Address to the Regional Committee for South-East Asia (61st session)
Dr Margaret Chan
Director-General of the World Health Organization
Mr Chairman, Regional Director Dr Samlee, honourable ministers, distinguished delegates, colleagues of the UN family, ladies and gentlemen,
First and foremost, let me extend my condolences to the millions of people, in northern India and Nepal, who have seen their rural villages devastated by the recent floods, which have now affected Bangladesh. These people have lost loved ones, their homes, crops, and livestock. Again we hear about a record-breaking disaster, with the worst flooding experienced in the area in 50 years.
Let me also extend my sympathy to the governments of these countries. We have seen the magnitude of the relief effort required when disaster strikes poor and populous areas. We know the cycle well: disaster, displacement, fear of outbreaks, disruption of routine health services, and a long wait until life returns to normal.
In this regard, it is good to see that emergency preparedness is one of six top priorities in your regional initiative on environment and health. South-East Asia already accounts for more than half of all deaths caused by natural disasters worldwide. We need to anticipate more disasters, and more intense disasters as this century progresses.
Health ministers in this region are concerned about climate change, and rightly so. As sea levels gradually rise, coastal cities and low-lying areas, especially in Bangladesh, India, and Maldives, are likely to be inundated. Such dramatic widespread flooding is not expected to occur until later in this century.
Other effects are more immediate, and some are being felt right now. The experts predict a warmer wetter monsoon, with rain falling in more intense bursts. This region knows, from long experience, that economies and social infrastructures are vulnerable to even small changes in monsoon rainfall.
Glaciers in the Himalayas are beginning to melt, increasing the risk of floods and landslides. But these glaciers and snowfields are also the natural water towers serving the domestic and agricultural needs of at least half a billion people in this region.
A savings account of water reserves, deposited over the centuries, is now melting away. This loss has major implications for water security, food production and, of course, health.
The experts tell us rather precisely what climate change means for health in South-East Asia: more malnutrition, and more endemic diarrhoeal disease and cholera in a region that already bears the greatest burden of these diseases. As documentation before this committee notes, insect vectors that are sensitive to temperature and rainfall are expected to expand their geographical distribution. We have heard your concerns about the increasing numbers of cases of dengue, malaria, and chikungunya.
The experts also tell us that the poor will suffer most. The Intergovernmental Panel on Climate Change is clear on this point: protection from the social factors that place poor and deprived populations at special risk is far more important that structural protection.
Social protection of the poor must be a high priority as the health sector prepares for an inevitable increase in extreme weather events.
Ladies and gentlemen,
At the end of August, the Commission on Social Determinants of Health issued its final report. The striking gaps in health outcomes are its main concern, and greater equity is the objective.
The report challenges the assumption that economic growth alone will reduce poverty and improve health. On present trends, increased economic prosperity tends to benefit populations that are already well-off, leaving others further and further behind. This trend is readily apparent in parts of South-East Asia.
As the report notes, the most important determinants of health arise from the social conditions in which people are born, live, work, and age. Economic growth will improve the health of the poor only when policies are in place that explicitly address these underlying social conditions.
In the absence of such policies, the majority of the world’s population will not achieve the level of health and economic productivity that is biologically possible. Social deprivation is not a matter of fate. It is a marker of policy failure.
The report places the responsibility for reducing health inequities squarely on the shoulders of policy-makers. And it does so in sectors well beyond health. It calls for a whole-of-government approach that makes health a part of all government policies, in all sectors. In other words: health in all policies.
The report recognizes that nearly all the social determinants of health fall outside the direct control of the health sector. We know this is true. Look at the major risk factors for chronic diseases: tobacco use, harmful consumption of alcohol, improper diet, and inadequate physical activity.
The health sector can issue advice on healthy nutrition, but the production, distribution, and marketing of food are beyond our control. The health sector can help a severely malnourished child survive. But what happens when the child returns to the same environment that caused near-starvation in the first place?
The Commission’s findings hold true at the international level. The forces that fuel inequities in health operate within countries under the authority of governments. But increasingly, these forces operate among countries under the influence of globalization.
Let me remind you: the health sector had no say in policies that have made climate change inevitable. We had no say in policies responsible for the crisis of soaring food prices.
