Director-General

Why the world needs global health initiatives

Dr Margaret Chan
Director-General of the World Health Organization

Address at the high-level dialogue on maximizing positive synergies between health systems and global health initiatives
Venice, Italy

22 June 2009

Honourable Mayor of Venice, honourable President of the Veneto Region, honourable ministers, colleagues from the United Nations system, representatives of global health initiatives, researchers and academics, civil society, ladies and gentlemen,

First, let me thank the city of Venice for hosting this event, and thank the government of Italy for its support .Let me thank the many contributors from around the world who have so generously given their time, their findings, and their thoughtful insights.

I think we can now let a long-standing and divisive debate die down. This is the debate that pits single-disease initiatives against the agenda for strengthening health systems.

As I have stated since taking office, the two approaches are not mutually exclusive. They are not in conflict. They do not represent a set of either-or options. It is the opposite. They can and should be mutually reinforcing. We need both.

This is one of the jobs, I believe, of this high-level dialogue: to craft policies and best practice that help the two approaches work together, in harmony, in ways that reduce waste and duplication, and improve efficiency.

We need them to work together to facilitate what I believe we all agree is the most important goal: to save lives and improve health outcomes. The Positive Synergies report has its limitations, which the co-authors readily admit. But it does give us the most solid ground yet for taking stock of where we stand today and establishing informed policies for the future.

Ladies and gentlemen,

Global health initiatives were established with a strong sense of purpose and great ambition. They set out to save lives, on an emergency basis, even though not everything was known at the start about everything that needed to be done, or the best way to do it.

There were risks, and there were missed opportunities, which better planning might have prevented. But there was also courage, or to use words from the report, “an invigorating sense of ambition and purpose.”

And there was a clear moral imperative to act. The AIDS epidemic demonstrated 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.

This is the essence of the equity argument: people should not be denied access to life-saving interventions for unfair reasons, including an inability to pay.

These global health initiatives have gathered knowledge along the way, and in so doing, they have shed light on a cause of much ill health in this world: weak and inequitable health systems.

Weak health systems are wasteful. They waste money, and dilute the return on investments. They waste money when regulatory systems fail to control the price and quality of medicine.

They waste training when workers are lured away by better working conditions or better pay. They waste efficiency when needless procedures are performed, or when essential procedures are precluded by interruptions in the supply chain.

They waste opportunities for poverty reduction when poor people are driven even deeper into poverty by the costs of care or by the failure of preventive services.

Above all, weak health systems waste lives.

Weak health systems are almost certainly the greatest impediment to better health in the world today. They are the central obstacle that blunts the power of global health initiatives.

The tuberculosis community clearly states the problem. The emergence of drug-resistant TB represents not just a failure of the control programme, but a failure of the entire health system in which that control programme operates.

In looking for ways to get beyond this impasse, we can take lessons not just from the evidence set out in the report, but also from history.

One reason for the success of smallpox eradication was a constant use of research to guide increasingly refined strategic operations. The smallpox campaign had a built-in capacity to respond, adapt, and shift gears as new evidence emerged.

The campaign to eradicate malaria did not. Of the many reasons put forward for the failure of this campaign, one is particularly relevant to today’s high-level dialogue. It is this: even the best-funded and managed initiatives will fail in the absence of basic infrastructures and services needed to sustain routine case detection and treatment.

The history of the onchocerciasis control programme provides another instructive example. At its start, this was the most vertical control programme imaginable: helicopters dropping insecticides from the sky.

As the burden of disease came down, the programme evolved. It brought us the strategy of community-directed distribution of a broadened range of interventions. This strategy is now an important tool for extending primary health care.

Ladies and gentlemen,

It is time to start listening to the evidence, and not to anecdotal reports or to praises or criticisms founded on ideology rather than on evidence. Let me highlight four points that I personally find important.

First, these initiatives have unquestionably done great good. They have saved or prolonged millions of lives. This was the overarching purpose. I do not need to say more.

Second, it is wrong to conclude, categorically, that these initiatives have weakened health systems. They were launched at a time when health systems were already weak, sometimes on the verge of collapse, following decades of neglect. The global initiatives may have exacerbated some specific pre-existing weaknesses, but they did not cause them.

The report identifies some problems. Better planning could have prevented the establishment of parallel systems for information and for the procurement and distribution of supplies. As we know, these parallel systems have contributed to duplication, higher costs, and the undermining of national capacities.

The mixed picture revealed by the report is often a function of differences in the capacity of health systems. Stronger health systems have been better positioned to maximize gains from support by these initiatives and to counteract potentially negative effects.

In reality, the momentum and drive of these initiatives have made specific weaknesses in health systems much more visible. This, in turn, has allowed a more precise definition of problems and a more targeted approach to solutions.

My third point is closely related. For me, some of the best news from the report is evidence that global health initiatives can be flexible and responsive.

Part of their “invigorating sense of ambition and purpose” is an ability to solve problems, often in highly innovative ways.

In their drive for results, they are devising solutions to the very problems they have revealed. As the report states quite simply: they are constantly adapting and improving.

My fourth point is a straightforward request to you. The report cites abundant examples of deliberate and successful innovations.

These innovations are helping to bring health staff to rural areas and keep them there, to change legislation so that nurses can prescribe drugs, and to fully engage community health workers and civil society organizations. They are reducing drug prices, rationalizing the switch to second-line treatments, and exploiting advances in information and communication technologies with a speed and efficiency that have defied the sceptics.

Pay close attention to these innovations. They have unquestionably streamlined operations, saved money, and led to great efficiency gains.

They have also improved the quality of care for patients. And this has been a distinctive shared feature of these initiatives: they have upgraded the quality of care with quality-assured interventions and standardized treatment protocols, setting a new benchmark for global health.

Ladies and gentlemen,

We are meeting at a time when the world faces multiple crises on multiple fronts. Global crises like the economic downturn and climate change will hit developing countries the hardest.

As these countries have the greatest vulnerability, they will bear the brunt of the consequences. As these countries have the least resilience, they will take the longest to recover.

As announced earlier this month, the world is at the start of the 2009 influenza pandemic. I firmly believe that this pandemic will reveal, in a highly visible, measurable, and tragic way, exactly what it means, in life-and-death terms, when health needs and health systems have been neglected, for decades, in large parts of the world.

The gaps and inequalities that we are all trying so hard to address are likely to grow even greater. The price of failure will keep getting higher.

We simply cannot afford to be distracted from our central purpose. We cannot let the momentum, the drive, stumble for a moment. We must pursue every possible opportunity to improve efficiency and reduce waste. We are learning as we keep moving on, with an appropriate sense of urgency.

We faced some challenges early on, but we are moving forward, learning, adapting, pulling together, saving lives.

WHO values all its partners in global health, and values their clear contributions to better health. I am proud of these partnerships, and greatly encouraged by the attention being given to health systems.

This is not easy work. This is not glamorous work. But it absolutely must be done.

Thank you.

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