WHO Director-General addresses ministerial meeting on universal health coverage

Dr Margaret Chan
Director-General of the World Health Organization

Keynote address at the Ministerial Meeting on Universal Health Coverage: the Post-2015 challenge
Singapore, 10 February 2015

Your Excellency, Prime Minister Lee Hsien Loong, Minister Gan, honourable ministers, distinguished experts, colleagues in public health, ladies and gentlemen,

It is a great honour to address a ministerial meeting on universal health coverage in Singapore, a city-state with an inclusive health system known for its affordable excellence. Last year, Bloomberg’s second annual ranking of countries with the most efficient health care placed Singapore at the top.

WHO also places Singapore at the top for key health indicators, especially maternal and infant mortality, two of the most sensitive indicators of a well-functioning health system. Through foresighted and visionary planning, Singapore achieved first-rate health care, with outstanding health outcomes, at a cost lower than in any other high-income country in the world.

This achievement was firmly anchored in a value system that places a premium on fairness and inclusiveness as a route to social cohesion, stability, and harmony.

Research guided individual strategies, but so did the wishes of the public, with opinion polls undertaken and conversations started to ensure that changes in the health system won public support and approval.

As we have just heard, Singapore’s version of universal health coverage balances the advantages of competitiveness and other market forces with the need for state intervention to steer these forces in the right direction. It balances freedom to choose providers, services, and facilities with an obligatory health savings account, the MediSave plan, with its emphasis on individual responsibility.

There is no free lunch. The plan works to protect against the over-consumption of care. To help inform responsible decisions, the Ministry of Health publishes hospital bills for common illnesses on its website.

Another innovation, MediShield Life, embodies the principle of collective responsibility through risk pooling. This is the safety net. It protects households from falling into financial ruin when medical bills are especially high. Studies conducted by WHO show that catastrophic medical bills force 100 to 150 million people below the poverty line every year. While many governments are working hard to lift people out of poverty, these efforts can be offset when the health system and its financing actually contribute to poverty.

As Singapore’s Minister of Health observed earlier this year, the scheme tells people that they “need not face life’s uncertainties alone, especially those who meet unexpected shocks in their life journeys.”

Of course, not all of these innovations can be applied elsewhere. UHC is intrinsically country-owned. To work well, it must be home grown in line with each country’s culture, domestic political institutions, the legacy of the existing health system, and the expectations of citizens.

In achieving UHC, Singapore had some distinct advantages. The huge challenge of extending health services to reach remote and impoverished rural areas was non-existent. Singapore has only one rural area, a small island and tourist attraction.

A tradition of cross-ministry collaboration makes it easier to address the upstream causes of ill health through environmental improvements and the use of fiscal and regulatory measures to encourage healthy lifestyles.

Singapore has also enjoyed political stability and a high level of public trust in government for decades. That helped as well.

With these advantages, UHC in Singapore has gone beyond providing and financing fair and inclusive health care. UHC in Singapore has worked as a strategy for building an inclusive, caring, and progressive society. These are assets for any country in the world.

Ladies and gentlemen,

Our world is in turmoil from multiple causes. The signs are there for anyone to see: fluctuating currencies, unstable economies, prolonged conflicts, ethnic clashes, and inexplicable acts of violence. Organized acts of terrorism are the newest omnipresent and unpredictable threat.

The climate is changing, antibiotics are failing, and health care costs are soaring. Inequalities, in income levels, opportunities, and access to social services, both within and between countries, have reached the highest levels seen in nearly a century.

Countries are losing their middle classes, the backbone of democracy. Last month’s Oxfam report on wealth distribution contains a startling statistic: just 80 rich and powerful people own more of the world’s total wealth than 3.5 billion people at the other end of the scale.

Many economists take optimism from the fact that several of the world’s fastest growing economies are in Africa, often fuelled by foreign extractive industries. But if you look at income distribution within these countries, what we are really seeing is more and more rich countries full of poor people.

An African medical blogger contrasted growths in GDP with weaknesses in health systems laid bare by the Ebola outbreak. He asked the following question. What good does it do to cover the ceiling of your house with golden paint when the walls and foundation have cracks?

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.

Universal health coverage is one of the most powerful social equalizers among all policy options. It is the ultimate expression of fairness. If public health has something that can help our troubled, out-of-balance world, it is this: growing evidence that well-functioning and inclusive health systems contribute to social cohesion, equity, and stability. They hold societies together and help reduce social tensions.

At a time when policies in so many sectors are actually increasing social inequalities, I would be delighted to see health lead the world towards greater fairness in ways that matter to each and every person on the planet.

