goals

Message from the Director-General vii MESSAGE FROM THE DIRECTOR-GENERAL I n May of this year, health ministers and leaders from around the world will gather in Geneva for the final World Health Assembly of the century. This year’s World health report – Making a difference reviews the accomplishments and challenges in world health and highlights their implications for WHO’s approach, priorities and work in the years to come. The world enters the 21st century with hope but also with uncertainty. Remarkable gains in health, rapid economic growth and unprecedented scientific advance – all legacies of the 20th century – could lead us to a new era of human progress. But darker legacies bring uncertainty to this vision – and demand redoubled commitment. Regional conflicts have replaced the global wars of the first half of the 20th century as a source of continued misery. Deep poverty remains all too prevalent. The sustainability of a healthy environment is still unproved. The Universal Declaration of Human Rights – now half a century old – is only a tantalizing promise for far too many of our fellow humans. The HIV/AIDS epidemic continues unchecked in much of the world, and it warns us against complacency about other, still unknown, microbial threats. We can make a difference. Those of us who commit our lives to improving health can help to make sure that hope will predominate over uncertainty in the century to come. Human health – and its influence on every aspect of life – is central to the larger picture. With vision, commitment and successful leadership, this report argues, the world could end the first decade of the 21st century with notable accomplishments. Many of the world’s poor people would no longer suffer today’s burden of premature death and excessive disability, and poverty itself would thereby be much reduced. Healthy life expectancy would increase for all. Smoking and other risks to health would fade in significance. The financial burdens of medical needs would be more fairly shared, leaving no household without access to care or exposed to economic ruin as a result of health expenditure. And health systems would respond with greater compassion, quality and efficiency to the increasingly diverse demands they face. Progress in the 20th century points to the real opportunity for reaching these goals. Dr Gro Harlem Brundtland

vill The World Health Report 1999 Opportunity entails responsibility. Working together we have the opportunity to trans form lives now debilitated by disease and fear of economicruin into lives filled with realistic opes. I have pledged to place health at the core of the global development agenda. That is where it belongs. Wise investments in health can prove to be the most successful strategies to lead people out of poverty This report argues that improvements in health have contributed to spur human and conomic development in the past-and that this will also prove true in the future I have always believed that you cannot make real changes in society unless the eco- nomic dimension of the issue is fully understood. I firmly believe that this is what took"the environment"from being a cause for the committed few to becoming a societal issue for the attention of major players. The scientific facts were gathered.The true costs of environmen- tal degradation were analysed and enumerated in figures. Then, gradually, governments and parliaments started to vote incentives to change behavioural patterns among industry and consumers. There is still far to go in the field of environment and sustainable devele ment, but the trend has been started A new trend may be set in motion as we see and understand the broader implications of poverty. For the World Health Organization this means real inspiration. We intend to col- lect, analyse and spread the evidence that investing in health is one major avenue towards overty alleviation. We must be realistic: there will be setbacks and difficulties. A greater collective effort will generate more demands on each of us individually and on the institutions we represent national and international, public and private Compressing the time required to accom- sh major and tangible results is the task for leadership in the 21st century. This leadership must be technical. It must be political. And it must be moral PROGRESS AND CHALLENGES An historic conference in Alma-Ata in 1978 established the goal of Health for All by the year 2000. It defined this goal as"the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically produc tive life". This report describes how the past few decades-the period following the decla ration of Alma-Ata- have witnessed revolutionary gains in life expectancy. These gains build on progress that began for some countries in the late 19th century Among todays high income countries, life expectancy increased by 30 to 40 years in this century. Most of todays low and middle income countries have experienced even more dramatic gains, although remaining inequalities needlessly burden disadvantaged populations and pro- long their poverty. Under WHOs leadership the world eradicated smallpox, one of the lost devastating diseases of history, and today a substantial majority of the worlds popu lation faces relatively low risk from infectious diseases of any sort These health gains have transformed quality of life and created conditions favouring stained fertility reductions and consequent demographic change. In many developing countries, for example, the total fertility rate -the expected number of children a woman will bear over her lifetime -declined from over six in the late 1950s to about three at present. These health and demographic changes have cont directly to the global diffusion rapid economic growth that, like the health revolution, constitutes an extraordinary accom plishment of the century now closing In an important sense, then, the world has made great progress towards better Health for All. Inspiration and guidance from Alma-Ata, with its major emphasis on the critical

