Sm. Sci. Med. Vol. 35, No. 4, pp. 541-547, 1992 Printed in Great Britain. All rights reserved
Copyright
SECTION REALITIES
OF HEALTH
FOR
0
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
N ALL
BY THE
YEAR
2000
TOMRATHWELL Senior
Lecturer,
Health
Care Systems, Nuffield Institute for Health University of Leeds, LS2 9JT, U.K.
Services
Studies,
Abstract-The
European Region of the World Health Organisation (WHO) took the global lead on Health For All when the Regional Committee in 1980 approved a European Health For All Strategy. This was an important breakthrough for WHO as it was the first time Member States in a Region endorsed a common health policy and agreed to be monitored on their progress towards attainment of the strategy. The paper reviews the progress of Member States to date towards the Regional Health For All goal. Progress is discussed within the context of the six fundamental principles which underpin the Health For All concept, vis: equity; health promotion; community involvement; multisectoral participation; primary (local) health care; and, international cooperation. The paper argues that the commitment of Member States to the Health For All Strategy has been patchy with only moderate success towards meeting the 38 Regional Targets. Poor progress is attributed to changing national and international political and economic circumstances and limited resources but perhaps most importantly to a lack of political will to take the strategy seriously. Key words--Health For All, evaluation, collaboration, primary health care
equity, health promotion,
INTRODUCTION
community
participation,
multisectoral
The paper reviews the progress achieved to date of HFA in the European Region. It makes no apology for focusing on the European Region to the exclusion of the rest of the globe, principally because of its decision to make HFA a high profile policy issue. The paper comprises three substantive parts. It begins with a brief overview of the European HFA strategy. This is followed by an assessment of progress towards HFA according to the six fundamental principles of the strategy. The paper concludes by highlighting some of the issues likely to affect future progress of and developments in HFA.
It is 15 years since the World Health Assembly (WHA) in May 1977 declared, as a global target, that: the main social target of Governments and WHO in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life (resolution WHA 30.43). The resolution could be interpreted as a global ‘mission statement’ for health. Mission statements, however grand and carefully they may be worded, are meaningless unless they are enshrined in policy. The international conference on primary health care held at Alma Ata in 1978 was an attempt to establish a policy framework based on the 1977 WHA resolution. The Declaration of Alma Ata [l] established the credentials of Health For All as a global strategy, which was formally adopted in 1981 by the Member States of the World Health Organisation (WHO) [2]. Although all Member States of WHO committed themselves to Health For All (HFA), it was the European Region of WHO which took the lead when in 1980 the Regional Committee for Europe agreed and approved a European Health For All Strategy [3]. This was an important breakthrough for WHO. Whereas the global strategy set out a policy framework for Member States to follow if they so wished, the European HFA strategy in fact was a common health policy for the Region with Member States agreeing to be monitored by the Regional Office of WHO on their progress towards attainment of the strategy.
HEALTH
FOR ALL IN EUROPE
Europe, of all the WHO Regions, arguably is the most advanced in both health and economic terms. All other WHO Regions embrace a mix of developed and developing nations, including the Pan American Region even though it embraces Canada and the United States. A major issue which led to the European HFA initiative was that despite the considerable advances and developments in health within the region, overall levels of health were much less than expectations. In other words, given its position relevant to other WHO Regions, Europe could and should be doing better. Two basic issues were singled out for special attention within the HFA strategy. These were the desire to reduce the existing inequality in health and health status both between countries and between areas and/or groups within countries, and to strengthen the part that health plays both for the 541
TOM RATHWELL
542
individual and for society. Strengthening within the WHO context of HFA means: l
l
l
health
adding life to years by enabling people to cope with and benefit from a healthy life; adding health to life by reducing disease and disability; adding years to life by reducing ‘avoidable deaths’ and thereby increasing life expectancy.
Equity and strengthening health, the twin thrusts of the European HFA Strategy, are themselves grounded in six major themes or principles. The six principles set the context within which member states are expected to meet the challenge implicit in HFA. The six key threads of the HFA strategy are: 0 equity-ensuring an equal opportunity for all citizens of obtaining and maintaining good health so that inequalities in health and health status no longer exist between and within countries. l health promotion-prevention of disease and promotion of healthy lifestyles and behaviour are necessary if people are to make the most of their physical, mental and social capabilities. 0 community involvement-people are partners with purchasers and providers in good health and as such they enjoy certain rights but also share some of the responsibility. People must have the information and the respect they need to take an active role in health. l multisectoralparticipation-the attainment of good health requires the coordinated support and action of all sectors of society. An acknowledgement that by itself the health sector can only achieve limited improvement in health and health status. l primary (local) health care-meeting the basic health needs of people by providing care and services as close as possible to where the people live and work. Care that is readily acceptable and accessible to the local community. a international cooperation-health problems do not respect administrative or political boundaries, especially national ones. Strong international cooperation is not only necessary to prevent the exportation of health damaging practices but also to ensure that new developments in health are readily disseminated. To give credence to the Regional HFA Strategy and to support its implementation, member states in 1984 adopted a set of 38 specific targets [4]. Broadly speaking the 38 targets are grouped under the following headings: Health For All by the Year 2000; Lifestyles Conducive to Health; Healthy Environment; Appropriate Care, and, Research and Health
Development Support. The targets are the framework against which success is to be measured. A detailed discussion of the targets is inappropriate here as this has taken place elsewhere [S]. It is not the relevance of the targets that is in question as they are only a means to an end, it is that end which is under scrutiny. ASSESSING PROGRESS
TOWARDS
HFA
It will be recalled that the Regional HFA Strategy was to be more than a statement of intent, as Member States agreed to undergo and to undertake regular monitoring and evaluation of their progress towards HFA. Member States agreed to be monitored on the basis of an approved set of indicators [6]. The Regional office must submit a report bi-annually (subsequently changed to tri-annually) to the Regional Committee and the World Health Assembly [7,8]. In addition, each Member State undertook to make 6 yearly evaluations of their individual HFA policies [9]. Do the good intentions of the Regional HFA Strategy, laudable though they may be, in reality get translated in action by the Member States? This crucial question is explored by examining the progress achieved by Member States to meet the aspirations of the strategy embodied in the 38 targets. Instead of assessing progress according to the 5 broad target headings described above, the focus is on the 6 main principles which underpins the Regional HFA Strategy. The rationale for this approach is simply that if the foundations of the strategy, as represented by the 6 principles, are not respected, then any progress on the targets is no more than cosmetic. Progress towards each of the 6 is now discussed in turn. Equity
