The quest for a coherent global health policy
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, distinguished delegates, ladies and gentlemen,
Thank you for this opportunity to address such a distinguished audience. Thank you, too, for the Communication on the European Union’s role in global health, and the other outstanding documents prepared to support this high-level conference.
The countries represented in this room are among the most generous contributors, and the most deeply engaged partners for international health development. I place great stock in your views about the future as well as your experiences during decades of international health cooperation.
Resources come with an expectation of results. It makes sense for you to seek the best possible return on your health investments.
Your ambitions are high. In looking for ways to strengthen the EU’s contribution to global health, you are exploring some extremely complex issues that are likely to shape international health development for some years to come.
This quest for a coherent global health policy is mutual. WHO is also addressing these issues, in dialogue with our Member States and development partners, as we think about the future financing of WHO in line with what we are expected, and best positioned, to deliver.
This conference also has immediate relevance, as the EU prepares its contribution to the September UN summit on the Millennium Development Goals. We are in the homestretch now. We need to move forward very fast. To do so, we need to understand what is holding us back and tackle these obstacles in smart ways that bring lasting results, well beyond 2015.
I appreciate, most especially, your commitment to the strengthening of health systems. You have made stronger capacities central to the overarching policy objective of universal coverage with high quality health services.
As we have learned since the start of this century, highly effective interventions and the money to purchase them will not bring better health outcomes in the absence of efficient and equitable systems for delivery. This is most especially true for poor and underprivileged populations, the focus of the MDGs and of health development in general.
Ladies and gentlemen,
The drive to reach the MDGs has spurred the creation of several global health initiatives designed to bring down mortality from individual diseases. Their power to do so is unfortunately blunted by weak national capacities.
Instruments of global health governance, like norms and standards for ensuring the safety of air, food, water, chemicals, and medicines, mean little in the absence of capacities for regulation, inspection, and enforcement.
The potential of legal instruments, like the Framework Convention on Tobacco Control and the International Health Regulations, to provide collective security against shared threats is compromised when countries cannot enforce legislation or detect outbreaks and identify the cause.
Progress cannot be measured and strategies cannot be refined in the absence of data from reliable information systems. Public health services that are short on supplies and staff will not be used, forcing poor people to turn to more expensive private services, even for routine care.
These are the realities we face today. They are barriers to reaching the health-related MDGs, and they are barriers to greater efficiency and fairness in delivering health care.
Ladies and gentlemen,
In my view, your commitment to universal coverage and your emphasis on capacity building form part of a classic health agenda, revamped to address the unique challenges of the 21st century.
In defining a more vigorous and coherent EU role in global health, you are looking for fairness as well as efficiency, and stressing prevention as well as cure. You honour the right to health and the obligation of governments to be in charge of their own health agenda.
In line with an emphasis on prevention, you stress the need to address the multiple root causes of ill health that arise in non-health sectors. Above all, an approach that aims to strengthen fundamental capacities sets the stage for sustainable solutions, builds self-reliance, and contributes to effective aid.
Though the problems being addressed have new dimensions of complexity, the approaches are well-established and have proven their worth. The working document on universal coverage of health services, prepared for this conference, describes the holistic and participatory approach to health, set out in the Declaration of Alma-Ata, as the basis for modern health systems. I fully agree.
I also believe we all agree that implementing these approaches is far more challenging today than it was 30 years ago when the Declaration of Alma-Ata was signed. Let me give just a few examples.
The issue of national ownership of the health agenda has become much more complex, touching the very roots of a government’s responsibility for health and accountability to its citizens. Health is an attractive area of engagement, and the landscape is crowded.
There are more partners and agencies implementing programmes in health than in any other sector. The problems are familiar: duplication of efforts, fragmentation of care, high transaction costs, poor alignment with national priorities and capacities, and unpredictable funding for a sector with high recurrent costs. In 2007, for example, Viet Nam hosted more than 750 donor missions. Can you imagine that!
I am sure you will agree we need to change our behaviour and walk the talk, on aid effectiveness, the Paris Declaration, the Accra Agenda for Action. We need to use the International Health Partnership Plus as a model for achieving greater coherence of our efforts within countries.
If the provision of health care is perceived as funded and delivered largely beyond government control, how can national authorities be held accountable for failure to meet public expectations? How can positive results strengthen the population’s confidence in its government and thus enhance political stability?
Participatory approaches are also more challenging. The revolution in information and communications technologies has contributed to rising public expectations for good quality and affordable care. On the positive side, this trend creates grassroots demands that politicians would be wise to heed.
On the other hand, people can now draw information from multiple sources. They make their own decisions about what to believe and who to trust. People make their own decisions about whether vaccines for measles, polio, or pandemic influenza are necessary and safe.