When we think about the Commission’s findings, we must also think about a fundamental paradox. At the international level, health has risen to a high place on the development agenda. Yet within most governments, the health ministry usually has less clout and negotiating power than other members of cabinet.
It is my fervent hope that, with the weight of the Commission’s findings as a support, health ministers will be better able to persuade other sectors to consider health when policies are set.
As I have said, this world will not become a fair place for health all by itself. The world’s trade and economic systems have no rules that guarantee fair distribution of the benefits. As stated in the Millennium Declaration, one of the central challenges of this century is to ensure that globalization is fully inclusive and equitable.
Let me take this one step further. I believe that public health must make some of the rules. And I believe that primary health care, with its strong values and incentives, is the best framework for doing so.
Ladies and gentlemen,
The Commission also has something to say about health systems. The report recognizes that equity is strongly influenced by the way health systems are organized and financed.
Primary health care is championed as a model for a system that acts on the underlying social, economic, and political causes of ill health. As stated, health systems do most to improve health when services are organized around the principle of universal coverage. They contribute most to better health when the system as a whole is organized around primary health care.
As is readily apparent in the documents before this committee, the issue of equity in access to health care is being taken very seriously by countries in this region. The National Rural Health Mission in India is just one example.
Let me express my deep appreciation for the regional conference on primary health care held last month in Jakarta. The report on this meeting sparkles with enthusiasm and commitment. This is an overwhelming endorsement not just of the relevance of primary health care, but also of its power.
You have issued some very precise and determined technical and practical recommendations. You are in a good position to do so, as many health ministers in this region have remained strong advocates for primary health care. Let me congratulate your Regional Director, Dr Samlee, for his passionate engagement in making the conference a success.
Let me also congratulate Dr Samlee for his annual report on the work of WHO. This report differs from previous ones in some important ways. It is more analytical, and it is more precise in showing the links between specific activities and their impact on people and problems.
It shows a solid spirit of collaboration, sometimes region-wide, sometimes among a group of countries, sometimes jointly with the Western Pacific region, and often as part of international initiatives
Above all, the report paints a picture of a strong approach to health that is shared throughout the region. I can summarize this approach in just a few words: systematic, strategic, smart, yet still struggling to solve some big problems.
Ladies and gentlemen,
A systematic approach gathers the data and measures the problem as a prerequisite for efficient programme planning. Good data are the foundation for improving services and expanding coverage. Good data can help you preserve your national health priorities in a complex environment of multiple donors and implementing partners.
For chronic diseases, most countries in this region have used the WHO STEP-wise approach to gather standardized data on the presence of major risk factors within their populations. This is a foundation for taking action.
At a time when chronic diseases are on the rise, the region still faces significant malnutrition. Your databases on iodine deficiency, vitamin A deficiency, and anaemia help pinpoint the problems, again as a guide to efficient programme planning.
The region’s approach to health is also strategic.
You have designed programmes for HIV/AIDS in ways that improve patient survival while also strengthening health systems.
I would like to commend the Minister of Health and Family Welfare of India for his commitment to ensure that men who have sex with men and other marginalized groups are not discriminated against.
Rational administration of antiretroviral therapy gives close attention to cost containment and the prevention of drug resistance. It has also strengthened drug procurement and laboratory capacities.
This region has done a remarkable job in progressing towards the global targets set for tuberculosis case detection and cure. DOTS facilities are now accessible to virtually the entire population of this region.
Programmes are extending their reach by engaging a wide range of private providers. All countries are making good use of the Stop TB Global Drug Facility to provide affordable and quality-assured anti-TB drugs.
But I must caution you to be very alert to the emergence of multi-drug resistant TB, which is much more difficult, and 100 times more expensive, to treat. Earlier this year, WHO issued a report showing that multi-drug resistant TB has reached the highest levels ever recorded. Good treatment programmes are your best protection.
I have described the region’s approach to health as smart.
This region has seen striking progress in reducing under-five mortality. You are collaborating with the GAVI Alliance to strengthen health systems as you increase immunization coverage. But you still have a long way to go.
