Adopted by the 40th World Medical Assembly, Vienna, Austria, September 1988
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 68th WMA General Assembly, Chicago, United States, October 2017
1. Health is not simply the absence of illness, but is also more than a state of physical, psychological and social flourishing, and includes an individual’s ability to adapt to physical, social and mental adversity. It is affected by many factors, including access to health care and especially the Social Determinants of Health (SDH), and its restoration is similarly multidimensional. Society has an obligation to make access to an adequate level of care available to all its members, regardless of ability to pay.
2. Health care professionals regularly confront the effects of lack of access to adequate care and health inequality and have a corresponding responsibility to contribute their expertise to work with governments at local, regional and national levels to ensure they understand the Social Determinants of Health and integrate reduction of factors leading to inequality into all policies. Health care policies should suggest ways to eliminate health inequality.
3. Access to health care is an important factor in reducing the short, medium and long term consequences of poor health, caused by adverse social and other conditions. Access is itself multidimensional, and is constrained by factors including health human resources, training, finance, transportation, geographical availability, freedom of choice, public education, quality assurance and technology.
Health care workers
4. The delivery of health care is highly dependent upon the availability of trained health care workers. The training should not only include socio-medical competencies, but particularly emphasize an understanding of how the social determinants of health affect people’s health outcomes.
The distribution of health care workers varies widely as do the demographics in most countries, where an ageing population forms a huge challenge for the years to come. There is global mal-distribution. While all countries train health care workers, global movement, especially from less to better developed countries, is leading to continuing shortages. The development of ethical recruitment codes may help to reduce inappropriate recruitment activities by states. Ethical recruitment codes should also be applied to commercial recruitment agencies.
5. Research is needed to determine the best mix of different health care workers for different clinical settings to meet the needs of populations. Mal-distribution within countries should be addressed by seeking methods of attracting health care workers to rural and remote areas, or other underserved regions, at least for a part of their careers. Innovative concepts should be explored to make working in underserved areas interesting; punitive and coercive recruiting methods must not be used. Recruiting students who express a wish to return to their home area may help to alleviate this problem.
6. Primary training of health care workers has to be appropriate, accessible and of good quality, which makes the training costly, with the country of origin meeting this cost. Workers move to continue with secondary training, including higher professional training and specialisation for physicians, and also to earn more money that may be remitted home to support the family and community.
7. The ambition for self-improvement is understandable; efforts to increase retention of health care workers should include consideration of encouraging a return to the home country, with use of the new skills and knowledge to improve health care access.
8. Countries should not actively recruit from other states. Even when they do so passively, this recruitment should take place in accordance with ethical standards and the WMA Statement on Ethical Guidelines for the International Migration of Health Care workers.
9. Access to care is essential for the whole population. Methods of financing care are for each country to decide, according to their own resources, health and social priorities, and health needs. Countries should develop revenue systems that reduce reliance on out-of-pocket payments and private health insurance as these increase inequalities between population groups.
10. No single system of finance is ideal for every country; the exact balance needs to be locally decided. In making decision about financing systems governments must understand the essential nature of health care, the absolute requirement that it be available to all, based upon clinical need and not on the ability to pay, and that access can be constrained by financial fears. Eligibility for care does not ensure access, especially if co-payment schemes exclude those with the fewest financial resources.
11. Innovative means should be used to provide comprehensive health care, including partnerships with private providers and commercial entities, who may be able to provide elements of specialised care. In doing so states must ensure that this does not limit specialised care to the wealthiest proportion of their population nor should this be seen as a preference for a private health care model.
12. Decisions to limit access to elements of health care should be done on the basis of objective information, based on the best available scientific data about the efficacy and safety of health care services. It must include public debate about, and acceptance of, the concepts involved. Nothing should be introduced which discriminates against the elderly or vulnerable populations.
13. The public should have access to clear information on the health care resources available to them and how they may be accessed. Specific processes should be established to ensure that poverty or illiteracy will never be a barrier to access care.
Vulnerable and hard to reach people
14. There are groups of people in every country who are hard to reach with health care messages, and who often seek health care late in the progress of disease.
15. A variety of methods should be used to ensure hard to reach people are aware of the availability of health care, without direct cost, including methods to reduce fear and other barriers to access.
16. Where specific vulnerabilities such as learning disabilities or sensory impairments exist, solutions should include identifying and dealing with those vulnerabilities.
17. Health care workers have a duty to provide care that is free from any form of unfair discrimination.
18. Health care facilities should be situated in locations that are easy to access. This may mean working with local transportation providers to ensure formal and informal public transport routes pass the facilities. Consideration should be made to making health care facilities more accessible by active transport methods. Especially in rural and remote locations, patients may travel considerable distances to attend the facilities.