This is a major, if not the major plank in the Regional Strategy. As far as WHO is concerned equity, “is the essence of health for all”. It is more than just decreasing inequalities in health in a group or population, it also means giving people the opportunity to fully realise their health potential. Here, more than anywhere else, if member states truly are committed to the principles as well as to achieving HFA, one should expect to see significant improvements in narrowing the differentials in health status between populations within countries and between countries. Data from the most recent Regional evaluation is disappointing-the results so far are poor, and the prognosis is not encouraging [lo]. It suggests that differences (inequalities) are persistent, and in some cases increasing instead of declining as expected. This is even true of a country like Finland which has a long tradition of pursuing a social welfare policy predicated on equity and social justice. Despite such policies, mortality is still greater among the lower social classes for both men and women, as
Realities of Health For All by the year 2000 is morbidity, as measured by self-reported chronic illness [1 11. Recent empirical work clearly shows that the health divide among nations is not getting better; indeed for most countries of central and eastern Europe it is worsening [12]. Member States, by adopting the common health policy embodied in the Regional Strategy, have recognised the theoretical importance of equity in health. The Regional Targets include one specifically about equity: Target 1-“By the year 2000, the actual differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” [4]. However, Member States have not developed practical measures to combat inequity in health status insofar as the programmes they have produced have been general in nature and not linked to outcomes. Indeed the recent WHO evaluation exercise notes that rarely are equity programmes backed by adequate financial and managerial support [lo]. Thus, the reality of equity is illusory; it has yet to get beyond the rhetoric. Health promotion
Many of the targets in support of the HFA strategy focus on aspects of disease prevention and health promotion (Targets 4-12, 16, 17). Although the evidence from the latest evaluation exercise is mixed, this is the one area in which HFA seems to have been successful. Indicators associated with most of the targets suggest that trends are downward, or at least, not increasing. Many Member States have achieved good results in reducing and in some cases eradicating certain infectious diseases, increasing life expectancy, and reducing maternal mortality [lo]. The one area where efforts at changing patterns has been unsuccesful is cancer mortality, with lung cancer the leading cause of cancer deaths. Predictions about an overall reduction by the year 2000 in cancer mortality are gloomy. Results from the latest evaluation of HFA suggest that only 6 countries are likely to reach the target with a further 9 showing a downward trend [lo]. These 15 countries cover only about one third of the European population, so the future picture on cancer mortality remains gloomy. The success of health promotion and disease prevention efforts in the European Region are overshadowed by the growing disparity between Western Europe and Central and Eastern Europe. Much of the difference is due to a much higher mortality of cardiovascular disease, diseases of the circulatory system and malignant neoplasms to be found in Central and Eastern Europe [13]. This East-West divide is characteristic of most of the targets measuring the progress of health promotion are preventive initiatives in the European Region. The reasons for the poor progress in many Eastern European countries are twofold: first, slower socioeconomic development has meant that their health
543
services operate less efficiently and they have been unable to invest in technological developments to the same extent as elsewhere in Europe. Second, service demands and low resources have meant that little priority has been given to disease prevention and health promotion [ 131. Central and Eastern Europe notwithstanding, one might have expected greater success in reducing disease and preventing illness in Europe, given the considerable investment being made in health promotional and educational activities. This criticism may be somewhat unfair given the long lead time in effecting behavioural change. Focusing on changing individual behaviour will only be partially successful unless and until governments are prepared to take a stronger stand on alcohol and tobacco consumption, either by banning the products (which seems unlikely considering the tax revenue at stake), deterring consumption through higher excise taxes, curtailing (or even banning) advertising of the products, or legislating against their use on public premises. The weak link in the health promotion chain is not so much recalcitrant individuals as weak-willed government and health care management. Community involvement
The HFA concept of this implies empowerment of the people-giving them the tools to help themselves to improve their level of health and to enable them to work with policy makers and providers in ensuring that the health care delivered is what they (the people) need and want. Only one target (13) specifically mentions effective public participation in all levels of health policymaking. It says much about governments, policy-makers and providers commitment to community participation, to learn that the country reports submitted to the European Regional office of WHO indicated an almost total disregard for this particular and important principle of HFA [lo]. WHO attributes the poor progress on this principle to several factors. First, the continuing resistance of managers and professionals to sharing their decision making power. The few attempts at power sharing have usually ended in ignomy [14]. Second, the seemingly ingrained view among professionals, managers and policy-makers that public participation means acceptance and compliance with government health plans and programmes. They generally do not accept or even understand that by enhancing the decision making skills of communities and people this will improve the collective benefits of health. Third, most governments assume that their decision making structures are democratic and see no reason to alter existing arrangements. There is no real political will to do other than pay lip-service to the concept of greater community involvement in health care. Finally, even when there is considerable evidence of greater community awareness and involvement in health issues (the health cities network for example) most governments
544
TOMRATHWELL
appear not to be prepared to give them serious consideration [ 151. The picture is not all doom and gloom. Small steps are being taken, usually at the grass roots level, of involving health care users in the decision making process. Evidence from a recently completed PanEuropean research project on primary health care confirms this [16]. However, little real sustained progress is likely to occur unless governments and others accept the democratic challenge inherent in greater community participation in health. Ironically, the lead on this is being taken by governments in Central and Eastern Europe who are trying to establish new political structures which facilitate and encourage greater community participation. The difficulty they face is that the people seem to distrust their motives and consequently are hesitant about utilising the new structure. Community participation in health in Europe remains firmly anchored in tokenism, the lowest rung on Arnstein’s ladder of Citizen Participation
Multisectoral participation Target 13 set a deadline of 1990 for Member States to establish national policies which ensure broad intersectoral support mechanisms. However, Targets 18-25 (Health Environment), equally depend for their success upon good intersectoral cooperation [4]. Developments within the Region towards the realisation of this principle have been patchy [lo]. While there has been increasing awareness across the Region of the importance of an intersectoral approach to health, this has yet to be matched by concerted action. Most of the progress which has been made on intersectoral actions has taken place at national level, with the emphasis being on reducing health damaging behaviour, legal and administrative measures on health promotion, and in a more limited way, on promoting positive behaviour [lo]. Unfortunately, intersectoral efforts at the national level have rarely been matched by developments and initiatives at regional and local levels. Although the trend is encouraging there is according to WHO ‘La tendency to look for ‘one-shot’ legal or administrative actions, rather than for the establishment of interactive mechanisms by which policy making could be further developed” [lo, p. 611. Perhaps the only notable exception to this is the healthy cities movement which has grown irrespective of government involvement. Progress on the HFA targets related to a healthy environment have been moderate across all targets, with the exception of target 22 (food safety) which
