Seminar at the King's Fund
London, 14 January 1999

PUBLIC HEALTH FOR A NEW ERA

Ladies and gentlemen,

My mission today is to highlight the role of health as a strategy for alleviating world poverty. My message can very shortly be summarized as follows:

There is solid evidence to prove that investing wisely in health will help the world take a giant leap out of poverty. We can drastically reduce the global burden of disease. If we manage, hundred of millions of people will be better able to fulfil their potential, enjoy their legitimate human rights and be driving forces in development. People would benefit. The economy would benefit. The environment would benefit. It is a complex process – but it can be done.

Let me at the outset pay tribute to the Kings Fund for their longstanding efforts to raise attention on the burden of poverty. We need strategic, vocal advocates – such as the Kings Fund.

I am also pleased today to be here together with Claire Short and Tessa Jowell and to pay tribute to the new and committed policies of the British Government. The White Paper on Eliminating World Poverty blew a fresh wind into the international struggle to reverse the spiral of growing poverty. Particularly, I like the message of opportunity – that it can be done – that the tides can be turned, and that poverty is not a permanent and given feature of human development.

It is a great pleasure to meet again with Professor Amartya Sen and to be able personally to congratulate him on his Nobel Prize award. Having placed poverty and development at the core of economic theory, linking the social and economic dimensions of human development, he has been instrumental in shaping international development thinking. For far too long the broad international community: governments, industry and scores of economic actors, regarded poverty and human suffering as a side effect of the modern world economy.

I have always believed that you cannot make real changes in society unless the economic dimension of the issue is fully understood. I firmly believe that this is what took the environment from being a cause for the convinced and marginal green to becoming an issue for real societal attention by major players. The scientific facts came in. The true cost of environmental degradation were analysed and spelled out in figures. Then, gradually, governments and parliaments started to vote incentives to change behavioural patterns among industry and consumers.

There is still far to go in the field of environment and sustainable development. But the trend is there. And a new trend may be set in motion as we see and understand the broader implications of poverty.

For the World Health Organization this means real inspiration. We have now strengthened our intellectual capacity to prove how economic logic can underpin sound health policies. We intend to collect, analyse and spread the evidence that investing in health is one major avenue towards poverty aliviation. And we share the British Government's conviction that we can succeed – because again – nothing is stronger than an idea whose time has come.

Overall this has been a remarkable century for human development. Half a century ago the majority of the world's population died before the age of 50. Today average life expectancy in developing countries is 64 years and is projected to reach 71 years by 2020.

But as we pride ourselves on the trends in the traditional macro-indicators of health status – life expectancy and infant and child mortality – poverty has been eating away at many of the health gains. I believe it can be said as harshly as this: We risk going down in history as the generation that allowed the hard-won health achievements of the century to be lost.

Let us look briefly at the facts.

For 20 years our global health strategy has been based on the principle and value of equity. Yet, inequalities have been opening up under our very feet – between nations, as well as within them. The focus in many countries has been on bridging the gap between the middle class and the very rich. The poorest are often left out of this effort. That must change.

Never have so many had such broad and advanced access to health care. But never have so many been denied access to health. The developing world carries 90 per cent of the disease burden, yet poorer countries benefit from only 10 per cent of the resources that go to health.

One fifth of humanity does not have access to modern health services. Half of us lack regular access to essential drugs.

Between 1996 and 1997 the human development index declined in more than 30 countries. Well over one billion people in the world are unable to meet their daily minimum consumption needs. Almost one third of all children are undernourished. The average African household consumes 20% less today than it did 25 years ago!

Let us be really global and focus attention also at poverty in rich industrialised countries. Here too, growing numbers of poor and socially excluded people bear a disproportionate burden of ill health.

The Human Development Index shows that even in affluent industrial countries, between 7 and 17 per cent of the population is poor. That adds up to more than 100 million people.

The recent Independent Enquiry into Inequalities in Health in England provides a detailed picture of how health has been affected by low income, limited education, unemployment and under-employment. In the United Kingdom a child born today in the highest social class can expect to live 5 years longer than a child born among the poorest. Across the Atlantic, the figures are even more striking. According to one study of differences in life expectancy within the United States, an affluent, white woman can expect to live a shocking 41 years longer than a poor black man.

Many rich countries are in danger of creating a permanently poor underclass. Many of these people are chronically ill, too sick for productive work and unable to give their children the start in life which could help them escape the predicament of their parents.

This is not only shameful. It is very costly that knowledge may be what decision-makers need to wake up to the realities that our societies have to deal with the effects of poverty even if we have not been able to prevent it. The main burden on the health care systems of rich nations in the next century will be from lung and heart diseases, cancer, diabetes, mental disorders and accidents. A disproportionate number of those suffering will come from the 7 to 17 per cent who live in poverty.