19. Patients who need referral to secondary and specialized care should be provided with access to transportation. Those needing help with accessing primary care should also receive support. Transportation should also be offered to isolated rural patients who require a level of care that can be found only in metropolitan medical centres. Telemedicine can sometimes be an acceptable substitute for transportation of patients.
20. Working with other health providers, including traditional birth attendants, may provide assistance. They should be integrated into the health care system, offered training, and be assisted to offer care that is safe and effective and that includes referral where necessary. This does not extend to the state health care system providing or funding care which is not evidence based, including so-called complementary therapies.
Freedom of choice
21. The freedom to choose care providers, and the options of care they offer is an essential element of care in every system. It requires the ability to understand that choice, and the freedom to choose a provider from among alternatives.
22. Barriers to freedom of choice may lie in access to financial resources, understanding of the options, and in cultural geographic, or other factors. Access to information about the available options is crucial in making an appropriately informed choice.
23. The health authorities should ensure that all populations understand how to access care, and should seek to ensure that populations have access to objective information about the availability of different health care suppliers.
24. Once individuals access care through a particular provider or physician they should be given opportunities to consider the clinical options open to them; access to systematically available information resources is an essential element supporting choice.
25. General education is a determinant of health; the better educated a person is, generally the better their health likelihood. When ill-health presents, prior education may be a determinant of the speed at which the person accesses health care. Education also aids individuals to make appropriate choices about the care options they access.
26. Specific education about health matters can be an important adjunct to lifestyle planning. While education alone does not, for example, stop people from smoking, using drugs or alcohol, it can aid in decision making about risk behaviour.
27. A general level of health literacy assists patients to make choices among different options for treatment, and to comply or co-operate with the requirements of that treatment. It will also improve self-care and the appropriateness of self-referral.
28. Educational programs that assist people in making informed choices about their personal health and about the appropriate uses of both self-care and professional care should be established. These programs should include information about the costs and benefits associated with alternative courses of treatment within the context of modern medicine; the use of professional services that permit early detection and treatment or prevention of illnesses; personal responsibilities in preventing illnesses; and the effective use of the health care system. Physicians should actively participate, wherever appropriate, in such educational efforts and must be provided with adequate resources to enable them to undertake such education.
29. Public education also assists governments by increasing understanding of public health measures, including taxation of tobacco, banning of human consumption of some products, and restrictions on individual freedoms because of health concerns. When legislative or other regulatory mechanisms are to be imposed by governments, a campaign of public education and explanation must be undertaken to gain public understanding and voluntary compliance.
30. Quality assurance mechanisms should be part of every system of health care delivery. Physicians share responsibility for assuring the quality of health care and must not allow other considerations to jeopardize the quality of care provided.
31. Technology is playing an increasing role in the provision of health care services. Capital purchase prices are high because of the need for specific logistical services, including skilled technicians and adequate facilities. Advanced technologies are not available in all locales; access to their benefits must be well planned to ensure they benefit all patients in need, not simply those local to advanced technology centres.
32. In extraordinary circumstances, including armed conflicts and major natural events such as earthquakes, physicians have a specific duty to ensure that policy makers protect access to care, especially for those most vulnerable and least able to move to more secure areas.
33. Social Determinants of Health greatly affect access to health care as well as directly impacting on health. Physicians should work with governments to ensure they are able to take effective action on SDH.
34. Access to health care requires systematic consideration to ensure appropriate conditions are met. These include:
34.1 Having an appropriate, universal, solidaristic and equitable health system, adequately resourced facilities, being available throughout a country, providing health centers and their professional staff with sufficient and sustainable financing, with individuals being treated on the basis of need and not on the ability to pay.
34.2 Patient choice should include which facility to access.
34.3 Access to adequate information for all is essential for making choices and for co-operating with health care providers.
34.4 Education is both a social determinant and a key factor in co-operation with health care provision, fostering responsible self-care with accessible support.
34.5 Health care professionals should be free to move around the world, especially to access educational and professional opportunities. This mobility must not damage resource availability, especially in resource poor countries.
34.6 Physicians must be provided with transparent and efficient ethical criteria for working in overcrowded or underserved areas.
34.7 Provision of health care requires action by government at all levels, working with populations to ensure that people understand the benefit of this care and are able to access it.
34.8 Physicians have an important role in ensuring that health care planning makes clinical sense, is communicated well to the population being served, and that patients are not endangered by inadequate resources, poor planning or other system flaws.
34.9 Physicians are aware of the health system and this forces them to play a socially conscious role regarding the social determinants of health and access to health care by themselves or through their representative medical associations.
34.10 Medical associations should work with their members to promote access to health care systems that equitably support the needs of populations.