viii The World Health Report 1999 Opportunity entails responsibility. Working together we have the opportunity to transform lives now debilitated by disease and fear of economic ruin into lives filled with realistic hopes. I have pledged to place health at the core of the global development agenda. That is where it belongs. Wise investments in health can prove to be the most successful strategies to lead people out of poverty. This report argues that improvements in health have contributed to spur human and economic development in the past – and that this will also prove true in the future. I have always believed that you cannot make real changes in society unless the economic dimension of the issue is fully understood. I firmly believe that this is what took “the environment” from being a cause for the committed few to becoming a societal issue for the attention of major players. The scientific facts were gathered. The true costs of environmental degradation were analysed and enumerated in figures. Then, gradually, governments and parliaments started to vote incentives to change behavioural patterns among industry and consumers. There is still far to go in the field of environment and sustainable development, but the trend has been started. A new trend may be set in motion as we see and understand the broader implications of poverty. For the World Health Organization this means real inspiration. We intend to collect, analyse and spread the evidence that investing in health is one major avenue towards poverty alleviation. We must be realistic: there will be setbacks and difficulties. A greater collective effort will generate more demands on each of us individually and on the institutions we represent – national and international, public and private. Compressing the time required to accomplish major and tangible results is the task for leadership in the 21st century. This leadership must be technical. It must be political. And it must be moral. PROGRESS AND CHALLENGES An historic conference in Alma-Ata in 1978 established the goal of Health for All by the year 2000. It defined this goal as “the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life”. This report describes how the past few decades – the period following the Declaration of Alma-Ata – have witnessed revolutionary gains in life expectancy. These gains build on progress that began for some countries in the late 19th century. Among today’s high income countries, life expectancy increased by 30 to 40 years in this century. Most of today’s low and middle income countries have experienced even more dramatic gains, although remaining inequalities needlessly burden disadvantaged populations and prolong their poverty. Under WHO’s leadership the world eradicated smallpox, one of the most devastating diseases of history, and today a substantial majority of the world’s population faces relatively low risk from infectious diseases of any sort. These health gains have transformed quality of life and created conditions favouring sustained fertility reductions and consequent demographic change. In many developing countries, for example, the total fertility rate – the expected number of children a woman will bear over her lifetime – declined from over six in the late 1950s to about three at present. These health and demographic changes have contributed directly to the global diffusion of rapid economic growth that, like the health revolution, constitutes an extraordinary accomplishment of the century now closing. In an important sense, then, the world has made great progress towards better Health for All. Inspiration and guidance from Alma-Ata, with its major emphasis on the critical

Message from the Director-General role of primary health care, contributed in no small measure to the health revolution. Con- tinued improvement in living standards has also played a role. More important, though, has probably been the generation and application of new knowledge about diseases and their control. These factors have yielded substantial success by any measure, but problems and challenges remain. Some problems emerge from the reduction in mortality from infectious disease and accompanying declines in fertility: the very successes of the past few decades will, inexora- bly, generate a"demographic transition"from traditional societies where almost everyone is young to societies with rapidly increasing numbers of the middle-aged and elderly. With this transition a new set of diseases rises to prominence: cancers, heart disease, stroke and mental illness figure prominently among them. Available interventions against these dis- eases, including preventive ones, yield less decisive results than we have achieved for most infectious diseases And their costs can be very high indeed Furthermore, as this report documents, over a billion people will enter the 21st century without having benefited from the health revolution: their lives remain short and scarred by disease. Many countries must deal with these disease problems of the poor while simul taneously responding to rapid growth in noncommunicable diseases: they face a double burden. Large numbers of other individuals, while not poor, fail to realize their full poten tial for better health because health systems allocate resources to interventions of low qual ity or of low efficacy related to cost. Increasing numbers of people forego or defer essential care or suffer huge financial burdens resulting from an unexpected need for expensive services.The continuing challenges to health ministries and to countries thus remain enor- mous. New problems constantly arise: witness the emergence of the HIV epidemic, the threat of resurgent malaria or the unexpected magnitude and consequences of the tobacco epidemic. Achieving better health for all is an ever-changing task. Success will make a major difference in the quality of life worldwide. And the difference for the poor will be not only in improving their quality of life but also, through increasing their productivity, in ddressing one of the root causes of poverty Global leadership and advocacy for health remain critical missing ingredients in the formula for making a difference and conveying evidence to the highest level of govern ent. We need to remind prime ministers and finance ministers that they are health min isters themselves and that investments in the health of the poor can enhance growth and reduce poverty. Leadership must motivate and guide the technical community to bring todays powerful tools to bear on the challenges before us Let us review the challenges to be addressed in order to improve the world's health First and foremost, there is a need to reduce greatly the burden ofexcess mortality and morbid- ity suffered by the poor. The OECD's Development Assistance Committee has establishe the target of halving the number of people living in absolute poverty by the year 2015 This goal is attainable, but it will require major shifts in the way that govemments all over the world use their resources. It will mean focusing more on interventions that we know can achieve the greatest health gain possible within prevailing resource limits.It will mean giving renewed attention to diseases like tuberculosis, which disproportion ately affect poor people, as well as malaria and HIVAIDS, which we now recognize as major constraints to economic growth. Women and children suffer poverty more than men: there is therefore a need for maternal and childhood nutrition. Reducing the burden of excess mortality andm.8 greater investment in reducing matemal mortality-and finding ways of improvin