We need a broad global focus on poverty, and the multi-dimensional deprivation which is part and parcel of it.

We have known for a long time that poverty breeds ill health. What some have long suspected but which only recently has become evident is that it works both ways. Ill-health perpetuates poverty.

So turning it around, we end up with a simple, but vastly significant assertion: Improved health is a key factor for human development and again for the development of nations and for their economic growth.

That brings us back to the role of health in economies. New research evidence shows us that health is a net contributor to long-term economic growth and particularly to lifting the poor out of poverty. Suddenly, in the space of a few years, perceptions are turning full circle. From being an unproductive consumer of public budgets, health is now gradually seen as a central element of productivity itself. At least when health services are properly organized and investments in health are well thought through.

I believe that until now the international health community, including WHO, has undersold this fact. In a time of global trade and investment, where nations are searching for ways to gain a competitive edge, we have been sitting on a great secret. We haven't really seen that this is a message we should take to the political decision-makers and to the private sector. We need to remind Presidents, Prime Ministers and Finance Ministers that they are health ministers themselves.

At the core of recent development thinking lies a new awareness of human capital; the knowledge, skills, experience and innovation which people contribute to production. We endorsed this approach at the highest political level at the Social Summit in Copenhagen in 1995.

Health, education and good nutrition are essential for building and maintaining human capital. Until it was halted by the recent economic crisis, the rapid economic growth in East Asia owed much to strong investment over the past 30 years in education and basic health services, including reproductive health, provision of safe drinking water and control of communicable diseases.

It can be disarmingly simple. A study from Indonesia shows that workers who are treated for anaemia are 20% more productive than those who are not treated. It can also be frustratingly complex, as the negative cycles of unemployment, poverty and ill-health in rich countries bear witness.

The emerging literature on these and other experiences is leading to a straightforward conclusion. Improving health in poor countries leads to increased GDP per capita. In richer countries, it reduces overall costs to society. The benefits are likely to be greatest for the poorest and most vulnerable.

But it is not automatic. The bottom line is access to quality services and the promotion of public health. The more countries move in the direction of universal coverage, the better the effect – on both social and human capital. This is the basic message WHO now is taking to decision-makers around the world.

At WHO we are starting to address what we see as the need for "a new universalism" - a new way of addressing universal coverage - the attainment of better health and the attainment of international development goals. Universal access to quality care remains the bedrock principle. Governments should be responsible for securing people's opportunity to attain these health goals. Only the Government can guarantee this basic universal right. Governments should provide strategic leadership - through setting priorities - accepting that there are limits to the care governments can finance, limits that each country has to define for itself.

A critical condition is to secure sustainable funding for the public sector – so often under constant attack. Globally we need to pledge our support to the Copenhagen Summit's 20/20 initiative. The aim is simple – to persuade donors to invest a minimum of 20% of their development aid in basic health, education and social services in exchange for similar commitments in the national budgets by recipient governments.

20/20 is about input. WHO will be focused on the outcome – on the strategies to reach concrete health outcomes for development.

This is not a call for the return to the simplistic philosophies of the 1960s and 1970s, which prophesised that pouring huge sums of aid into the public coffers of poor countries would quickly bring prosperity and development. We need to develop new and transparent partnerships to strengthen the foundations for development.

Many developing countries experience scores of donors coming on separate missions, offering partial assistance, and all to often overburdening the capacity to properly tailor the assistance to the real needs. At WHO we will embark on a thorough reform of the way we work to support countries – aiming at strengthening the health sector to define its own priorities and seeing to it that the approach to development is sector-wide and not fragmented.

Today, we are living in a sober age of complex economic realities. Although many countries spend far less on health than necessary, a few may even spend too much. In USA, health care expenditure exceeds 16% of GDP. Yet more than 40 million Americans don't have health insurance.

In India, as a result of pollution and environmental degradation, annual health costs are estimated at nearly five per cent of GDP or more than eight billion dollars. In other words, health systems have become the dumping ground for the consequences of inadequate policy.

Either way both health and money are wasted.

Striking the right balance between controlling health costs and ensuring that adequate resources are available for health is a delicate political and economic exercise. Economic realism, linked to science-based knowledge and the basic principle of the right to health care for all, must be the foundation for any health systems development in the coming century.

This means strengthening the planning and decision-making capacities of governments in developing countries. WHO's role is to be an advisory partner in this challenge.

