Keynote speech at an informal meeting of the health ministers of the European Union
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, colleagues in public health, ladies and gentlemen,
Prevention is the heart of public health. Equity is the soul. And these days, politics must be our bedside manner if we want to get results. I am sure Sir Michael would agree.
I thank the Spanish Ministry of Health for this invitation and welcome the opportunity to address some issues surrounding the pursuit of greater equity in health. I am aware of Spain’s commitment to this goal during its presidency of the European Union, and its leadership on other health issues, including chronic noncommunicable diseases.
In terms of equitable access to health care, European health systems are often put forward as a model of admirable values and workable solutions for the rest of the world. As the critics say, your success shows that a well-managed welfare state is not the enemy of globalization. Instead, it is the saviour.
I believe this thinking applies to international health development as well. In a sense, the Millennium Declaration and its goals are a corrective strategy. Founded on the principles of equity and social justice, they aim to compensate for international systems that create benefits yet have no rules that guarantee the fair distribution of these benefits.
Aid for development can be the saviour of globalization, if it is well managed. The logic for good aid is straightforward. 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 in a fundamental way.
I welcome the EU’s commitment to effective aid, to the principles set out in the Paris Declaration, and to the process set out in the International Health Partnership. I welcome the goal of coherence in all your policies, in multiple sectors, that can contribute to greater equity in health outcomes and in access to quality health care.
Public health provides a good platform for looking at equity and how it is influenced by the way societies are organized and power and resources are distributed. In the health sector, equitable access to quality care makes a clear-cut life-and-death difference. This difference can be measured. It is often shocking. It violates our sense of fairness and justice. And it compels us to act.
When we decide to act, we need to think about more than just the money needed to purchase commodities. I welcome, in particular, the EU’s commitment to strengthening health systems, information systems, the health workforce, access to medicines, infrastructure, and logistics as essential for the delivery of equitable health care.
Ladies and gentlemen,
Prevention and equity are traditional pursuits for public health. But since the start of this century, the route to both has become far more complex at a time when the need for both has increased.
All around the world, health is being shaped by the same powerful forces, like demographic ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles. Policy spheres are no longer distinct. More and more, the causes of ill health arise in other sectors, or from policies in the international systems that govern finance, economies, commerce, trade, and foreign affairs.
More and more, the true upstream causes of ill health lie beyond the direct control of public health. More and more, health is on the receiving end of bad policies made in other sectors.
Let me be specific. I am talking about policies that caused food prices to soar. Policies responsible for climate change. Policies that have industrialized food production and globalized the marketing of unhealthy lifestyles. And policies that have undercut the market for agricultural products in developing countries, where agriculture remains the backbone of most national economies.
Last month, South African Archbishop and Nobel laureate Desmond Tutu answered ten questions for Time Magazine. When asked what Africa needs most to make progress, his answer was succinct. Fair trade, he said. A fair international economic system.
Global trends also threaten equity in unprecedented ways. What makes events, such as the global financial crisis, so broadly damaging is the fact that they come at a time of radically increased interdependence among nations.
These days, the consequences of a crisis in one part of the world quickly ricochet throughout the international systems that bind us all so closely together. Though highly contagious, the consequences are not evenly felt. In fact, they are profoundly unfair. Developing countries have the greatest vulnerability and the least resilience. They are hit the hardest and take the longest to recover.
Already now, the differences, within and between countries, in income levels, in opportunities, in health status, life-expectancy, and access to care are greater than at any time in recent history. Already now, nearly one billion people live on the margins of survival. It does not take much to push them over the brink.
Ladies and gentlemen,
For all of these reasons, an approach to health that addresses social determinants as prime causes of ill health has much to offer. Of course, we have known, intuitively, for ages that factors like poverty, social disadvantage, crowded substandard housing, and filthy environments contribute to ill health.
The primary health care approach, as articulated in the Declaration of Alma-Ata more than 30 years ago, recognized that prevention requires collaboration with multiple non-health sectors.The report of the Commission on Social Determinants of Health, issued just weeks before the financial crisis hit the headlines, takes the agendas for prevention and equity several steps forward.