You have expanded coverage with the strategy for the Integrated Management of Childhood Illness. And you have gone a step further. You are now institutionalizing this approach through pre-service education in medical and nursing schools. This is a cost-effective – and smart – way to sustain your impressive gains.
A smart approach not only measures the problem and attacks it strategically. It also defines weak points and obstacles, and focuses the resources there.
A prime example is the way you are tackling the problem of high maternal and neonatal mortality. We have known for some time that maternal mortality will not go down until more women have skilled attendants at birth and access to emergency obstetric care.
This session will be considering some innovative strategies for tackling the staff shortages for maternal and neonatal care. You are working towards a policy that knows the gaps in the workforce and has plans for addressing these gaps for each category of worker, from community health workers, to midwives and nurses, to doctors and specialists.
These policies and plans are tailored to the situation in individual countries, and aim to improve workforce management in line with well-defined needs. This is what I mean by smart.
Ladies and gentlemen,
Congratulations! You are on the right track. I personally believe that your enduring commitment to primary health care helps explain some of the steady progress you are seeing in many areas. I may, of course, be guilty of bias.
But some big struggles remain. Let me mention two.
Tobacco kills 1.2 million people in the region each year. Tobacco use is one huge risk factor that can be controlled.
We have the WHO Framework Convention on Tobacco Control as a powerful tool. We also have a package of six policy measures, known as MPOWER, that can help countries implement the provisions in the Convention. All six measure have a proven ability to reduce tobacco use in any resource setting. But tobacco taxes are by far the most effective.
Let me commend the government of India for the excellent progress in tobacco control.
Let me also commend the governments of Thailand and Myanmar. You rank among the top four countries with the best tobacco tax policies in the world.
Let me stress one point. As the document on this item notes, tobacco control depends absolutely on national capacity to develop legislation. Without this capacity, you will never get the necessary political commitment and meaningful enforcement.
National tobacco control legislation in many countries has gaps and many laws are not fully compatible with the provisions in the Framework Convention. Let me warn you again: don’t give the tobacco industry any loopholes.
Polio eradication is another struggle. During the past year, public health history has been made in this region.
A year ago, the technical feasibility of polio eradication looked uncertain. And this uncertainty focused on Uttar Pradesh, India – the world’s most tenacious reservoir of type 1 poliovirus. Nowhere has it been harder to stop polio in recent years.
I believe we can put questions about technical feasibility to rest based on what has happened in Uttar Pradesh in just the past 12 months. Here we can say with confidence: polio is in retreat.
The remaining problems are not technical. They are operational. They are problems of implementation, programme quality, and strategic performance. As we all know, operational problems can be managed.
But the progress is still fragile, as disturbing importations of type 1 polio have occurred in western Uttar Pradesh.
The document on this item describes the effort in India as “colossal.” No one will disagree. Please maintain your colossal effort.
This is one clear case where success in South-East Asia will benefit the entire world.
Ladies and gentlemen,
Public health is increasingly asked to tackle problems that are beyond our direct control. At the international level, health enjoys a high profile as a poverty reduction strategy.
But economic growth within a country will not automatically alleviate poverty or reduce the present great gaps in health outcomes. Health systems will not automatically gravitate towards greater equity and efficiency. These changes require deliberate policy decisions.
It is not easy to make a value, such as health equity, count at the political level, especially when health competes against powerful trade and economic interests. But it can be done.
The May resolution on Public Health, Innovation and Intellectual Property was a triumph. It demonstrates that international agreements that affect the global trading system can indeed be shaped in ways that favour health. Allow me to express my appreciation to the countries of this region for their collaboration in making sure this was a success.
It is not easy to make health equity a guiding principle for health systems, especially when market forces make health care a commodity and encourage inefficient consumption. But it can be done.
In October, the World Health Report on primary health care will be issued to commemorate the anniversary of Alma-Ata. The report offers practical and technical guidance for reforms that can equip health systems to respond to health challenges of unprecedented complexity.
The report asks political leaders to pay close attention to rising social expectations for health care. Increasingly, people want care that is fair as well as efficient.
People want care that incorporates many of the values so brilliantly articulated at Alma-Ata 30 years ago, and so recently revitalized in this region.
This, I believe, is a solid way forward.