The health challenge: where do we stand?

Dr Margaret Chan
Director-General of the World Health Organization

Introductory remarks at the Aspen for the G8 Global Health Forum

Honourable ministers, colleagues in public health, leaders of the business community and civil society, ladies and gentlemen,

I have been asked to speak about the health challenge: where do we stand? One answer to this question is simply stated: we stand firm.

We are at the start of what the experts say may be the most severe global financial crisis and economic downturn seen since the Great Depression began in 1929.

We are also in the midst of the most ambitious drive in history to reduce poverty and to reduce the great gaps in health outcomes.

Health enjoys a high place on the development agenda, and this place was earned by a wealth of evidence. A financial crisis does not change the weight of evidence.

The Millennium Development Goals are driven by the values of social justice and fairness, also in access to life-saving and health-promoting care. A financial crisis should not make the world’s moral compass point in another direction.

We must hold governments, political leaders, and the international community accountable, not just to their promises and commitments, but also to the evidence. As I said: we stand firm.

We need to learn from the experience of past recessions. We need to recognize that health is an investment. In the past, mistakes were made. Health spending was cut.

Inefficiencies in the delivery of services were introduced that increased costs and encouraged waste. Access to care was distorted, with the best care going to the wealthy and the poor left to fend for themselves.

The values and approaches of primary health care – of equity, prevention, multisectoral action, and self-help as the best help – were pushed aside in many policy decisions. Health care in Africa and in large parts of Latin America and Asia has still not recovered from these mistakes. Health care lost fairness, and it lost efficiency.

Today, the gaps in health outcomes, both within and between countries, are greater than ever before in recent history. Differences in life expectancy between the richest and poorest countries exceed 40 years.

A child in Lesotho can expect to live 42 years less than a child in Japan. Annual government expenditures on health range from as little as US$ 20 per person to more than US$ 6000.

WHO estimates that, each year, the costs of health care push around 100 million people below the poverty line. This is a bitter irony at a time when the development community is committed to poverty reduction. It is all the more bitter at a time of severe financial crisis.

Ladies and gentlemen,

Let me give you a brief historical perspective on today’s health challenges.

In the 1990s, health was struggling for a place on the development agenda. The expanded programme on immunization, a legacy of smallpox eradication, was a success story, but coverage had reached a stubborn plateau.

HIV/AIDS was cancelling out health gains, setting back life expectancy, and ripping societies apart, especially in sub-Saharan Africa. The resurgence of tuberculosis, including its drug-resistant forms, was declared a global health emergency by WHO.

The malaria situation was described as stable, because it could not get any worse.

Donors expressed scepticism about the effectiveness of aid, with the blame firmly placed on recipient countries: lack of commitment, weak capacity to absorb aid, and corruption that siphoned off the benefits.

Things changed in 2000 when the power of health to drive socioeconomic progress was reflected in the Millennium Declaration and its goals. Cash quickly followed. Commitments of official development assistance for health rose from US$ 6.5 billion in 2000 to more than US$ 14 billion in 2006.

We saw a string of innovations: the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the GAVI Alliance, initiatives launched by presidents and prime ministers, money from philanthropists, money from a levy on airline tickets, the selling of bonds to finance immunization, and advance market commitments to stimulate the development of new vaccines.

For the first time, childhood deaths from vaccine-preventable diseases dropped below the 10 million mark, sinking to an estimated 9.2 million deaths last year. Access to life-prolonging antiretroviral therapy for HIV/AIDS was extended to more than 3 million people in low- and middle-income countries.

TB control made steady and impressive progress in several countries. Traditionally cash-starved malaria reached its billion-dollar moment.

But the commitments and the cash were not enough. Progress stalled. As we learned, powerful interventions and the money to purchase them will not buy better health outcomes in the absence of equitable systems for delivery.

We saw another problem as well. As the number of health initiatives grew, recipient countries were overwhelmed by inefficient aid: duplication, fragmentation, multiple reporting requirements, high transactions costs, and fierce competition for scarce health staff.

