Making investments in health work at a time of financial austerity
Dr Margaret Chan
Director-General of the World Health Organization
Minister Oda, Minister Mponda, excellencies, distinguished delegates, colleagues in public health, ladies and gentlemen,
Let me begin by thanking Canada for organizing this action-oriented forum. Canada has demonstrated outstanding leadership in maternal, newborn, and child health, exemplified by the G8 Muskoka initiative of last year.
Discussions during the forum are clearly designed to expedite the delivery, in different country contexts, of rapid results for the health of women and children.
The forum takes its impetus from the September 2010 UN Global Strategy on Women’s and Children’s Health and the need to spend, in smart ways, the $40 billion commitments of support.
The forum takes its focus from the May 2011 report of the Commission on Information and Accountability for Women’s and Children’s Health. I was asked to coordinate the Commission together with the Secretary-General of ITU. The Commission was co-chaired by President Kikwete of the United Republic of Tanzania and Prime Minister Harper of Canada.
The Commission set out an accountability framework with three interconnected processes: monitor, review, and act. These processes are aimed at learning and continuous improvement.
The framework places accountability soundly where it belongs: at the country level, with strong links between country-level and global mechanisms for tracing resources and tracking their results.
The Commission’s recommendations are sharp, smart, and lean. They include a small but balanced set of core indicators for measuring results, charting progress, and adjusting strategies accordingly.
Broad indicators for monitoring the health status of women and children are supported by a tracer set of eight coverage indicators that can more precisely show progress over short periods of time. These tracer indicators are more sensitive and timely, designed to monitor almost real-time changes in coverage.
By informing more people about the Commission’s recommendations and engaging them in discussion, the forum vastly increases the likelihood that these recommendations will be followed and implemented as intended.
The forum takes its practical guidance from a detailed workplan for translating the Commission’s recommendations into action. The workplan was finalized in September following a two-day consultation with stakeholders.
The workplan has its eye on both making fast results feasible and sustaining those results by building specific capacities. It proposes 29 activities for making the Commission’s recommendations operational.
It greatly facilitates rapid action by identifying existing instruments, methodologies, guidelines, and best practices that can be used immediately or easily modified to fill gaps or tackle problems.
Oversight, which includes identifying the best value-for-money approaches, has been assigned to an independent Expert Review Group, which was established in September of this year. The Group will hold its first meeting during this forum.
I have given specific dates to show you how fast things are moving. This is because a multitude of stakeholders are now in a position to work in unison according to uniform methods and unified operational approaches.
We are working to concentrate the efforts of the international community on an institutional need that has been neglected for decades. That is, the need for well-functioning systems for collecting and analysing health information, including information on resources and expenditures.
Accountability means counting: counting the resources actually delivered and measuring their impact, but also counting births and deaths, and investigating and recording the causes of these deaths.
We are working to rapidly accelerate progress on the two MDGs where problems have been especially stubborn and progress has been way too slow. We have hit the ground running, but are running out of time.
We can take heart from the Commission’s expert opinion. Although many low-income countries remain off-track to meet the goals for maternal and child health, it is not too late for the goals to be attained.
Ladies and gentlemen,
I find what has happened, is such a short time, extremely exciting and extremely promising as a model for better international health cooperation, but also as a model for good global health governance.
At a time of deepening financial austerity, countries that have traditionally supported health development are under intense domestic pressure to spend money cautiously and wisely. This pressure is reshaping development assistance with a firm emphasis on value for money and a demand to demonstrate that investment brings rapid and tangible results.
I believe this is the beauty of where we stand today as you look at ways to deliver results. We have dared to step into the real, almost Wild-West territory of neglected needs for capacity, and to address them, head-on, as a top priority.
In the past, initiatives have tended to build bridges and expressways over these needs, hoping to bypass them, yet still get results. This did not happen.
The territory is sadly familiar. Health system infrastructures and capacities have been crumbling, falling apart, throughout the developing world for decades.
A Wild-West frontier is usually lawless. And this has been the case, with no firm operational plan coordinating the behaviour of multiple development partners and implementing agencies, no mechanisms in place for holding donors, recipient countries, and other partners accountable.
Finally we have the will, and the tools, to address these fundamental problems, with countries in the driver’s seat.
Ladies and gentlemen,
Without information, at country level, we can never have accountability. Without information, we can never know what a “best” or a “wise” investment really means. Without information, we are working in the dark, pouring money into a black hole.
Against this background, let me profile our new prospects for success that you will be exploring during this forum.
The Commission identified 75 countries that together account for 98% of maternal and child deaths. Of these, 49 lowest-income countries have been targeted for particular focus.
More than 40 countries with the greatest burden of women’s and children’s ill health have made written commitments following the Secretary-General’s call for action. Some include explicit or implicit commitments of domestic resources, the true proof of political resolve, which is essential for success.
In addition, special efforts are being made to engage fragile states and countries characterized by low government capacity, especially as the burden of maternal and child mortality is often highest in this group of countries.
Thanks to IHP+ and other initiatives, including the H4+, mechanisms are already in place in several countries for greater coordination of partners and greater accountability in recipient countries.
And now, just this month, we have a brand new guide setting out the steps to follow when developing a country-led platform for information and accountability.
The guidance was developed by WHO in close collaboration with GAVI, the Global Fund, and the World Bank. We also collaborated with many partner and country representatives in the context of IHP+ and related initiatives. In other words, this guidance is trustworthy, and it has been tested where it counts: in countries.
As another bonus, catalytic funding is now available to get the ball rolling and attract more funds. For example, catalytic funding can be used to help a ministry of health draw up a good survey plan. A good plan can convince in-country donors that funding the actual survey is a wise investment with a solid pay-back.
As another example, catalytic funding can support an initial facility assessment to verify the reliability of data being generated, thus building confidence for all users of the data.
Finally, the Commission and related workplan fully recognize the potential of information and communication technologies to help countries, and their information systems, take a huge leap forward. Ways of doing so, including benefiting from the work of the Broadband Commission, are set out in the workplan.
But let me also profile the magnitude of the challenge with just a few statistics.
At present, 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.
The existing system of health accounts gives countries a set of consistent methods for producing health expenditure estimates. But only 43 countries have the capacity to produce such estimates routinely, instead of on a costly one-off basis.
Unfortunately, very few of these countries are among the 75 countries targeted by the Commission. In addition, only seven countries have used sub-accounts to generate estimates of spending on child health.
Of the 75 priority countries, WHO was successful with only 15 in its efforts to collect information on government expenditure and budget allocation to reproductive, maternal, newborn, and child health.
As yet another problem, a considerable proportion of development assistance for health, as reported by donors, never reaches the countries. This money may be spent in the donor’s own home institutions or on their administrative expenses, further complicating the tasks of resource tracking and securing predictable funds.
This also makes it even harder to know if promises are being kept.
These are some of the challenges, and we are now in a position to address them.
Ladies and gentlemen,
We are poised to move forward quickly with a well-planned and frontal attack on stubborn health problems that have persisted despite great advocacy and great efforts over many decades.
This tells us: something is wrong in the way we have been doing things. This tells us: we must change the approach in radical ways.
And this is what has happened. This is where we stand today as this forum moves us, yet again, forward.
I see us, too, as embarking, together, on a revolutionary shift towards good global health governance, building not just capacity within countries, but a model for better international health cooperation that will serve us well in the future.