Health, Poverty and Human Rights
London School of Economics
Lord Desai, Ambassador, ANSA Members, Ladies and Gentlemen,
It is a great pleasure to be here this evening and speak on a subject central to my work and close to my heart.
It is no coincidence that the idea to establish a world health organization emerged from the same process that identified the universal value of human rights. WHO’s mandate is universal. Our constitution states that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition".
Protecting and promoting human rights is central to the work of all UN agencies. Based on our mandates we are pursuing different paths towards that goal.
What do we mean by the right to health? Clearly there is a major gap between the ideal and current realities.
In many parts of Africa, some parts of the Middle East and some countries in Latin America and Asia, people have seen decades - in some places more than a generation - of stagnation. They are certainly not progressing; sometimes they are even moving backwards.
Many are living in countries where too many people cannot meet their basic daily needs - food, water and shelter. They cannot access the services they need for survival, including essential health care and personal protection. They are vulnerable and insecure. The average African household consumes 20 per cent less today than it did 25 years ago!
I am not talking about small numbers. Between 1990 and 2000, the human development index declined in nearly 30 countries. Well over a billion people - more than one fifth of the world's population - are unable to meet their daily minimum needs. Almost one third of all children are undernourished. The UN last year stated that access to water is a human right. Yet 1.1 billion people do not have such access.
In many countries which have seen economic growth, increasing inequality means that the poorest part of the population has seen little or none of its benefits.
Over the past 15 years, the populations in many of the poorest countries have also become much harder to reach. As the iron hand of the cold war loosened its grip, some countries enjoyed new freedoms, but in other areas, paradoxically, the result was armed conflict and seriously weakened states.
In countries in crisis, people are suffering, locked in a vicious cycle of poverty, insecurity and ill-health. Look below the surface of a crisis thought to be due just to natural disaster such as drought, and you will often find it is actually the expression of layer upon layer of inter-related problems. Look at parts of southern Africa: civil conflict, economic collapse, poor governance, the ravages of HIV/AIDS, chronic under-investment in basic services. A deadly combination, in which the poor - as always - come off worst.
Given this gap between the ideal and reality, is there any point then in speaking about health as a human right? Don't human rights - like access to health and water - become meaningless when faced with such an enormous gap?
Juxtaposing the highest ideals with our sad reality can lead to apathy and inaction. But this will not help anyone. Moreover, it represents a lack of understanding of how our world works. The interplay between globally-set goals and normative frameworks on one hand, and concrete action for development on the other, is precisely how progress can be achieved.
Let us be clear: the right to health does not mean that poor governments must put in place expensive services that they cannot afford. What it does mean, though, is that the covenants they have signed require states to take steps in the right direction - they are obliged to pursue and to show that they are pursuing the progressive realisation of peoples’ rights.
One hundred and forty-five nations have ratified the International Covenant on Economic Social and Cultural Rights, which contains, in Article 12, the most authoritative interpretation of the Right to Health. As the definition of the Right to Health is refined, so we have a framework that sets out what people have a right to expect, and a potentially powerful means through which states can be held accountable.
Creating a system of rules and norms which are practicable, enforceable and fair is one of the many faces of globalization. Many people see globalization just in terms of the spreading reach of multinational corporations and global finance mechanisms. But if globalization is to realise its potential as a force for good, we have to look more closely at the means by which we handle our growing interdependence. We do not have a world government, but we do have an increasingly complex network of institutions that are concerned with global governance. They are central to our future and international human rights law, and the systems by which countries report against these norms is an important component.
In this form, globalization can help to transform the lives of millions. If, as many critics warn, it leads to inequity, it is a sign of failure. Our challenge is to make the positive things happen. To shape the world. To make certain that the forces of globalization contribute to a more just and inclusive global society.
Creating systems and institutions that bind nation states into a system of cooperation is not easy. Take trade: 150 years ago, it was not so difficult for a handful of countries to come to an agreement, and what could not be solved around the negotiating table was often settled with a few gun boats without much danger of escalation. Even when the UN was created, it consisted of only 51 nations.
Today, nearly 145 members of the WTO, nearly 200 nations in the UN, are struggling to agree on a large number of very complex issues. At the ongoing TRIPS negotiations, for example, some very difficult balances have to be made between the right to access to lifesaving medicines on the one hand and the need to maintain incentives for innovation on the other, while keeping in check national interests and domestic pressures.
