Address to the Regional Committee for Africa (58th session)
Dr Margaret Chan
Director-General of the World Health Organization
Mr Chairman, excellencies, honourable representative of the African Union, Regional Director Dr Sambo, honourable ministers, excellencies of the diplomatic corps, distinguished delegates, ladies and gentlemen,
Let me begin with a single statistic that has huge implications. In 27 countries in this region, annual health expenditure from all sources, including foreign aid and loans, averages less than 30 dollars per person.
This amount is well below what is needed to purchase a minimum “survival kit” of essential health interventions.
One implication is obvious. The resource base is too small to support major improvements in the health of the African people. The figure looks even smaller when viewed against the huge unmet needs in your countries. As noted in the African Health Strategy, health systems are too weak and services are too under-resourced to support a targeted reduction in the disease burden.
Absolute poverty in Africa is gradually declining, and this is a most welcome trend. But according to World Bank statistics for 2007, 41% of the people in this region are still living on less than one dollar a day.
We all know the links between poverty and health. A dollar a day won’t keep the doctor away.
Two years ago, at a special summit of the African Union, health ministers adopted a resolution on health financing in Africa. That resolution expressed concern about a situation dominated by inequitable and impoverishing direct household payments for health care.
It also expressed concern about the huge shortfalls in the estimated resources needed to reach international health targets. It noted that these shortfalls are well above what can be raised from domestic sources in most African countries. Again, the resource base is too small.
This reality has multiple implications – for health governance and the effectiveness of aid, for balancing priorities and making strategic choices when budgets are fixed. It has a decisive impact on the likelihood that national and international health targets, including the Millennium Development Goals, will be met.
As Health Ministers in Africa have themselves noted, resources make the difference between user fees and social protection, between health care for the privileged few, and universal coverage.
The resolution on health financing in Africa urged development partners to provide long-term and predictable financial flows. You asked them to do so in a coordinated, efficient way that supports country ownership, builds local capacity, and integrates single-disease initiatives into the general health system.
This is happening right now, as part of several recent trends and events that hold great promise for health in Africa. Above all, these trends and events make health leadership more important now than ever before.
Ladies and gentlemen,
Health leadership is needed, and health leadership is rewarded. When you take the lead, the international community stands behind you, and resources follow.
We have reached a milestone. At the end of last year, nearly 3 million people in low- and middle-income countries were receiving antiretroviral therapy for AIDS, with the vast majority in the African region.
What many considered impossible has now been achieved. Drug prices can drop. Complex interventions can be delivered in resource-poor settings. Patients can adhere to treatment regimens. Treatment outcomes here in Africa can be just as good as anywhere else in the world.
You have demonstrated that, with enough commitment and support, truly anything can be done.
You are finding ways to improve the efficiency of health services. Separate services for HIV and TB do not make sense, not for operational efficiency, and not for patients.
In Africa, TB is the number one killer among people living with HIV. Untreated, TB can kill within weeks, also in patients receiving antiretroviral therapy.
Where is the benefit if people receive these life-prolonging drugs for AIDS, yet die quickly from TB?
Let me commend countries like Kenya, Malawi, and Rwanda for their striking progress in integrating HIV and TB services. This shows the way forward and tells us that we can set our sights high.
With leadership, also from your heads of state, we are finally making progress against malaria, as you have just heard from Mr Ray Chambers.
On 18 September, WHO will issue the most comprehensive analysis of the global malaria situation published to date. For each endemic country, it traces not just changes in morbidity and mortality, but also the impact of specific interventions. This will help countries refine their strategies and direct their resources with even greater precision.
With support from the GAVI Alliance, this region has done an exceptionally good job of introducing underutilized vaccines. By the end of this year, all but five countries will have introduced the Hib vaccine. Next year, Gambia, Kenya, and Rwanda plan to introduce the new pneumococcal vaccine.
