The World Health Report 2008 Primary Healtb Care-Now More Tban Ever in the world where access to qualified providers Secondly, there is considerable variation in at childbirth is not progressing achievement across countries with the same Mirroring the overall trends in child sur- income, particularly among poorer count ival, global trends in life expectancy point example, life expectancy in Cote d'lvoire(GDP IS to a rise throughout the world of almost eight 1465)is nearly 17 years lower than in Nepal(GDP years between 1950 and 1978, and seven more I$ 1379), and between Madagascar and Zambia, years since: a reflection of the growth in average the difference is 18 years. The presence of high income per capita. As with child survival, widen- performers in each income band shows that ing income inequality(income increases faster the actual level of income per capita at a given in high-income than in low-income countries) moment is not the absolute rate limiting factor is reflected in increasing disparities between the average curve seems to imply the least and most healthy. Between the mid 1970s and 2005, the difference in life expectancy Growth and stagnation between high-income countries and countries in Over the last 30 years the relation between eco sub-Saharan Africa, or fragile states, has wid- nomic growth and life expectancy at birth has ened by 3. 8 and 2.1 years, respectively shown three distinct patterns(Figure 1.5) The unmistakable relation between health and In 1978, about two thirds of the world's popula wealth, summarized in the classic Preston curve tion lived in countries that went on to experience (Figure 1.4), needs to be qualified ncreases in life expectancy at birth and consider Firstly, the Preston curve continues to shift 2. able economic growth. The most impressive rela An income per capita of IS 1000 in 1975 was tive gains were in a number of low-income coun- associated with a life expectancy of 48.8 years. tries in Asia(including India), Latin America and In 2005, it was almost four years higher for the northern Africa, totalling 1.1 billion inhabitants same income. This suggests that improvements 30 years ago and nearly 2 billion today. These in nutrition, education2, health technologies, countries increased life expectancy at birth by the institutional capacity to obtain and use 12 years, while GDP per capita was multiplied by information,and in society's ability to translate a factor of 2.6. High-income countries and coun this knowledge into effective health and social tries with a GDP between IS 3000 and IS 10 000 action2, allow for greater production of health in 1975 also saw substantial economic growth for the same level of wealth and increased life expectancy In other parts of the world, GDP growth was Figure 1.4 GDP per capita and life expectancy at birth in 169 countries not accompanied by similar gains in life expect ancy. The Russian Federation and Newly Inde Life expectancy at birth byears pendent States increased average GDP per capita 2005 substantially, but, with the widespread poverty that accompanied the transition from the former 1975 Soviet Union, womens life expectancy stagnated ticularly for those lacking education and job security. 2. After a period of technological and organizational stagnation, the health system co lapsed. Public expenditure on health declined in the 1990s to levels that made running a basic South africa system virtually impossible in several countries ined with the ° o SWaziland gration of public health programmes, and the unregulated commercialization of clinical serv 5000 000 15000 20 000 25000 30 000 35 000 40 00 ices combined with the elimination of safety DP per capita, constant 2000 international S nets has offset any gains from the increase in Only outlying countries are named average GDP26. China had already increased its
The World Health Report 2008 4 Primary Health Care – Now More Than Ever in the world where access to qualifi ed providers at childbirth is not progressing18. Mirroring the overall trends in child survival, global trends in life expectancy point to a rise throughout the world of almost eight years between 1950 and 1978, and seven more years since: a refl ection of the growth in average income per capita. As with child survival, widening income inequality (income increases faster in high-income than in low-income countries) is refl ected in increasing disparities between the least and most healthy19. Between the mid- 1970s and 2005, the difference in life expectancy between high-income countries and countries in sub-Saharan Africa, or fragile states, has widened by 3.8 and 2.1 years, respectively. The unmistakable relation between health and wealth, summarized in the classic