has declined [lo]. Awareness of the multisectoral dimension of a healthy environment was recognised by the adoption by most Member States of the European Charter on Environment and Health [19]. Signing the Charter is one thing, implementing its recommendations is another. Past experience of international charters suggests that we should not be too sanguine about this one. Attempts by some countries to establish mechanisms for coordinating policies between agencies whose policy have a bearing on health or where they share a complementarity for health, while welcomed, often end in recriminations and failure [20]. Government agencies are not known for willingness to help each other, especially where there may be a financial consequence of such assistance. Thus, it is impossible not to be pessimistic about future developments because policy-makers (where they share responsibility) appear to have neither the resources and/or the will to work effectively together on health issues. Primary {local) care Despite the health care reforms in Southern Europe during the latter half of the 1970s and the early 1980s which re-focused attention on primary health care (PHC), results of the previous evaluation of progress towards HFA concluded that “decisions on ways of ensuring full . . implementation of PHC often seem to be lacking” [9]. This may be, as the latest evaluation report indicates, because PHC coverage is fairly complete in Member States; at least judging by the nature of PHC elsewhere. PHC may be well developed in the European region but in terms of re-orienting health care towards primary health care as called for in the Alma Ata Declaration [l], and embodied in the HFA Targets on Appropriate Care (26-31) [4], progress has been moderate at best. Moreover, member states collectively have made little or no progress on a rational and preferential distribution of resources according to need (target 27), nor on improving the content and effectiveness of PHC being provided [lo]. Poor progress such as this is attributable to the existence of well established hospital based services and professional preferences coupled with both the provider and public perception of the low status of primary care [21]. Health care in Europe currently is changing. Most, if not all of the Member States have, or are reviewing their health care systems. The search is on for a better and more efficient paradigm to deliver health care [22]. Many of the mechanisms under consideration seek to strengthen primary health care and to lessen the demand for and inappropriate use of secondary care [23]. While it is too early to be categorical about the reform measures, a popular feature seems to be some form of mixed economy of health based on notions of public competition [24,25]. What the reforms eventually mean for PHC in Europe is unclear. WHO is sanguine, believing that
Realities of Health For All by the year 2000 whatever the outcome the profile of PHC will be enhanced. Although this may be the case, early comments on the reforms in Britiain suggest that, despite all the rhetoric about patient choice and meeting local needs, the changes are essentially structuralist and consolidate rather than weaken the dominance of secondary care [26]. What then is the likelihood of the picture being any different elsewhere in Europe? International cooperation
Of the six principles this is the one that is most difficult to assess. There is only one target (18) which refers to international cooperation and then only in a relatively narrow way. This is not to suggest that environmental matters, especially those such as pollution which is no respector of international boundaries, are unimportant, but merely to note that wider issues, such as the exportation of questionable health practices and procedures, do not appear to be addressed by the HFA targets. A number of countries have signed international conventions such as the Montreal Protocol on Ozone, the Convention on the Control of Transboundary Air Pollution, and the Basle Convention on the Control of Transfrontier Transport of Special Waste. Despite such public utterances of concern for environmental issues, an overwhelming concern for economic development has meant that few resources have been channelled into action on the environment. Once again, policy makers appear more worried about their public image-to be seen to be concerned about environmental issues is all that matters, actually doing something is of lesser importance. Signing up is considered better than cleaning up! The lack of reference to the exportation of dubious health products by countries, or more specifically, the industries and manufacturers based therein is disheartening. Governments seem powerless to prevent multi-nationals based in these countries from pursuing elsewhere, especially in the developing world, questionable practices which they themselves severely regulate or prohibit. As Page has argued, such practices cannot and should not be tolerated, if we are really serious about HFA [27]. Thus international cooperation is much more than tackling environmental issues which transcend international boundaries, it is all about being responsible global citizens. PREVAILING ISSUES
The purpose of the paper is not to provide an indictment of the progress so far towards HFA. Rather, the intention is to offer a critical appraisal of the policy. The paper has been deliberately provocative in order to stimulate thought and debate. WHO would certainly argue that HFA is a success even though progress as measured against the 38 Targets can only be described as moderate (Table 1). But then WHO, as a global organisation, has no
545
executive power. It cannot compel its Member States to adopt and implement a HFA policy; it can only cajole.’ Not many countries like Finland [I l] are prepared to be an exemplar but by so being, it sets the standard for the rest to follow. It remains to be seen if any other nation is willing to open its HFA policies to such scrutiny. The tendency of the past is likely to set the pattern for the future. That is, governments and policy makers are unlikely to hold themselves accountable either to their populations or to the wider European community, for their HFA policies. They may participate in WHO evaluation exercises, but like most governments they will only highlight those aspects of the HFA strategy which put them in a good light. They will play the game but only according to their own rules. The drive for efficiency in health care systems taking place across Europe will reinforce structural changes in health care. It is not at all clear, despite the aspirations of WHO, that this reforming process will lead to greater emphasis on HFA through enhancing the role of primary health care. HFA-type developments will continue to take place at the local level because the problems are more obvious at this level; politicians are more accountable and visible to the local community; and local government agencies and bodies interact more easily (less is at stake) than is the case at the national level [28]. National policy makers will be happy to see local initiatives continue, as this will absolve them of charges that they are neither concerned about nor committed to HFA. Commentators have argued that the 38 targets by their very nature have hindered rather than helped the cause of HFA [29]. The targets were intended to have a dual purpose: First, to provide a basis against which each member state could monitor and evaluate progress towards HFA; and second, to set the broad Regional objectives and agenda for HFA. The targets have been criticised by some, perhaps unfairly, of being too precise; not precise enough; unrealistic; unachievable; and/or, too comprehensive in nature. WHO is in the process of revising the HFA targets and an updated version of the targets has been approved by the Regional Committee. The revised targets go a long way towards meeting the criticisms levelled at the original 38. The challenge to Member States inherent in the original targets is carried on in the revised version. It remains to be seen whether Member States will respond more positively to the new targets than they have to the original set. Finally, even though the, at present, 31 Member States of the European Region have resolved that HFA will be their common strategy, the political will of each Member State to draft a HFA policy and then to implement it remains suspect. Only half of the Member States have, or are in the process of producing national HFA policies [30]. Producing a national HFA document demonstrates intent, not necessarily commitment. It is this latter ingredient which will
TOM RATHWLL
546
Table I.Progress towards Health For All taruets
Regional No.
