June 2006 - Priorities in Health Care

In every country, rich or poor, there is a wide gap between the needs and wants of people for health care and the available resources to meet these needs and wants. The gap is likely to increase in the future because of the deterioration of the global environment, newly emerging infectious diseases, the aging of the population and the high cost of new medical treatments. It is necessary, therefore, to establish priorities in health care in order to determine how scarce health resources can best be used.

Health care priority setting can be explicit or implicit. Most governments prefer implicit approaches such as continuing the status quo, adopting the priorities of influential pressure groups, and responding to media reports. Politicians generally avoid evidence-based policy making, most likely because it can undermine their own priorities.

Some countries, however, have developed explicit approaches that include both procedural and substantive elements. The procedures have included the establishment of a national or regional organization to advise the government on priorities (for example, the Swedish National Centre for Priority Setting in Health Care), various means of seeking public input on priorities, and periodic review of priorities in the light of new data. Governments have had no shortage of substantive criteria for priority setting from which to choose, thanks to the work of many academic policy experts in this field. Some focus narrowly on economic costs and benefits while others include ethical considerations such as justice. All rely on evidence (data) for their conclusions. The International Society on Priorities in Health Care is a source of information and networking for governments and academics interested in explicit approaches.

Establishing health care priorities is not a task only for national or regional governments. Local health authorities and institutions also need to determine how to allocate their scarce resources. So also do international health organizations, whether public or private. The U.N. Milennium Development Goals include several priority areas for improving global health; the WHO has adopted these priorities.

Priority setting is also necessary in specific sectors of health care such as research. There is much unease about current research priorities that do not reflect the global burden of disease. The Global Forum for Health Research was established in 1998 to overcome the '10/90 gap', whereby 10% of the global health research resources were being applied to the health problems of developing countries, which accounted for over 90% of the world's health problems. One of the first products of the Global Forum was A Practical Framework for Setting Priorities in Health Research.

Medical associations have generally been reluctant to engage in discussions about health care priorities. The Hippocratic tradition of medical ethics has required physicians to consider above all the needs of their individual patients, which can conflict with the needs of other patients and of society in general. However, this attitude has been undergoing gradual change in recent years as physicians, and their medical associations, realise that their experience and expertise is needed (though not always wanted) by governments when they establish health care priorities.

One example of a National Medical Association's contribution to priority setting was the Canadian Medical Association's 'Core and Comprehensive Health Care Services' project. It developed criteria for determining which services are medically necessary and should be publicly funded ('core services') and which are desirable as part of a broad package of health care ('comprehensive services').

The WMA would like to hear from other National Medical Associations about their priority setting initiatives.

May 2006 - Environmental Health

The importance of the environment for human health has long been recognized by international organizations, both political and medical. Political initiatives on this topic include the following:

• On 14 December 1990 the United Nations General Assembly adopted Resolution 45-94 on the need to ensure a healthy environment for everyone. The Resolution declares that each person has the right to live in an environment adequate for their health and well-being.
• The Declaration of Rio de Janeiro on the Environment and Development of 13 June 1992 specifies that human beings are at the centre of preoccupations concerning sustainable development and that they have a right to a healthy and productive life in harmony with nature.
• The World Health Organization and the U.N. Environmental Program have undertaken a Health and Environment Linkages Initiative to support action by developing country policymakers on environmental threats to health. Environmental hazards are responsible for an estimated 25% of the total burden of disease worldwide, and nearly 35% in regions such as sub-Saharan Africa.
• The WHO Regional Office for Europe is engaged in a project on Climate Change and Adaptation Strategies for Human Health.
• The U.N. Population Fund (UNFPA) supports countries in using data for policies and programmes to address the complex linkages between population dynamics, poverty and sustainable development that have major implications for both the environment and health.
• The European Commission adopted in 2003 an EU Strategy on Environment and Health, with the overall aim to reduce diseases caused by environmental factors in Europe. This was followed up by the European Environment and Health Action Plan 2004-2010 that proposes an Integrated Information System on Environment and Health as well as an coordinated approach to Human Biomonitoring between Member States to render the assessment of the environmental impact on human health more efficient.

The WMA has been concerned with environmental health for more than 30 years. In 1976 the General Assembly adopted a Statement on Pollution (since rescinded and archived). In 1988 it approved a Statement on the Role of Physicians in Environmental and Demographic Issues; this is currently undergoing revision. In 2004 a Statement on Water and Health was adopted. And on 15-16 November 2004 the WMA collaborated with the World Ocean Observatory on a conference in New York dealing with The Ocean, Water and Public Health.

The Australian Medical Association has been very active on environmental issues. In 2002 it organized an Environmental Health Summit and in 2004 adopted a position statement on Climate Change and Human Health. In 2005 it co-sponsored a report on Climate Change Health Impacts in Australia and encouraged the Australian Government to ratify and implement the Kyoto Protocol.

The Canadian Medical Association also supported the Kyoto Protocol and is a member of the Canadian Coalition for Green Health Care headed by the Canadian Association of Physicians for the Environment. Its mission is to minimize the adverse environmental and human health impact of Canada's health care system.

Other National Medical Associations that have adopted policy statements on environmental health include the American Medical Association and the British Medical Association.