Preston curve (Figure 1.4), needs to be qualifi ed20. Firstly, the Preston curve continues to shift12. An income per capita of I$ 1000 in 1975 was associated with a life expectancy of 48.8 years. In 2005, it was almost four years higher for the same income. This suggests that improvements in nutrition, education21, health technologies22, the institutional capacity to obtain and use information, and in society’s ability to translate this knowledge into effective health and social action23, allow for greater production of health for the same level of wealth. Secondly, there is considerable variation in achievement across countries with the same income, particularly among poorer countries. For example, life expectancy in Côte d’Ivoire (GDP I$ 1465) is nearly 17 years lower than in Nepal (GDP I$ 1379), and between Madagascar and Zambia, the difference is 18 years. The presence of high performers in each income band shows that the actual level of income per capita at a given moment is not the absolute rate limiting factor the average curve seems to imply. Growth and stagnation Over the last 30 years the relation between economic growth and life expectancy at birth has shown three distinct patterns (Figure 1.5). In 1978, about two thirds of the world’s population lived in countries that went on to experience increases in life expectancy at birth and considerable economic growth. The most impressive relative gains were in a number of low-income countries in Asia (including India), Latin America and northern Africa, totalling 1.1 billion inhabitants 30 years ago and nearly 2 billion today. These countries increased life expectancy at birth by 12 years, while GDP per capita was multiplied by a factor of 2.6. High-income countries and countries with a GDP between I$ 3000 and I$ 10 000 in 1975 also saw substantial economic growth and increased life expectancy. In other parts of the world, GDP growth was not accompanied by similar gains in life expectancy. The Russian Federation and Newly Independent States increased average GDP per capita substantially, but, with the widespread poverty that accompanied the transition from the former Soviet Union, women’s life expectancy stagnated from the late 1980s and men’s plummeted, particularly for those lacking education and job security 24,25. After a period of technological and organizational stagnation, the health system collapsed12. Public expenditure on health declined in the 1990s to levels that made running a basic system virtually impossible in several countries. Unhealthy lifestyles, combined with the disintegration of public health programmes, and the unregulated commercialization of clinical services combined with the elimination of safety nets has offset any gains from the increase in average GDP26. China had already increased its Figure 1.4 GDP per capita and life expectancy at birth in 169 countriesa , 1975 and 2005 Life expectancy at birth (years) GDP per capita, constant 2000 international $ a Only outlying countries are named. 35 85 0 Namibia 5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000 South Africa Botswana Swaziland 75 65 55 45 2005 1975
Chapter 1. Tbe challenges of a changing world Figure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975-2005 Life expectancy (years) b chinan - income countries Indic H. Fragile statese LOW-income African countrie 0008000900010000 20000250003000 countries, 766 million( 975.953Mn2005 India, 621 M inhabitants in 1975. 1 10 t13 Low-income African countries, fragile states excluded. 71 M inhabitants in 1975,872M in 2005. deration and 1D Newty Independent States NIS), 186 M inhabitants in 1985, 204 M in 2D06 h China, 928M No data for 1975 for the Newby Independant States. No historical data for the remaining countries. Sources: Life expectancy, 1975, 1985: UN World Population Prospects 2006: 1995, 2005: WHO, 9 November 2008(draft: China: 3rd, 4th and sth Nat on censuses.1981,1990ad2000P0200732 life expectancy substantially in the period before of law, and lack of mechanisms for generating 1980 to levels far above that of other low-income legitimate power and authority. They have a countries in the 1970s, despite the 1961-1963 huge backlog of investment needs and limited famine and the 1966-1976 Cultural Revolution. government resources to meet them. Half of The contribution of rural primary care and them experienced negative GDP growth during urban health insurance to this has been well the period 1995-2004 (all the others remained documented2.28. With the economic reforms of below the average growth of low-income coun the early 1980s, however, average GDP per capita tries), while their external debt was above aver- increased spectacularly, but access to care and