Right now, every country in the region is including hepatitis B vaccine, which also protects against liver cancer, in routine immunization. As we know from your agenda, liver cancer is one of the most important cancers in the African region. This is an especially devastating cancer. It is nearly always fatal, and it tends to kill adults in their prime of life.
If you can maintain the current commitment, liver cancer will drop off the list of leading health problems in our lifetime. This will be true progress for public health.
Eradication of a disease is the ultimate form of sustainable progress. Unfortunately, African countries are again at risk of polio.
A new outbreak of type 1 polio – the most dangerous strain of the disease – is affecting the northern states of Nigeria. And this outbreak has already begun to spread to neighbouring countries. I commend the efforts of governments, supported by WHO, to conduct emergency immunization campaigns. But in some cases, the quality of these campaigns needs to improve.
Ridding the world of polio is no longer a technical challenge. It is a strategic and operational challenge, and this can be managed.
The whole world needs your leadership to prevent a major setback. We cannot jeopardize all our collective efforts and investments over so many years. I count on your support.
Ladies and gentlemen,
What does it take to turn good intentions, like the health-related Millennium Development Goals, into real and lasting results?
We are beginning to get some solid answers. The determination to improve health is resolute, and this resolve spurs action. When obstacles are uncovered, innovative solutions are found, gears shift, and the drive for results speeds ahead.
I have referred to some encouraging events and trends. These are now converging in ways that broaden the agenda for health and brighten its prospects.
We have the Millennium Declaration and its health-related goals as a yardstick and a time-bound commitment that whips us into action. Health is attracting more money, also from new sources. Since the beginning of this century, aid for health from official and private sources more than doubled, from US$ 6.5 billion in 2000 to US$ 16.7 billion in 2006. More funds will come if we can demonstrate results
This welcome trend is accompanied by others. They explicitly acknowledge that increased resources alone will not automatically “buy” better health outcomes.
The major funding agencies are now combining the purchase of interventions with funds to strengthen systems for their delivery. International partnerships and health initiatives now recognize that progress depends on strengthened health infrastructures and service delivery. We saw this very clearly at the AIDS conference in Mexico.
Last month, the government of Ethiopia became the first country to sign a national compact with development partners as part of the International Health Partnership Plus. Other “first wave” African countries will follow shortly.
This partnership is a direct response to your call for more efficient and better coordinated technical and financial support. The partnership represents a deliberate effort to reduce fragmentation, align projects with national priorities and capacities, reduce transaction costs, and mobilize new resources.
In other words, it is designed to enable African leaders to achieve the health results they want, for their people.
Ladies and gentlemen,
Tomorrow, a high-level ministerial forum on aid effectiveness will open in Accra. The event is a follow-up on commitments made and targets set three years ago in the Paris Declaration.
Since then, the OECD has been rigorously monitoring progress in 54 countries. The results, to be released this week, provide the strongest body of evidence to date of what makes aid work in different country settings.
Based on this evidence, the meeting will endorse an agenda for action which includes some very precise commitments on the part of donors and recipient countries.
These commitments show how far thinking about development assistance has evolved. The last decade of the previous century saw considerable scepticism about the impact of aid, with blame placed on weak capacity, commitment, and governance in recipient countries. Today, efforts to unlock the full potential of aid are looking more closely at the policies and practices of donors.
The agenda coming from that meeting promises real progress for Africa through its commitments to country ownership, the use of existing infrastructures to deliver aid, and the provision of predictable and sustainable financial flows.
The health sector is distinguished by an unusually high proportion of recurrent costs. This makes sustained and predictable aid absolutely essential for good health governance. Health governance improves when funds are available to train staff, pay wages, maintain facilities and equipment, and collect and analyse data.
Addressing inequalities of income and opportunity within countries and between states is essential to global progress.
Ladies and gentlemen,
Again we see how trends converge. This principle in the Accra Agenda was strongly articulated last week when the Commission on Social Determinants of Health issued its final report. Of its many conclusions and recommendations, let me highlight just a few.