Ladies and gentlemen,

As the world enters the post-2015 era, it faces health challenges that are far more complex than they were at the start of this century.

The sharp distinctions between health problems in wealthy and developing countries are dissolving. Everywhere, health is being shaped by the same universal pressures: the globalized marketing of unhealthy products, population ageing, and rapid urbanization.

Our very definition of what constitutes socioeconomic progress is being challenged.

Beginning in the 19th century, improvements in hygiene and living conditions were followed by vast improvements in health status and life-expectancy. These environmental improvements aided the control of infectious diseases, totally vanquishing many major killers from modern societies.

Today, the tables are turned. Instead of diseases vanishing as living conditions improve, socioeconomic progress is actually creating the conditions that favour the rise of noncommunicable diseases. Economic growth, modernization, and urbanization have opened wide the entry point for the spread of unhealthy lifestyles.

The ancient burden of deaths from infectious diseases has been joined by a newer burden of even more deaths from NCDs. Rapid unplanned urbanization has added a third burden: deaths from road traffic crashes and the mental disorders, substance abuse, and violence that thrive in impoverished urban settings.

The rise of NCDs adds considerably to the costs of health care. The costs of cancer care, for example, are becoming unaffordable for even the wealthiest countries in the world. In 2012, the US Food and Drug Administration approved 12 drugs for various cancer indications. Of these 12, 11 were priced above $100,000 per patient per year. How many countries can afford this cost?

Prevention is by far the better option, but this, too, is more problematic than for infectious diseases, many of which can be prevented by vaccines or cured by medicines, all delivered by the health sector.

The root causes of NCDs reside in non-health sectors. They escape the direct purview of health. When health policies cross purposes with the economic interests of sectors like trade or finance, economic interests will trample health concerns nearly every time.

Implementation of the WHO Framework Convention on Tobacco Control is a notable exception. It provides one of the best examples of cross-ministry collaboration, driven by overwhelming evidence of the health and economic costs of tobacco use.

It tells us that the health sector, working in tandem with others, can generate huge benefits. It can even tackle a powerful, devious, and dangerous industry on multiple fronts, including through fiscal and regulatory measures.

As yet another challenge in the post-2015 era, health and medical professionals in every region of the world are losing their first-line antimicrobials as drug resistance develops. In several cases, second-line medicines are failing as well. For some cases of multi-drug resistant tuberculosis and gonorrhoea, even last-resort antibiotics fail.

With few replacement products in the pipeline, the world is moving towards a post-antibiotic era in which common infectious diseases will once again kill. A post-antibiotic era is a game-changer on a par with climate change. But antimicrobial resistance will kill us before climate change.

Ladies and gentlemen,

I began with the strategies used by Singapore to achieve and sustain universal coverage. Let me conclude with the strategies used in a very different country: Bangladesh.

The Bangladeshi story shatters the long-held assumption that countries must first reduce poverty, then better health will follow almost automatically. Bangladesh decided to reverse the order by first freeing populations from the misery caused by ill health.

Driven by a commitment to equity, the country aimed for universal coverage of its vast and very poor population with a package of high-impact interventions. To compensate for a severe shortage of doctors and nurses, the country trained and then closely supervised a brigade of community health workers, mostly women, who followed a doorstep-delivery approach.

The country also used its world-class research capacity to experiment with innovations. Formal and contractual arrangements were made with nongovernmental organizations that were best placed to win community trust and reach marginalized populations. Improvements in school enrolment, especially for girls, and in agriculture brought huge benefits for health.

The efforts of Bangladesh were driven by another reality. When government health services fail to reach poor areas, private providers and shops selling medicines will mushroom. Charges for services from these unregulated and largely unqualified health care providers work to deepen poverty, not reduce it. To prevent this from happening, the government built and ran nearly 12,000 strategically located community clinics

Perhaps most important was the strong strategic bias towards women and girls. The approaches used explicitly recognized that empowered women will turn health into a nation-building strategy.

Their needs, including for sexual and reproductive health services, came first. Their human rights were legally protected. That approach led to a stunning reversal in excessive mortality of girls compared with boys

As we have learned from ample evidence, investing in health is investing in economic growth, investing in the health and well-being of people. Every country needs healthy human capacity to sustain development. Without this capacity, it is hard to even begin to talk about sustainable development.

The Singapore experience and all of the other experiences we have heard about give us one compelling message. Any country that really wants to move towards universal health coverage can do so. There are no excuses.

Health is likely one of the most precious commodities in life. But it is highly political and it requires investment. You need political leadership. You need commitment. And you need a conversation with the public, as has been done here in Singapore. I thank you for the opportunity to participate in this discussion.

Thank you.