age These countries were among those with social protection deteriorated, particularly in the lowest life expectancy at birth in 1975 and rural areas. This slowed down improvements to have experienced minimal increases since then. a modest rate, suggesting that only the improved The other low-income African countries share living conditions associated with the spectacular many of the characteristics and circumstances economic growth avoided a regression of average of the fragile states- in fact many of them have life expectancy? suffered protracted periods of conflict over the Finally, there is a set of low-income coun- last 30 years that would have classified them as es,representing roughly 10% of the worlds fragile states had the LICUS classification existed population,where both GDP and life expectancy at that time. Their economic growth has beer stagnated. These are the countries that are very limited, as has been their life-expectancy considered as"fragile states"according to the gain, not least because of the presence, in this low-income countries under stress"(LICUS)I group, of a number of southern African countries criteria for 2003-2006.As much as 66% of the that are disproportionally confronted by the HIV/ population in these countries is in Africa. Poor AIDS pandemic. On average, the latter have seen governance and extended internal conflicts are some economic growth since 1975, but a marked common among these countries, which all face reversal in terms of life expectancy similar hurdles: weak security, fractured soci- What has been strikingly common to fragile etal relations, corruption, breakdown in the rule states and sub-Saharan African countries for
5 Chapter 1. The challenges of a changing world life expectancy substantially in the period before 1980 to levels far above that of other low-income countries in the 1970s, despite the 1961–1963 famine and the 1966–1976 Cultural Revolution. The contribution of rural primary care and urban health insurance to this has been well documented27,28. With the economic reforms of the early 1980s, however, average GDP per capita increased spectacularly, but access to care and social protection deteriorated, particularly in rural areas. This slowed down improvements to a modest rate, suggesting that only the improved living conditions associated with the spectacular economic growth avoided a regression of average life expectancy29. Finally, there is a set of low-income countries, representing roughly 10% of the world’s population, where both GDP and life expectancy stagnated30. These are the countries that are considered as “fragile states” according to the “low-income countries under stress” (LICUS) criteria for 2003–200631. As much as 66% of the population in these countries is in Africa. Poor governance and extended internal confl icts are common among these countries, which all face similar hurdles: weak security, fractured societal relations, corruption, breakdown in the rule of law, and lack of mechanisms for generating legitimate power and authority32. They have a huge backlog of investment needs and limited government resources to meet them. Half of them experienced negative GDP growth during the period 1995–2004 (all the others remained below the average growth of low-income countries), while their external debt was above average33. These countries were among those with the lowest life expectancy at birth in 1975 and have experienced minimal increases since then. The other low-income African countries share many of the characteristics and circumstances of the fragile states – in fact many of them have suffered protracted periods of confl ict over the last 30 years that would have classifi ed them as fragile states had the LICUS classifi cation existed at that time. Their economic growth has been very limited, as has been their life-expectancy gain, not least because of the presence, in this group, of a number of southern African countries that are disproportionally confronted by the HIV/ AIDS pandemic. On average, the latter have seen some economic growth since 1975, but a marked reversal in terms of life expectancy. What has been strikingly common to fragile states and sub-Saharan African countries for Life expectancy (years) 0 Figure 1.5 Trends in GDP per capita and life expectancy at birth in 133 countries grouped by the 1975 GDP, 1975–2005* 50 45 Chinah 55 60 65 70 75 80 1000 2000 3000 4000 5000 6000 7000 8000 9000 10 000 Middle-income countriesb Russian Federation and NISg Low-income African countriesf Low-income coutriesd Indiac Fragile statese 20 000 25 000 30 000 a 27 countries, 766 million (M) inhabitants in 1975, 953 M in 2005. b 43 countries, 587 M inhabitants in 1975, 986 M in 2005 . c