HEALTH Security is a strategic goal that is anchored in the bedrock of health as a basic human right – a right enshrined in the Universal Declaration of Human Rights.
   The state has the right and responsibility to establish and foster conditions conducive to the enjoyment of good health by all, and not by some only. Health security is a precondition and an outcome of health equity.
   Health security advances social justice and enhances social solidarity. Good health is not merely a state of physical and mental well-being but also a sine qua non for realizing high social and economic productivity leading to human development
   Health security does not mean equal health care for all because the health needs of people differ. But it means access to, and assurance of, health care when and where needed unfettered by economic, social or geographic barrier.
   ‘Health for All’ a social target
   The World Heath Organisation is the specialised United Nations agency on health. In 1977, WHO articulated the goal of heath security by proposing ‘Health for All’ (by 2000) as the main social target of its member states. In May 1977, the World Health Assembly – the World Parliament on Health – by a landmark resolution acclaimed the ‘Health for All’ target. The assembly meeting in Geneva also determined that the disparity in health conditions of people between and within countries was unacceptable.
   In 1978, the joint WHO-UNICEF international conference at Alma Ata (in former Soviet Union) adopted the historic Alma Ata Declaration. The declaration elaborated primary health care principles and eight elements as the key strategic approach to the attainment of ‘Health for All’ by 2000. The declaration urged global and country-level action to implement PHC approach and considered investment in health and improvement of human conditions clearly in the long-term interest of not only human development but also world peace and security. This writer participated in that historic conference in the city of Alma Ata in Kazakhstan (then of the USSR). It was an inspiring world event; it resounded with acclamation of international solidarity and cooperation for advancement of peace and human development.
   ‘Health for All’ remains a distant goal
   World events, however, took a cruel turn. Nearly three decades since 1978, ‘Health for All’ eluded countries and peoples in a turbulent and tense world. The high hopes for worldwide cooperation for social and economic development in a climate of peace with justice under a new world order failed to materialise. Even the end of Cold War failed to reap the much expected peace dividend for world development.
   On the contrary, conflicts raged and colossal amounts of resources were being spent on armaments and military warfare. Not even a small fraction of those vast resources was available for spending on social and health services for human development. Far greater resources went to war preparations and wars in the name of national security. Yet, this failed to enhance either military or human security.
   Once universally acclaimed the ‘Health for All’ goal receded and seems now beyond reach anytime soon. Health disparity and insecurity remain pervasive within and between countries and peoples, rich and poor alike.
   For global public health community and those who signed the historic Declaration of Alma Ata, the failure of the countries and the global community comes as a huge blow.
   Now that globalisation of world trade and economic liberalisation has brought sweeping reforms with structural adjustments the paradigm of social and human development has changed greatly. Many poor countries are saddled with heavy debt burden; free market forced public sector to shrink and abdicate many of its normal duties and obligations. Public health became an early casualty of financial stringency; governments retreated from provision of essential public health services.
   Free market regime with private sector dominance made significant sections of the population in many countries, including even rich countries, lose access to essential health care, paradoxically when the supply of services expanded hugely in the private market Those who needed most were getting least. Equity as the bedrock of health security has been seriously undermined. Yet, ‘Health for All’ has not lost its validity as a social target or an ideal to cherish for human dignity and peace with social justice in the world of tomorrow and beyond.
   Undeniable is the fact that public health services benefit the entire populations; their decline precipitated a major setback to public health in many countries. It is a cruel irony that the ‘health market’ of many countries is flush with abundant modern, high technology medical care, but those whose needs are higher go without care because they are unable to pay; those who utilise private care often pay a price they cannot afford. For many households, a serious accident or illness becomes a catastrophic experience. A paradox of scarcity in a market of plenty has set in. An unacceptable number of people in poor and rich countries alike live precariously. That is unacceptable because that diminishes value of humanity; that denies minimum human rights to citizens in both rich and poor world.
   What is health security?
   Health security is neither a product nor a function of how much per capita is spent on health in a country. A wealthy country that spends highest per capita on health can leave a significant number of people precariously insecure without access to health care.
   Health security is primarily a function of distribution of health resources, of how and where governments and private sector allocate and spend their health resources. When governments spend preferentially on public health and health-related activities such as environment, safe and healthy food supply, promotion of healthy life style, they produce higher health outcomes, thus higher health security for their entire populations.
   But governments alone cannot bring about health security. Private health-care providers and health-related sectors have important, often complementary roles. But it works best when the partners act with greater social responsibility and within a modicum of social control. Any talk of social control has become an anathema but in human and health security it is mandatory, simply because market can be notoriously inequitable and socially delinquent.
   Finally, individuals, families and communities have the right and duty to protect and promote their own health and adopt behavioural changes conducive to healthy living.
   Health security comes through partnership across a wide spectrum of sectors and enterprises. Private-public partnership has been quoted often but it is not a substitute for accountability and social responsibility. Partnership has sometimes been used to support subsidies and concessions which is a form of distortion, an ‘equity in reverse’ at the cost of the public sector.
