By far the most bizarre aspect of the authors of the Draft is that while drawing up a blueprint for HFA for the first two decades of the 21st century, it has steadfastly avoided making any analysis of the factors which had come in the way of WHO in implementing the mandate it had received at Alma Ata.

There must be some method behind this ‘forgetfulness’. The focus of the suggested alternative is on the organization, and not on individuals or groups of individuals who might be acting as conduits for the articulation and implementation of the agenda assigned to the organization by the forces of international polity and economy which has major influence on its functioning. An influential group of personnel in WHO have their socialization in the milieu of almost ‘vulgar affluence’.
This is not consistent with the much vaunted promise to ensure transparency in its activities. These two approaches are simply not compatible. There is a strong case for WHO to bring about fundamental changes in the recruitment and training policies for all its personnel - a virtual ‘cultural revolution’- if it were to redeem the pledges it had made to the people of the world at Alma Ata.
Some areas of concern indicated below deserve attention at the session of the World Health Assembly; these concerns are related to the interaction between Globalization trends, encouragement to market-oriented private provision of medicine, and the spectacular advances in medical technology. All these factors provide both opportunities and threats, especially to the poorer countries in South Asia with a quarter of World’s population and with substantial poverty levels. South Asia, in addition, has a very large double burden of communicable and non-communicable diseases.

The document does not adequately highlight the reasons why Alma Ata declarations for health for all could not be implemented.

This failure has seriously jeopardized the health status of poorer sections of society in both developed and developing countries. Sincere implementation backed by more committed international cooperation would have led to a greater success.

