Using pragmatic tools in pursuit of its visionary goal, WHO strives to respond to its constitutional mandate through its evolving program of activities. These are based on the needs and priorities of activities determined by member states themselves through the organization's governing bodies, the World Health Assembly and the Executive Board. Changes in program emphasis occur in response to altered political, social, economic, and environmental realities.
For example, respecting the new issues and priorities of the times for WHO includes meeting the challenge implicit in redirecting the human and financial resources that, logically, should be released by the breakup of old Cold War alliances; forging new partnerships to mobilize social, political, and therefore financial support for health development and international health cooperation; and opening itself up still further to all sectors of society, including NGOs and the private sector. It means grappling with the multiple consequences for health of accelerating social and demographic changes, including population growth and encroachment on forest areas and other ecological zones, aging population structure, migration—including the mass movement of disaster-affected populations—and urbanization. It calls for dealing creatively with the impact of the indebtedness, incurred over time, that has led many countries to reduce public spending in health services, which are often regarded as being only an expenditure rather than an investment in human potential. Ironically, this last challenge comes at the very moment when WHO itself is operating within severe financial constraints. After working with a zero-growth budget policy since 1984-1985, WHO's 1996-1997 budget suffered a drastic reduction estimated at 14% in real terms, while the number of staff worldwide dropped from just under 5400 in 1990 to 4300 in 1998. In contrast, the extraordinary changes in the political landscape during the same period saw the number of WHO member states increase from 166 to 191.
WHO must face up to threats to human health that respect no national boundaries, such as uncontrolled dumping of toxic wastes and pollution of land, water, and air, and prodigious consumption and mismanagement of natural resources. The solution of these problems hinges, to a large extent, on the degree to which WHO is able to harness the interdependence of nations and peoples as a positive force for conciliating between competing present and future needs.
In the face of changing demands, WHO is doing its utmost to preserve its inclusive approach to health and to emphasize the continuity between prevention, care, rehabilitation, and health promotion for all people through the different stages of their lives. In restructuring its programs and activities in the light of resource constraints, WHO is placing emphasis on meeting the most pressing health needs based on the following priorities:
• those which present a health emergency;
• those which affect the poorest countries and the most vulnerable groups;
• those which produce the heaviest burden of death, suffering, and disability;
• those which represent a major impediment to social and economic development.
In 1995 the Executive Board and the World Health Assembly, as part of an overall global reform process, identified the need to review the basic primary health care principles of Alma-Ata, recommit member states to those principles, and renew aspects of the strategy to achieve Health for All in the light of changing global circumstances. Since 1978 many countries not present at Alma-Ata had attained statehood; a generation of health workers had graduated; and several key determinants of health—social, political, economic, demographic, and epidemiologi-cal—had profoundly affected the health profile of populations and the level of inequalities between various subgroups. Moreover, the opportunity for improving health through multisectoral approaches, application of appropriate technology, and greater emphasis on participatory approaches all require that countries, regions, and the international community look afresh at how international health policy for this century can truly improve the long-term health status of the world's poorest countries and communities.
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