   ‘Health for All’: a duty or a charity?
   Democracy is essentially founded upon a sacred social contract. I would argue, therefore, that health security of people is not an extension but an essential component of the social contract, and a duty rather than a charity or benevolence. Social contract stipulates that health is a public good that the state has primary duty to dispense with equity and social justice in rich and poor countries alike though not equally in contents. Yet, governments alone cannot or need not provide personal health care to everyone when and where needed. The public too cannot entirely depend on governments. Let politicians make promises they cannot deliver. Political parties in Bangladesh promised health care to the people at their ‘doorstep’. Obviously, they did not work out the technical or operational feasibility, or its financial affordability. Such political promises are not to be taken seriously.
   But governments have one overriding duty. That duty is to promote and protect health of the people by ways individuals cannot do. That duty is better done if and when governments perform essential public health functions. Essential public health functions include, at the minimum, health protection through essential services such as safe drinking water and sanitation; healthy environment (air, water and soil) reasonably free of avoidable health hazards; and dissemination of valid health information and education to empower families and communities to promote and protect their own health through behavioural change.
   An expanded list of these functions will include universal immunisation of infants and children against life-threatening infections; safe pregnancy and childbirth; food safety and hygiene; epidemic disease control and surveillance. The determination of which functions shall get priority will depend upon available resources and benefits intended.
   Resources are by definition limited in all countries. But that is more reason why essential public health functions should command government priority over other health outlays including hospitals. Well-performed essential public health functions benefit the entire population; yield higher health outcomes and impact with equity and social justice. These make essential public health functions eminently cost effective.
   Good and adequate public health actions reduce the burden of preventable illnesses. At personal and family level, acute illness can have devastating effects on poor households often forced to spend money beyond their capacity.
   A programme approach to health security
   Health security can be approached from several entry points, namely health needs, health demands, disease epidemiology, etc. But from an operational standpoint, a simple approach to the goal of health security is grouping of the population preferably according to their health needs and potentials of health outcomes.
   Children and women, the elderly, chronically ill, the adolescents represent groups of particular interest. Specific programmes can be focused upon with targets of service coverage, cost-benefit ratios, and aggregate health outcomes. Each of these groups is vulnerable to specific health risks and benefits from health promotion and protection.
   For example, all eligible infants and children must be protected by immunisation against diseases that could cause premature death and disability. Immunization should be universal to give maximum security to all.
   Young children and young adults require proper food and nutrition to secure normal physical and mental growth and development; thereby secure better learning and better human capital for economic and social progress.
   Women in reproductive age need security of care during pregnancy and a safe motherhood; their health needs are met by care before, during and after pregnancy and childbirth, and beyond.
   Adolescents have special health needs ranging from health education, health promotion, and protection including life skills and knowledge of sexual hygiene and safety.
   Men and women in fertile age group need correct knowledge of contraceptive methods to exercise power to plan and attain their reproductive goals and practices; specifically family size, birth intervals, and overall reproductive health and security.
   The elderly population (above 55 or 60 years) needs care for chronic and degenerative conditions. This group includes people who have retired from regular employment and no longer earn previous income making it difficult for them to get medical care. They need security of health care mainly assurance of getting medicines and supplies regularly needed cheaply and conveniently.
   Other groups with special needs are ethnic minorities (tribal, hill, river, char population) and remotely located people who have little or no ready access to central facilities. Health security for these groups may mean mobile or specifically designated facilities and most commonly needed care.
   And there are very poor people who live well below poverty level; they may not gain health care even when cheap or free which in most cases it is not. Health security for the poor is a direct contribution to poverty reduction – a goal included in the Millennium Development Goals.
   The impact of free market and liberal economy has been mixed; the poor, the underprivileged, the minority and remote population segments have not benefited and some have had a worse deal.
   Since the growing trend of liberalisation may escalate, the least the state can and should do is to provide a safety net to give some semblance of health security to the most vulnerable, those marginalised in the free market.
   Bangladesh has a good tradition of social solidarity and egalitarian ethos nurtured by a homogenous population free from caste ethnic or tribal divisions. These constitute a huge social asset. Only if the state sector can put its priorities right and determine its social and economic policies free of coercive dictates by neo-liberal economic dogmatists, health security can be achieved in the foreseeable future.
   Economic pundits may scoff at the idea of social health insurance. But conventional wisdom can be overturned by innovation and enterprise at the grassroots level left largely to local governments and small-scale entrepreneurs. People of Bangladesh have shown great resilience and innovation in the face of countless past calamities natural or manmade; have a string survival capability. People in small communities need support by technology (means, methods, ad material) and a level field minus constraints and obstacles on the path to self-reliance to which misplaced or condescending charity is a huge impediment; it is also insulting while genuine empowerment and encouragement are enabling.
   If human health is a social good, which it undoubtedly is, the state and the public sector cannot abdicate its duty.