Ministerial Meeting on Health and the Environment
Honourable Ministers, Ladies and Gentlemen,
The eight Millennium Development Goals represent a unique global compact. They reflect an unprecedented commitment by the world’s leaders to tackle the most basic forms of injustice in our world: poverty, illiteracy and ill-health.
In September, three months from now, political leaders will re-convene in New York and assess progress towards the goals they set five years ago at the Millennium Summit. There has been some progress. But too many countries — particularly the poorest — are falling behind. Where health lags, other areas fall short as well: education, gender equality, poverty reduction and protection of the environment. In short, the Millennium vision — to build a fairer world — will fail unless we do more, and do it quickly, to improve the health and the environments of poor people.
I know that I am talking here to an audience that needs little convincing. The leadership shown by the Minister of Health and the Environment, our host in Argentina, has been exemplary. In spite of a devastating financial crisis, Argentina has achieved a reduction of 12% in child mortality in 2004. But there are others who still do not realize the urgency of our cause.
Let me start by taking a global view of progress towards the goals. With 10 years to go to the target year of 2015, where do we stand?
The good news is that world is on track to meet the overarching goal of reducing poverty. But this is largely due to the rapid progress made in recent years by India and China. While their performance is to be applauded, this phenomenon highlights the need to look beyond aggregate global measures to the situation in individual countries.
When we look at some of the directly health-related goals, we see that no region of the developing world is currently on track to meet the target for reducing child mortality. For maternal mortality, evidence indicates that declines have been limited to countries with lower levels of mortality. Countries with high maternal mortality are experiencing stagnation or even reversals. This is an alarming situation and it reflects the high priority we have given in WHO to maternal and child health.
Data on coverage for some health interventions are more hopeful. For example, the proportion of women who have a skilled medical person with them during delivery has increased rapidly in some regions — especially in Asia, albeit from a low baseline. Use of insecticide-treated bednets has risen. Coverage with effective TB treatment has expanded.
However, we also have evidence suggesting that coverage of child health interventions is not following this pattern: the median coverage rate for key preventive and curative child survival interventions remains less than 25%.
HIV/AIDS remains by far the leading cause of premature mortality in sub-Saharan Africa and the fourth-biggest killer worldwide. Its effects are devastating: on individuals, families, communities and nations. At the end of 2003, an estimated 40 million people globally were living with HIV. In sub-Saharan Africa, prevalence rates among adults have reached around 7.7%. However, we must not forget that the Caribbean is the second most affected region in the world with prevalence among adults at around 2.5%.
The eighth Millennium Goal is about the partnerships which make progress possible. Access to essential drugs to developing regions, as a result of efforts by national governments, donors, the private sector, and others, is one of the indicators used to track progress against Goal 8.
A major boost to this effort occurred in 2001, when the World Trade Organization ruled that the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement should be interpreted to support countries’ rights to safeguard public health and promote access to medicines for all. This was followed by a WTO decision in 2003 to ease restrictions on the importation of generic drugs by the poorest countries for diseases such as AIDS, malaria, and tuberculosis.
Lastly in our tour of progress, let us turn to the environment. In terms of water there is good news to report. Between 1990 and 2002, nearly 1.1 billion people gained access to improved water sources. However, 1.1 billion people globally still do not have access to any type of improved drinking-water facility. Measured in these terms the Millennium Goal is attainable globally but sub-Saharan Africa will lag behind and will not reach the target if the current trend continues. But in sub-Saharan Africa the difference between rural and urban areas is stark: only 45% of the rural population have access, compared to 82% of their urban neighbours. Even in Latin America there is a 26% difference between the two groups.
Global sanitation coverage rose from 49% in 1990 to 58% in 2002. Still, some 2.6 billion people — half of the developing world — live without improved sanitation. Sanitation coverage in developing countries (49%) is only half that of the developed world (98%). Though major progress was made in South Asia from 1990 to 2002, little more than a third of its population are currently using improved sanitation. In sub-Saharan Africa as well, coverage is a mere 36%. Over half of those without improved sanitation — nearly 1.5 billion people — live in China and India. The world will only meet the Millennium target for sanitation with a dramatic acceleration in the provision of services.
Access to drinking-water and sanitation represent a crucial element in reducing poverty and inequity. The poor are disproportionately affected when basic drinking-water and sanitation services are not available. Halving the proportion of people who lack satisfactory water and sanitation services by 2015 would avert 470 thousand deaths a year. It would result in an extra 320 million productive working days annually. Four simple actions by mothers can make a huge difference to the health of their babies: safe disposal of faeces; hand-washing; disinfection and safe storage of drinking-water at home.
In addition, most international and national development agendas ignore the basic energy needs of families. 170 million people — 20% of the population of the Americas — continue to rely on wood, dung and other solid fuels for cooking and heating. While urban populations in Latin America tend to use gas, rural populations are exposed, day in day out, to high levels of health-damaging indoor air pollution. Because ill-health causes poverty, the target of halving the proportion of people living on less than $1 a day can only be achieved if the number relying on solid fuels is reduced to less than 1.85 billion by 2015.
The differences between urban and rural populations — whether in relation to sanitation or child health — highlights another issue which requires our attention. The health-related Millennium goals are concerned with averages. It is quite possible therefore for a country to report good progress whilst nothing changes for the poorest in the population. It is not only freedom that requires eternal vigilance: equity requires it just as much.
Let us now turn to the issues that lie behind the headline figures. Some of the challenges are fundamental, and characteristic of poverty and lack of development in general, but many are specific to the health sector. It is only by taking up these broad challenges — within the health sector and well beyond — that we will really start to accelerate progress.