• Health For All (HFA) was to be achieved by locally valid strategies in each country within the primary health care approach. Logically, this should have led to a self-reliant country-specific planning to which global assistance could have been supplemented. On the whole, this has not happened. Was the reason behind this failure due to insensitive, vertical imposition of programmes?
• In several ways Globalization, especially in the areas of trade investment would normally stunt the growth of local initiative for solutions to local problems. Unless great care is taken to moderate the play of Globalization in areas such as pharmaceutics, technology, health risk industries such as tobacco, liquor etc., the primary goal of equity in health will not be achieved. In that sense, uncontrolled Globalization could be antithetical to primary health care.
• Globalization will not only promote greater market-oriented transaction, but given the unequal power relationship between countries, it would inevitably lead to dominance of the technologically advanced richer countries. The draft seems to be in favour of much greater private sector responsibility for health. In the process, it seeks to diminish the role of the state to the minimal level, whether this approach is theoretically valid or not.
• The Alma Ata declaration was sponsored by the WHO on the twin anchor of health and justice. Such a stand was totally consistent with the concern for equity reflected in the WHO constitution itself. Further, the elaboration of strategies was left to country-initiatives supplemented by WHO-led global health action. The situation changed considerably towards the end of 80s with an economic return on investment paradigm applied to health, especially by the World Bank. This paradigm seeks to anchor itself on health and development, seeking cost-effective return on investment. Unfortunately, the development pattern arising from economic policy cannot be adopted to the health sector without significant decline in equity.
• In fact, WHO must share our anxiety about how to assist the state in its capacity to prepare appropriate public policy that would retain the focus on justice while giving health a central place in development. This involves many specific steps such as global consensus on controlling health diminishing industries like tobacco, alcohol, junk food, commercial infant food, hazardous chemicals and pesticides etc. The role played by MNCs in promoting products with negative health consequences; the combination of medical technology industry with the power to dominate the medical profession should be curtailed. Unless lead is given in these complex issues at an international level to carve out a consensus in the direction of health care in the 21st century, the consequences would be grim.
• Another phenomenon in the 90s is the overwhelming dominance in international health funding by the World Bank, Regional Development Bank and selected bilateral donors, with budget cuts in social sectors previously being enforced as part of the structural adjustment programme dictated by the IMF. Two consequences arise, first WHO gets marginalized systematically in the absence of large funding capacities and the ability of other institutions to bypass the WHO even for technical advise. Second, assistance from the new donors comes with conditionalities and dictated patterns, structures.
• Promotion of technology in medicine has always had a cost-enhancing effect and also creates a reinforced need for more high cost technology. Certainly some sections of the population in poorer countries also can create a "demand" for such technology but the cost rules out any access to the poor. Furthermore, even when access occurs it merely leaves the poor pauperized. The relevance and dependency effect created by the nexus between technology, medicine and advertising poses a grave danger for affordable health care. While control over such technology is not easy, WHO must remain as the central forum to express concern over the damaging effects of uncontrolled medical technology. In the South Asian experience, the poor have been served well by indigenous health practices and traditional systems of medicine. The paper does not show any concern for the recognition of the relevance of this phenomenon, not to speak of coordinated promotion of such indigenous systems. On the other hand, the power structure in any international agency is oriented towards the West, the professional and generally towards the male. WHO is no exception.
• There is a need to focus on the large unfinished agenda for the Third World poor, especially women and children. They live in countries caught up in debt, financial crisis imposed upon them by international capital markets, down sizing of public sector health care, agricultural failure etc. A steady focus on nutrition and provision of low-cost curative services with quality, need sustained public investments in health are recognized to be state responsibilities. As against this, the concept of sustainable health development, based on cost effective intervention in diseases, selected for value for money, would leave the overall health situation in these countries in total disarray.
• The private sector in medicine works on motivation of returns on investment or fee for service. Increasingly, this sector is getting commercialized. Changes in education of doctors and other health professionals for greater social understanding will have a long term effect. Meanwhile, it is necessary to create a consensus across countries on appropriate regulation for purpose of competent service, quality and accountability. It is necessary also to distinguish the voluntary sector from the private sector for profit, because the motivation and commitments of both are totally different. The draft should not club the private and voluntary sectors together, for it would give legitimacy to privatisation.
• What the WHO can do with regard to the large financial requirements of the health sector in major countries will always remain limited, but should have a catalytic effect and for providing leadership for country-specific planning. Unless distortions in national priorities are avoided at the planning stage itself, desirable health outcomes cannot occur, especially when donor interests differ from country interests. How well should the WHO restructure itself for the 21st century depends crucially on how much the country can control its health planning and action.
• A major omission in the draft document relates to the essential drug programmes (WHO Drug Action Programme). No other global network in trade is more powerful than the international pharmaceutical industry. Their reach over the local drug industry is changing in terms of control over ownership, technology, imports and exports etc. As a result, the focus on essential drugs (a tedious task undertaken by WHO over two decades) is getting lost. Prices of drugs are already reaching global level whereas incomes remain at country level. With a significant proportion of the population below the poverty line, medical care especially purchase of pharmaceuticals is becoming a significant cause of indebtedness.
• Promotion of false assumption and promises of the role of biotechnology industry, with increasing control of indigenous knowledge and resources, through blatantly unjust patent regimes and increasing bio-piracy and bio-prospecting, decreases the possibility of self-reliance and sustainability of the local communities, public sector and local industry, besides the existing indigenous system of medicine specially Ayurveda.
• The concept of essential health function is a useful step in defining tasks in the health sector. Indeed, it improves upon the narrow mechanistic formulation by the World Bank ("Investment in Health", World Development Report 1993) of essential clinical services and essential public health services. It must be remembered that in relation to health of the population, government stands in a position of trust and responsibility and their functions cannot be too narrowly defined. The draft document conceives essential public health functions as a supplementary to Primary Health Care. Caution is needed to give meaning to this new concept with due regard to the health of the population.
• Sustainable health development as a concept is wider than health but runs the danger of relegating health to severe tests of financial viability. It is true that the health sector must also be appropriately cost effective, but health is of such foundational value to human beings that it must be preserved, promoted and protected without reference to the immediate financial costs. Such a concept was inherent in viewing health as part of social development. This focus should not be lost sight of.

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