Wealth alone is not sufficient to ensure good health. The social conditions in which people are born, live, and work are the single most important determinant of good health or ill health, of a long and productive life, or a short and miserable one.
Poverty and social deprivation are not matters of fate. They are markers of policy failure.
The report places the responsibility for improving health equity squarely on the shoulders of policy-makers, and not just in the health sector. It calls for far more attention to health when international trade and economic agreements are negotiated.
The report recognizes that equity is strongly influenced by the way health systems are organized and financed. In particular, primary health care is championed as a model for a health system that acts on the underlying social, economic, and political causes of ill health.
The report calls for a whole-of-government approach that makes health and health equity a part of all government policies, in all sectors. In other words: health in all policies.
Anyone who doubts the relevance of these findings would do well to look at the documents before this committee.
Alcohol. Look at the impact of unrestrained marketing strategies, especially those targeting youth. As the document notes, governments focus on the tax revenues. Mechanisms for regulating trade in alcohol almost never consider the health consequences.
Maternal mortality, which is rightly described as one of Africa’s most tragic health problems. Can the health sector, all by itself, tackle root problems like discrimination, violence, especially against women, food taboos, and the lack of opportunities for education and employment? The resolution on this item is a clear call for high-level multisectoral action.
Cancer. With so little capacity for early detection and treatment, with costs for radiotherapy and chemotherapy beyond your health budgets, prevention must be given top priority. Yet the risk factors for cancer and other chronic diseases lie beyond the direct control of the health sector. Fortunately, we have the Framework Convention on Tobacco Control and the MPOWER package of six proven interventions to reduce tobacco use.
It is my fervent hope that, with the weight of the Commission’s findings as a support, the health sector will have greater power to persuade other government sectors to pay close attention to the impact their policies will have on health.
Our experiences in May with the Intergovernmental Working Group on Public Health, Innovation and Intellectual Property demonstrate that international agreements that affect the global trading system can indeed be shaped in ways that favour health.
Ladies and gentlemen,
The Commission’s emphasis on social justice, equity, intersectoral action, and tackling the root causes of poverty and ill health echoes the principles and values set out in the Millennium Declaration and its Goals. It also broadens, and deepens the sphere of action.
Both seek to ensure that the benefits of globalization are fairly shared for the sake of poverty reduction and better health, especially in marginalized groups.
These principles and values take us back to the Declaration of Alma-Ata signed 30 years ago. And they turn our attention towards the great promise of primary health care.
Let me congratulate this region and its Director for the commitments set out in the Ouagadougou Declaration.
In October, WHO will issue the World Health Report on Primary Health Care. Among its achievements, the report shows how many of the encouraging trends seen in public health today can be captured in the way health systems are organized. It provides some compelling economic and social arguments for making primary health care the hub of the health system.
Let me commend you, too, for the overview of the World Health Report which was prepared for this meeting. From a large and sometimes complex report, it brilliantly extracts the messages that have greatest relevance to health systems in the African Region.
I am confident that the evidence and arguments set out in the report will support your implementation of the Ouagadougou Declaration. Ladies and gentlemen,
When I took office at the start of last year, I expressed my deep commitment to the health of the African people. We have no magic bullets. There are no major breakthroughs on the horizon that will diminish the health challenges in this region.
But the stars are aligned as never before. The agenda for health has broadened and the prospects have brightened.
The international commitment to health development is unwavering. Funds for health have more than doubled. The environment for development assistance has shifted in your favour.
The Commission on Social Determinants of Health gives you unprecedented arguments for raising the profile of health and revitalizing primary health care. The World Health Report will take this further.
Africa is making progress on multiple fronts, and many more than I have mentioned. For example, immunization coverage in 2006 reached 72% – the highest ever recorded.
Africa is doing its part. Financial support has increased, but in this region, more than 70% of all resources for health continues to come from your domestic sources.
Above all, space has been made for you to exercise your leadership, for your priority health needs, for your people.