This will require good governance. Let us be frank. For far too long, in many developing countries, resources have been misdirected away from the poor and the needy, in a system that lacks transparency and accountability. When the bill to clean up after the financial disasters caused by years of cronyism and corruption is presented, the poor all too often again have to pay the price through cuts in spending on health and education.

The international financial institutions must clearly emphasise good governance as one of their lending criteria. In WHO, we will strengthen our emphasis on this aspect in our advisory role with our Member States, and in our advisory role to the Bretton Woods institutions.

But let us also recall the unresolved issue of crippling debt which eats up resources, and, as in East Asia, precipitates entire economies into chaos. In Mozambique debt servicing in 1994 represented the size of the budgets of health, education, police and judicial systems combined. In WHO, we are gearing ourselves to provide better advice to governments, as well as to financial institutions on mitigating the negative effect of these problems on health.

And in doing so – let us not forget another sad fact: development assistance is in severe decline. Rich countries have committed to 0.7 per cent of GDP. I know that is a tall order – having had to defend the budgets of a country that has consistently earmarked close to 1 per cent. A very few countries stick to their obligations – but the world average is getting close to 0.2 per cent. As Martin Luther King said : The check has come back from the bank of justice marked « insufficient funds ».

Why is it that we are making such a limited impact on poverty and its health consequences when there is such convincing experience and scientific evidence in favour of effective policies and action?

Part of the answer is complacency. It's the philosophy which says "I don't have to prevent it because when I get it, I'll just take a pill." Let's not underestimate that complacency. It's promoted by powerful interests in health care technology, and too often by the health professions themselves.

Part of the answer is the tendency for health professionals to see themselves first and foremost as scientists and technicians. Sometimes we tend to forget our roles as responsible citizens. Let us recall the words of Rudolf Virchow written 150 years ago: "Medicine is a social science and politics is nothing but science on a large scale." This has been my own life-time experience.

The health professions should have not only a moral and civic interest but also a genuine professional interest in poverty reduction, although many choose to push poverty aside by saying that poverty is purely an economic phenomenon, and therefore none of their business.

I welcome the initiative of the Royal Colleges in this country to establish the Intercollegiate Forum on Poverty and Health. It's an unequivocal statement that the health professions can and must play their part in tackling poverty and its health consequences. I'm delighted that the Forum is a partner of WHO.

I feel a critical part of the answer lies with public health. Public health used to have a leadership role in development, with tangible results. Over the years public health may has lost on its leadership role – although country after country committed to Health for All. We need to rebuild public health for a new era. I am determined that WHO will play its key role in that process – especially by bringing the message to decision-makers beyond the health community.

To be effective, public health professionals must learn to work at the heart of the political process with their elected political leaders. The UK government has given health a push in this direction – and let me use this occasion to salute one specific and recent initiative; the White Paper on Tobacco control – Smoking Kills. I know how Tessa Jowell has fought for this issue – and I truly know we will need such commitment as WHO takes its Tobacco Free Initiative forward – and especially as we begin a crucial process in shaping a Framework Convention on Tobacco Control.

Good evidence – based health policies are not the property of the left or the right side of the political spectrum. However, that does not mean that we should not go out into the political field. Unless we do, we will not influence change.

Success will depend on forming public opinion and stimulating public action through elected representatives and civil society - at local, national, regional and global levels. In doing so we need to argue the case that health is a fundamental human right. We need to draw on the key values enshrined in the Universal Declaration of Human Rights. Health security is a notion which encompasses many of the rights enlisted in the Declaration. It means universal access to adequate health care, access to education and information, the right to food in sufficient quantity and of good quality, but also the right to decent housing and to live and work in an environment where known health risks are controlled. Equity is the core principle of public health. Let us never cease to promote it.

And let us not forget the gender bias – that women bear the largest unfair health burden of poverty. I am determined that WHO will do a better job in meeting their health needs. Women represent half of the world's population, more than half of the world's poor but much less than half of the world's political and economic decision-makers.

WHO cannot change that. But we can make a contribution. I have appointed a senior management team with equal numbers of men and women, in fact at present we are 60 per cent women and 40 per cent men at the highest level. But much remains to be done to achieve parity throughout the organization. We will chart a steady course towards that goal.

I am happy that Mrs Poonam Khetrapal Singh is here with me today. She is the Executive Director responsible for the cluster of programmes dealing with Sustainable Development and Healthy Environments. This is a new emphasis at WHO – pulling together programmes that in the past worked separately – acknowledging that sustainable development and health cuts across sectors.

Following the initial period of restructuring at WHO Headquarters I intend to establish a high-level group of external advisers on the role of health in poverty reduction. A majority of its members will be drawn from beyond health, from economics and development.