India, 621 M inhabitants in 1975, 1 103 M in 2005. d 17 Low-income countries, non-African, fragile states excluded, 471 M inhabitants in 1975, 872 M in 2005. e 20 Fragile states, 169 M inhabitants in 1975, 374 M in 2005. f 13 Low-income African countries, fragile states excluded, 71 M inhabitants in 1975, 872 M in 2005. g Russian Federation and 10 Newly Independent States (NIS), 186 M inhabitants in 1985, 204 M in 2005. h China, 928 M inhabitants in 1975, 1 316 M in 2005. High-income countriesa * No data for 1975 for the Newly Independant States. No historical data for the remaining countries. Sources: Life expectancy, 1975, 1985: UN World Population Prospects 2006; 1995, 2005: WHO, 9 November 2008 (draft); China: 3rd, 4th and 5th National Population censuses, 1981, 1990 and 2000. GPD: 200737
The World Health Report 2008 Primary Healtb Care-Now More Tban Ever much of the last three decades, and differentiates Without growth, peace is considerably more dif- them from the others that started out with less ficult and without peace, growth stagnates:on than IS 3000 per capita in 1975, is the combination average, a civil war reduces a country's growt of stagnating economic growth, political instabil- by around 2. 3% per year for a typical duration of ity and lack of progress in life expectancy. They seven years, leaving it 15% poorers accumulate characteristics that hamper improve- The impact of the combination of stagnation ment of health Education, particularly of females, and conflicts cannot be overstated.Conflicts are a develops more slowly, as does access to modern direct source of considerable excessive suffering communications and knowledge-intensive work disease and mortality. In the Democratic Republic that broadens people s intellectualresources else- of the Congo, for example, the 1998-2004 conflict where People are more exposed and more vulner- caused an excess mortality of 450000 deaths able to environmental and other health threats per year 5. Any strategy to close the health gaps that, in today's globalized world, include lifestyle between countries-and to correct inequalities threats, such as smoking, obesity and urban vio- within countries-has to give consideration to lence. They lack the material security required to the creation of an environment of peace, stability invest in their own health and their governments and prosperity that allows for investment in the lack the necessary resources and/or commitment health sector. to public investment. They are at much greater risk A history of poor economic growth is of war and civil conflict than richer countries 0. I history of stagnating resources for health wh Box 1.2 Higher spending on health is associated with better outcomes, but with large differences between countries In many countries, the total amount spent on health is insufficient spending band are comparatively small. Tajikistan, for example to finance access for all to even a very limited package of essential has a HALe that is 4.3 years less than that of Sweden-less than health care This is bound to make a difference to health and the difference between sweden and the United states These dif- survival. Figure 1. 6 shows that Kenya has a health-adjusted life ferences suggest that how, for what and for whom money is spent expectancy(HALE)of 44. 4 years, the median for countries that matters considerably. Particularly in countries where the envelope currently spend less than Is 100 per capita on health. This is 27 for health is very small, every dollar that is allocated sub-optimally years less than germany, the median for countries that spend seems to make a disproportionate difference nore than Is 2500 per capita. Every IS 100 er capita spent on heath corresponds to a Figure 1.6 Countries grouped according to their total health expenditure 1. 1-year gain in HALE. in 2005(international S) However, this masks large differences in HALE (years) outcomes at comparable levels of spend There are up to five years difference in HALl between countries that spend more than 70 is 2500 per ca year on health. The spread is wider at lower expenditure levels, 60 even within rather narrow spending bands Inhabitants of Moldova, for example, enjoy 24 50 more HALE years than those of Haiti, yet they are both among the 28 countries that spend Is 40 250-500 per capita on health. These gaps car 口 Swan and日 Botswana 口 Outliers 口 Esol even be wider if one also considers countries Sierra Leo that are heavily affected by HIv/AlDS. Lesotho spends more on health than Jamaica, yet its eople have a hale that is 34 years shorter 雷0n100如5器m5器 In contrast, the differences in hale between Total health expenditure( no of countries) the countries with the best outcomes in each
