... Even in the use of apparently simple statistics such as birth or death rates, major problems arise in the quantitative expression of 'health' in many Third World individuals and communities, because of the lack of reliable data. Many births and deaths go unrecorded or are registered without any detail. Nevertheless, some attempts at quantification are important and the different conceptions of health noted above are of relevance in so far as they influence the 'nature' of restorative or promotive activities embarked upon ... involving the improvement and upgrading of the social and physical environment as well as of bodies and minds. This demands a much greater total involvement than medical intervention alone. Such a realization has great implications for the nature of nations' health care as to whether 'top-down' intervention and programs are imposed, whether 'total packages' are adopted or whether selective medical care is sought. This will also partly determine the extent to which people can become involved in, and take responsibility for, their own health and welfare.

Health and Development:
There appears to be a reciprocal relationship between 'development', broadly defined and health, equally broadly defined. Traditionally, a healthy population and workforce have been assumed to favor economic development, whilst an unhealthy population has been associated with poverty and underdevelopment ... Today, it is recognized that there is not a simple one-way relationship between 'health' and development. Whilst development generally brings improved diets, housing, social change and reductions in infectious diseases, it is also usually associated with rises in degenerative diseases, mainly apparently of non-infectious aetiology [inquiry into the origin or causes of disease: Essem] (often called 'Western' diseases).

One problem of analyzing relationships between health and development is that development is a rather vague notion. Some organizations are reasonably content to identify development in terms of changes in certain economic or socio-economic indicators. For example, an increase in per capita income is taken by some as a proxy for development. 'Orthodox' development is assumed to be along Western lines, usually involving industrialization, often on increasing scales, and associated with economic growth measured via increased GNP. However, others are less happy with this rather narrow view of development ... In addition to the economic productivity aspects of development, broader issues may involve national development that enhances the power and independence of nation-states - relating to improved distribution or to increased economic efficiency of industrialization, but the necessity for Western-styled industrialization is often questioned.

It is important to realize, from the standpoint of health, that modernization theory initially did not consider adequately or explicitly the possible detrimental effects of Western innovation or the widespread emergence of Western diseases. Whilst it appears that many 'Western' diseases actually did exist in traditional societies, modernization with increased life expectation has brought epidemiological change and such conditions are growing in importance. Health-care needs change and new health resource problems both replace and stand alongside the old.

In conceptual and practical terms, populist and 'small is beautiful' ideologies have their counterparts in health care as well in economic development. Enormous improvements in health can and should be gained without the use of high technology. However, a broader based development for health demands considerable intersectoral collaboration, which is often difficult to achieve. Globally, there has been something of a shift in philosophy - if not always in practice - from favoring large-scale, top-down (vertical), technology-oriented development projects to smaller-scale, bottom-up or 'grass-roots' approaches to development and provision of human services such as health care. Nevertheless, top-down vertical approaches remain commonplace in health care provision, particularly in selective disease-oriented programs, even if broader-based, horizontal, 'community' approaches in Primary Health Care (PHC) have for some years been gaining prominence. Basic needs provision and a basic needs approach to development have become widely appreciated. Small-scale approaches to development are frequently regarded as more human, more satisfactory, less externally imposed and generally less prone to many of the adverse side-effects that have often accompanied large-scale modernization projects. For probably the majority of poorer Third World residents, the benefits of many neo-modernization strategies have been elusive and the measures possibly even counter-productive. Certainly, the effects of large-scale, expensive strategies in terms of health and quality of life have been often ambiguous at best and lethal at worst, as the environmental degradation and dangers to health in places such as Cubatao in Brazil and Bhopal in India sadly illustrate. Large-scale, largely uncontrolled modernization along Western lines may be highly damaging to health in the Third World.

... Today, the debate has moved on. In the 1970s and early 1980s, ideas of dependency had come to the fore, particularly with the suggestion that Third World development was being prevented and underdevelopment even being exacerbated by dependent relations with industrial countries. The publication in 1980 of the Brandt Report argued the need for common action at a global scale based on the recognition of mutual interests. Whilst this is still widely accepted, the means of achieving common goals are now questioned. In simple terms, there has been a theoretical and political shift in the debate, in which conviction is growing among some that market liberalization can mutually benefit the Third World and First World and bring about development. The debate tends to be between dependency and and free-market thinkers. Whilst this juxtaposition of two schools of thought inevitably oversimplifies a deep and complex issue, it is nevertheless important, since, if the free marketeers come to the fore, it will have major implications for health and health provision in much of the Third World (in particular, for the future perception of state responsibility for health care and, perhaps, how this might be minimized).
 

Major characteristics of health care in the Third World:
Many people see 'planning without people' as a major danger for the implementation of specific, selective interventions (such as immunization or malaria control); the converse risk, of course, is a broad level of popular participation but with little practical progress.

It has often been felt that there is little direct relationship between conventional medical inputs and traditionally defined health outputs. It appears that prevention of disease by social improvements and environmental management is a more promising avenue for enhancing health than merely increasing expenditure on medical technology. Indeed, it is often argued that the principal determinants of health in any society are basically nutritional status and environment.

There is something of a tendency in the Third World to regard health care in a rather narrow, technical light. The provision of comprehensive PHC has become an important thrust in the 1980s in Third World health care and this will no doubt continue in the 1990s. However, it is not difficult to reduce even theoretically comprehensive PHC itself to a technocratic strategy that ignores the wide role of the state (in distribution of resources, for example), and regards 'health' as something determined by (or created by) the delivery of health services rather than by overall development. An imbalance in the use of resources available for health care can therefore be perpetuated and a neglect of social-environmental management can occur, which may remain the poor relation of 'high-tech' medicine. The interest of many institutions, training systems and technology and pharmaceutical companies continues to be served by the 'Asclepian cult', favoring medical intervention. Collier (1989) attributes the the excessive use of medication and multiplication of useless drugs to the extensive influence of multinational pharmaceutical companies. Others seek to explain health more abstractly as being largely a function of rational living and personal lifestyles. Clearly, some balance needs to be achieved.
 

