Global partnerships for health*

There are two items in this issue–the first is a response to G.H. Brundtland's paper published in European Journal of Public Health, Volume 15(1). The second is on public health genetics. As a reflexion on Dr Brundtland's speech, I would like to stress the important role global partnerships can play in the struggle for equitable health improvement. Dr Brundtland's focus, reasonably, is on infectious diseases with an emphasis on HIV/AIDS and SARS. She puts much emphasis on the undoubted successes in 2003 in controlling SARS, but less emphasis on our shamefully slow response to HIV/AIDS. The real lesson from SARS is the appalling state of public health services in most countries, both wealthy and poor. The Canadian post-SARS experience has had a major effect; the lessons have been learnt and a new public health agency has been established. However, it remains to be seen whether other countries, notably China, will be able to make the long term investments needed to improve the public health infrastructure which was sorely tested by SARS. It is only in the last year that WHO has played a critical role in ensuring that treatment is more readily available for HIV/AIDS patients, though this remains an extremely difficult task because of the decades of neglect of health systems in most countries. The effective response to SARS, and increasingly to HIV/AIDS, is based on a partnership model and this approach must now be generalised to all major global public health challenges. Dr Brundtland pays some attention to tobacco control and chronic, noncommunicable disease. The WHO Framework Convention on Tobacco Control is an important milestone in the global fight against tobacco. Forty countries must ratify the Convention before it comes into effect and this will likely be achieved before the end of 2004. However, the implementation of the Convention at the national level, especially in key countries like India and China, will require long term support from WHO and other partners, and tobacco control policies must be integrated with the response to chronic diseases more generally. Chronic diseases are responsible for 60% of global mortality and approximately one third of the global burden of disease. WHO still devotes less than 5% of its budget to chronic diseases, despite the fact that the true extent of these epidemics was highlighted by the World Bank over a decade ago. Furthermore, these epidemics were not seriously considered by Dr Brundtland's Commission on Macroeconomics and Health and are not integral to the Millennium Development Goals. The causes of these epidemics are well known and the same in men and women in all regions. Moreover cost effective interventions are available and are working. The decline in cardiovascular disease rates explain the increasing life expectancy in many wealthy countries, although these declines began long before serious prevention and control programmes were established – testifying to the importance of the dissemination of the results of public health research. The main challenge now in the field of chronic disease prevention and control is to ensure that the knowledge and experience gained helps the low and middle income countries, especially India and China, where the epidemics have still not generated an effective and coordinated response; partnerships will facilitate the required response. WHO under its new Director General, Dr Jong–wook Lee, is reemphasising the importance of the Organization's Constitution with its strong social justice underpinning. Operationalising these sentiments has always been difficult for WHO, but it is the concern for poor and disadvantaged people which is driving the 3 by 5 initiative to bring HIV/AIDS drugs to millions of people. The same force is behind the creation of the Commission on the Social Determinants of Health, to be launched in early 2005, with the aim of assisting countries respond in a practical manner to the underlying determinants of health which have so far been given only token attention by the public health workforce. WHO is the only agency with responsibility for improving the health of all populations. At its best, WHO unites on-the-ground efficacy at country level with the exercise of global authority and coordination functions. It bonds the most advanced science to a normative commitment to justice and human rights. However, as an intergovernmental organisation accountable to 192 Member States and with an annual budget of approximately $1.4 billion, WHO faces unique difficulties in achieving its broad goal. Tensions emerge between WHO's need to be responsive to the agendas of Member States and its mandate to provide leadership based on scientific evidence. Likewise, the interests of different countries clash, as can those of non-governmental organizations and representatives of the for-profit sector, when they seek to collaborate within the public – private partnerships so important to many aspects of WHO's global health work today. When such difficulties arise within WHO, they must be resolved through painstaking compromise, rather than by unilateral executive decision. Unwieldy as they may be, however, democratic processes remain preferable to any known alternative, especially in the promotion of such fundamental public goods as health. It is within a democratic forum that the voices and health needs of vulnerable groups stand the best chance of being heard. The global community must confront today's emergencies while laying sustainable foundations for a healthier future. This means synergizing targets such as “3 by 5” with the broad scale-up of equitable, integrated health systems that can meet the needs of communities and make quality health services available to everyone. Neither WHO nor indeed any other single institution can accomplish such a task. But, working closely with countries and partners, WHO can provide the initial leadership to develop appropriate partnerships. It remains to be seen whether the global community will muster sufficient political commitment and sufficient resources to shape a healthier future for all people, especially the most disadvantaged. Enormous technical and political challenges stand in the way. Democratic, inclusive institutions such as WHO must be used to their full potential, along with all partners, if progress toward health equity is to become a reality. These comments are the views of the author and do not necessarily reflect the stated policy of WHO.

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