Prevention is likewise much more demanding. Worldwide trends, like demographic ageing, urbanization, and the globalization of unhealthy lifestyles, have contributed to a rise in chronic noncommunicable diseases and a shift in the burden. The diseases of affluence have become companions of the poor. Around 80% of the disease burden is now concentrated in countries with the least capacity to mange the costs and demands of chronic care.
Prevention is by far the better option, yet the shared risk factors for these diseases reside in sectors beyond the direct control of public health.
Ensuring sustainable gains for health has become more costly, more fragile, and ethically more perilous. Though the costs have dropped substantially, antiretroviral therapy for AIDS is still expensive.
In times of economic downturn, a dangerous calculus often emerges. How many lives can be saved for a given amount of money? These are the kinds of questions often asked by finance ministers in the past. How many children could be vaccinated for the cost of keeping one adult with AIDS alive?
In my view, it cheapens life when the costs of interventions set the priorities, especially when so many millions of people continue to be infected with HIV. Antiretroviral therapy is a lifeline, for a lifetime. The only ethically acceptable exit strategy is to prevent HIV infections in the first place.
We have a vaccine to protect against cervical cancer, the most common cancer among women in the developing world. We have new vaccines to prevent pneumonia and diarrhoeal diseases, the two biggest killers of young children worldwide. But can countries, donors, development partners, and the GAVI Alliance afford to introduce these new vaccines and sustain their delivery?
In the best of all possible worlds, every person would have access to the best that science and medicine can offer. In reality, money and social position often determine who lives and who dies.
This is the essence of the equity argument: people should not be denied access care, to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes.
As a final example, the goal of improving access to medicines no longer aims mainly to match essential medicines with priority needs and ensure affordability. Today, questions of access touch very difficult issues of intellectual property rights, the promotion of quality generic products, incentive schemes for developing products for diseases of the poor, the de-linking of prices from the costs of R&D, TRIPS, TRIPS-plus, and other difficult trade-related issues.
Your agenda is a good one, right on target, and supported by a compelling value system. As I said, you are aiming high. None of this is easy, but the problems, many of which have been neglected for decades, simply must be addressed. In the homestretch to 2015, we cannot wait any longer.
Ladies and gentlemen,
As we continue this mutual quest for a coherent global health policy, let me offer two brief pieces of advice.
First, maintain the momentum. The MDGs have been good for public health. They have demonstrated the value of focusing international action on a limited number of time-bound objectives. Though progress has been slower than hoped, we have also seen some stunning improvements in access to care and reductions in mortality.
In addition, the drive to reach the Goals has unleashed the best of human ingenuity. It has given us a range of new instruments and mechanisms for financing health initiatives, making aid more effective, motivating industry to develop badly needed medicines and vaccines for diseases of the poor, securing funds for purchasing drugs from entirely new sources, and making the prices of medicines more affordable.
The experience during the past decade tells us: increased investment in health development is working.
Much attention is now focused on reducing maternal and newborn mortality, and this should be welcomed. A focus on the need to reduce these deaths means a focus on the absolute need to strengthen health systems.
At the same time, this focus must not draw attention away from other pressing health problems, including chronic noncommunicable diseases, as well as HIV/AIDS, tuberculosis, and the neglected tropical diseases. Recent measles outbreaks remind us of the need to maintain childhood immunization coverage at its current, unprecedented levels.
Second, make fairness a cornerstone of policies for international health development. Too many models of health development assumed that living conditions and health status would somehow automatically improve as countries modernized, liberalized their trade, and experienced rapid economic growth. This did not happen.
Instead, differences, within and between countries, in income levels, opportunities, health status, access to care, and life expectancy are greater today than at any time in recent history.
In a sense, the MDGs operate as a corrective strategy. They aim to compensate for international systems, for finance, commerce, trade, and foreign affairs, that create advantages, yet have no rules that guarantee the fair distribution of these benefits.
No wonder, then, that countries with developing and emerging economies are suspicious of international agreements, fearful that the rules are rigged to favour the privileged and the powerful. No wonder that international trade negotiations break down and agreement on the best collective response to climate change remains elusive.
Decades of experience tell us that this world will not become a fair place for health all by itself. Health systems will not automatically gravitate towards greater equity or naturally evolve towards universal coverage. Economic decisions within a country will not automatically protect the poor or promote their health.
Globalization will not self-regulate in ways that ensure fair distribution of benefits. 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. Equity happens only when equity is an explicit policy objective.
The values of equity and social justice are explicitly present in the EU approach to global health. They also underpin the design and delivery of health services in your own countries, which gives your voice on international issues added legitimacy and authority.
As I said, you are aiming high, addressing the hard issues, but I believe, right on track. And I want to commend you for your courage.
The MDGs represent the most ambitious attack on human misery in history. If the drive to reach these goals results in strengthened health systems and greater self-reliance, it will boost the health prospects of poor people living in poor places well beyond 2015.