Access to services
Access to health services in the developed countries has been largely complete for many years, and a few developing countries report 80 to 100 per cent coverage. Maternal and child health services have increased in most developing countries, but care for children under five years of age is still very limited. Availability of essential drugs and treatment for common diseases and injuries are quite widespread, but lack of resources and poor transportation and communications are still major obstacles in rural areas.
In all countries, demand for more sophisticated health services has increased. Overcrowded, costly hospitals in urban areas and poorly equipped intermediate health facilities cannot satisfy the demand. Economically sound approaches are needed to clear this bottleneck in the health-care delivery system. Very few countries have incorporated health goals into the revised national budgets that have been compelled by the severe economic problems in the 1980s. These goals can minimize the impact of disease and protect high- risk groups most vulnerable to adverse effects of recent austerity measures. Increased access to food and primary health care is needed, especially for women and children, working populations at high risk and the poor and underprivileged.
Projections of life expectancy indicate that current inequalities in women's health between developed and developing regions will remain largely unaltered by the year 2010. Policies to improve female health care in developing countries in childhood and the reproductive years should remain a priority, especially in rural areas where maternal mortality rates are highest. Medical examinations and basic medical care should be brought to the village, the school, the farm, and other places of employment.
In 1977, the Thirtieth World Health Assembly decided that the main social goal of Governments and WHO in the coming decades should be worldwide attainment by the year 2000 of a level of health that would permit all people to lead socially and economically productive lives. The key to attaining this goal is availability of primary health care: essential health care made accessible at a cost the country and community can afford, with methods that are practical, scientifically sound and socially acceptable. Everyone in the community should have access to it and be involved in it. Primary health care should include community education on prevalent health problems and methods of preventing or controlling them; the promotion of adequate food supplies, proper nutrition, sufficient safe water and basic sanitation, and maternal and child health care, including family planning; the prevention and control of locally endemic diseases; immunization against the main infectious diseases; appropriate treatment of common diseases and injuries; and the provision of essential drugs.
In the early 1980s, WHO estimated that primary health care could be provided in the developing countries for $10 to $15 per person per year (excluding food, water and sanitation). This amount is more than most Governments spent for health during the early 1980s (among the developing countries with data), especially in Africa and South and Southeast Asia. Total governmental and private expenditures combined would be sufficient to provide primary health care in many countries, however, if the services were priced and distributed more equitably than they are now. In the poorest countries— mainly in South Asia and sub-Saharan Africa—the total expenditures would have to increase by $5 or $10 per capita (roughly 3 to 4 per cent of GDP per capita), along with development of a wider delivery system to reach more of the rural and low-income urban population. But as little as $1 to $5 per capita could significantly reduce child mortality in many low income countries, if allocated to the most cost-effective means of primary health care and delivered by health care workers paid according to national per capita income levels.
The mobilization and management of financial resources for health have been identified by WHO as critical for achieving the long-term goal of "Health for All by the Year 2000" through primary health care. While financial cutbacks present major problems in the short run, the best long-run options are to tap additional and new sources of domestic resources, and to make more efficient use of all available resources. In many countries, national health plans have been found to be too expensive to fund and implement. A greater mobilization of domestic resources is possible: employers and employees could contribute to health insurance plans; employers could provide health services directly; public or private institutions might be created to attract voluntary insurance  contributions;  other  types  of community  financing might be developed; and consumers might be required to pay direct fees for some of the health services they use. Recent studies suggest that it would be both equitable and efficient to charge middle-income and upper-income groups for curative services, thus preventing excessive consumption of free services and allowing limited government funds to provide health care to more of the low- income population. Even if it is necessary to charge user fees to low-income groups, this can provide better health to more people than systems that rely on inadequate government funds. Even if health, broadly conceived, is accorded very high priority, national development planners face complex trade-offs. They must try to estimate the relative effectiveness of allocating limited resources among investments and operating expenses for primary health care facilities, high- technology hospitals, modern and traditional medical training, public health education, nutrition programmes, safe water supply and sanitation, shelter, etc. Focusing on specific goals and timetables, such as reducing the infant mortality rate below 50 by the year 2000, helps to mobilize the necessary resources.
The recent rise in concern with cost-containment in many countries is likely to continue throughout the early 2000s. Determining the appropriate mix of public and private services, providers and funding sources will call for considerable research and public policy debate. There is substantial room for improvement in the cost-efficient allocation of resources among drugs, surgery and other methods of health care. A strong case can also be made for a reorientation of health services towards primary health care and rural areas.