Time to get back on track to meet the Millennium Development Goals
Dr Margaret Chan
Director-General of the World Health Organization
Mister President, honourable ministers, excellencies, distinguished delegates, Dr Mahler, ladies and gentlemen,
Public health must never cease to learn from its successes, and its failures.
Thirty years ago, the World Health Assembly declared that "the world and all its people have won freedom from smallpox". That official death certificate for an ancient scourge marked an unprecedented achievement in the history of public health. It provided dramatic proof of the power of collective action to improve the human condition in a permanent way.
This is worth remembering at a time when the international community is engaged in the most ambitious attack on human misery in history, with just five years left until 2015.
Smallpox eradication was a single-disease initiative. That killing, blinding, disfiguring disease never had a cure. The cornerstone of the campaign was prevention at a time when most health systems around the world were designed to deliver curative care.
An initiative that broke every single chain of virus transmission in every corner of the world was the ultimate example of universal coverage. This tells us what collective action for a common cause can achieve.
Among its many legacies, the eradication campaign spawned the Expanded Programme on Immunization at a time when less than 20% of children in the developing world were covered by immunization programmes.
Throughout the 1980s, the so-called "lost decade for development", the expansion of childhood immunization was a robust and inspiring success story in the midst of an oil crisis, a recession, a crushing debt crisis, and structural adjustment programmes that slashed national spending for social services, including health. This reminds us of how greatly health can suffer from policies made in other sectors.
The point I want to make is this. As we enter the second decade of the 21st century, and the homestretch for reaching the Millennium Development Goals, we need to draw on every lesson, every approach, instrument, and innovative way of raising funds or collaborating together, from heads of state to civil society. We have very little time left, and little space for unproductive debates. We need to move forward fast.
We need horizontal and we need vertical approaches. We need to scale up the delivery of commodities, and we need to strengthen the fundamental capacities that allow us to do so. We need coherence in policies, within and beyond the health sector, and we need complementarity of efforts.
Reaching the health-related Goals is not about national averages. It is about reaching the poor, who are almost invariably the hardest to reach. This is the challenge, and the measure of success.
The Millennium Development Goals promote health as part of an overarching strategy for poverty reduction. To put it bluntly, if we miss the poor, we miss the point.
We have a long way to go, especially for maternal and newborn mortality, and we welcome the efforts being made, on multiple fronts, to accelerate progress in this area. But let us take heart from what has already been achieved.
Success in public health nearly always saves lives. But it also has symbolic value. Recent progress tells us that when the international community is fully committed to a goal, creative solutions can be found and obstacles, including financial ones, can be overcome.
Since the start of this century, the number of under-five childhood deaths dropped below the 10 million mark for the first time in nearly six decades, and then dropped again to below 9 million.
The number of people in low- and middle-income countries receiving antiretroviral therapy for AIDS moved from under 200,000 in late 2002, to 3 million, then beyond 4 million, an achievement unthinkable a decade ago.
The rate of people newly ill with tuberculosis peaked and then began a slow but steady decline. For the first time in decades, we are seeing signs that the steadily deteriorating malaria situation might be turned around.
Progress in controlling the neglected tropical diseases continued to make impressive strides. By the end of 2008, some 670 million people had been reached with preventive chemotherapy for at least one of these diseases. Cases of guinea worm disease are at their lowest level ever, now confined to only four countries.
I think we can conclude: increased investment for health development is working.
Like the smallpox eradication campaign, the drive to reach the Millennium Development Goals has already left some legacies that benefit public health across the board. Let me mention a few.
First, the Millennium Declaration and its Goals turned thinking about development upside down. For a long time, factors such as access to safe water and sanitation, literacy rates, infant and young child mortality, and maternal mortality were regarded as indicators of a country’s level of socioeconomic development.
According to the logic at that time, living conditions and health status would gradually improve as economies developed and prosperity increased. That happened, of course, but frequently not to the benefit of society’s poorest and most marginalized people. All too often, economic growth has meant wealth creation for some, and increased poverty for others.
The Goals turned this thinking around. Instead of waiting for living conditions and health status to gradually improve, the Goals called for a direct attack on the conditions and diseases that anchor people in poverty. This was put forward as the best, and probably the fastest, route to equitable and more balanced progress.