The point I want to stress is that just because these negotiations are difficult and contentious does not mean that they are ineffective or unproductive. Rather, it shows how a global democracy of nations functions: on compromise and a will to find common ground. But we have to answer the legitimate critics of these institutions. Some rich countries and regions carry a lot of weight and are tough negotiators. Our challenge therefore as an international community, is to do what we can to ensure a level playing field. Rich and poor countries alike need the resources and advice to present their case effectively.
Let me talk for a moment about another example of how the world community comes together to find solutions to global issues. Next week, the final negotiations begin on a landmark treaty. The Framework Convention on Tobacco Control is the first global treaty initiated by WHO, and is based on its more than 50-year old Constitution which gives it the mandate to create such treaties.
Why would tobacco warrant this form of legal action? As one journalist asked me last week in Brussels: why make problems for a legal product? The answer is: simply because it is a dangerous product which shouldn't have been here - had it been introduced today, it would certainly never have become legal - but it does exist and we need regulation which is commensurate with the damage it causes.
In 2002, 4.9 million people died from tobacco-related causes. That was a jump from 4.2 million only two years ago. Nine lives lost every minute. Each death preceded by months or years of suffering for the individual and a staggering cost to society.
Yet the number of smokers keeps going up. In the early 1990s, eleven hundred million people smoked. By 2000, this number had increased to almost thirteen hundred million. If this expansion continues, the number of tobacco-related deaths will reach more than 9 million a year in 2020.
And as always, it is the poor who bear the biggest burden. The entire growth in deaths over the coming 20 years will occur in the developing world. The cost of tobacco-related disease will place an undue burden on societies already struggling against poverty to build viable health systems.
Yet, some still argue that in the name of free trade, tobacco, as a legal product, should not be regulated. Such logic is flawed. Wherever we turn in a shop, there are regulations which safeguard us against substandard or unsafe products. And take cars: perfectly legal, yet through rules, laws and taxes we regulate engine size, emissions, design, safety and a host of other features. We also regulate how they are used, by speed limits, traffic restrictions, seat belts and drunk driving laws. This is part of civilized society. Yet at the moment, despite killing half of their consumers, tobacco companies do not even have to list the ingredients of their products.
So far, I have outlined the importance of global legal frameworks in taking forward the ideals and principles we all subscribe to. But let us not forget that national political decisions still remain paramount and that economic realities still dominate the outlook and priorities of most national decision-makers.
Only when we convince these decision-makers about the wider social and economic benefits to their country of investing in health, will we create a proper momentum for improved health care.
To do this, we need to place health within a larger context of poverty reduction and development.
Over the past five years, we have been able to show forcefully that health is a crucial element of development, and that the priority given to health will be a significant determinant of the success of our wider development effort.
People are at the centre of sustainable development, and health is at the centre of human development and prosperity.
About 18 years ago, I was given the task of chairing the World Commission on Environment and Development. The task we set ourselves then was to link firm evidence with a clarion call for action. Our findings helped influence the course of development because the arguments succeeded in reaching future decision-makers such as yourselves, as well as Finance Ministers and Heads of State. Sustainable development was only possible if the key links between environment and development were forged.
I brought this experience with me to WHO. You cannot make real changes in society unless the economic dimension of an issue is fully understood. I firmly believe that this is how the environment moved from being a cause for the converted to an issue for real attention by key decision-makers.
In 1999, I asked leading economists and health experts from around the world to come together and consider the links between health and economic development. There was a need for change.
For too many years, investments in health were seen by many economists as an add-on which developing countries could only afford after having reached a higher income level. I was convinced this was wrong: you need a two-pillar approach. A healthy population is as much a prerequisite for growth as a result of it.
Just over a year ago, Professor Jeffrey Sachs presented me with the Report of the Commission on Macroeconomics and Health. It shows, quite simply, how disease is a drain on societies, and how investments in health can be a concrete input to economic development. It goes further, stating that improving people's health may be the single most important determinant of development in Africa.
This Report has made a considerable impact. Health used to be the poor cousin in the family of development. Throughout the past two decades, it was too often neglected while the focus was on building other infrastructure and creating favourable investment climates. The world has slowly seen the importance of education for development, but education alone cannot ensure sustainable development. Now, health should be given its rightfully central role.
