Address to the Regional Committee for Africa
Dr Margaret Chan
Director-General of the World Health Organization
Your Excellency Mr Mvouba, Prime Minister of the Republic of Congo, honourable Minister Raoul, Republic of Congo, honourable Minister Tedros Yesus, Chairman of the 56th session of the Regional Committee, honourable representative of the African Union, Regional Director Dr Sambo, honourable ministers, excellencies of the diplomatic corps, distinguished delegates, colleagues of the UN family, ladies and gentlemen,
In April of this year, ministers of health from this continent, meeting under the leadership of the African Union, adopted the first harmonized region-wide health strategy for Africa.
I welcome this strategy, and give it my full support.
This is a forward-looking strategy, extending to 2015, the year given so much significance, and so much promise, by the Millennium Declaration and its goals.
It is a comprehensive strategy, and it brings cohesion and unity of purpose to health leadership in Africa.
Despite the great diversity of African countries and cultures, it recognizes common problems and common needs, and the benefits of a shared approach.
Above all, the strategy sends a strong message to implementing agencies and development partners: external support is necessary and appreciated, but Africa is in charge.
As I have heard repeatedly, African leaders know their people’s health problems very well.
You also know the solutions, and these are being set out in a growing number of national health plans and strategies.
You are creating the right conditions for health development.
Your commitment comes with full awareness of the obstacles within Africa, many of which are tied to factors of history, geography, climate, and an ecology that favours the proliferation of pathogens and their vectors.
You also know the obstacles that arise outside the borders of Africa.
Let me name just a few. International aid is not always effective. Promises are not always kept.
Many good initiatives are left stranded when the interests of donors shift. African countries are littered with the remains of failed development projects.
Funding can be unpredictable, short-lived, or inflexible, making it difficult, if not impossible, to launch long-term plans.
Transaction costs are high, as are the demands of reporting to multiple partners. Health districts are crowded.
Parallel systems for delivering a limited range of interventions are being introduced at a time when the greatest need is for comprehensive basic care.
Preventive approaches may be left by the wayside.
Opportunities for operational efficiency are missed. Overlapping diseases are managed by separate initiatives. Single diseases are managed by multiple initiatives, sometimes using different strategies and drugs.
The capacity of the health system to respond has diminished at a time when the health burden is growing. Health workers trained in your countries are being hired to work elsewhere.
Sufficient staff are no longer available to meet the bare essentials of health care.
Health systems are crumbling following decades of failure to invest in basic infrastructures.
For some diseases that disproportionately affect Africa, better drugs and new vaccines are badly needed, yet incentives for research and development are biased towards markets that can pay.
When all of these problems are considered together, it is not surprising that few countries in Africa are on track to meet the Millennium Development Goals.
Yet despite this bleak picture, Africa’s health leaders are convinced that these obstacles can be overcome. As you have stated, the legacy can change.
We are seeing signs of success, which I will turn to later.
I fully agree. The obstacles that hold back health development in Africa can and must be overcome. And this needs to happen on the most urgent basis possible.
Africa has far more than its fair share of disease, misery, and premature death. Much of this suffering is needless.
Effective and affordable interventions exist to prevent or treat almost all the causes of ill health that plague Africa.
This is the great social injustice. This is the moral imperative that compels urgent action.
This is a time of great significance for Africa. We are near the mid-point in the countdown to 2015.
The Millennium Development Goals represent the most ambitious commitment ever made by the international community. They attack the causes of poverty at their roots, and recognize that these causes interact.
The goals acknowledge the strong two-way link between poverty and health.
Poverty contributes to poor health, and poor health anchors populations in poverty. But better health allows people to work their way out of poverty, and spend households incomes on something other than illness.
Above all, the goals champion health as a key driver of economic and social progress. With this recognition, the role of health has been elevated as never before.
Health is no longer a mere consumer of resources. It is also a producer of economic gains.
This change of thinking is increasingly reflected in international approaches to health and development.
On 5 September, we will see a compelling example of this change in thinking.
The United Kingdom, in partnership with Norway, Germany, Canada, WHO and other major agencies working to improve health, will launch a new initiative, with a new compact of commitment.
The aim is to ensure that resources work more efficiently to improve health outcomes. It responds to many of the problems, which I just mentioned, that arise when aid is unpredictable, uncoordinated, and constantly shifting.
It respects the need for long-term flexible funding, and it respects the need to support country-led plans. Several African countries will be included in the first wave of implementation.
Let me quote one of the guiding principles: “There is no better way to reduce the devastating injustice of global poverty than by working to improve people’s health.”
So what does all of this mean for the health of African people?
First, the injustice is, indeed, devastating. It is also intolerable.
The Millennium Development Goals are driven by a spirit of solidarity and the ethical principle of fairness.
As stated in the Millennium Declaration: “Those who suffer or who benefit least deserve help from those who benefit most.”
This spirit of solidarity and commitment to fairness has placed the health needs of Africa at the centre of the development agenda.
Of all the regions in the world, Africa stands to gain the most, by far, from achievement of the goals.
As a second consequence, concern about the slow progress, especially in Africa, has forced the international community to take a hard look at the reasons.