Target Abridged description
Good
Moderate
Little or none
Negative
Health For All by the Year ZOO0 X
2 3 4 5 6 1 8 9 10 I1 12
Equity in health Adding life to year Better opportunities for disabled Reducing disease and disability Eliminating seven specific diseases Life expectancy at birth Reducing infant mortalily rates Reducing rates of maternal mortality Combating diseases of the circulatory system Combating cancer Reducing accidents Stopping increase in suicides
13 14 15 16 17
LVestyles conducive to health Healthy public policy Social support systems Knowledge and motivation for healthy behaviour Promoting positive health behaviour Decreasing health-damaging behaviour
18 19 20 21 22 23 24 25
Healthy environment Policies for a healthy environment Monitoring, assessment and control of risks in the environment Water Pollulion Protection against air pollution Food safety Protection from hazardous waste Healthy homes Healthy working conditions
26 27 28 29 30 31
Appropriate care A health care system based primary health care Rational and preferential distribution of resources according to need Content of primary health care Providers of primary health care Coordination of community resources for primary health care Ensuring the equality of services
I
32 33 34 35 36 31 38
Healtn WCnnOlOgy
1. World Health Organisation/United Nations Children’s Fund. Alma Ara 1978: Primary Health Care: Report of
5.
X X X X X X X X X X X X X X X X X X X X X X X X X
X
X X X X X X
Second Evaluation of the Strategy For Health For All by the Year 2000 [IO].
REFERENCES
4.
X
assessment
determine the outcome of the HFA exercise. So far, if the evaluative exercises undertaken by WHO are anything to go by, commitment seems to be in rather short supply. If HFA is ever to become the reality envisioned by WHO, the crucial question remains; how to get all Member States to take the initiative seriously.
3.
X
Research and Health Development Support Research and health for all Policies for health for all Management of planning and resource allocation Health information systems Planning, education and use of health personnel for health for all Education of personnel in other sectors to support health for all _*.. . .
Source: World Health Organisation.
2.
X X X
the International Conference on Primary Health Care, Alma Ata, U.S.S.R. WHO/UNICEF, Geneva, 1978. World Health Organisation. Global Strategy for Health For All by the Year 2000. WHO, Geneva, 1981. World Health Organisation. Regional Strategy for Attaining Health For All by the Year 2ooO. Regional Office for Europe, Copenhagen, 1982. World Health Organisation. Targets for Health For All. Regional Office for Europe, Copenhagen, 1985. See for example Rathwell T. Pursuing Health For All in Britain-an assessment. Sot. Sci. Med. 34, 169-182, 1992.
6. World Health Organisation. Revised List of Indicators and Procedure for Monitoring Progress Towards Health For All in the European Regions 1987-88. Regional
Office for Europe, Copenhagen, 1987. 7. World Health Organisation. Monitoring of the Strategy Healrh For All by the Year 2OU0, Part I. The Situation in the European Region, 1987/88. Regional Office for Europe, Copenhagen, 1989. 8. World Health Organisation. Monitoring of the Strategy for Health For AILby the Year 2tW0, Part Ii. Monitoring by Country. 1988/89. Regional Office for Europe, Copenhagen, 1989. 9. World Health Organisation. Eualuafion of the Strategy for
for Health For All by the Year 2000: Seventh Report on the World Health Situation, Vol. 5. European Region.
Regional Office for Europe, Copenhagen, 1986. 10. World Health Organisation. Second Evaluation of the Strategy for Health For All by the Year 2000. Regional Committee for Europe, Copenhagen, 1991. 11. World Health Organisation. Health For All Policy in Finland. Regional Office for Euros, Copenhagen, 199I. 12. Space does not permit, nor is it appropriate for, a full scale discussion of equity/equality in health. Readers interested in European comparative studies are referred to: Fox J. (Ed.) Health Inequalities in European Countries. Gower, Aldershot, 1989; Illsley R. and
Realities of Health For All by the year 2000 Svenson P. G. (Eds) Health inequalities in Europe. Sot. Sci. Med. 31, 323420, 1990. 13. World Health Organisation Health of Europe, Summary of the Health For All Evaluation. Regional Office for Europe, Copenhagen, 1991. 14. See for example, Rathwell T. A management partnership for the mentally handicapped. J. Publ. Hlth Policy 9, 80-91, 1988. 15. See for example Ashton J. (Ed.) Healthy Cities. Open
University Press, Milton Keynes, 1991. World Health Oraanisation, Healthy Cities Prolect: A Project Becomes a Movement. Review of Progress 1987 to 1990 (Edited bv Tsoures A.). Regional Office for
Europe, Copenhagen, 1991. ’ 16. Godinho J., Rathwell T., Gott M. and Daley J. Final Scientific Report of the Research Project: Tipping the Balance Towards Primary Health Care. Brussels, 1991. 17. Arnstein S. R. A ladder of citizen participation. J. Am. Inst. Planners 35, 216-244, 1969. 18. Alford R. R. Health Care Politics. University of
22. Organisation for Economic Cooperation and Development. Health Care Systems in Transition: the Search for Eficiency. Social Policy Studies No. 7. OECD Paris, 1990. 23. Bengoa R. and Hunter D. (Eds) New Directions in Managing Health Care. World Health Organisatiom University of Leeds, Nuffield Institute for Health Services Studies, Leeds, 1991. 24. Sahman R. B. and Van Otter C. Public competition versus mixed markets: an analytic comparison. Hlth Policy 11, 43-55, 1989. 25. Harrison S. Working the market: purchaser/provider separation in English health care. In?. J. Hlth Services 21, 625435, 1991. 26. Harrison S. et al. Competing for Health. University of
27. 28.
Chicago Press, Chicago. 1975. 19. World Health Organisation. Environment and Health: The European Charter and Commentary, First European Conference on Environment and Health, Frankfurt,
7-8 December 1989. Regional Office for Europe, Copenhagen, 1990. 20. For an excellent discussion of this see Klein R. The Politics of the National Health Sewice, 2nd edn. Longman, London 1989. 21. Van Oyen H. J. Health For All in Europe: An Epidemiological Review. World Health Organisation., Regional Office for Europe, Copenhagen, 1990.
547
29.
30.
Leeds, Nuffield Institute for Health Services Studies, Leeds, 1989. Page B. B. Social justice and equity: a conceptual overview. Paper presented at International Conference on Social Justice and Equity in Health, Leeds, 1985. Evans A., Farrant W. and Trojan A. (Eds) Healthy Public Policy at the Local Level. European Centre for Social Welfare Policy and Research, Campus/Westview, Vienna, 1990. World Health Organisation. Consultation of Countries with National Health For All Policy Documents. A Report from the programme on Health Policies and Plannina. Regional Office for Eurone. Conenhaaen. 1990. World Health Organisation. Background Pa&r ‘Based on Analysis of Replies to the Checklist. Prepared for the consultation of countries with HFA Policy Documents at National Level, Sofia, Bulgaria, Regional Office for Europe, Copenhagen, 1989.