The Commission argues for a comprehensive, global approach to health with concrete goals and specific time frames. It wants to see the forces of globalization harnessed to reduce suffering and to promote well-being. The proposed investments are well-tried interventions that are known to work. Their impact can be measured in terms of reducing the disease burden and improving health system performance. The emphasis throughout is on results; on investing money where it makes a difference.
Three diseases - HIV/AIDS, tuberculosis and malaria - are overwhelmingly important. Maternal and child conditions, reproductive ill-health, injuries and the health consequences of tobacco, are also global health priorities. Any serious attempt to stimulate global economic and social development, and so to promote human security, must successfully address the burdens caused by this range of conditions.
HIV/AIDS makes up just over half of the global burden these three diseases represent, both in terms of healthy life-years lost, and mortality. Malaria and tuberculosis share the rest on a roughly equal basis. It means that more than 90 million healthy life-years are lost to HIV/AIDS each year, 40 million to malaria and nearly 36 million to TB. More than five and a half million lives are lost every year to these three diseases, globally.
The Commission's Report is the first detailed costing of the resources needed to reach some of the key goals set in the Millennium Declaration. We are talking about an annual investment of $66 billion from year 2007. Most of this will come from the developing countries’ own resources. But about half must be contributed by the rich countries of the world - in the form of effective, fast and result-oriented development assistance.
Governments have taken action, trying to develop efficient mechanisms to move funds rapidly to where they are needed. They are encouraging independent monitoring of development action, using global standards, and the prompt reporting of results. At the same time, they do not want to create new and overlapping institutions.
The recent record in global health speaks for itself. The Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization are examples of these new interactions between public, private and civil society entities, the academic community, the media, international organizations and development agencies.
Listening to the persuasive and eloquent arguments of Professor Sachs, one is easily led to believe the task of ensuring health for all is simple: basic vaccination for all, information about the dangers of unsafe sex, smoking and unhealthy diet, wide access to affordable medicines, primary health care in every village, ward and hamlet. Yet Professor Sachs himself is the first to stress that to deliver such care in a sustainable manner is a daunting task.
Over the past five years, WHO has done a lot of work looking at health systems to see how they can deliver such care even in the poorest countries. We consider all the actions and institutions which aim at improving people's health and health systems, whether they are within or outside the health sector, private or public.
One of the important findings was that performance of health systems can vary markedly, even between countries with very similar levels of health spending.
France, Austria, Norway, Sweden, and Denmark all spend between $2200 and $2500 per person per year on health. Yet they ranked number 1, 9, 11, 23 and 34, respectively in WHO's first global health systems performance assessment.
In contrast, Costa Rica, the United States, Slovenia and Cuba ranked 36 to 39, with per capita health expenditures ranging from $4187 to $131.
In other words, some do some things much better than others, and there is an enormous potential for countries to learn from each other.
The next task is to help the systems work better. Our work to date has led us to some important conclusions:
- Many governments do not use their health system funds as well as they could. The impact of this failure is borne disproportionately by the poor.
- Health systems are not just concerned with improving people’s health but also with protecting them against the financial costs of illness. The challenge is to reduce the impact on poor people of their out-of-pocket payments for health care, expanding pre-payment schemes, spreading financial risk and reducing the spectre of catastrophic health care expenditures by those who are seriously ill.
- Many national health ministries focus exclusively on the public sector. They disregard private provision of, and finance for, care. This is often much larger than the public spend. Or by privatizing large parts of the health sector, they also abdicate their responsibilities. Governments need to harness the energies of the private and voluntary sectors without giving up their role as stewards. This will help them achieve better health systems performance, and offset the effects of market failure.
- There is an absolute lower limit for health expenditure. No country can provide even basic health care for its population if it spends less than $60 per capita per year. Yet the majority of countries with a per capita GDP of less than $1,000 spend less than $20. No wonder people get ill and die!
Over the past four years, we have made some progress on broadening access to knowledge and technology. As I mentioned earlier, access to life-saving medicines is now very much accepted as a basic right. The fact that public health shall take priority over commercial concerns in international trade rules is quite a revolutionary change. So is the acceptance of differential pricing of medicines as a tool to bring key patented medicines to populations in countries that cannot afford to pay Western-level prices.