Message from the Director-General ix role of primary health care, contributed in no small measure to the health revolution. Continued improvement in living standards has also played a role. More important, though, has probably been the generation and application of new knowledge about diseases and their control. These factors have yielded substantial success by any measure, but problems and challenges remain. Some problems emerge from the reduction in mortality from infectious disease and accompanying declines in fertility: the very successes of the past few decades will, inexorably, generate a “demographic transition” from traditional societies where almost everyone is young to societies with rapidly increasing numbers of the middle-aged and elderly. With this transition a new set of diseases rises to prominence: cancers, heart disease, stroke and mental illness figure prominently among them. Available interventions against these diseases, including preventive ones, yield less decisive results than we have achieved for most infectious diseases. And their costs can be very high indeed. Furthermore, as this report documents, over a billion people will enter the 21st century without having benefited from the health revolution: their lives remain short and scarred by disease. Many countries must deal with these disease problems of the poor while simultaneously responding to rapid growth in noncommunicable diseases: they face a double burden. Large numbers of other individuals, while not poor, fail to realize their full potential for better health because health systems allocate resources to interventions of low quality or of low efficacy related to cost. Increasing numbers of people forego or defer essential care or suffer huge financial burdens resulting from an unexpected need for expensive services. The continuing challenges to health ministries and to countries thus remain enormous. New problems constantly arise: witness the emergence of the HIV epidemic, the threat of resurgent malaria or the unexpected magnitude and consequences of the tobacco epidemic. Achieving better health for all is an ever-changing task. Success will make a major difference in the quality of life worldwide. And the difference for the poor will be not only in improving their quality of life but also, through increasing their productivity, in addressing one of the root causes of poverty. Global leadership and advocacy for health remain critical missing ingredients in the formula for making a difference and conveying evidence to the highest level of government. We need to remind prime ministers and finance ministers that they are health ministers themselves and that investments in the health of the poor can enhance growth and reduce poverty. Leadership must motivate and guide the technical community to bring today’s powerful tools to bear on the challenges before us. Let us review the challenges to be addressed in order to improve the world’s health. • First and foremost, there is a need to reduce greatly the burden of excess mortality and morbidity suffered by the poor. The OECD’s Development Assistance Committee has established the target of halving the number of people living in absolute poverty by the year 2015. This goal is attainable, but it will require major shifts in the way that governments all over the world use their resources. It will mean focusing more on interventions that we know can achieve the greatest health gain possible within prevailing resource limits. It will mean giving renewed attention to diseases like tuberculosis, which disproportionately affect poor people, as well as malaria and HIV/AIDS, which we now recognize as major constraints to economic growth. Women and children suffer poverty more than men: there is therefore a need for greater investment in reducing maternal mortality – and finding ways of improving maternal and childhood nutrition. Reducing the burden of excess mortality and mor-