Copyright
SECTION REALITIES
OF HEALTH
FOR
0
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
N ALL
BY THE
YEAR
2000
TOMRATHWELL Senior
Lecturer,
Health
Care Systems, Nuffield Institute for Health University of Leeds, LS2 9JT, U.K.
Services
Studies,
Abstract-The
European Region of the World Health Organisation (WHO) took the global lead on Health For All when the Regional Committee in 1980 approved a European Health For All Strategy. This was an important breakthrough for WHO as it was the first time Member States in a Region endorsed a common health policy and agreed to be monitored on their progress towards attainment of the strategy. The paper reviews the progress of Member States to date towards the Regional Health For All goal. Progress is discussed within the context of the six fundamental principles which underpin the Health For All concept, vis: equity; health promotion; community involvement; multisectoral participation; primary (local) health care; and, international cooperation. The paper argues that the commitment of Member States to the Health For All Strategy has been patchy with only moderate success towards meeting the 38 Regional Targets. Poor progress is attributed to changing national and international political and economic circumstances and limited resources but perhaps most importantly to a lack of political will to take the strategy seriously. Key words--Health For All, evaluation, collaboration, primary health care
equity, health promotion,
INTRODUCTION
community
participation,
multisectoral
The paper reviews the progress achieved to date of HFA in the European Region. It makes no apology for focusing on the European Region to the exclusion of the rest of the globe, principally because of its decision to make HFA a high profile policy issue. The paper comprises three substantive parts. It begins with a brief overview of the European HFA strategy. This is followed by an assessment of progress towards HFA according to the six fundamental principles of the strategy. The paper concludes by highlighting some of the issues likely to affect future progress of and developments in HFA.
It is 15 years since the World Health Assembly (WHA) in May 1977 declared, as a global target, that: the main social target of Governments and WHO in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life (resolution WHA 30.43). The resolution could be interpreted as a global ‘mission statement’ for health. Mission statements, however grand and carefully they may be worded, are meaningless unless they are enshrined in policy. The international conference on primary health care held at Alma Ata in 1978 was an attempt to establish a policy framework based on the 1977 WHA resolution. The Declaration of Alma Ata [l] established the credentials of Health For All as a global strategy, which was formally adopted in 1981 by the Member States of the World Health Organisation (WHO) [2]. Although all Member States of WHO committed themselves to Health For All (HFA), it was the European Region of WHO which took the lead when in 1980 the Regional Committee for Europe agreed and approved a European Health For All Strategy [3]. This was an important breakthrough for WHO. Whereas the global strategy set out a policy framework for Member States to follow if they so wished, the European HFA strategy in fact was a common health policy for the Region with Member States agreeing to be monitored by the Regional Office of WHO on their progress towards attainment of the strategy.
HEALTH
FOR ALL IN EUROPE
Europe, of all the WHO Regions, arguably is the most advanced in both health and economic terms. All other WHO Regions embrace a mix of developed and developing nations, including the Pan American Region even though it embraces Canada and the United States. A major issue which led to the European HFA initiative was that despite the considerable advances and developments in health within the region, overall levels of health were much less than expectations. In other words, given its position relevant to other WHO Regions, Europe could and should be doing better. Two basic issues were singled out for special attention within the HFA strategy. These were the desire to reduce the existing inequality in health and health status both between countries and between areas and/or groups within countries, and to strengthen the part that health plays both for the 541
TOM RATHWELL
542
individual and for society. Strengthening within the WHO context of HFA means: l
l
l
health
adding life to years by enabling people to cope with and benefit from a healthy life; adding health to life by reducing disease and disability; adding years to life by reducing ‘avoidable deaths’ and thereby increasing life expectancy.
Equity and strengthening health, the twin thrusts of the European HFA Strategy, are themselves grounded in six major themes or principles. The six principles set the context within which member states are expected to meet the challenge implicit in HFA. The six key threads of the HFA strategy are: 0 equity-ensuring an equal opportunity for all citizens of obtaining and maintaining good health so that inequalities in health and health status no longer exist between and within countries. l health promotion-prevention of disease and promotion of healthy lifestyles and behaviour are necessary if people are to make the most of their physical, mental and social capabilities. 0 community involvement-people are partners with purchasers and providers in good health and as such they enjoy certain rights but also share some of the responsibility. People must have the information and the respect they need to take an active role in health. l multisectoralparticipation-the attainment of good health requires the coordinated support and action of all sectors of society. An acknowledgement that by itself the health sector can only achieve limited improvement in health and health status. l primary (local) health care-meeting the basic health needs of people by providing care and services as close as possible to where the people live and work. Care that is readily acceptable and accessible to the local community. a international cooperation-health problems do not respect administrative or political boundaries, especially national ones. Strong international cooperation is not only necessary to prevent the exportation of health damaging practices but also to ensure that new developments in health are readily disseminated. To give credence to the Regional HFA Strategy and to support its implementation, member states in 1984 adopted a set of 38 specific targets [4]. Broadly speaking the 38 targets are grouped under the following headings: Health For All by the Year 2000; Lifestyles Conducive to Health; Healthy Environment; Appropriate Care, and, Research and Health
Development Support. The targets are the framework against which success is to be measured. A detailed discussion of the targets is inappropriate here as this has taken place elsewhere [S]. It is not the relevance of the targets that is in question as they are only a means to an end, it is that end which is under scrutiny. ASSESSING PROGRESS
TOWARDS
HFA
It will be recalled that the Regional HFA Strategy was to be more than a statement of intent, as Member States agreed to undergo and to undertake regular monitoring and evaluation of their progress towards HFA. Member States agreed to be monitored on the basis of an approved set of indicators [6]. The Regional office must submit a report bi-annually (subsequently changed to tri-annually) to the Regional Committee and the World Health Assembly [7,8]. In addition, each Member State undertook to make 6 yearly evaluations of their individual HFA policies [9]. Do the good intentions of the Regional HFA Strategy, laudable though they may be, in reality get translated in action by the Member States? This crucial question is explored by examining the progress achieved by Member States to meet the aspirations of the strategy embodied in the 38 targets. Instead of assessing progress according to the 5 broad target headings described above, the focus is on the 6 main principles which underpins the Regional HFA Strategy. The rationale for this approach is simply that if the foundations of the strategy, as represented by the 6 principles, are not respected, then any progress on the targets is no more than cosmetic. Progress towards each of the 6 is now discussed in turn. Equity
