” I believe that you do not measure the health of a society by GNP, but by the condition of its worst off. ”
Zygmunt Bauman

Equitable access to health care was the theme of this years meeting of the Global Forum of Health Research in Beijing and Margaret Chan, director general of WHO set the scene. Fighting off the effects of a cold ( too much travelling to see her “bosses ” in WHO’s 193 member states) she said that despite increased investment in health , knowledge of effective interventions, and the “flurry” of support from international philanthropists, the health gap between rich and poor countries showed no signs of narrowing.More… Her challenge to the 800 or so assembled researchers from 80 different (mostly low and medium income) countries was to define the barriers that prevent access to treatment for preventable disorders and do more to ensure that services reach- and are affordable to, the poor. The health sector must, she urged, take the lead in pushing for a fairer distribution of the benefits of globalisation.

On evidence for action ,Professor Michael Marmot, chair of WHO’s Commission on Social Determinants for Health (www.who.int/social_determinants) beamed the message via video link that we don’t need randomised controlled trials to tell us what works. The commissions nine networks already have sufficient evidence from literature reviews, analyses of policy, case studies and experience gleaned from civil society groups, to implement interventions to address the social, economic and environmental factors which underpin health inequity. As he emphasised, its not biological factors that result in a woman in Botswana having a life expectancy of 34 years and one in Japan 86, but life circumstances, which are amenable to change. The range of interventions which can reduce health inequity is wide and highly context specific. One successful example Marmot cited was from Rio de Janeiro where adolescents have been trained to act as “health promoters.” This has resulted in a fall in the rates of violent crime, teenage pregnancy, and drug trafficking.

Assessment of health status and the impact of interventions to improve it are bedevilled by poor and patchy data collection. This was highlighted in a session devoted to the “scandal of invisibility.” In low income countries around a third of births and deaths are not registered. Where the latter are documented the cause of death is often ill defined. Without accurate and reliable health surveillance data it is impossible to develop effective health policies. Civil registration systems need to be strengthened and countries supported to collect good epidemiological data on causes of death, speakers underlined. To spur better data collection a new resource kit was launched at the meeting aimed at helping national agencies, development partners and epidemiologists to strengthen monitoring systems (healthmetrics@who.int). A call was also sent out to international agencies to devote a larger proportion of their aid to supporting data collection, collation and evaluation. As the discussion unfolded it was evident that poor data collection stems from more than a lack of epidemiological expertise. Governments may, it was suggested, be reluctant to expose politically sensitive health problems. People may fear what the government will use the data for. Low expectations is another factor. In countries where infant mortality rates are high parents may wait for several months or even years before they are certain their child will survive. It is only then that they register its birth.

Health equity is a issue that worries China’s public health policy makers. The country’s spectacular economic growth has been accompanied by a “slow down of improvement in population health and a rise in health inequalities,” said Tang Shenglan, health and policy advisor to WHO in Beijing. This, he said, was due to a rapid increase in health care costs (in a predominantly fee for service system), poor population coverage by health insurance (less than 40% of the urban population are insured), and no medical safety net. Out of pocket payments for health care have risen steadily over the past 25 years and now account for 54% of total health care expenditure. This has put health care beyond the reach of many and impoverished many more. The aim of China’s new health reforms,which were launched last week, is to enhance equity and access to health care, particularly for vulnerable groups. Reforms undertaken four years ago to increase the proportion of health costs borne by local governments has already resulted in “over 400 million peasants joining China’s rural coperative medical scheme,” Shenglan said. He also pointed to the need for greater emphasis on community based primary health care – a call which many repeated, during the conference.

As you enter China by plane you have to fill in a Health Declaration form. I worked my way down the list (thankfully) ticking “No” to questions on close contact with poultry or birds, fever, snivel, cough, headache, breathing difficulties, venereal disease, psychosis , and active pulmonary TB. Its not hard to see why the country requests such information; SARS is still fresh in the memory and China shoulders a quarter of the global burden of TB. But several speakers at the forum made the point that in both China and India along with other transitional countries, the greatest health challenge is not infectious disease but chronic non communicable disease which accounts for half of the total disease burden. To tackle this, Sania Nishtar, president of the Pakistan NGO Heartfile, argued, these countries must “reconfigure their health services” which are currently more orientated towards to dealing with acute and communicable disease. More focus on disease prevention and health promotion, is needed, not least with respect to reducing tobacco consumption and tackling rising obesity rates.

Any new visitor to Beijing is likely to be struck (as I was) by two things. Firstly the sheer size of this city of 17 million in habitants with its specatacular and dense clusters of high rise buildings, and secondly, the equally dense slow moving traffic. Bicycles, rickshaws, and motor cycles have been relegated to the sidelines. Helmets, reflectors, and lights are noticeably absent. Some wear masks to reduce their exposure to pollutants. As the city prepares (by day and by night) to host of the Olympic Games it was interesting to hear, albeit in the corridors, about air and water pollution in China. Earlier this year a report prepared by the Peoples Republic of China and the World Bank documented just how high a toll pollution exerts on health. Werner Christie, science and technology counsellor at the Norwegian Embassy in Beijing, said that the report (which was not widely aired) estimates that the health costs of pollution in China is around 5.7% of GDP. Tackling it may be expensive but would be cost effective; the net gain to the economy from reduced ill health would more than compensate. It all comes down to political will – which is of course, at both national and international level, the key determinant of whether our panoply of global health inequities gets addressed any time soon.

Further information about the Global Health Forum, including the programme and press releases is available at www.globalforumhealth.org. Details of the proceedings can also be read at a new internet portal launched at the forum aimed at fostering research into tropical disease: www.Tropika.net