The World Health Organisation s goal of health for all by 2000 has clearly failed. Will its strategy for the 21st century fare any better, wonders Wendy Moore

There are no wild celebrations, champagne or fireworks at the Geneva headquarters of the World Health Organisation this week.

As the 21st century dawns, it is clear we have failed to achieve the global dream of health for all by the year 2000.

More than 2 billion people in the world have no basic sanitation, nearly 1.3 billion live on less than $1 a day and more than 5 million die each year from water-borne disease.

This comes as no surprise to most people. The Health For All goal, declared in Alma-Ata in 1978, was always a Utopian ideal. The European region's own Health For All strategy, launched with 38 targets in 1984, was equally ambitious. It included the goals of clean water , adequate food, sufficient income, decent housing, well-run health services and, crucially, health equality.

There is better health for some. Life expectancy has increased in many countries, rich and poor, WHO's world health report revealed last year.

Scourges like leprosy and guinea worm disease are being overcome.

Polio has been eradicated in the Americas and - just in the nick of time - appears to have disappeared this year in Europe, too.

Y et the world community has only ever managed to wipe one disease - smallpox in 1978 - from the face of the planet. Threats once thought defeated, like TB and malaria, are resurgent, and new diseases have emerged - 30 in the past 20 years - including HIV/AIDS, which has claimed 16 million lives across the globe.

In Europe, life expectancy actually fell in the former Soviet bloc following the collapse of communism in the early 1990s. Of the 38 European targets, good progress has been made towards only five, and only one - for children and young people - is a direct health improvement, according to Health in Europe 1997 , published last year.

In the UK the latest analysis - The Widening Gap , published by researchers at Bristol University - shows health inequalities are at record levels and widening.

Nevertheless, WHO in Europe has swept aside failure by announcing a new strategy for the 21st century , Health 21 .

So was Health For All a legitimate planetary vision or a colossal waste of time?

Professor John Ashton, regional public health director for North West region, remains a devotee. An enormous amount has been achieved, says Professor Ashton, who co-ordinated WHO's European Healthy Cities movement, the offshoot of Health For Al launched in 1986. Activists may have been frustrated at the pace of change, he says, but the HFA goals were stakes in the ground towards changed thinking.

The original Health For All ideals - multidisciplinary, inter sectoral action to reorientate health services towards primary care and fight the root causes of disease - have become part and parcel of British government policy , he says. New primary care trusts will be charged with just those aims.

But Sir Sandy Macara, former chair of the British Medical Association, says he always believed the 2000 deadline for HF A goals was ridiculous . It was obvious from the start that world health could not change dramatically in 20 years. It was so unrealistic, so idealistic it discredited the idea of targets, he says.

The impossible dream was compounded by lack of leadership, when Hiroshi Nakajima took over the WHO helm from the dynamic Halfdan Mahler in 1988, and lack of resources due to a refusal by the US to stump up its dues.

In the end, WHO has done probably as well as they were able to do, says Sir Sandy . But as an inter-governmental agency it could only ever achieve what governments would allow.

Nevertheless, there have been huge strides, he believes. Family planning has brought better population control to Africa and Latin America, diseases like river blindness have been brought to the brink of eradication, cholera is controlled through oral rehydration programmes, and child immunisation has been a success.

The biggest problem remains lack of access to decent healthcare.

The poorest countries in Africa are paying more to service their debts, which their appalling dictators incurred, than they spend on all their health education and health services put together, says Sir Sandy. It is disastrous.

In the UK, although health inequalities have widened, at least the health of the poor has improved. But Maddy Halliday, who was the UK s first Health For All co-ordinator when she headed the Sheffield Healthy City project in 1987 and who later took on the same role for Glasgow, looks back in anger.

The 2000 deadline was the biggest mistake, she says. The WHO agenda was visionary, but the barriers to progress were so huge that success was impossible.

Over the last 20 years it has been very hard to make progress, says Ms Halliday. I am actually quite angry about this. I think it has been a great tragedy , she says.

She believes WHO was naive , given the world social economic climate, and weak in its inability to steer the political changes needed for success. In Britain, opposition to tackling poverty from a hostile government was compounded by professional barriers to change. Those charged with delivering health for all had insufficient power, status and resources, she says.

The figures bear her out. The six parliamentary constituencies with the worst record for premature death in Britain are all in Glasgow, according to the Bristol study.

But for Dr San Griffiths, public health director for Oxfordshire HA, there is nothing wrong with unrealistic aspirations. I think there is a validity in inspirational targets and it is very easy to be cynical.

Oxford was another pioneer Healthy City during the 1980s, and although the project has disbanded the cultural legacy remains, she says.

The thinking is still there and it is deeply influential. The HF A ideals have informed new projects like Oxford s Sure Start work with young children and its single regeneration budget project.

Dr Alex Scott-Samuel, senior lecturer in public health at Liverpool University, who has also been heavily involved in the HFA initiative, agrees.

I think it was always seen as a symbolic, inspirational concept aimed at motivating people and I think it has been very successful, he says.

The fact the government eventually signed up to the HF A targets in 1985, despite Margaret Thatcher s refusal to accept the influence of poverty on health, fed directly into the Conservatives Health of the Nation white paper , he says. Ultimately, the same ideals produced New Labour s public health strategy.

Geof Rayner , chair of the UK Public Health Alliance, believes HF A raised horizons , but without government commitment in Britain it was doomed to failure.

But it is important to have the vision thing , he says and quotes Oscar Wildes appeal that a map of the world must include Utopia. l