Indicators of development became engines for development. A quest for economic development became a quest for social development. The report of the Commission on Social Determinants of Health has taken this thinking many steps forward.
Second, the MDGs changed thinking about aid effectiveness, as reflected in the Paris Declaration and the Accra Agenda for Action. An almost fashionable scepticism about the value of aid, with blame placed on weak capacities and governance in recipient countries, was replaced by recognition that the policies and behaviours of donors could also be at fault. Accountability for results must be mutual.
Good aid honours the priorities, capacities and responsibilities of recipient governments to their citizens. Good aid aims to eliminate the very need for aid. It does so by investing in the capacities and the infrastructures needed to move towards self-reliance.
If aid does not explicitly aim for self-reliance, the need for aid will never end. For obvious reasons, breaking the cycle of dependence on aid contributes to equity among nations in a fundamental way.
Third, the drive to reach the health-related MDGs unleashed the best of human creativity, bringing a host of innovations for improving health, especially among the poorest.
The list is long: the GAVI Alliance, the Global Fund, UNITAID, new partnerships to develop medicines and vaccines for diseases of the poor, advance market commitments as an incentive for industry, a finance facility for immunization, a facility to reduce the costs of malaria drugs, and the International Health Partnership as a new way of working within countries.
We have all contributed in some way to these innovations for international health cooperation.
The great spirit of collaboration and consensus-seeking seen in recent Health Assemblies has added to this list, notably through the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property.
The trend continues. Earlier this year, the Bill and Melinda Gates Foundation launched the Decade of Vaccines by pledging $10 billion over the next ten years to help deliver existing vaccines and develop new ones.
This commitment is most welcome. Vaccines are one of the best life-saving buys on offer, preventing an estimated 2 to 3 million deaths each year.
WHO and UNICEF, in close collaboration with the Gates Foundation, countries, and partners, are initiating a process to define the ambitions and scope of this Decade of Vaccines.
The momentum that has been growing since the start of this century must continue. Last month, WHO launched simultaneous immunization weeks in more than 100 countries. These events are building public and professional awareness of the value of immunization as well as saving lives.
You will be well aware of the setbacks that occur when people decide that vaccines are risky, unnecessary, or even part of a conspiracy. This has been a problem for measles, for the uptake of pandemic vaccines, and most especially for polio.
Vaccines touch your agenda at several points. You will be considering accelerated action to reduce deaths from pneumonia, the feasibility of measles eradication, and the prevention of hepatitis B virus infection through immunization of infants.
As requested by the 61st Health Assembly, you will also be considering an aggressive new strategic plan to complete polio eradication. The plan incorporates several new strategies that respond to different transmission dynamics in different settings, make use of a new bivalent vaccine, and address head-on the problem of international spread that has made progress so fragile.
Significantly, the plan maps out a more systematic engagement of the initiative in the broader effort to strengthen immunization systems. This is a most welcome emphasis.
The polio initiative knows how to deliver interventions to hard-to-reach populations. This know-how becomes broadly beneficial in the homestretch to 2015, where the greatest challenge lies in reaching underserved populations.
Last month’s polio outbreak in Tajikistan, in a region certified as polio-free since 2002, is a stark reminder that finishing eradication is the only viable option for responding to this disease. A resurgence of polio, of deaths, and childhood paralysis is the predictable consequence if we fail to stay the course. Collectively, countries and partners have a moral duty to finish the job.
Ladies and gentlemen,
Good news for public health usually arises from factors like political commitment, sufficient resources, strong interventions and implementation capacity, equitable delivery, and alignment with national priorities and capacities. Sometimes, though, we are just plain lucky.
This has been the case with the H1N1 influenza pandemic. The virus did not mutate to a more lethal form. Cases of resistance to oseltamivir remained few and isolated. The vaccine closely matched circulating viruses and showed an excellent safety record.
Emergency wards and intensive care units were often strained, but few health systems were overwhelmed and the effects were usually short-lived. Schools closed, but borders remained open, and disruptions to travel and trade were far less severe than feared.
Had things gone wrong in any of these areas, we would have a very different agenda before us today.
This has been the most closely watched and carefully scrutinized pandemic in history. It is normal that every decision and action, especially on the part of WHO, will likewise be closely scrutinized and critically assessed. We welcome this process.
