Scaling up research and learning for better health
Dr Margaret Chan
Director-General of the World Health Organization
Honourable ministers, colleagues in public health, Dr Horton, ladies and gentlemen,
First and foremost, let me thank you for coming to Divonne on such short notice.
I have been asked to address an obvious question. Why did I convene this high-level consultation?
On the surface, the answer is simple. Progress in reaching the health-related Millennium Development Goals has stalled, and this is alarming. Progress has slowed despite unprecedented commitment and determination, a boom in funding, powerful interventions, and proven strategies for their implementation.
With so much working in our favour, we can see what is holding us back. It is this. After decades of neglect, health systems in many countries are in a shambles. The main obstacles to progress are no longer a lack of cash, commitment, or commodities. Progress is stalled because of bottlenecks and barriers in health systems and service delivery.
Solutions to most of the big problems facing health development depend on a well-functioning health system. We need to address this reality head-on.
For example, multiple partnerships and initiatives have formed to tackle high-priority diseases. The ability of these initiatives to improve health outcomes depends on a well-functioning health system. Yet the strengthening of health systems has rarely been included as an explicit objective, also for funding.
This situation is now changing. Those of us working in health have learned the lesson. Investment in technology and interventions alone will not automatically “buy” better health outcomes. We must invest more in human and institutional capacity, in health information, and in systems for delivery.
What we need most is expert guidance and, if possible, agreement on the priority problems that research can solve. The attention now being given to health systems has been a long time coming. The commitment to invest is most especially welcome. But if we mismanage this opportunity, I doubt we will be given another one for some time to come.
Donors usually prefer to invest in initiatives that bring quick and measurable results: numbers of children reached, or drugs distributed, or deaths averted. Measuring attribution of investments in health systems is difficult. Robust monitoring and evaluation processes are yet to be designed. Best practices need to be collected and documented.
Ladies and gentlemen,
This brings me to the end of my simple, straightforward observations. All the rest – the task before you today – is highly complex. We face an enormous challenge that needs to be overcome in a very short time. We do not have the luxury of starting from scratch. We need to steer this mounting concern, the desire to act, to commit funds, in ways that bring results and show that investment in health systems pays off.
My discussions with ministers of health reinforce this need. Ministers are under enormous pressure to improve the performance of health systems. They appreciate the need for more equitable delivery of services. Many depend on external financial support for health, but they also want guidance on ways to manage domestic investments in staff, commodities, and infrastructures with greater efficiency.
Health systems are highly context-specific. No consultation, no matter how high the level, can produce a blueprint that works well in all settings. I believe our starting point must be the constraints health ministers face in their day-to-day work. Obviously, when resources are constrained, policy decisions must aim for maximum efficiency and impact.
Moreover, because health systems are dynamic and constantly evolving, developing countries need to be able to conduct their own research, to answer their own policy questions, to devise their own solutions to rapidly changing problems.
Let me give some examples of questions where policy-makers, in their quest for greater equity and efficiency, need evidence-based guidance.
Can community insurance schemes raise enough money to provide true protection from catastrophic illness? What are the consequences, for service delivery, for financing, for staff, of the dramatic rise in chronic diseases?
How can more health workers be trained quickly, without sacrificing quality? Can financial incentives help draw staff to work in rural areas?
How can rules and regulations governing the public sector be extended to the private sector? How do you address corruption within the health system?
What can be done to compensate for the total absence of vital registration systems in large parts of the developing world? How can staff be motivated to collect essential health data, keep them up-to-date, and ensure they are used?
Health ministries constantly struggle to get a better share of government expenditure. Evidence can help them. When health becomes a high political priority, the status of health ministers rises, giving them more say in the health-related activities of other sectors.
Research continues to develop simplified tools, increasingly well-suited to home- and community-based care. How should these tools be delivered to improve health outcomes, especially for the poor?
For example, TDR has recently completed a multi-country study of the effectiveness of community-directed approaches for the distribution of integrated interventions. This research has documented some striking improvements in morbidity and mortality, especially for malaria, lower costs, and excellent sustainability. Yet, at many study sites, progress was hindered by failures in the procurement system.
Later today, WHO, UNAIDS, and UNICEF will launch a report on the HIV/AIDS situation in 2007, including progress towards the goal of universal access. Nearly 3 million people in low- and middle-income countries are now receiving antiretroviral therapy.
This is a striking achievement. Yet, as the report clearly states, weaknesses in the health system impede further progress. Stockouts of drugs are a common problem. Late diagnosis reduces the power of these drugs to prolong life.
Next week, the UN Secretary-General is hosting the first-ever global leadership forum to address the co-epidemics of HIV and TB. Tuberculosis is the leading cause of death among HIV infected people worldwide. Yet services for the two diseases are insufficiently integrated. Where is the benefit if a person is placed on antiretroviral therapy, yet dies from TB?
These are just some of the practical, sometimes life-and-death questions that have major policy implications. As I said, in settings where resources are severely limited, answers to these questions need much better guidance from evidence.
We all know the importance of health initiatives that are country-led and closely aligned with national priorities and capacities. If we want the multiple international efforts under way to bear fruit, national leadership must be supported. Policymakers need much better data on the likely impact of their decisions.
Ladies and gentlemen,
Why did I convene this consultation? I have mentioned the stalled progress, the increased focus on health systems, and the many challenges that need to be addressed. I have also mentioned the urgent need for guidance, especially among policymakers.
Let me add one other point that justifies this consultation: research has great persuasive power at the policy level.
I challenge you to be ambitious in your thinking and in your proposals for the future. The time between now and the Bamako event is short but significant. I ask you to think outside the box.
Wild ideas are most welcome. Your moderator will no doubt help whip them into shape! I have every confidence that, under Dr Horton’s guidance, the outcome will be big and bold, in line with the size of the challenges we face.