Health systems, health and wealth
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, distinguished delegates, Dr Danzon, ladies and gentlemen,
First and foremost, let me extend my appreciation to the government of the Republic of Estonia for hosting this event. I am personally impressed by the beauty of your rich cultural heritage, which stands in the midst of modern comfort and convenience. In particular, the many castle towers make this a good setting for lofty ideas!
Let me also thank the WHO Regional Office for Europe and its Director, Dr Danzon, for preparing this meeting so carefully and organizing it so efficiently.
You are using evidence about the dynamic link between health and economic prosperity to make the case for giving serious political attention to the performance of health systems. This is a smart move. I am pleased to note that ministers of finance and economic affairs are also present at this event. This is also a smart move.
You are using evidence to show how performance assessment can work as a tool to improve health systems in targeted ways. You are using evidence to argue that investment in health systems brings results that can be measured, as better health and as greater wealth.
This is a visionary meeting, and a strategic one. I have every confidence that this conference will yield significant insights, policy options, assessment tools, and practical guidance on what works best in different settings.
I am pleased to see that you are discussing failures as well as successes. This is the way we learn.
I also believe that all the preparatory work, the reports and policy briefs, the meetings, the messages being delivered by speakers, are fully justified given the significance of the issues before you.
Ladies and gentlemen,
I am speaking to you at a time of unprecedented interest in health systems, both within countries and at the international level.
At the international level, progress in reaching the health-related Millennium Development Goals has stalled in many parts of the world. This has happened despite the availability of powerful interventions, unprecedented funds to purchase them, strong political commitment, and proven strategies for implementation.
As we now know, cash, commitment, and commodities cannot boost adequate progress in the absence of delivery systems that reach those in greatest need, on an adequate scale, in time.
Our collective ability to reach these goals stands or falls on the efficiency of delivery systems. It stands or falls on the extent to which health systems are committed to fair access and universal coverage, and capable of delivering on this commitment.
Progress in reaching the Millennium Development Goals is not measured by national averages. It is measured by changes in the health status of poor and marginalized populations.
Ladies and gentlemen,
Improvements in the efficiency of health systems and the quality of performance are important. But the ultimate objective of health system reform is to reduce the gaps in health outcomes and raise the overall level of health within populations.
This is why I find this conference so extraordinary. In terms of health outcomes, the countries represented in this room are the envy of the world. Your citizens enjoy some of the longest life expectancies and highest overall levels of health ever seen.
And yet, health and finance ministers have gathered here from the 53 countries in this region to systematically explore ways to improve the organization and performance of health systems. This sends a powerful message to the rest of the world.
Improving the performance of health systems is an urgent high-level priority, even in very wealthy countries with excellent levels of health. It is most especially a priority in countries undergoing transition.
When countries modernize, some strong assets of health systems, such as the provision of universal access to basic care, are all too often lost. There are some important lessons here as well. Your frank assessment of successes and failures has significance for countries well beyond Europe.
Health systems have strong political dimensions and face strong political pressures. For example, health ministers in Europe know how very difficult it is, politically, to close a hospital. This is difficult even when all the evidence, and all the arguments support such a decision.
As we know, political pressure often leads to the construction of expensive show-case hospitals, while poor communities struggle with rudimentary or non-existent care. Moreover, huge capital outlays for hospitals sometimes fail to make provisions for the costs of salaries and the recurring costs of equipment, supplies, and maintenance.
When this happens, the investment loses its impact. Good evidence, based on experience, can help avoid such costly mistakes.
And there are other major concerns.
Ladies and gentlemen,
Health in all regions is increasingly shaped by the same powerful forces. Disease trends, especially for chronic conditions, are global, and they are alarming. The complexity of patient care is growing, as are the demands on health systems.
The huge increase of international air travel has made emerging and epidemic-prone diseases a much larger menace. Trade agreements influence the global availability and prices of commodities, including food and pharmaceutical products, often with little regard for the impact on health.
Urbanization and demographic ageing are global trends. The epidemiological transition has been joined by nutritional and behavioural transitions.