I shall also seek the collaboration of eminent public health professionals from around the world, North and South, to establish a partnership, modelled on the Cochrane Collaboration, devoted to reviewing experiences and impacts of broad, inter-sectoral, public health responses to poverty. I look forward to the opportunity to discuss how institutions in this country might play a leading role in building this collaboration for public health.

There may be signs of change. My recent experience is that at the highest political levels, globally and in countries, health is increasingly seen as a key dimension in the human development process and in the urgent task of poverty reduction.

A few weeks ago I met at length with President Jiang Zemin and Prime Minister Zhu Rongji of China. We discussed public health issues which are at the very core of China's future economic and social development. These included the need to drastically reduce tobacco consumption; the implications of HIV/AIDS and TB; health sector reform and the need for securing universal access to basic health services.

My meetings with many political leaders in the months preceding and following my

election have convinced me that a new political commitment can be forged to correct the mistakes and excesses of market liberalisation, and to take seriously the vision of sustainable human development. In part this commitment has emerged as consensus from the series of UN Summits on social issues which started at Rio with environment in 1992 and concluded with the Social Summit at Copenhagen in 1995.

Summits in themselves do not solve problems. But they may focus attention, help mobilize attention and build commitment. Into a new century time will come to place a new global focus on health, gathering support for new knowledge of the crucial role played by health in development, connecting health to the broader process of societal change and seeking endorsement of crucial principles of equity and human rights.

We need a firmer grasp of the political agenda. It happens that political decision-making is driven by vested interests and concerns of organised groups. At the end of the day, what makes the difference is the ability to compete, negotiate and influence in order to win attention and support for change.

Too often, public health has been a very weak competitor. Even within the health sector itself, public health is too often the loser in competition for budgets. Typically, public health receives less than 5% of total health care budgets and policy concerns are dominated by the demands of medical care and treatment rather than prevention.

In tackling poverty and its myriad effects on health we will require effective advocates of the key health interest in other fields, such as fiscal or trade policy, food security or accident prevention – where the primary responsibility lies with other sectors.

The poor are the most exposed to the risks of a hazardous environment, and the least informed about threats to health. It is the poor who bear the brunt of crude structural adjustment policies and unregulated globalisation, of epidemics such as HIV/AIDS, malaria and tuberculosis.

WHO will play its role in putting poverty alleviation first – in the firm belief that poverty is the main source of ill health – as it is the main source of environmental degradation. We are in the process of reorganising and streamlining our structure to help us work more effectively in the development arena. This includes much closer partnerships with sister agencies of the UN system, the Bretton Woods Institutions, the NGO community and with the private sector.

On Roll Back Malaria – aimed at fighting one of the most devastating diseases of the poor - we work in alliance with UNDP, UNICEF, the World bank and private industry. On the Tobacco Free Initiative – aimed at fighting the number one cause of disease and suffering into the next century – tobacco - we are partners with the World Bank, UNICEF and a number of NGOs. Such alliances are crucial. Any single agency will not make it alone.

Both the World Bank and the International Monetary Fund have undertaken significant policy shifts. They are advocating a central role for health - calling on Ministries of Finance to protect health budgets, even to increase them, and, in the case of the Bank, substantially increasing lending for health.

I have agreed with Mr Wolfensohn and Mr Camdessus that they and WHO will strengthen links and collaboration. This is a brand new kind of co-operation. Truly, we have different roles to play – and often different interests to defend. But we need to pull together. We are there to serve the same member states – and ultimately to help foster sustainable development.

Together, we will provide better policy advice to countries on the contribution of health in reducing poverty and how best to allocate budgets so that health gains are maintained even during economic crises. We have already initiated collaboration in selected countries.

The events of the last two years – the HIV/AIDS pandemic, the dramatic health decline in Russia, the social consequences of the crises in Asia – they all have provided us with a new chance to detect the weaknesses and stresses in some rapidly changing social and economic systems. It is a chance we should grasp. In many ways, the events at the end of this decade have been a warning light. Unless we act now, we may face crises of ever more severe consequences the next time around.

A window of opportunity has opened up. We should use it to provide convincing advice, backed up by hard evidence, on the best policies and cost-effective processes through which health can fulfil its development potential.

So let me repeat the message:

There is solid evidence to prove that investing wisely in health will help the world take a giant leap out of poverty. We can drastically reduce the global burden of disease. If we manage, hundred of millions of people will be better able to fulfil their potential, enjoy their legitimate human rights and be driving forces in development. People would benefit. The economy would benefit. The environment would benefit. It is a complex process – but it can be done.

Thank you.