Some specific features of health care in the Third World:

Availability and accessibility:

• Health facilities, especially Western facilities, are often geographically inaccessible to the majority of populations. Women and children in particular may experience difficulties in reaching a source of care;
• Urban and rural differences and inequalities frequently persist in health and health care;
• The availability of services and treatment (such as drugs or X-ray) is often erratic, not only in rural areas but also in some parts of towns;
• Official health facilities sometimes fail to provide the necessary medicines, whereas the private black market may do so;
• Economic as well as physical barriers exclude many people from formal health services, transport costs and time lost from work may prove too great for poor people to be able to use services;
• Imbalances therefore characterize health care; imbalances between individuals and communities (rich versus poor; favored versus unfavored), between regions, between urban and rural areas, and between countries.

• Curative medicine is often emphasized, whilst prevention and early treatment, which need an effective system, are frequently neglected;
• Related to this, hospital facilities are often excessive in relation to primary and community provision; they are also often accessible only to a small proportion of national populations;
• The 'cost explosion' in health care often has disproportionately serious effects for Third World countries, which have limited financial resources and, frequently, debt burdens.
• Education of physicians is rarely geared to conditions in the country;
• Common health problems are often neglected, as are appropriate technologies, whilst relatively unusual diseases and high-technology equipment may be emphasized in professional training and facility provision;
• By contrast, an extensive 'appropriate' system of traditional medicine often coexists with the modern, but its degree of integration, official recognition or support is extremely varied;
• Health workers, especially in rural areas, are frequently inadequately trained, supported and supervised;
• There is often heavy, sometimes excessive, reliance on paramedics or community workers without wholesale community participation.

• Referral and advisory support systems are often weak or non-existent;
• Community participation in health is sometimes weak, and intersectoral integration of health (with housing, education and infrastructure) is often underdeveloped;
• Integrated approaches are increasingly recognized as a major vehicle for improving health at the wider level, but political jealousies and intersectoral rivalries have frequently hindered effective coordination.

• Considerable political importance is often attached to health development although practical activity and assistance is often inadequate. Unattainable statements of intent can be promulgated: 'slogan-led' health care is frequently apparent;
• The state often assumes responsibility for health care but it is rarely equal to the task. This can be particularly true in the poorest countries and/or revolutionary regimes where conditions are unstable;
• Development of selective health care programs (with limited objectives) is sometimes promoted whilst citizens remain exposed to other, continuing hazards;
• Social security systems are at best partial and at worst non-existent, so families and individuals are often reliant on their own financial resources to support care.

• The socioeconomic environment is often injurious to health; housing, working and travel conditions may pose hazards and create extra health burdens. This may be exacerbated by a lack of environmental controls, and weak industrial or labor legislation;
• Natural environmental disasters such as flooding, drought, hurricanes and fires may drain financial and other resources, as well as creating greater pressures on existing health provision.

Intersectoral action for health: integrated components?
Recently, a major concern has become the health and well being of communities as a whole, as opposed to simply the technical cure of varieties of sickness; so too has the focus of action shifted to integrated development among many inseparable sectors impinging on health. Agencies, ministries and organizations responsible for health and health care have increasingly recognized that these topics cannot be solely a responsibility of one group of professionals. The intersectoral strategy recognizes that the improvement of health will require contributions from many sectors of the economy and society.

To enhance the chances of success of integrated actions at the local level, it is imperative that high-level blessing is given and the avenues and mechanisms for intersectoral collaboration are established ... It is hardly novel to recognize the significance of the linkages between the major sectors of health, agriculture, education and environment.

In agriculture, output, production, land ownership, technology and decision-making have crucial health impacts. For example, the choice of whether to grow cash crops as opposed to staple foods can influence food availability, costs and access for vulnerable groups. Sen's (1981) discussion of the concept of food entitlement is relevant. The income from cash-crop sales rarely accrues in sufficient proportions to those growing and tending crops ... Changes in land holdings and lack of access to credit can reduce small-scale farmers to landless labourers. This group is often identified as most at risk, and its members are sometimes seen as victims of Green Revolution strategies. At a macro-scale, economic policies that influence food prices, distribution and availability can have immense impact on the nutritional status of the population, with concomitant correlations with health levels.

Education can have a similar critical role in health improvement. Formal education is generally felt to be decisive in improving health and reducing mortality (especially among infants) in developing countries. A few years basic schooling can make a crucial difference to an individual's ability to cope with the living environment and use services effectively, and to his or her awareness of nutrition and hygiene requirements. Universal primary education is intrinsically linked to the 'health for all' goal, and basic education is the foundation for heath education. The health sector therefore has great interest in promoting equity-oriented education policies that allocate priority to primary education and especially to the health-related needs of women. Reduction of female illiteracy rates is regarded as particularly important, as women so often play the major role in child rearing, the determination of family size, nutrition, and health care utilization.

Other, but by no means less important, sectors that should be involved in collaboration are those of water, sanitation and housing development. The linkages between water, sanitation, housing and health are many. Frequently, water and sanitation projects do not give sufficient attention to socioeconomic and socio-cultural conditions of the communities served. Basic personal hygiene, for example, needs to be maintained even with improved sanitation. The message of boiling drinking water is now widely accepted, but boiled water is often reinfected on storage by the use of dirty receptacles and by dipping unclean hands into it, negating the benefits of boiling. A by-product of this apparent failure of the relatively expensive boiling to prevent infections may be to make people skeptical of other health-promotion messages.