The World Health Report 2008 6 Primary Health Care – Now More Than Ever much of the last three decades, and differentiates them from the others that started out with less than I$ 3000 per capita in 1975, is the combination of stagnating economic growth, political instability and lack of progress in life expectancy. They accumulate characteristics that hamper improvement of health. Education, particularly of females, develops more slowly, as does access to modern communications and knowledge-intensive work that broadens people’s intellectual resources elsewhere. People are more exposed and more vulnerable to environmental and other health threats that, in today’s globalized world, include lifestyle threats, such as smoking, obesity and urban violence. They lack the material security required to invest in their own health and their governments lack the necessary resources and/or commitment to public investment. They are at much greater risk of war and civil confl ict than richer countries30. Without growth, peace is considerably more diffi cult and without peace, growth stagnates: on average, a civil war reduces a country’s growth by around 2.3% per year for a typical duration of seven years, leaving it 15% poorer34. The impact of the combination of stagnation and confl icts cannot be overstated. Confl icts are a direct source of considerable excessive suffering, disease and mortality. In the Democratic Republic of the Congo, for example, the 1998–2004 confl ict caused an excess mortality of 450 000 deaths per year35. Any strategy to close the health gaps between countries – and to correct inequalities within countries – has to give consideration to the creation of an environment of peace, stability and prosperity that allows for investment in the health sector. A history of poor economic growth is also a history of stagnating resources for health. What In many countries, the total amount spent on health is insuffi cient to fi nance access for all to even a very limited package of essential health care39. This is bound to make a difference to health and survival. Figure 1.6 shows that Kenya has a health-adjusted life expectancy (HALE) of 44.4 years, the median for countries that currently spend less than I$ 100 per capita on health. This is 27 years less than Germany, the median for countries that spend more than I$ 2500 per capita. Every I$ 100 per capita spent on heath corresponds to a 1.1-year gain in HALE. However, this masks large differences in outcomes at comparable levels of spending. There are up to fi ve years difference in HALE between countries that spend more than I$ 2500 per capita per year on health. The spread is wider at lower expenditure levels, even within rather narrow spending bands. Inhabitants of Moldova, for example, enjoy 24 more HALE years than those of Haiti, yet they are both among the 28 countries that spend I$ 250–500 per capita on health. These gaps can even be wider if one also considers countries that are heavily affected by HIV/AIDS. Lesotho spends more on health than Jamaica, yet its people have a HALE that is 34 years shorter. In contrast, the differences in HALE between the countries with the best outcomes in each Box 1.2 Higher spending on health is associated with better outcomes, but with large differences between countries spending band are comparatively small. Tajikistan, for example, has a HALE that is 4.3 years less than that of Sweden – less than the difference between Sweden and the United States. These differences suggest that how, for what and for whom money is spent matters considerably. Particularly in countries where the envelope for health is very small, every dollar that is allocated sub-optimally seems to make a disproportionate difference. Figure 1.6 Countries grouped according to their total health expenditure in 2005 (international $)38,40 HALE (years) Total health expenditure (no. of countries) 20 80 70 50 30 THE < I$ 100 (30) 40 60 Tajikistan Sierra Leone THE I$ 100–250 (28) Moldova Haiti Lesotho THE I$ 250–500 (30) Panama Swaziland THE I$ 500–1000 (23) Finland Botswana THE I$ 1000–2500 (16) Japan THE > I$ 2500 (15) Germany Phillippines Gabon Colombia Iran United Kingdom / New Zealand Hungary Sweden USA Kenya Saint Vincent and the Grenadines Highest Median Lowest Outliers