The World Health Report 1999 bidity also means revitalizing and extending the coverage of immunization programmes still one of the most powerful and cost-effective technologies at our disposal. The elimination of poliomyelitis in the Americas in the past decade, and great progress in control elsewhere, hold out the promise that polio will join smallpox as a disease known The new focus on reducing the burden of disease suffered by poor people is not just a call to governments alone. To make real inroads into absolute poverty will mean harnessing the energies and resources of the private sector and civil society as well. We need to be clear about what the world should be aiming to achieve and the resources needed to achieve global goals. We believe there is a good case for negotiating realistic national and international targets as a means of mobilizing resources, concentrating international attention on the most important problems, and ensuring proper monitor- ing of progress and achievement Second, there is a need to counter potential threats to health resulting from economic crises, unhealthy environments or risky behaviour. Tobacco addiction is one of the single most important threats. It is not just an issue for the north: over 80% of all smokers today live in developing countries. a global commitment to tobacco control can potentially avert scores of millions of premature deaths in the next half century, and its success can point the way for effective control of other threats Preparing effective responses to emerging infections and countering the spread of resistance to antimicrobials will help insure against the prospect of a significantly increased infectious disease threat Beyond countering specific threats, promotion of healthy lifestyles underpins a proactive strategy for risk reduction: cleaner air and water, adequate sanitation, healthy diets and safer transportation-all are important. And all are facilitated by stable economic growth and by ensuring that females as well as males have opportunities to increase their educational attainment Third, there is a need to develop more effective health systems. In many parts of the world, health systems are ill-equipped to cope with present demands, let alone those they will face in the future. The institutional problems which limit health sector performance are have been relatively neglected by governments and development agencies alike often common to all public services in a country. But, despite their importance, We now recognize that dealing with issues such as pay and incentives in the oublic sector, priority setting and rationing, and unregulated growth in the private se tor constitute some of the most challenging items on the international health agenda. The report's chapter on health systems development points to change taking place in all parts of the world-change that responds to different problems in different ways. The pressure for change provides the opportunity for reform. But reform requires a sense of direction. In my view, the broad goal of better health for all should guide reform. Beyond this, however there is a need to be clear about the desirable characteristics of health systems. The goal must be to create health systems that can mprove health status; enhance responsiveness to legitimate expectation increase efficiency: .protect individuals, families and communities from financial loss, nhance fairness in the financing and delivery of health care

x The World Health Report 1999 bidity also means revitalizing and extending the coverage of immunization programmes – still one of the most powerful and cost-effective technologies at our disposal. The elimination of poliomyelitis in the Americas in the past decade, and great progress in control elsewhere, hold out the promise that polio will join smallpox as a disease known only to history. The new focus on reducing the burden of disease suffered by poor people is not just a call to governments alone. To make real inroads into absolute poverty will mean harnessing the energies and resources of the private sector and civil society as well. We need to be clear about what the world should be aiming to achieve and the resources needed to achieve global goals. We believe there is a good case for negotiating realistic national and international targets as a means of mobilizing resources, concentrating international attention on the most important problems, and ensuring proper monitoring of progress and achievement. • Second, there is a need to counter potential threats to health resulting from economic crises, unhealthy environments or risky behaviour. Tobacco addiction is one of the single most important threats. It is not just an issue for the north: over 80% of all smokers today live in developing countries. A global commitment to tobacco control can potentially avert scores of millions of premature deaths in the next half century, and its success can point the way for effective control of other threats. Preparing effective responses to emerging infections and countering the spread of resistance to antimicrobials will help insure against the prospect of a significantly increased infectious disease threat. Beyond countering specific threats, promotion of healthy lifestyles underpins a proactive strategy for risk reduction: cleaner air and water, adequate sanitation, healthy diets and safer transportation – all are important. And all are facilitated by stable economic growth and by ensuring that females as well as males have opportunities to increase their educational attainment. • Third, there is a need to develop more effective health systems. In many parts of the world, health systems are ill-equipped to cope with present demands, let alone those they will face in the future. The institutional problems which limit health sector performance are often common to all public services in a country. But, despite their importance, they have been relatively neglected by governments and development agencies alike. We now recognize that dealing with issues such as pay and incentives in the public sector, priority setting and rationing, and unregulated growth in the private sector constitute some of the most challenging items on the international health agenda. The report’s chapter on health systems development points to change taking place in all parts of the world – change that responds to different problems in different ways. The pressure for change provides the opportunity for reform. But reform requires a sense of direction. In my view, the broad goal of better health for all should guide reform. Beyond this, however, there is a need to be clear about the desirable characteristics of health systems. The goal must be to create health systems that can: • improve health status; • reduce health inequalities; • enhance responsiveness to legitimate expectations; • increase efficiency; • protect individuals, families and communities from financial loss; • enhance fairness in the financing and delivery of health care

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