In just the past decade, the landscape of public health has changed remarkably.
For the first time, we have political commitment, funds from new sources, powerful interventions, and proven strategies for their implementation.
Finally, with so much working in our favour, we can see what is holding us back. Health systems are the stumbling block.
We are not able to deliver essential interventions to those in greatest need on an adequate scale.
Part of the problem arises from decades of failure to invest, in nearly all parts of the world, in basic public health infrastructures.
But we also face a dilemma. In the past decade, we have seen an enormous growth in the number of partnerships and initiatives implementing programmes in countries.
These initiatives are focused on delivering specific health outcomes, often for a single disease.
The ability to deliver these outcomes depends on a properly functioning health system. Yet the strengthening of health systems is rarely a core purpose of these initiatives.
Here is where all this welcome commitment, funding, and momentum reaches an impasse. Progress is blocked by inadequate delivery systems and inadequate numbers of staff.
I want to take this conclusion one step further.
I do not believe we will be able to reach the health-related Millennium Development Goals unless we return to the principles, values, and approaches of primary health care.
As some world leaders have recently noted, the lack of progress in Africa is not just a call for urgent action. It is a development emergency.
I fully agree. This is indeed an emergency.
These should be times of tireless effort and sleepless nights for all of us with a leadership role in health.
It takes time to build health systems and train staff. But we must find ways to move forward despite these problems.
We have no time to start from scratch. We cannot afford false starts, inefficiencies, or waste.
We must use existing interventions to maximum strategic advantage, while keeping up the pressure for new tools.
We must find ways to circumvent the problems of weak delivery systems and shortages of staff, while simultaneously seeking sustainable improvements.
In Africa, this also means using traditional medicine, and its practitioners, in more effective and systematic ways.
We must continue to step up prevention, treatment, and care for HIV/AIDS, tuberculosis, and malaria.
At the same time, we must look for ways to integrate these activities into general health services, and bring them in line with the principles of primary health care.
Above all, we must seize every opportunity to improve our operational efficiency. Let me suggest some strategies for doing so.
First, manage overlapping diseases in an integrated way. The WHO strategy for the Integrated Management of Childhood Illness is one good example, as noted in the Africa health strategy.
This approach recognizes that most childhood deaths result from a handful of causes that can be prevented by a handful of cost-effective interventions.
It attacks these causes, including malnutrition, in an integrated way, using standardized treatment protocols. It delivers first-rate clinical care, in a public health approach, according to the principles of primary health care.
Here is a second example. Last year, WHO launched an integrated strategy for the management of several of the neglected tropical diseases, all of which disproportionately affect the poorest of the poor in Africa.
Instead of a host of individual programmes going their separate ways, we now have a unified, integrated strategy that simplifies drug distribution, reduces duplication, and lessens some of the demands on health systems and staff.
Second, manage single diseases according to a unified approach. We know the confusion and waste that arise when multiple partners attack the same disease using multiple approaches and drugs.
A clear technical strategy, founded on evidence, is the most persuasive way to unite partners in a cohesive approach.
This has been done with the “three ones” for HIV/AIDS and with the DOTS strategy for tuberculosis.
Finally, this is being done for malaria.
At the start of last year, WHO issued clear policy guidance on the use of artemisinin-based combination therapies, and pressured industry to remove monotherapies from the market.
WHO put its authority behind the use of DDT for indoor residual spraying.
Just ten days ago, WHO ended the debate about the best way to distribute mosquito nets. Long-lasting insecticide-treated nets should be made available at no cost or at a highly subsidized price. Broad population coverage should be the goal.
Third, make existing delivery systems work for more diseases. Immunization programmes generally do the best job of delivering interventions to hard-to-reach populations. It makes sense to use these programmes to deliver additional interventions.
In campaigns to reduce measles mortality, Africa has led the way. Deaths from measles dropped, on this continent, by 75% in six years, surpassing the goal.
This achievement is now value-added, multiplying the benefits for health. In Africa, measles campaigns are distributing mosquito nets, de-worming tablets, vitamin A supplements, polio vaccine, and tetanus vaccine for pregnant women.
Fourth, keep in mind the principles of primary health care. Three decades of experience have taught us: this is the best route to sustainable, equitable, and acceptable care.
The strategy of community-directed treatment, developed to ensure the sustainable delivery of ivermectin, is a good example.
Using this approach, communities are now delivering mosquito nets, vitamin A supplements, and drugs for the home-based care of malaria, in addition to ivermectin.
An ongoing trial in Uganda shows that coverage rates have increased by from two-fold to four-fold.
When properly supported, communities will take charge of their health, with impressive and sustainable results.
There is another lesson here. The campaign to eliminate river blindness began as the most vertical programme imaginable: helicopters dropping insecticides out of the sky.
In its quest for sustainability, the programme now embraces the principles of primary health care.
A fifth strategy is closely related: empower women to realize their human potential and live the lives they desire. This can be done through microfinancing schemes, education, vocational training, legislation, or other approaches.
Abundant evidence tells us: the lives women desire are healthy lives for themselves and their families.
As I have said, women are not just a vulnerable group and not just a free source of care.