Chronic noncommunicable diseases are on the rise in every country. The burden they place on health systems is different from the intermittent burden of infectious diseases. During an episode of infection, the patient usually either dies or survives. Not so for chronic diseases, which frequently require long-term management. Countries also face a burden from growing numbers of the frail elderly.
All countries are looking for ways to manage the added strain on health services. They are looking for staff with the appropriate level of skills, and they are looking for ways to manage the costs.
Everywhere, the costs of health care are escalating. The expectations of consumers are rising. The law of inverse care holds true. The availability of good medical care tends to vary inversely with the need for it in the population served.
Advances in medicine and science continue their impressive march forward. Sophisticated new technologies are constantly being placed on the market. New vaccines and new generations of drugs are nearly always much more expensive.
Hand-in-hand with these advances, ill health is becoming increasingly expensive. It is costly for economies, and it is costly for individuals, especially in the absence of fair systems of financial protection.
If health systems do not address these problems, we must anticipate that gaps in health outcomes will grow even wider.
All health systems have room for improvement. All health systems have inefficiencies. In fact, some even have built-in incentives that encourage inefficiency. As famously stated, if a country really wants to, it can easily duplicate the huge waste and inefficiency seen in health systems that were not organized with equity and fairness as guiding values.
Health systems will not automatically gravitate towards greater efficiency or greater equity in access. Unless deliberate steps are taken, steady advances in medical care will continue to benefit the privileged few. The poor will continue to be excluded from basic essential care. And the gaps in outcomes will grow wider, both within and between countries.
This is not a healthy situation in the broadest sense. A world that is greatly out of balance in matters of health is neither stable nor secure.
I am personally thrilled by the value system so clearly evident in the draft Tallinn Charter you plan to adopt. It is also gratifying to see the strong commitment to health promotion, disease prevention, programmes for the integrated management of diseases, and collaboration with the many other sectors that influence health. This is a clear and appropriate legacy of the Declaration of Alma-Ata.
Ladies and gentlemen,
Let me explain why I believe the outcome of this conference is so important at the global level.
Health leaders in all countries want to know how to make health systems perform better. They want to know what should be done, and they want to measure the results. This is one way to earn a better share of the national budget.
Health leaders in all countries are looking for greater efficiency and seeking the right incentives. They are looking at options for fair financing. They want to know how financing instruments can be used as an incentive to improve provider performance. They want to procure medicines rationally and ensure rational prescribing and use.
European countries have experience with a range of schemes for financing care. Better social protection against the costs of illness, especially the catastrophic costs of chronic diseases, is critically needed throughout the developing world.
WHO estimates that, each year, health expenses cause 150 million people to suffer financial catastrophe and push 100 million below the poverty line. If we want better health to work as a poverty reduction strategy, we need to solve this problem on a most urgent basis.
All countries are seeking ways to get other sectors to pay greater attention to the impact their activities have on health. The Declaration of Alma-Ata fully recognized the need for collaboration with multiple government sectors. But this, too, has become more complex.
For example, chronic diseases are largely caused by a limited number of lifestyle-related factors, yet these factors lie beyond the direct control of the health sector. Today, efforts to shape the determinants of health increasingly place the interests of public health against those of powerful industries with powerful marketing strategies.
As we saw during the World Health Assembly in May, this is another area where European ministers of health have assumed a global leadership role. I thank you, in particular, for your leadership in the prevention of chronic diseases and in food marketing and alcohol policies.
Ladies and gentlemen,
As we all know, health systems are highly context-specific. No conference, no matter how high the level, can produce a blueprint that works well in all settings.
In 1994, a WHO evaluation of progress in the reorientation of health systems towards primary health care reached the following conclusion: the exchange of practical experiences in overcoming problems is the most important tool for progress. This conclusion remains valid.
I thank the WHO Regional Office for Europe, and its Director, for organizing an event that so strongly encourages the open exchange of ideas, concerns, and experiences, with a deliberate effort to go beyond conventional thinking.
By stressing the dynamic relationship between health and wealth, you tell a watchful world that work to improve health systems is indeed worthy of high-level political attention. You are saying: the health sector should not be viewed as a mere drain on resources. It is also a producer of economic gains.
And it produces the most gains when health systems operate with top efficiency.