Address to the Eleventh Global Forum for Health Research
Dr Margaret Chan
Director-General of the World Health Organization
Honourable Minister, Prof. Chen Zhu, honourable Vice-Chairman of the Standing Committee of the National People’s Congress, Prof. Han Qide, Executive Director, Dr Matlin, distinguished Chairperson, Dr Senanayake, colleagues in public health and the medical sciences, ladies and gentlemen,
I am most pleased to participate in the opening of this 11th Global Forum for Health Research. WHO collaborates closely with the Global Forum and benefits from its work.
Public health depends on research in multiple ways. Some of the greatest strides forward for health have followed research breakthroughs that led to new drugs, vaccines, and diagnostics. This is the glamorous research that makes the headlines and attracts the funds. But this, as we know, is not enough given the challenges we face today.
It is not enough when strides forward benefit only the privileged few. It is not enough when diseases and premature death are so closely linked to poverty, and health is expected to reduce this poverty.
It is not enough when health is central to the Millennium Development Goals, which call for greater fairness in the distribution of our enormous collective wealth. It is not enough when trends at the global level are causing gaps in health outcomes to grow even wider.
Equitable access is the theme for this forum. It is a theme at the core of the most ambitious commitment ever made by the international community. Progress in meeting the health-related Millennium Development Goals will not be measured by national averages. It will be measured by how well we reach the poorest and most marginalized populations with essential and sustainable care.
To do so, we need support from health research. If we want health to work as a poverty-reduction strategy, we must reach the poor. This has implications for research on equitable service delivery. If we want health to reduce poverty, we cannot allow the costs of care to drive impoverished households even deeper into poverty. This has implications for research on fair financing and social protection.
These are issues we must address. Thanks to constant progress in biomedical research, medicine has never possessed such a sophisticated arsenal of tools and technologies for curing disease and prolonging life.
Yet each year, more than 10 million young children and pregnant women have their lives cut short by largely preventable causes. Life expectancy can differ by as much as 40 years between wealthy and poor countries. This is not fair.
Research continues to make it possible to provide ever better medical care. But research needs to do much more. I am glad the Global Forum is working as an advocate and catalyst to address the health problems of the poor.
We are all working at a time of unprecedented opportunities and unprecedented challenges.
Health has never before received such attention or enjoyed such wealth. Novel philanthropy is making big money available for health initiatives, including R&D. Public-private partnerships have formed to develop new products, especially for diseases of the poor. Partnerships are delivering drugs, donated by industry, in campaigns aimed at eliminating some of humanity’s oldest diseases.
These are all most welcome trends. But research needs to tell us if all this money, all this flurry of activity is actually having an impact on health outcomes. We need evidence to formulate rational health policies and to reliably monitor results. But above all, research needs to tell us why so many people continue to die from preventable causes.
In matters of health, our world is badly out of balance. Nor will this world become a fair place for health all by itself. We all know the problem. No one questions the close association between income level and health. Globalization creates wealth but has no rules that guarantee fair distribution of this wealth.
I believe there is no sector better placed than health to insist on equity and social justice. When health is concerned, equity really is a matter of life and death.
No one should be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes. These are some of the issues being addressed by the Commission on Social Determinants of Health, which will issue its report next year.
Equity in access to health care comes to the fore as a way of holding globalization accountable, of channelling globalization in ways that ensure a more fair distribution of benefits.
Again, these are the issues you have chosen to address. I know you will be looking for answers, and for ways to make these answers guide more efficient policies. This means policies that use resources wisely, have a measurable impact on health and, above all, contribute to greater equity in health outcomes.
Ladies and gentlemen,
We have every reason to be concerned, every motivation to find some answers.
The Millennium Declaration and its Goals are all about equity, and specifically, equity in a globalized society. As the Declaration states: "The central challenge we face today is to ensure that globalization becomes a positive force for all the world’s people." The underlying principle is clearly stated: "Those who suffer or benefit least deserve help from those who benefit most."
Midpoint in the countdown to 2015, we have to face the reality. Of all the goals, those directly related to health are the least likely to be met.
How can this be? These are the goals that can make the biggest life-and-death difference for millions of people. These are the goals with powerful tools - first-rate vaccines, drugs and other interventions - to support their attainment.
Something is wrong.
For the first time, public health has commitment, resources, and powerful interventions. What is missing is this. The power of these interventions is not matched by the power of health systems to deliver them to those in greatest need, on an adequate scale, in time.
In part, this lack of capacity arises from the failure of governments all around the world to invest adequately in basic health systems. It also arises, in part, from the fact that research on health systems has been so badly neglected and underfunded.
The two go together. So long as investments in health systems are given low priority, research in this area will also be neglected. In the absence of sound evidence, we will have no good way to compel efficient investments in health systems.
This is my first point. We need evidence on ways to improve the performance of health systems. During this Forum, WHO and the Alliance for Health Policy and Systems Research will be launching a new publication, Sound Choices. It addresses some well-known problems. This field of research is relatively young and inherently multi-disciplinary. Work is needed to develop sound methodological approaches and support their use.
Research on health systems is highly context-specific. This makes it difficult to generalize from one setting to others, or to establish universally applicable best practices. Developing national capacity to conduct health systems research is critical.
Information about the effects of health system interventions is largely derived from studies in high-income settings. This is another inequality in the evidence base that needs to be addressed.
