Address to the Regional Committee for the Eastern Mediterranean (55th session)
Dr Margaret Chan
Director-General of the World Health Organization
Mr Chairman, Dr Gezairy, honourable ministers, distinguished delegates, ladies and gentlemen,
As your Regional Director has noted, commitment to polio eradication in this region is now at its highest level. Significant progress was made in 2007. Polio was restricted to a few endemic reservoirs in Pakistan and Afghanistan, and outbreaks following importations in Sudan and Somalia were successfully contained.
Our resolve has been tested this year. In Afghanistan, we have tragically lost three brave Afghan nationals, Dr Taheri, Dr Kakar, and Mr. Almas. These people were killed in southern Afghanistan when a suicide bomb hit their convoy on 14 September as they were on their way to prepare for a polio immunization campaign.
I was deeply moved by the strong determination of the government of Afghanistan and its partners to push ahead with the vaccination campaign, and to do so in memory of their colleagues. With their heroic efforts, we were able to access all districts in Afghanistan during the UN Peace Days later in September.
In Pakistan, we are now experiencing an outbreak in previously polio-free regions and outside the key endemic areas. This resurgence clearly demonstrates that polio must be eradicated. Control is not an option. In Sudan, we are again seeing a small outbreak following an importation. This outbreak comes after a two-year period in which a single case was reported.
In this region, the principal barrier to success arises from the difficulty of accessing children in areas of insecurity, while maintaining high coverage in all other areas. These are operational problems, and they can be overcome. Experiences in Somalia show that we can stop polio under the most challenging conditions. More than 12 months have passed since Somalia has reported a case.
The drive to eradicate polio compels us to reach all children, even in the most insecure areas. By finding ways to do so, with cleverness and courage, we also carve out ways to deliver a range of additional health and humanitarian interventions so critically needed in these underserved areas.
Ladies and gentlemen,
Let me commend this Regional Office for its support to ministries of health challenged by crises, conflict, and complex emergencies. This region has more than its fair share of conflicts and disasters, and this has been a tremendous technical and operational challenge for the Regional Office as well as for affected countries.
The deteriorating humanitarian situation in Afghanistan and Somalia is a cause for great concern. Continuing conflict has increased vulnerability to stresses such as drought, other extreme weather events, and soaring food prices, all against a backdrop of severe poverty that has endured for decades.
Standard health indicators for these two countries are among the worst in the world. In Somalia alone, some 3.2 million people are on the verge of famine. Among young children in Somalia, one in six is acutely malnourished. Recent reports that food aid is being disrupted give us even greater cause for alarm.
But in Afghanistan, as elsewhere, bad news on the political front can obscure good work for health. Let me commend the Afghan Ministry of Public Health for some courageous decisions.
Despite considerable challenges, the ministry has introduced reforms aimed at improving access to a basic package of health services, especially in rural areas. Primary health care has been the backbone for improved service delivery that is equitable and, equally important, responsive to people’s needs.
The delivery of health services that meet social expectations can help legitimize a government. The reforms are making a contribution not only to health, but also to the security and welfare of the Afghan people and thus also to a stable political environment.
Ladies and gentlemen,
This year marks the 60th anniversary of WHO and the 30th anniversary of the Declaration of Alma-Ata. I agree entirely with Dr Gezairy’s statement in his annual report to this committee. Primary health care was a far-sighted vision.
As your Regional Director notes, countries in this region that retained a commitment to comprehensive primary health care have achieved better health outcomes than expected given their limited resources.
Today, we understand better than ever the political, social, and economic value of a healthy society. We understand better than before the contribution that equitable health outcomes can make to social cohesion and stability, both within and between countries.
As I have stated, a world that is greatly out of balance in matters of health is neither stable nor secure.
Thirty years ago, the Declaration of Alma-Ata articulated primary health care as a set of guiding values for health development, namely: equity, social justice, and universal coverage. It articulated a set of principles for the organization of health services, namely: local ownership, priority to vulnerable groups, a holistic view of health, and a definition of prevention that addresses the fundamental determinants of health.
Operational approaches flowed logically from these values and principles, namely: community participation, multisectoral action, prevention as well as cure, and technology choices that align with priority needs.
The Declaration of Alma-Ata launched the health for all movement, which was almost immediately misunderstood. It was a radical attack on the medical establishment. It was utopian. It was confused with an exclusive focus on first-level care. For some proponents of development, it looked cheap: poor care for poor people, a second-rate solution for the developing world.
Today, primary health care is no longer so deeply misunderstood. Several trends and events have clarified the relevance of primary health care in ways that could not have been imagined 30 years ago. In fact, primary health care looks more and more like a smart way to get health development back on track.
Ladies and gentlemen,
The Millennium Declaration and its Goals breathed new life into the values of equity, social justice, and universal coverage, this time with a view towards ensuring that the benefits of globalization are more evenly distributed.
The AIDS epidemic showed the relevance of equity and universal access in a substantial way. With the advent of antiretroviral therapy, an ability to access medicines and services became equivalent to an ability to survive for many millions of people.
Stalled progress towards the health-related Millennium Development Goals has forced a hard look at the consequences of decades of failure to invest in basic health infrastructures, services, and staff. As we have seen, powerful interventions and the money to purchase them will not buy better health outcomes in the absence of efficient systems for delivery.