This is a major, if not the major plank in the Regional Strategy. As far as WHO is concerned equity, “is the essence of health for all”. It is more than just decreasing inequalities in health in a group or population, it also means giving people the opportunity to fully realise their health potential. Here, more than anywhere else, if member states truly are committed to the principles as well as to achieving HFA, one should expect to see significant improvements in narrowing the differentials in health status between populations within countries and between countries. Data from the most recent Regional evaluation is disappointing-the results so far are poor, and the prognosis is not encouraging [lo]. It suggests that differences (inequalities) are persistent, and in some cases increasing instead of declining as expected. This is even true of a country like Finland which has a long tradition of pursuing a social welfare policy predicated on equity and social justice. Despite such policies, mortality is still greater among the lower social classes for both men and women, as
Realities of Health For All by the year 2000 is morbidity, as measured by self-reported chronic illness [1 11. Recent empirical work clearly shows that the health divide among nations is not getting better; indeed for most countries of central and eastern Europe it is worsening [12]. Member States, by adopting the common health policy embodied in the Regional Strategy, have recognised the theoretical importance of equity in health. The Regional Targets include one specifically about equity: Target 1-“By the year 2000, the actual differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” [4]. However, Member States have not developed practical measures to combat inequity in health status insofar as the programmes they have produced have been general in nature and not linked to outcomes. Indeed the recent WHO evaluation exercise notes that rarely are equity programmes backed by adequate financial and managerial support [lo]. Thus, the reality of equity is illusory; it has yet to get beyond the rhetoric. Health promotion
Many of the targets in support of the HFA strategy focus on aspects of disease prevention and health promotion (Targets 4-12, 16, 17). Although the evidence from the latest evaluation exercise is mixed, this is the one area in which HFA seems to have been successful. Indicators associated with most of the targets suggest that trends are downward, or at least, not increasing. Many Member States have achieved good results in reducing and in some cases eradicating certain infectious diseases, increasing life expectancy, and reducing maternal mortality [lo]. The one area where efforts at changing patterns has been unsuccesful is cancer mortality, with lung cancer the leading cause of cancer deaths. Predictions about an overall reduction by the year 2000 in cancer mortality are gloomy. Results from the latest evaluation of HFA suggest that only 6 countries are likely to reach the target with a further 9 showing a downward trend [lo]. These 15 countries cover only about one third of the European population, so the future picture on cancer mortality remains gloomy. The success of health promotion and disease prevention efforts in the European Region are overshadowed by the growing disparity between Western Europe and Central and Eastern Europe. Much of the difference is due to a much higher mortality of cardiovascular disease, diseases of the circulatory system and malignant neoplasms to be found in Central and Eastern Europe [13]. This East-West divide is characteristic of most of the targets measuring the progress of health promotion are preventive initiatives in the European Region. The reasons for the poor progress in many Eastern European countries are twofold: first, slower socioeconomic development has meant that their health
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services operate less efficiently and they have been unable to invest in technological developments to the same extent as elsewhere in Europe. Second, service demands and low resources have meant that little priority has been given to disease prevention and health promotion [ 131. Central and Eastern Europe notwithstanding, one might have expected greater success in reducing disease and preventing illness in Europe, given the considerable investment being made in health promotional and educational activities. This criticism may be somewhat unfair given the long lead time in effecting behavioural change. Focusing on changing individual behaviour will only be partially successful unless and until governments are prepared to take a stronger stand on alcohol and tobacco consumption, either by banning the products (which seems unlikely considering the tax revenue at stake), deterring consumption through higher excise taxes, curtailing (or even banning) advertising of the products, or legislating against their use on public premises. The weak link in the health promotion chain is not so much recalcitrant individuals as weak-willed government and health care management. Community involvement
The HFA concept of this implies empowerment of the people-giving them the tools to help themselves to improve their level of health and to enable them to work with policy makers and providers in ensuring that the health care delivered is what they (the people) need and want. Only one target (13) specifically mentions effective public participation in all levels of health policymaking. It says much about governments, policy-makers and providers commitment to community participation, to learn that the country reports submitted to the European Regional office of WHO indicated an almost total disregard for this particular and important principle of HFA [lo]. WHO attributes the poor progress on this principle to several factors. First, the continuing resistance of managers and professionals to sharing their decision making power. The few attempts at power sharing have usually ended in ignomy [14]. Second, the seemingly ingrained view among professionals, managers and policy-makers that public participation means acceptance and compliance with government health plans and programmes. They generally do not accept or even understand that by enhancing the decision making skills of communities and people this will improve the collective benefits of health. Third, most governments assume that their decision making structures are democratic and see no reason to alter existing arrangements. There is no real political will to do other than pay lip-service to the concept of greater community involvement in health care. Finally, even when there is considerable evidence of greater community awareness and involvement in health issues (the health cities network for example) most governments
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TOMRATHWELL
appear not to be prepared to give them serious consideration [ 151. The picture is not all doom and gloom. Small steps are being taken, usually at the grass roots level, of involving health care users in the decision making process. Evidence from a recently completed PanEuropean research project on primary health care confirms this [16]. However, little real sustained progress is likely to occur unless governments and others accept the democratic challenge inherent in greater community participation in health. Ironically, the lead on this is being taken by governments in Central and Eastern Europe who are trying to establish new political structures which facilitate and encourage greater community participation. The difficulty they face is that the people seem to distrust their motives and consequently are hesitant about utilising the new structure. Community participation in health in Europe remains firmly anchored in tokenism, the lowest rung on Arnstein’s ladder of Citizen Participation
Multisectoral participation Target 13 set a deadline of 1990 for Member States to establish national policies which ensure broad intersectoral support mechanisms. However, Targets 18-25 (Health Environment), equally depend for their success upon good intersectoral cooperation [4]. Developments within the Region towards the realisation of this principle have been patchy [lo]. While there has been increasing awareness across the Region of the importance of an intersectoral approach to health, this has yet to be matched by concerted action. Most of the progress which has been made on intersectoral actions has taken place at national level, with the emphasis being on reducing health damaging behaviour, legal and administrative measures on health promotion, and in a more limited way, on promoting positive behaviour [lo]. Unfortunately, intersectoral efforts at the national level have rarely been matched by developments and initiatives at regional and local levels. Although the trend is encouraging there is according to WHO ‘La tendency to look for ‘one-shot’ legal or administrative actions, rather than for the establishment of interactive mechanisms by which policy making could be further developed” [lo, p. 611. Perhaps the only notable exception to this is the healthy cities movement which has grown irrespective of government involvement. Progress on the HFA targets related to a healthy environment have been moderate across all targets, with the exception of target 22 (food safety) which