Public health experts have long known that health status is determined in large part by political, social and economic factors, and by the environment in which people are born, learn, live and work. Strategies to improve health therefore need to look beyond health service delivery and act on these determinants of health. There are many such determinants that could be mentioned. I will highlight three:
First, access to food. We know that 53% of child deaths are associated with malnutrition. Hunger and poor nutrition also affect women’s health, with iron-deficiency anaemia contributing to 20% of maternal deaths.
Second, we need to work for gender equality if we are to reduce maternal mortality, combat the spread of HIV/AIDS and promote healthy lifestyles. Improving women’s access to education must be part of the gender strategy. This in turn will improve maternal health and child health, and reduce fertility.
Third, environmental factors — such as contaminated water, lack of sanitation, vectors of disease, toxicants, and indoor air pollution from solid fuels — are responsible for at least 25% of the global burden of disease. Our meeting today reflects our recognition of their importance. As you know, environmental conditions have a massive impact on child health and the spread of communicable disease. About 1.9 million children under 5 die every year because of diarrhoeal disease. This means that a child dies every 15 seconds from diarrhoea, caused largely by unsafe water and inadequate sanitation. Moreover, indoor air pollution causes an estimated 1.6 million deaths a year, with nearly one million of these deaths falling on children under five.
Although there is a need for dramatically increasing the current level of investments in building new infrastructure in order to attain the Millennium target for drinking-water target, it is possible, with relatively small investments, to take action that would reduce drastically the current 1.9 million annual deaths of children under 5 due to diarrhoeal diseases. Home water treatment, for example, offers a very effective tool to improve drinking- water quality at the point of use, which would accelerate health gains affecting mainly the poor and underserved. Lead, mercury, and other chemicals can result in long-term, irreversible effects on the intelligence and learning abilities of children, compromising the future of countries. WHO estimates that 13% of the burden of minor mental retardation may be due to lead exposure in children.
Long-standing knowledge of the social and environmental determinants of health has, more recently, evolved into a more comprehensive approach. This has aimed to promote health within a broad development framework. We need to know how public systems — and public policy more generally — affect and are affected by health.
If we are to increase salaries for health staff we need to engage in civil service reform. If we are to improve the functioning of district health services we need to ensure that budget and expenditure systems work well, and are transparent. And we need to manage decentralization processes so as to ensure that health facilities become more responsive to local needs.
The Millennium Development Goals recognize that development is an intersectoral and interdependent process, that health is central to poverty reduction, and that safe and clean environments are crucial for health. This means that health needs to be at the heart of countries’ poverty reduction strategies. This is an area where we need to do much more. Research carried out by WHO suggests that most national development plans do not prioritize health as much as they need to.
At the global level it is now widely recognized that better health and environmental conditions are pre-requisites for economic development. We now need to turn that knowledge into action at country level. This will require, among other things, a process of genuine participation which brings poor men and women — the most vulnerable in society — into the planning process. If we want to serve the poor, and improve their health, we need to understand their lives and listen to their concerns.
The Millennium Goals are about better health outcomes. If we are failing to deliver these outcomes, we have to look at the means by which they are to be achieved. At the centre of this human crisis is the failure of health systems. In too many countries they have failed to protect the poor from the consequences of ill-health, and in some cases they have contributed to more widespread social breakdown.
Much of the burden of disease can be prevented or cured with better health systems and technologies which are known and affordable. The problem is in getting staff, medicines, vaccines, and information to those who need them, through a system that works.
In too many countries, the health systems needed to achieve these objectives either do not exist or are on the point of collapse. We have examples of successful delivery strategies for single diseases like TB, which have worked on a large scale in low- and middle-income countries. The difficulty has been in achieving similar results for all causes of disease and disability.
National health systems worldwide have evolved in response to changing historical, economic, and social circumstances. It is not surprising that health systems often mirror the problems that beset societies more broadly. If societies are inequitable, it should be no surprise that health systems and health outcomes are inequitable too. The converse is also true: in countries where health systems are at risk of collapse, the causes — such as chronic underinvestment or the impact of HIV/AIDS — do not affect the health sector alone.
The challenge we face then is to define the elements of a clear and practicable agenda for health systems development. That agenda must overcome malfunctions in the health sector itself, and at the same time acknowledge that success depends on a range of factors in the wider society.
We talk about systems and services, but it is people that count. Health workers are dying. They are leaving public service because the conditions are bad and getting worse. In many countries health workers themselves live below the poverty line. They are moving from rural to urban areas, migrating to countries that pay them better, or leaving health care altogether.
Taking on the challenge of human resources will require work to improve pay, and incentives for those working in poorer areas. This requires a major effort to upgrade the skill-mix of health workers, and to form better partnerships with private providers, nongovernmental organizations, and community members.
Where migration is stripping health systems of vital personnel, we have to find ways — within countries and among them — to manage mobility without infringing individual rights. The crisis demands political as well as technical solutions.
It will also require money. We cannot shy away from this fact. When developing countries adopted the Millennium Development Goals — and when rich countries pledged to support them — the resource implications were clear. The time has come to make good on that commitment.
Thankfully, the amounts of money needed are relatively small in global terms. If rich countries honoured their commitment to provide 0.7 per cent of their GNP as aid it would be enough. However, the amounts so urgently needed now are significantly higher than what is currently being made available through investment in the health sector.
Resources will also need to come from the governments of developing countries themselves. Even the poorest countries have some scope to increase domestic health and environment spending. Reaching the health Millennium Development Goals for health will require an increase in aid. Improved health plans and strategies will help to attract these resources.