In August, the International AIDS Conference in Mexico gave major emphasis to the importance of strengthening health systems. The successful drive to reach 3 million people with antiretroviral therapy has revealed the critical barriers caused by weak systems for drug procurement and delivery, weak laboratory support, and inadequate numbers of staff.
The rise of chronic diseases has uncovered further problems. It has demonstrated the burden of long-term care on health systems and budgets. It has revealed the catastrophic costs that drive households below the poverty line. It has shown us the bitter irony of promoting health as a poverty-reduction strategy at a time when the costs of health care can themselves be a cause of poverty.
Prevention is by far the better option, and this requires behaviour change and coherence of government policies. At the same time, the main risk factors for chronic diseases lie beyond the direct control of the health sector.
In other words, the response to chronic diseases and many other health problems requires efficiency in the delivery of comprehensive care, fairness in access and social protection, and multisectoral action to address the underlying causes.
Ladies and gentlemen,
Let us look at some of the items on your agenda.
This region, like many others, faces a critical shortage of properly trained health workers. Development of the nursing and midwifery professions is on your agenda. This, too, is a health systems issue.
An adequate workforce of properly trained and motivated nurses and midwives is essential for the delivery of primary health care and the achievement of the health-related Millennium Development Goals.
Efforts to improve the numbers of nurses and midwives, their training, motivation, supervision, and working environment have acquired critical urgency in this region. As frankly stated in your documentation, the low status of these workers, including their low pay scales, contributes to workforce migration. Conflict understandably encourages migration. Countries in crisis, such as Iraq, have lost much of their health workforce at a time when staff and services are needed most.
Though the challenges are great, it is good to see the importance given to family health nursing as an approach that addresses the social determinants of health and promotes prevention and integrated service delivery at the community level.
You will be discussing the first regional strategy for the prevention and control of sexually transmitted infections. To address this problem, policy-makers need better data on the magnitude of the disease burden. Preventive, diagnostic, and treatment services need to improve.
But social factors must also be addressed. Stigma and discrimination often block access to services in groups at greatest risk. We know, too, that the vast majority of people living with HIV/AIDS in this region do not know their infection status and do not actively seek testing.
Climate change is on your agenda. All the experts tell us: developing countries will be the first and hardest hit. Countries in this region have well-documented vulnerabilities, including water scarcity and many flood-prone areas. Countries with robust health systems will be best able to absorb these added shocks.
Protection of health from the effects of climate change is a health systems issue, but it also has a social dimension. 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.
Malaria elimination is on your agenda. We know that malaria elimination is a feasible goal for many countries in this region. I urge you to seize this opportunity. I urge you to take full advantage of unprecedented international interest in this disease, supported by unprecedented funds.
Malaria is a climate-sensitive disease. Malaria is also a huge burden on health systems and a major impediment to development. One less disease is one less burden for health systems as the adverse effects of climate change continue to mount.
This is the point I want to make. No one questions the values of equity, social justice, and universal coverage. But primary health care has more to offer than a set of unifying values. The very problems you will be addressing during this session illustrate the importance of an operational approach that promotes community participation, encourages multisectoral action, and addresses the fundamental social determinants of health.
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. Increased economic prosperity tends to benefit populations that are already well-off, leaving others further and further behind.
As the report clearly states, social factors are the most important determinants of health. Economic growth will improve health only when policies that explicitly address these social factors are in place. And these policies need to be made in multiple sectors other than health.
Gaps in health outcomes are not matters of fate. They are markers of policy failure.
The report also has something to say about health systems. It recognizes that equity is strongly influenced by the way health systems are organized, financed, and managed. Not surprisingly, the Commission champions primary health care as a model for a system that acts on the underlying social, economic, and political causes of ill health.
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 countries, the health ministry usually has less clout and negotiating power than other members of cabinet.
Let us be frank. In most countries, an appeal to the value of health equity will not be sufficient to gain high-level political commitment. It is naive to think that ministers of finance, trade, transport, education and others will include health on their agendas for ethical or moral reasons alone.
The health sector must produce solid evidence, and political and economic arguments that make it smart for governments to include health in all policies. Leaders and managers in health, at all levels, must equip themselves with the skills and competencies to make the case.
Ladies and gentlemen,
Public health is increasingly faced with problems that arise from policies made outside the health sector, both nationally and internationally. At the international level, health enjoys a high profile as a poverty reduction strategy and a boost to overall development. But health remains neglected in many other policies.
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 fairness and efficiency. Globalization will not self-regulate in ways that favour fair distribution of benefits. All of these changes require deliberate policy decisions.
It is not easy to make a value, such as health equity, count at the international policy level, especially when health competes against powerful economic interests. But it can be done. At the last World Health Assembly, the 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.
It is not easy to make health equity a guiding principle for health systems, especially when health care is treated as a commodity driven by market forces. But it can be done, as several countries in this region have shown.
Later this month, 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. As mounting evidence shows, people want care that is fair as well as efficient. People want care that incorporates many of the values, principles, and approaches articulated at Alma-Ata 30 years ago.
Again, I agree entirely with your Regional Director. Primary health care was a far-sighted vision, and its relevance continues to grow.