Previous scepticism about aid effectiveness shifted to an admission that donor policies and practices also need to change.

Fortunately, the need to strengthen health systems is now recognized. It is receiving long overdue attention from many, including donors, international agencies, the Global Fund, the GAVI Alliance, the International Health Partnership, and the G8.

Under last year’s leadership by Japan, the G8 gave the strengthening of health systems a high profile and clarified the needs for personnel, money, and data. We need to continue this momentum.

Ladies and gentlemen,

Let me congratulate the organizers of this forum for putting together an outstanding agenda. You have captured today’s leading health challenges, and they are enormously complex.

Of all the MDGs, the goal set for reducing maternal mortality is the least likely to be met in all regions. This should come as no surprise. Reductions in maternal mortality depend absolutely on a well-functioning health system.

As your agenda rightly notes, the control of infectious diseases is an unfinished business.

There are no quick fixes for broken health systems, but there are quick wins when drugs prevent the transmission of HIV from a mother to her infant, DOTS cures TB, or a bednet protects a child from malaria.

We need to do both: strengthen health systems while also combating high-mortality diseases. The two approaches are not in conflict, but they do need to be better balanced and better integrated in initiatives that are truly country-led and aligned with national priorities and capacities.

We face problems in addition to those targeted by the MDGs.

Health all around the world is being shaped by the same powerful forces. Health in rich and poor countries alike is now threatened by three universal trends: population ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles.

As a result, chronic diseases, long considered the companions of affluent societies, have changed places. Globally, 80% of the burden of diseases like heart disease, hypertension, cancer, and diabetes is now concentrated in low-income and middle-income countries.

The rise of chronic diseases creates an enormous burden on health systems, and contributes to two more problems: high-cost long-term care, and a severe global shortage of health-care workers. You will be addressing both of these problems.

Fortunately, chronic diseases share a limited set of risk factors that make them highly suitable for prevention. Unfortunately, most risk factors arise in sectors beyond the direct control of public health.

This brings me to yet another source of complexity.

We have been told that the financial crisis is so severe and so contagious because it comes at a time of unprecedented interconnectedness. But it is not just countries, economies, and markets that are interconnected. Different sectors, like agriculture, energy, transportation, and the environment, are also closely interrelated.

Policy spheres are no longer distinct. Many health problems now demand joint policy action with non-health sectors. Likewise, policy action in other sectors has important health consequences. Climate change, with its multiple dangers for health, is one clear example.

Health is shaped by the systems that govern international relations in trade, finance, commerce, foreign affairs, and other areas. The net result of all our international policies should be to improve the quality of life for as many of the world’s people as possible.

Greater equity in the health status of populations, within and among countries, should be regarded as a key measure of how we, as a civilized society, are making progress.

As reflected in your agenda, we need better public-private partnerships, the right incentives for health research, more abundant and predictable financing, also for health systems, and more effective use of aid.

But we also need more efficient service delivery. Strengthened health systems, ideally based on primary health care, are a reliable route to greater efficiency and fairness in health care and greater security in the health sector and beyond.

When a health system strives for universal coverage, it articulates a value system, driven by fairness, social justice, and respect for the needs and aspirations of all people. These are basic human values. Good governance honours them.

Ladies and gentlemen,

Let me conclude with a challenge to the G8 as it moves to Italian leadership.

As I said at the start, we do not need to change directions. But we do need visionary, innovative thinking, and we need moral leadership.

This world will not become a fair place for health all by itself. Economic decisions within a country will not automatically protect the poor or guarantee universal access to basic health care.

Globalization will not self-regulate in ways that favour fair distribution of benefits. Corporations will not automatically look after social concerns as well as profits.

International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines.

All of these outcomes require deliberate policy decisions. The G8 has the leverage and the clout to shape these decisions.

The price of failing to take action, especially at a time of crisis, is high. A world that is greatly out of balance in matters of health is neither stable nor secure.

Thank you.