They are agents of change and a critical resource for sustainable development.
Finally, use international instruments to strengthen collective defence against health threats that respect no borders.
Such threats include the marketing and distribution of tobacco products, and the international spread of emerging and epidemic-prone diseases.
The Framework Convention on Tobacco Control has become one of the most widely embraced treaties in the history of the United Nations. This is preventive medicine, on a global scale, at its best.
In June of this year, the greatly strengthened International Health Regulations came into force.
The revised Regulations move away from the previous focus on passive barriers at national borders, to a strategy of pro-active risk management.
This strategy aims to detect an event early and stop it at source, before it has an opportunity to become an international threat.
In this regard, I want to commend the government of Uganda, the WHO country office, and the Regional Office for the impeccable management of last month’s outbreak of Marburg haemorrhagic fever.
At the first suspicions of this disease, the government launched an urgent response on multiple fronts.
Rapid response teams were deployed. Equipment was organized. Isolation wards were established.
Further transmission was stopped. Efficient contact tracing and testing made it possible to conclude, with authority, that the outbreak was over in record time.
It had no chance to become a national or international threat.
The struggle between microbes and their human hosts is a constant one. We have very few opportunities to win a decisive victory.
We have some unfinished business. I am referring to polio eradication.
We have never been so close. In Africa, Nigeria is the only country where polio remains endemic. As of 21 August, Nigeria had reported 159 cases for this year, compared to 687 cases for the same period last year.
But outbreaks and sporadic importations continue to affect an additional four countries in Africa. In some cases, the imported virus has circulated for more than a year.
Campaigns must continue in these re-infected areas until all outbreaks are stopped. Eradication requires this absolute persistence.
I have expressed my personal commitment to finish the job. I thank Dr Sambo for his full support in this endeavour.
I also welcome offers of cross-regional collaboration from other WHO regions. Together, we will get the job done.
Ladies and gentlemen,
I have made the health of Africa one of my priorities. Health outcomes in Africa are a measure of the overall effectiveness of WHO’s work.
I have described some of the obstacles and outlined some ways to increase operational efficiency.
I now want to look at some examples of African leadership in today’s complex landscape of public health.
In 2000, a rigorous multi-country evaluation of the strategy for Integrated Management of Childhood Illness was launched, with support from the Bill and Melinda Gates Foundation.
When the results for Tanzania were made available, the Ministry of Health adopted the strategy for nation-wide implementation.
This is a comprehensive strategy with a systems-wide approach. It is demanding and it is not cheap, but it brings results.
This example shows us: African governments will take on ambitious health projects, and will take them to scale, when given evidence of a cost-effective impact. I applaud this commitment.
Here is a second example of African leadership. The WHO policy for the distribution of mosquito nets is based on evidence generated in Kenya, where a recent, rigorously monitored campaign resulted in a 44% drop in malaria deaths.
Financial support came from external sources. WHO provided technical and logistic support.
But the strategy was devised by the Ministry of Health. The commitment was provided by Kenya’s President, who personally launched the campaign.
Apart from reducing malaria deaths by almost one half, this leadership produced the results that changed international policy. It produced a model worthy of replication throughout Africa.
Imagine the impact this strategy is going to have in the coming years.
The malaria results have certainly been well-received. They made headline news in capital cities all around the world.
This reinforces my personal view: the world wants good news out of Africa, wants Africa to succeed.
During this year’s Health Assembly, WHO and the GAVI Alliance launched a new initiative for yellow fever. Support from this initiative will allow the vaccination of 48 million people over the coming five years.
Doing so will build an immune barrier that will effectively eliminate the risk of explosive urban outbreaks. Routine childhood immunization will then sustain this achievement.
The initial focus is 12 high-burden countries in Central and West Africa.
The fact that governments in each of these countries have already demonstrated political and financial commitment to yellow fever was decisive in securing this external support.
Once again, we see the power of commitment to win support, on your terms.
Commitment to health goals can also unleash the great power of human ingenuity.
Africa, with its strong tradition of community ties, has brought us proof that behavioural change can work.
Women in Uganda developed the Stepping Stones approach for changing traditional practices that contribute to the spread of HIV. It is now used worldwide.
When we reach the goal for guinea-worm disease – and we are very close – this will be the first disease eradicated by behavioural change alone, without support from a vaccine or drug.
Mr Chairman, honourable ministers, distinguished delegates, ladies and gentlemen,
Time and time again, we see the same powerful forces at work: political commitment, leadership, the persuasive power of evidence, and the creative power of human determination.
I agree. The obstacles facing health development in Africa are great, but they can be overcome.
The legacy can change.
In just the past few months, I have witnessed important shifts in the thinking of bilateral aid agencies, international agencies working in health, and major funding agencies.
As just two example, the need to strengthen health systems is recognized, as is the importance of supporting health financing for the poor.
The costs of health care should not drive impoverished households even deeper into poverty.
Your messages are being heard, and your strategic directions are being heeded.
Leadership in Africa is creating the right conditions for health development, on your terms.
Increasingly, Africa is in charge.
You have the full support of WHO, its country offices, and its regional office behind you, as Africa charges ahead. Thank you.