The focus on pricing has made it even clearer that price is only one of the factors that determine access. WHO is working very hard to assist countries in developing the quality assurance regimes, distribution capacity and the health infrastructure and knowledge needed. The publication last April of treatment guidelines for AIDS in resource-poor settings was a milestone in this context.
In December, we then launched a broad coalition to improve access to antiretrovirals, the medicines that mean the difference between life and death for those living with HIV. The target is, by the end of 2005, to attain access for at least half of the six million people in the world who now could benefit from these medicines but who don't get them. That means a tenfold increase from today, but we are optimistic that we will reach that target.
Another type of initiative with a lot of promise for change is the collaboration we have started with more than 30 scientific publishers. They have agreed to make over 2000 medical journals available on-line to universities and hospitals in more than 100 developing countries, either free or at drastically reduced prices.
In this way we are using information technology to break down barriers to research and knowledge distribution worldwide. In this simple scheme lies the seed of a knowledge revolution. Access to cutting edge scientific knowledge has been one of the major handicaps holding back the development of medical research in and for developing countries. This project is also a model of how public-private partnerships can work and how the idea of differential pricing can take shape in practice for a number of products needed to save lives in the developing world.
For future health expenditure to be manageable, countries need to focus more on preventing disease. We must identify risks and take action to reduce them. The Framework Convention on Tobacco Control is one example of such action.
Last year's World Health Report focused on identifying the greatest risks and pointing to ways of reducing them. It was the result of one of the largest research projects the World Health Organization has ever undertaken.
The findings in the Report are a wake-up call. The world is living dangerously. A large part of the world's population does so because they have little choice. But a large part does so because they make the wrong choices.
We selected 25 major preventable risks for in-depth study. These risks are much more important than is widely believed. We found that the top ten together account for about 40 per cent of the 56 million deaths that occur annually worldwide and one-third of the global loss of healthy life years.
Which, then, are the ten highest risks? Childhood and maternal underweight; unsafe sex; high blood pressure; tobacco; alcohol; unsafe water, sanitation and hygiene; high cholesterol; indoor smoke from solid fuels; iron deficiency and overweight/obesity.
So, in fact, both under-nutrition and over-nutrition paradoxically figure among the ten leading risks globally.
Blood pressure, cholesterol, tobacco, alcohol and obesity, and the diseases which are linked to these risks, are well known to wealthy societies. They dominate in all middle- and upper-income countries. The real drama is that they are becoming more prevalent in developing countries as well, where they create a double burden on top of the infectious diseases that always have afflicted poorer communities.
Let me put it another way.
We are six billion people co-existing on our fragile planet, many of whom are dangerously short of the food, water and security they need to live. In contrast, there are millions who suffer because they use too much. All of them face high risks of ill-health.
Maybe the most extreme contrast is this: some 170 million children in poor countries are underweight, mainly from lack of food, while more than one billion adults worldwide - in middle-income and high-income countries alike - are overweight or obese. About half a million people in North America and Western Europe die from overweight/obesity-related diseases every year.
Unless action is taken, the number of deaths from tobacco will have doubled by the early 2020s. Five million people will die from conditions linked to overweight and obesity, compared to three million now. The number of healthy life years lost by underweight children will be 110 million which, although lower than 130 million today, is still enormously high.
The Report provides a road map for how societies can tackle a wide range of preventable conditions which are killing millions of people prematurely and robbing tens of millions of a healthy life. In fact, healthy life expectancy can be increased by 5-10 years worldwide, if governments and individuals make combined efforts against the major health risks each population is facing.
I started out by describing the large gap between our ideal of a world where all enjoy the right to health, and the reality of a world where half of us are denied this right. Yet I hope that over this half-hour I have also shown you that we have the knowledge, the tools and the ability to close this gap.
The key to success lies in the interplay between national action and international collaboration. In the Millennium Development Goals, sound priorities have been agreed and clear targets have been set.
But the Goals cannot be reached without a fundamental change in the financing for development. Far too few countries give development assistance which equals or exceeds 0.7 per cent of their GDP. Here again, we must build the case for national politicians so they are able to argue to their constituencies for increased development assistance as well as for debt relief and changes in foreign policy priorities.
The next ten years will be crucial. We have a window of opportunity. With vision, commitment and successful leadership, the world could end the first decade of the 21st century having drastically reduced the gap between the rich and the poor.