The pandemic has also been the first major test of the functioning of the revised International Health Regulations, which entered into force in 2007.
During the January session of the Executive Board, I proposed that a previously scheduled review of the functioning of the Regulations could also be used to assess the international response to the influenza pandemic. The Board agreed to this proposal. A report of the Review Committee’s first meeting is before you.
When I opened that meeting, I stressed the need for a frank and critical assessment of performance, including WHO’s performance, in a process that is independent, credible, and transparent. We want to know what worked well. We want to know what went wrong and, ideally, why. We want to know what can be done better and, ideally, how.
We are seeking lessons, about how the International Health Regulations have functioned, about how WHO and the international community responded to the pandemic, that can aid the management of future public health emergencies of international concern. And I can assure you: there will be more.
The report of the Review Committee’s first meeting summarizes issues and questions repeatedly raised and likely to guide the review. The Committee further agreed to look into criticisms that have been levelled at WHO for its management of the pandemic. As I said, we welcome this review.
Ladies and gentlemen,
We have some solid evidence that aid for health development is working. But it needs to work much better. The drive to reach the health-related MDGs has taught us a major lesson, and this is a lesson about failure.
For decades, we have collectively failed to invest adequately in basic health systems, infrastructures, training of staff, information systems, regulatory capacity, and systems for social protection. This is an absolute barrier, and trying to bypass it by building separate single-purpose systems is not the answer.
International donors, partners, and governments themselves have failed to rally around national health policies, strategies, and priorities. This contributes to fragmentation, duplication, added demands and costs, and defeats national ownership. We have learned this.
How can we scale up interventions or aim for universal coverage when health systems in so many countries are on the verge of collapse? Or when the world faces a shortage of 4 million doctors, nurses, and other health personnel?
Weak health systems blunt the power of global health initiatives to reach their goals. 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 medicines or the costs of care in the private sector.
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 the failure of preventive services. Above all, weak health systems waste lives.
This problem is now recognized by countries and donors alike, and it is being addressed by a range of new and existing initiatives, including several global health initiatives. Though designed to deliver specific health outcomes, these initiatives now recognize that meeting their goals depends on a well-functioning health system. In my view, this shift of attention is nothing short of revolutionary.
Equity and social justice are at the heart of the Millennium Declaration and its Goals. They were always at the heart of the primary health care approach. As last year’s resolution on primary health care noted, principles such as universal access to services, multisectoral action, and community participation form a solid basis for strengthening health systems.
Efforts to reduce maternal and newborn deaths have shown the slowest progress of all the Millennium Development Goals in all regions. This should come as no surprise, as reducing these deaths depends absolutely on a well-functioning health system.
In preparation for the September UN summit on the Millennium Development Goals, the Secretary-General’s office is finalizing a Joint Action Plan to accelerate progress in reaching the health-related MDGS, with a special focus on maternal and child health. I encourage you to participate in the technical briefings on the Millennium Development Goals, as your views will be decisive in shaping the development of this plan.
Health systems are an issue for other items on your agenda. Drug-resistant forms of tuberculosis arise because of shortcomings in general health services, including years of neglect of laboratory services, inadequate regulatory capacity to ensure the supply and quality of medicines, and a dire shortage of health personnel.
In the so-called virus importation belt in sub-Saharan Africa, the spread of polio has become predictable, as the virus travels by exploiting weaknesses in health systems.
Strong regulatory capacity underpins efforts to reduce the harmful use of alcohol, to control tobacco, to protect children from harmful marketing practices, and to assure the safety and quality of medical and blood products.
Some 85 countries, representing 65% of the world’s population, do not have reliable cause-of-death statistics. This means that causes of death are neither known nor recorded, and health programmes are left to base their strategies on crude and imprecise estimates.
On the positive side, work to improve facility-based health care, which is critical for reducing maternal and newborn deaths, will increase the capacity to respond to the vast new challenges that come with the rise of chronic noncommunicable diseases.
These are some of the issues you will be discussing this week. Improving fundamental capacities helps reach international commitments, increases efficiency as well as fairness, improves health outcomes in sustainable ways, and moves countries towards greater self-reliance.
We have failed to do this job properly in the past. As we enter the homestretch, we must get back on the right track.