Geneva,
9 April 1999

En français

Global Health into a New Century

Here is – as I see it – the big picture in global health.

We are leaving a century of remarkable progress which has revolutionized the health conditions of most of humanity. But over a billion people have not shared in the health gains of the last decades. The gap between what is potentially achievable and what we actually achieve is wider than ever before.

Bridging this gap – dealing with the unfinished agenda of the 20^th century – is not only key to improving the health of millions. It is fundamental to a much larger goal – reducing the number of people that live in absolute poverty.

My main message to you is that with wise investments and the right policies we can achieve major breakthroughs in the fight against poverty over the next 10 to 15 years. I believe the role of health in combating poverty has been underestimated. The key players in the UN family – working closer together – reaching out to other partners in development – underpinning our collective advice with solid evidence - can help change that.

We stand on the brink of a massive transition in global health.

Today, three conditions contribute disproportionately to the global burden of disease: respiratory diseases, diarrhoea, and perinatal conditions. It is a familiar landscape which has not changed much for the last 50 years.

The leading risk factor is still malnutrition. Then follows poor water and sanitation and finally unsafe sexual behaviour – largely linked to the spread of HIV/AIDS.

Looking ahead towards 2020 the picture will change. The three leading causes of lost years of healthy life are likely to be heart disease, depression and road accidents – unless there are new and yet unforeseen surprises caused by communicable diseases.

What is driving this transition?

An ageing population will dramatically alter the range of problems that health systems have to address. Non-communicable diseases and injuries are on the rise and they are more common in older age groups. Ageing and changing lifestyles will significantly increase the number of people suffering from these conditions.

The decline in mortality from childhood communicable diseases is expected to continue, although the rise in antibiotic resistance looms as a very serious threat.

We know that the tragedy of the HIV epidemic which has so dramatically increased young adult mortality in Sub-Saharan Africa will continue to take its toll.

And finally there is the other emerging epidemic related to tobacco use. Deaths from tobacco are expected to increase from 4 million in 1995 to nearly 8.5 million in 2020 with the largest increases in Asia. That represents 10 per cent of all disease burden worldwide, making tobacco the single largest cause of disability and premature death.

As a result of these trends, most low and middle income countries are already facing a double burden of disease. They suffer an unacceptable backlog of common infections, malnutrition and reproductive health problems. At the same time, without having addressed these challenges, they have to cope with the emerging problems represented by non-communicable diseases, heart disease, cancer, new infections and injuries.

The health sector will face major challenges in dealing with these mounting trends.

One of the most profound social transformations of the 20^th century has been the consolidation of a specialised sector of the economy dealing with health care. Today, formal health services represent a vast industry absorbing 9% of world product - more than 2000 billion dollars per year.

But there is an inverse relationship between the distribution of need and the distribution of resources. 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.

These aggregate figures disguise even more disturbing inefficiencies and inequities within countries. All over the world national health systems misallocate resources to interventions of low quality or of low cost efficacy.

There is growing evidence from a number of countries that the poor spend a higher proportion of household income on out-of-pocket payments for health services. We know too that the catastrophic expenditures that results when a family member suffers major illness can be one of the most important causes of deepening poverty.

Solidarity in health care financing counts among the major social achievements of the 20^th century in all but a few of the industrialised nations. With notable exceptions, most low and middle-income countries have not been able to fully develop such systems. On the contrary, many of these governments are now forced to cut budgets and downsize the public sector, moving even further away from universal coverage.

This creates new inequities in health and perpetuates poverty. And growing inequities are not only an ethical question. It is also economically inefficient and leads to loss in productivity and undermines the potential for economic growth.

So, what should be our agenda?

First we must clearly be focusing on those interventions that can reduce the burden of excess mortality and morbidity suffered by the poor.

This will mean giving renewed attention to diseases like malaria and tuberculosis which disproportionately affect poor people, as well as HIV/AIDS. These diseases are human tragedies but also major constraints to economic growth. Roll Back Malaria and the Stop TB initiative are attempts to mobilise a new kind of partnership to attack these leading killers.