Chapter 1. Tbe challenges of a changing world happened in sub-Saharan Africa during the years Many of the changes that affect health were following Alma-Ata exemplifies this predicament. already under way in 1978, but they have accel After adjusting for inflation, GDP per capita in erated and will continue to do so sub-Saharan Africa fell in most years from 1980- Thirty years ago, some 38% of the world's 199436, leaving little room to expand access to population lived in cities; in 2008, it is more than health care or transform health systems. By the%, 3. 3 billion people. By 2030, almost 5 bil early 1980s, for example, the medicines budget lion people will live in urban areas. Most of the in the Democratic Republic of the Congo, then growth will be in the smaller cities of developing Zaire, was reduced to zero and government dis- countries and metropolises of unprecedented size bursements to health districts dropped below and complexity in southern and eastern Asia*2 UsS 0.1 per inhabitant; Zambia's public sector Although on average health indicators in health budget was cut by two thirds; and funds cities score better than in rural areas, the available for operating expenses and salaries for enormous social and economic stratification the expanding government workforce dropped by within urban areas results in significant health up to 70% in countries such as Cameroon, Ghana, inequities* 44.45. 46. In the high-income area of Nai- Sudan and the United Republic of Tanzania 6 For robi, the under-five mortality rate is below 15 health authorities in this part of the world, the per thousand, but in the Emabakasi slum of the 1980s and 1990s were a time of managing shrink- same city the rate is 254 per thousand".These ng government budgets and disinvestment. For and other similar examples lead to the more the people, this period of fiscal contraction was general observation that within developing coun a time of crippling out-of-pocket payments for tries, the best local governance can help produce under-funded and inadequate health servi 75 years or more of life expectancy; with poor In much of the world, the health sector is often urban governance, life expectancy can be as low assively under-funded In 2005, 45 countries spent as 35 years".One third of the urban population less than I$ 100 per capita on health, including today-over one billion people-lives in slums: in external assistance. In contrast, 16 high-income places that lack durable housing, sufficient living countries spent more than Is 3000 per capita. Low- area, access to clean water and sanitation, and income countries generally allocate a smaller pro- secure tenure" Slums are prone to fire, floods portion of their GDP to health than high-income and landslides; their inhabitants are dispropor ountries, while their GDP is smaller to start with tionately exposed to pollution,accidents, work and they have higher disease burdens place hazards and urban violence. Loss of social Higher health expenditure is associated with etter health outcomes, but sensitive to policy Figure 1.7 Africa's children are at more risk of dying from traffic accidents than choices and context(Box 1. 2): where money is European children: child road-traffic deaths per 100 000 population scarce, the effects of errors, by omission and by commission, are amplified. Where expenditure [Africa EUrope, low-and middle- icome countries EUrope, high-income countries increases rapidly, however, this offers perspec- ng and adapting health sys tems which are much more limited in a context of stagnation Adapting to new health challenges A globalized, urbanized and ageing world The world has changed over the last 30 years: I few would have imagined that children in Africa ould now be at far more risk of dying from traf- fic accidents than in either the high-or the low- 10-14 and middle-income countries of the European region(Figure 1.7)
7 Chapter 1. The challenges of a changing world happened in sub-Saharan Africa during the years following Alma-Ata exemplifi es this predicament. After adjusting for infl ation, GDP per capita in sub-Saharan Africa fell in most years from 1980– 199436, leaving little room to expand access to health care or transform health systems. By the early 1980s, for example, the medicines budget in the Democratic Republic of the Congo, then Zaïre, was reduced to zero and government disbursements to health districts dropped below US$ 0.1 per inhabitant; Zambia’s public sector health budget was cut by two thirds; and funds available for operating expenses and salaries for the expanding government workforce dropped by up to 70% in countries such as Cameroon, Ghana, Sudan and the United Republic of Tanzania36. For health authorities in this part of the world, the 1980s and 1990s were a time of managing shrinking government budgets and disinvestment. For the people, this period of fi scal contraction was a time of crippling out-of-pocket payments for under-funded and inadequate health services. In much of the world, the health sector is often massively under-funded. In 2005, 45 countries spent less than I$ 100 per capita on health, including external assistance38. In