has declined [lo]. Awareness of the multisectoral dimension of a healthy environment was recognised by the adoption by most Member States of the European Charter on Environment and Health [19]. Signing the Charter is one thing, implementing its recommendations is another. Past experience of international charters suggests that we should not be too sanguine about this one. Attempts by some countries to establish mechanisms for coordinating policies between agencies whose policy have a bearing on health or where they share a complementarity for health, while welcomed, often end in recriminations and failure [20]. Government agencies are not known for willingness to help each other, especially where there may be a financial consequence of such assistance. Thus, it is impossible not to be pessimistic about future developments because policy-makers (where they share responsibility) appear to have neither the resources and/or the will to work effectively together on health issues. Primary {local) care Despite the health care reforms in Southern Europe during the latter half of the 1970s and the early 1980s which re-focused attention on primary health care (PHC), results of the previous evaluation of progress towards HFA concluded that “decisions on ways of ensuring full . . implementation of PHC often seem to be lacking” [9]. This may be, as the latest evaluation report indicates, because PHC coverage is fairly complete in Member States; at least judging by the nature of PHC elsewhere. PHC may be well developed in the European region but in terms of re-orienting health care towards primary health care as called for in the Alma Ata Declaration [l], and embodied in the HFA Targets on Appropriate Care (26-31) [4], progress has been moderate at best. Moreover, member states collectively have made little or no progress on a rational and preferential distribution of resources according to need (target 27), nor on improving the content and effectiveness of PHC being provided [lo]. Poor progress such as this is attributable to the existence of well established hospital based services and professional preferences coupled with both the provider and public perception of the low status of primary care [21]. Health care in Europe currently is changing. Most, if not all of the Member States have, or are reviewing their health care systems. The search is on for a better and more efficient paradigm to deliver health care [22]. Many of the mechanisms under consideration seek to strengthen primary health care and to lessen the demand for and inappropriate use of secondary care [23]. While it is too early to be categorical about the reform measures, a popular feature seems to be some form of mixed economy of health based on notions of public competition [24,25]. What the reforms eventually mean for PHC in Europe is unclear. WHO is sanguine, believing that
Realities of Health For All by the year 2000 whatever the outcome the profile of PHC will be enhanced. Although this may be the case, early comments on the reforms in Britiain suggest that, despite all the rhetoric about patient choice and meeting local needs, the changes are essentially structuralist and consolidate rather than weaken the dominance of secondary care [26]. What then is the likelihood of the picture being any different elsewhere in Europe? International cooperation
Of the six principles this is the one that is most difficult to assess. There is only one target (18) which refers to international cooperation and then only in a relatively narrow way. This is not to suggest that environmental matters, especially those such as pollution which is no respector of international boundaries, are unimportant, but merely to note that wider issues, such as the exportation of questionable health practices and procedures, do not appear to be addressed by the HFA targets. A number of countries have signed international conventions such as the Montreal Protocol on Ozone, the Convention on the Control of Transboundary Air Pollution, and the Basle Convention on the Control of Transfrontier Transport of Special Waste. Despite such public utterances of concern for environmental issues, an overwhelming concern for economic development has meant that few resources have been channelled into action on the environment. Once again, policy makers appear more worried about their public image-to be seen to be concerned about environmental issues is all that matters, actually doing something is of lesser importance. Signing up is considered better than cleaning up! The lack of reference to the exportation of dubious health products by countries, or more specifically, the industries and manufacturers based therein is disheartening. Governments seem powerless to prevent multi-nationals based in these countries from pursuing elsewhere, especially in the developing world, questionable practices which they themselves severely regulate or prohibit. As Page has argued, such practices cannot and should not be tolerated, if we are really serious about HFA [27]. Thus international cooperation is much more than tackling environmental issues which transcend international boundaries, it is all about being responsible global citizens. PREVAILING ISSUES
The purpose of the paper is not to provide an indictment of the progress so far towards HFA. Rather, the intention is to offer a critical appraisal of the policy. The paper has been deliberately provocative in order to stimulate thought and debate. WHO would certainly argue that HFA is a success even though progress as measured against the 38 Targets can only be described as moderate (Table 1). But then WHO, as a global organisation, has no
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executive power. It cannot compel its Member States to adopt and implement a HFA policy; it can only cajole.’ Not many countries like Finland [I l] are prepared to be an exemplar but by so being, it sets the standard for the rest to follow. It remains to be seen if any other nation is willing to open its HFA policies to such scrutiny. The tendency of the past is likely to set the pattern for the future. That is, governments and policy makers are unlikely to hold themselves accountable either to their populations or to the wider European community, for their HFA policies. They may participate in WHO evaluation exercises, but like most governments they will only highlight those aspects of the HFA strategy which put them in a good light. They will play the game but only according to their own rules. The drive for efficiency in health care systems taking place across Europe will reinforce structural changes in health care. It is not at all clear, despite the aspirations of WHO, that this reforming process will lead to greater emphasis on HFA through enhancing the role of primary health care. HFA-type developments will continue to take place at the local level because the problems are more obvious at this level; politicians are more accountable and visible to the local community; and local government agencies and bodies interact more easily (less is at stake) than is the case at the national level [28]. National policy makers will be happy to see local initiatives continue, as this will absolve them of charges that they are neither concerned about nor committed to HFA. Commentators have argued that the 38 targets by their very nature have hindered rather than helped the cause of HFA [29]. The targets were intended to have a dual purpose: First, to provide a basis against which each member state could monitor and evaluate progress towards HFA; and second, to set the broad Regional objectives and agenda for HFA. The targets have been criticised by some, perhaps unfairly, of being too precise; not precise enough; unrealistic; unachievable; and/or, too comprehensive in nature. WHO is in the process of revising the HFA targets and an updated version of the targets has been approved by the Regional Committee. The revised targets go a long way towards meeting the criticisms levelled at the original 38. The challenge to Member States inherent in the original targets is carried on in the revised version. It remains to be seen whether Member States will respond more positively to the new targets than they have to the original set. Finally, even though the, at present, 31 Member States of the European Region have resolved that HFA will be their common strategy, the political will of each Member State to draft a HFA policy and then to implement it remains suspect. Only half of the Member States have, or are in the process of producing national HFA policies [30]. Producing a national HFA document demonstrates intent, not necessarily commitment. It is this latter ingredient which will
TOM RATHWLL
546
Table I.Progress towards Health For All taruets
Regional No.