This Forum will also see the launch, by the Health Metrics Network, of a Lancet series on civil registration and vital statistics. This initiative responds to a shocking statistic, the so-called "scandal of invisibility". Less than a third of the world’s population is covered by accurate data on numbers of births and deaths, and the causes of these deaths.
We need to do more to persuade countries and development partners to recognize that civil registration systems are a core component of development infrastructure. They are a prime source of fundamental health intelligence.
No single UN agency is responsible for ensuring that births and deaths are registered, so it has fallen between the cracks. That is why we have failed to establish, support, and sustain civil registration systems over the past 30 years in the developing world. Without the statistics that these systems produce, we can have only a partial view of the impact of 120 billion dollars spent annually in official development aid.
Ladies and gentlemen,
The great drive to accelerate health development is giving us some ground-breaking models. Let me focus on one, the Meningitis Vaccine Project.
This project was launched in 2001 as a partnership between WHO and the Programme for Appropriate Technology in Health, or PATH, with funding from the Bill and Melinda Gates Foundation. This is a public-private partnership that aims to do something about a disease, epidemic meningitis, that is exclusively a problem for countries in sub-Saharan Africa. In other words: there is no market incentive.
The project has been strategic and visionary right from the start. It began with a look at the ideal vaccine - a vaccine that could move control efforts away from the present reactive response to emergencies, towards an opportunity to actually eliminate the threat of devastating epidemics.
For Africa, the features of an ideal vaccine include costs. African leaders were consulted about what they could afford to pay, and a price of less than 50 cents per dose was fixed. The project required collaboration with several commercial companies, and broke new ground in the management of intellectual property rights.
In record time, it has developed a conjugate vaccine for use in Africa that is immunogenic in young children, will provide long-term protection and induce herd immunity, and can be used in mass immunization campaigns aimed at population-wide protection.
A high-quality vaccine manufacturer in India is producing the vaccine. In a model of north-south technology transfer, the company now has the capacity and the know-how to produce other conjugate vaccines. Such capacity building can change the dynamics of the market for public health vaccines.
Epidemic meningitis gives us another lesson. When setting priorities, do not be guided by mortality figures alone. This is one of the most feared diseases in all of Africa. Outbreaks are accompanied by public panic and enormous economic and social disruption. To address this problem by developing a superior and affordable tool is socially responsible research at its best.
We know that the issues surrounding product innovation and intellectual property are highly complex. These issues are being addressed by the Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property.
Ladies and gentlemen,
We must never forget: evidence has great strategic and persuasive power at the policy level. As one example, the Integrated Management of Childhood Illness has had a rigorous monitoring and evaluation component since 2000.
In Tanzania, the results from study sites, compared with control sites, showed a 13% greater reduction in under-five mortality over a two-year period, substantial improvements in nutritional status, and a higher quality of overall care. These findings prompted the Ministry of Health to adopt the strategy for nationwide implementation.
This shows how the persuasive power of evidence can overcome one of the biggest hurdles in public health: taking a project to national scale. Several other countries - from Egypt to Uganda - are likewise approaching national coverage with this strategy.
The Special Programme for Research and Training in Tropical Diseases, or TDR, has contributed a large number of further examples. We are all aware of exciting new research, from scientists in Kenya, showing how bednet use can cut deaths from malaria by as much as 44%. In fact, TDR initiated the first large-scale multi-country trials demonstrating the efficacy of bednets almost a decade ago.
The challenge now is a classic one: reach large-scale coverage. In this regard, community-directed interventions are an especially promising strategy that places communities in charge. The strategy has been used, for more than 10 years, to sustain high treatment coverage with ivermectin to treat river blindness in Africa.
This sustained success is now being studied as a possible platform for the integrated delivery of additional health interventions. A large three-year study was launched to determine whether community volunteers could also deliver bednets, drugs for the home management of malaria, and vitamin A supplements, in addition to ivermectin.
Findings are now demonstrating that this approach works. In communities using the approach, the number of children sleeping under a net tripled. The number of children receiving appropriate treatment for malaria within 24 hours after fever onset more than doubled. The number of pregnant women sleeping under a net increased fourfold.
Efforts to prevent congenital syphilis provide yet another example. Each year, half a million children are stillborn because of congenital syphilis and another half a million are born with this disease. This occurs despite the fact that low-cost tools to prevent congenital syphilis have been available for more than 50 years. Again, we see a classic problem of service delivery.
This situation is changing. With TDR support, research evaluated numerous rapid diagnostic tests. Those found to work well were placed on the WHO procurement list so that governments could purchase them at low cost.
Studies are now under way to determine whether the combination of a rapid test and single-dose oral treatment could work as a package for programmes, close to homes, to prevent this disease.
And let us look at the persuasive power of this evidence. Some 20 countries in Africa, Asia, and the Americas have adopted national policies to use these tools. Some countries have gone a step further, setting a goal to eliminate congenital syphilis. That, of course, would be the ultimate sustainable achievement.
I like these success stories. I have called for a return to primary health care as a way to strengthen health systems. Many of these approaches align well with the principles of primary health care.
They are simple, low-cost, and correspond to the needs and priorities defined by communities. They are sustainable and produce impressive results. Above all, when well-designed studies measure results, we see the impact at the policy level. As I have said, what gets measured gets done.
When policies aim for national coverage, we see the potential of health research to improve the lives at the focus of this forum: poor and marginalized populations beyond the reach of formal health services. In short, they contribute to equitable access - in a big and sustainable way.
I wish you a most productive meeting on what is surely one of the greatest challenges facing public health today.