contrast, 16 high-income countries spent more than I$ 3000 per capita. Lowincome countries generally allocate a smaller proportion of their GDP to health than high-income countries, while their GDP is smaller to start with and they have higher disease burdens. Higher health expenditure is associated with better health outcomes, but sensitive to policy choices and context (Box 1.2): where money is scarce, the effects of errors, by omission and by commission, are amplifi ed. Where expenditure increases rapidly, however, this offers perspectives for transforming and adapting health systems which are much more limited in a context of stagnation. Adapting to new health challenges A globalized, urbanized and ageing world The world has changed over the last 30 years: few would have imagined that children in Africa would now be at far more risk of dying from traffi c accidents than in either the high- or the lowand middle-income countries of the European region (Figure 1.7). Many of the changes that affect health were already under way in 1978, but they have accelerated and will continue to do so. Thirty years ago, some 38% of the world’s population lived in cities; in 2008, it is more than 50%, 3.3 billion people. By 2030, almost 5 billion people will live in urban areas. Most of the growth will be in the smaller cities of developing countries and metropolises of unprecedented size and complexity in southern and eastern Asia42. Although on average health indicators in cities score better than in rural areas, the enormous social and economic stratification within urban areas results in signifi cant health inequities43,44,45,46. In the high-income area of Nairobi, the under-fi ve mortality rate is below 15 per thousand, but in the Emabakasi slum of the same city the rate is 254 per thousand47. These and other similar examples lead to the more general observation that within developing countries, the best local governance can help produce 75 years or more of life expectancy; with poor urban governance, life expectancy can be as low as 35 years48. One third of the urban population today – over one billion people – lives in slums: in places that lack durable housing, suffi cient living area, access to clean water and sanitation, and secure tenure49. Slums are prone to fi re, fl oods and landslides; their inhabitants are disproportionately exposed to pollution, accidents, workplace hazards and urban violence. Loss of social Figure 1.7 Africa’s children are at more risk of dying from traffic accidents than European children: child road-traffic deaths per 100 000 population41 0 50 30 20 10 40 0–4 5–9 10–14 15–19 Africa Europe, low- and middle-income countries Europe, high-income countries
The World Health Report 2008 Primary Healtb Care-Now More Tban Ever cohesion and globalization of unhealthy lifestyles injuries increasingly important causes of morbid contribute to an environment that is decidedly ity and mortality(Figure 1.8)51. There is a striking unfayourable for health shift in distribution of death and disease from These cities are where many of the world'sI younger to older ages and from infectious, peri nearly 200 million international migrants are natal and maternal causes to noncommunicable founds. They constitute at least 20% of the popu- diseases. Traffic accident rates will increase lation in 41 countries, 31% of which have less tobacco-related deaths will overtake HIV/AIDS than a million inhabitants. Excluding migrants related deaths. Even in Africa, where the popu from access to care is the equivalent of denying lation remains younger, smoking, elevated blood ll the inhabitants of a country similar to Brazil pressure and cholesterol are among the top 10risk their rights to health. Some of the countries that factors in terms of overall disease burdens.In have made very significant strides towards ensur- the last few decades, much of the lack of progress ing access to care for their citizens fail to offer and virtually all reversals in life expectancy were the same rights to other residents. As migration associated with adult health crises, such as in the continues to gain momentum, the entitlements of Russian Federation or southern Africa.Improved non-citizen residents and the ability of the health- health in the future will increasingly be a ques- care system to deal with growing linguistic and tion of better adult health cultural diversity in equitable and effective ways Ageing has drawn attention to an issue thatis are no longer marginal issues of particular relevance to the organization of serv This mobile and urbanized world is ageing fast ice delivery: the increasing frequency of multi- and will continue to do so. By 2050, the world will I morbidity