Target Abridged description
Good
Moderate
Little or none
Negative
Health For All by the Year ZOO0 X
2 3 4 5 6 1 8 9 10 I1 12
Equity in health Adding life to year Better opportunities for disabled Reducing disease and disability Eliminating seven specific diseases Life expectancy at birth Reducing infant mortalily rates Reducing rates of maternal mortality Combating diseases of the circulatory system Combating cancer Reducing accidents Stopping increase in suicides
13 14 15 16 17
LVestyles conducive to health Healthy public policy Social support systems Knowledge and motivation for healthy behaviour Promoting positive health behaviour Decreasing health-damaging behaviour
18 19 20 21 22 23 24 25
Healthy environment Policies for a healthy environment Monitoring, assessment and control of risks in the environment Water Pollulion Protection against air pollution Food safety Protection from hazardous waste Healthy homes Healthy working conditions
26 27 28 29 30 31
Appropriate care A health care system based primary health care Rational and preferential distribution of resources according to need Content of primary health care Providers of primary health care Coordination of community resources for primary health care Ensuring the equality of services
I
32 33 34 35 36 31 38
Healtn WCnnOlOgy
1. World Health Organisation/United Nations Children’s Fund. Alma Ara 1978: Primary Health Care: Report of
5.
X X X X X X X X X X X X X X X X X X X X X X X X X
X
X X X X X X
Second Evaluation of the Strategy For Health For All by the Year 2000 [IO].
REFERENCES
4.
X
assessment
determine the outcome of the HFA exercise. So far, if the evaluative exercises undertaken by WHO are anything to go by, commitment seems to be in rather short supply. If HFA is ever to become the reality envisioned by WHO, the crucial question remains; how to get all Member States to take the initiative seriously.
3.
X
Research and Health Development Support Research and health for all Policies for health for all Management of planning and resource allocation Health information systems Planning, education and use of health personnel for health for all Education of personnel in other sectors to support health for all _*.. . .
Source: World Health Organisation.
2.
X X X
the International Conference on Primary Health Care, Alma Ata, U.S.S.R. WHO/UNICEF, Geneva, 1978. World Health Organisation. Global Strategy for Health For All by the Year 2000. WHO, Geneva, 1981. World Health Organisation. Regional Strategy for Attaining Health For All by the Year 2ooO. Regional Office for Europe, Copenhagen, 1982. World Health Organisation. Targets for Health For All. Regional Office for Europe, Copenhagen, 1985. See for example Rathwell T. Pursuing Health For All in Britain-an assessment. Sot. Sci. Med. 34, 169-182, 1992.
6. World Health Organisation. Revised List of Indicators and Procedure for Monitoring Progress Towards Health For All in the European Regions 1987-88. Regional
Office for Europe, Copenhagen, 1987. 7. World Health Organisation. Monitoring of the Strategy Healrh For All by the Year 2OU0, Part I. The Situation in the European Region, 1987/88. Regional Office for Europe, Copenhagen, 1989. 8. World Health Organisation. Monitoring of the Strategy for Health For AILby the Year 2tW0, Part Ii. Monitoring by Country. 1988/89. Regional Office for Europe, Copenhagen, 1989. 9. World Health Organisation. Eualuafion of the Strategy for
for Health For All by the Year 2000: Seventh Report on the World Health Situation, Vol. 5. European Region.
Regional Office for Europe, Copenhagen, 1986. 10. World Health Organisation. Second Evaluation of the Strategy for Health For All by the Year 2000. Regional Committee for Europe, Copenhagen, 1991. 11. World Health Organisation. Health For All Policy in Finland. Regional Office for Euros, Copenhagen, 199I. 12. Space does not permit, nor is it appropriate for, a full scale discussion of equity/equality in health. Readers interested in European comparative studies are referred to: Fox J. (Ed.) Health Inequalities in European Countries. Gower, Aldershot, 1989; Illsley R. and
Realities of Health For All by the year 2000 Svenson P. G. (Eds) Health inequalities in Europe. Sot. Sci. Med. 31, 323420, 1990. 13. World Health Organisation Health of Europe, Summary of the Health For All Evaluation. Regional Office for Europe, Copenhagen, 1991. 14. See for example, Rathwell T. A management partnership for the mentally handicapped. J. Publ. Hlth Policy 9, 80-91, 1988. 15. See for example Ashton J. (Ed.) Healthy Cities. Open
University Press, Milton Keynes, 1991. World Health Oraanisation, Healthy Cities Prolect: A Project Becomes a Movement. Review of Progress 1987 to 1990 (Edited bv Tsoures A.). Regional Office for
Europe, Copenhagen, 1991. ’ 16. Godinho J., Rathwell T., Gott M. and Daley J. Final Scientific Report of the Research Project: Tipping the Balance Towards Primary Health Care. Brussels, 1991. 17. Arnstein S. R. A ladder of citizen participation. J. Am. Inst. Planners 35, 216-244, 1969. 18. Alford R. R. Health Care Politics. University of
22. Organisation for Economic Cooperation and Development. Health Care Systems in Transition: the Search for Eficiency. Social Policy Studies No. 7. OECD Paris, 1990. 23. Bengoa R. and Hunter D. (Eds) New Directions in Managing Health Care. World Health Organisatiom University of Leeds, Nuffield Institute for Health Services Studies, Leeds, 1991. 24. Sahman R. B. and Van Otter C. Public competition versus mixed markets: an analytic comparison. Hlth Policy 11, 43-55, 1989. 25. Harrison S. Working the market: purchaser/provider separation in English health care. In?. J. Hlth Services 21, 625435, 1991. 26. Harrison S. et al. Competing for Health. University of
27. 28.
Chicago Press, Chicago. 1975. 19. World Health Organisation. Environment and Health: The European Charter and Commentary, First European Conference on Environment and Health, Frankfurt,
7-8 December 1989. Regional Office for Europe, Copenhagen, 1990. 20. For an excellent discussion of this see Klein R. The Politics of the National Health Sewice, 2nd edn. Longman, London 1989. 21. Van Oyen H. J. Health For All in Europe: An Epidemiological Review. World Health Organisation., Regional Office for Europe, Copenhagen, 1990.
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29.
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Leeds, Nuffield Institute for Health Services Studies, Leeds, 1989. Page B. B. Social justice and equity: a conceptual overview. Paper presented at International Conference on Social Justice and Equity in Health, Leeds, 1985. Evans A., Farrant W. and Trojan A. (Eds) Healthy Public Policy at the Local Level. European Centre for Social Welfare Policy and Research, Campus/Westview, Vienna, 1990. World Health Organisation. Consultation of Countries with National Health For All Policy Documents. A Report from the programme on Health Policies and Plannina. Regional Office for Eurone. Conenhaaen. 1990. World Health Organisation. Background Pa&r ‘Based on Analysis of Replies to the Checklist. Prepared for the consultation of countries with HFA Policy Documents at National Level, Sofia, Bulgaria, Regional Office for Europe, Copenhagen, 1989.