Women and children suffer poverty more than men. We need greater investments in reducing maternal mortality and we know how little it takes to improve maternal and childhood nutrition. WHO will intensify its effort in the field of Reproductive Health as a follow-up to the Cairo conference – working in new ways and in closer collaboration with sister agencies and bilateral partners. I had good discussions with Nafis Sadik yesterday and the two of us will now jointly address our country representatives to reiterate our common goals and objectives.

We need to revitalise and extend the coverage of immunization - one of the most powerful and cost-effective technologies available. Together with UNICEF and the World Bank we are working to strengthen a partnership with private industry and major foundations to take full advantage of the new breakthroughs in immunization.

Let me also include the eradication of poliomyelitis which is due by the end of next year. It will require a major effort, and WHO – together with UNICEF – is mobilising for the final stretch of this historic effort.

We also need to assist countries to counter threats to health resulting from economic crises, unhealthy environments or risky behaviour.

The single most important of these threats is tobacco consumption. This epidemic will hit countries with very weak means of defence. It is driven by a part of industry which is massively focusing its marketing efforts on youth and women in developing countries.

We work with the World Bank, UNICEF and other UN partners to strengthen control, taxation policies, and a ban on advertising – all potential elements of a Framework Convention on Tobacco Control which we will ask the World Health Assembly to sign up to in May.

Second, we need to help develop more effective and equitable health systems.

In many countries health systems are ill-equipped to cope with present demands, not to talk about those they will face from the emerging double burden of disease.

The institutional problems which limit health sector performance are often common to all public services in a country. Despite their importance, they have all too often been neglected both by governments and development agencies. Dealing with issues such as salaries in the public sector, priority-setting and unregulated growth in the private sector constitute some of the most challenging items on the international health agenda.

There are limits to what governments can finance and to their capacity to deliver services. We need realistic public policies that recognise these limits. But the role of governments remains central when it comes to setting broad policy directions, creating an appropriate regulatory environment and securing the financing of basic health services.

A growing number of member states ask WHO: How do we strike the balance in the financing of health sectors? How do we create an equitable system which renders essential services to all?

WHO will now devote more resources to these questions, and we are hoping to work closely with the World Bank, IMF and the regional development banks.

Third, we need new partnerships for health in development.

We need to better understand the key role of health in fostering human and economic development. Looking at the underlying factors that have hampered growth in Africa new knowledge tells us how public health plays a vital role. We have known for long that poverty breeds ill-health. But it also works the other way - ill-health breeds poverty. Major gains can be won against poverty by making the right health interventions.

This will clearly change the way we consider investments in health. Controlling malaria, tuberculosis and HIV/AIDS are major strategies for development. Devoting resources to research in areas such as tropical diseases and reproductive health is investing in the knowledge base that made the health achievements and the social and economic progress of the 20^th century possible. But it is critical that this knowledge is made available and applicable to all.

We around this table can make a difference through our strategic advise. Above all we need to anchor health more firmly within the global development agenda. We need new ways of working together – and with other partners - to have a strategic impact. Jim Wolfensohn`s ideas on a Comprehensive Development Framework is taking such efforts an important step in the right direction and WHO is ready to contribute.

I believe that the agencies working in the social and economic field need to better define common objectives and to agree on how to share responsibilities according to their comparative advantages – among the heads of agencies – but also in the field. We have tried that in Roll Back Malaria and the results are encouraging.

Let me end on an optimistic note.

In considering the changes in mortality we can identify an emerging success story.

Child mortality is now declining. In the 1990s child mortality worldwide has declined by nearly 20 per cent. This remarkable improvement has occurred even in the face of declining income per capita in Sub-Saharan Africa and a number of countries in other regions.

Many factors may explain this trend and we will study the causes further. But clearly, the dissemination of new knowledge and affordable technologies to effectively address the problems of child health has played a crucial role. This knowledge base – made available and accessible to all - is one of the most critical public goods available.

Agencies around this table can take some credit for this development. This progress is not a signal of a job almost completed – to the contrary – it is evidence of successful interventions and a call for increased attention to give all children a safe start in life.

Our job is crucial. Because the guarantor for the availability and accessibility to this global public good remains the UN family.

Thank you.