In the industrialized world, as many count 2 billion people over the age of 60, around as 25%of 65-69 year olds and 50%of80-84 year 85%of whom will be living in today's developing olds are affected by two or more chronic health countries, mostly in urban areas. Contrary to conditions simultaneously. In socially deprived today's rich countries, low-and middle-income populations, children and younger adults are countries are ageing fast before having become also likely to be affected 53 54.35. The frequency of rich, adding to the challenge. multi-morbidity in low-income countries is less Urbanization, ageing and globalized lifestyle well described except in the context of the HIV/ changes combine to make chronic and noncom- AIDS epidemic, malnutrition or malaria, but it is municable diseases-including depression, dia- probably greatly underestimated56, 57As diseases betes,cardiovascular disease and cancers-and I of poverty are inter-related, sharing causes that Figure 1. 8 The shift towards noncommunicable diseases and accidents as causes of death Dea baths(millions) □ Road-traffic accidents a Cerebrovascular diseases a Ischaemic heart diseases 口 Acute respirato 口 Diarrhoeal diseases 口 HNIAJDS 15 口 Tuberculosis ■口 自自自自 Selected causes 20042005200620072008200920102011201220132014201520162018202020222024202620282030
The World Health Report 2008 8 Primary Health Care – Now More Than Ever cohesion and globalization of unhealthy lifestyles contribute to an environment that is decidedly unfavourable for health. These cities are where many of the world’s nearly 200 million international migrants are found50. They constitute at least 20% of the population in 41 countries, 31% of which have less than a million inhabitants. Excluding migrants from access to care is the equivalent of denying all the inhabitants of a country similar to Brazil their rights to health. Some of the countries that have made very signifi cant strides towards ensuring access to care for their citizens fail to offer the same rights to other residents. As migration continues to gain momentum, the entitlements of non-citizen residents and the ability of the healthcare system to deal with growing linguistic and cultural diversity in equitable and effective ways are no longer marginal issues. This mobile and urbanized world is ageing fast and will continue to do so. By 2050, the world will count 2 billion people over the age of 60, around 85% of whom will be living in today’s developing countries, mostly in urban areas. Contrary to today’s rich countries, low- and middle-income countries are ageing fast before having become rich, adding to the challenge. Urbanization, ageing and globalized lifestyle changes combine to make chronic and noncommunicable diseases – including depression, diabetes, cardiovascular disease and cancers – and injuries increasingly important causes of morbidity and mortality (Figure 1.8)51. There is a striking shift in distribution of death and disease from younger to older ages and from infectious, perinatal and maternal causes to noncommunicable diseases. Traffi c accident rates will increase; tobacco-related deaths will overtake HIV/AIDSrelated deaths. Even in Africa, where the population remains younger, smoking, elevated blood pressure and cholesterol are among the top 10 risk factors in terms of overall disease burden52. In the last few decades, much of the lack of progress and virtually all reversals in life expectancy were associated with adult health crises, such as in the Russian Federation or southern Africa. Improved health in the future will increasingly be a question of better adult health. Ageing has drawn attention to an issue that is of particular relevance to the organization of service delivery: the increasing frequency of multimorbidity. In the industrialized world, as many as 25% of 65–69 year olds and 50% of 80–84 year olds are affected by two or more chronic health conditions simultaneously. In socially deprived populations, children and younger adults are also likely to be affected53,54,55.The frequency of multi-morbidity in low-income countries is less well described except in the context of the HIV/ AIDS epidemic, malnutrition or malaria, but it is probably greatly underestimated56,57. As diseases of poverty are inter-related, sharing causes that Cerebrovascular diseases Ischaemic heart diseases Cancers Figure 1.8 The shift towards noncommunicable diseases and accidents as causes of death* Perinatal causes Acute respiratory infections Diarrhoeal diseases Malaria HIV/AIDS Tuberculosis * Selected causes. Deaths (millions) 0 2004 35 30 25 20 15 10 5 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2018 2020 2022 2024 2026 2028 2030 Road-traffic accidents