The Commission found abundant evidence that the true upstream drivers of health inequities reside in the social, economic, and political environments. In the final analysis, the distribution of health within a population is a matter of fairness in the way economic and social policies are designed.
In its traditional concern with prevention, public health has much to gain when biomedical approaches to health and disease are extended by a focus on social factors that directly shape health outcomes and explain inequities.
As obvious examples, the health sector can treat the costly consequences of bad diets, obesity, tobacco use, the harmful use of alcohol, and traffic crashes. But prevention, which is by far the better option, depends on action in other sectors, whether involving trade agreements, food production and marketing policies, road design, or regulations and their enforcement.
Importantly, this is not a call for more financial investment. Health programmes do not need to invest in these other sectors, but they do need to work with them to realize shared benefits in a whole-of-government approach to health.
Ladies and gentlemen,
The Millennium Development Goals have been good for public health. They have demonstrated the value of focusing international action on a limited number of time-bound objectives.
They are strategic and selective, and do not cover all health problems important for development. But in the drive to reach the Goals, weaknesses are being uncovered and solutions are being found that benefit public health across the board.
I am speaking to officials from countries that have been unwavering in their commitment to the health-related Goals. I am speaking to officials who represent one of the biggest and best partners for health development.
Your governments are not only the leading source of financial support, but also key players in capacity development, and a decisive and trusted voice in shaping international policies. Let me assure you that your contributions are deeply appreciated, and they are bringing results.
During the previous decade, 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 number of under-five deaths dipped below 10 million for the first time in almost six decades and then dropped again to below 9 million.
The yearly number 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.
But the goal set for reducing maternal mortality, the goal that depends absolutely on a well-functioning health system, is the least likely to be met of all the eight goals, in all parts of the world.
Nonetheless, I do believe we have cause for optimism. The global health initiatives formed to drive progress towards the health-related goals are sometimes accused of weakening health systems. I do not agree. Following decades of neglect, health systems were already weak, sometimes near the breaking point.
The AIDS epidemic demonstrated the importance of equity in access to health care in a compelling way. When antiretroviral therapy became available, an ability to access medicines and services became equivalent to an ability to survive for many millions of people.
An articulate community of activists insisted that an unmet need on such a scale and of such life-and-death significance demanded action. This is the essence of the equity argument. People should not be denied access to life-saving interventions for unfair reasons, including those with economic or social causes. The same is true for vaccine-preventable diseases, malaria, and tuberculosis.
The global health initiatives formed to address these diseases were established with a strong sense of purpose and 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.
One of the strengths of these initiatives is their capacity to learn and adapt. The momentum and drive to reach the health-related goals have made specific weaknesses in health systems much more visible and much more obvious as significant obstacles to progress. This, in turn, has allowed a more precise definition of problems and a more targeted approach to solutions.
And solutions have come. Innovations are helping to bring health staff to rural areas and keep them there. They are reducing drug prices, changing legislation, and exploiting advances in information and communication technologies. These innovations have unquestionably streamlined operations, created efficiency gains, saved money, and saved lives.
Perhaps most important, they have upgraded the quality of patient care with quality-assured interventions and standardized treatment protocols, setting a new benchmark for global health.
The countries represented in this room have contributed to, and often led, many innovations that promote greater equity. Like advance market commitments, the international finance facility for immunization, UNITAID, and a new breed of strategic R&D partnerships that are developing new medicines and vaccines for diseases of the poor.
These innovations have already had a measurable impact. But they also have great symbolic value. They tell 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.
Ladies and gentlemen,
As I conclude, let me give you a frank assessment of the challenges we face.
Changing human behaviours is harder than delivering commodities. Both are critical for public health. Securing funds to strengthen fundamental health capacities is harder than securing funds to buy medicines, vaccines, bednets, and condoms. Public health needs both.
Working for health in a country riddled by conflict and corruption is much harder than seeking health gains in a stable country with good governance. This is no excuse for ignoring unmet health needs or turning a blind eye to human misery.
But the hardest thing of all is persuading world leaders or ministers in other sectors that health concerns can, in some instances, be more important than economic pursuits.
This is what a social determinants approach asks us to do. This is why sharp political skills, an ability to diagnose the political landscape, must be the bedside manner of public health if we want to get results.
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.