Excellencies, ladies and gentlemen,
Thank you for the opportunity to speak to you today.
You are all familiar with the clarion call of the Sustainable Development Goals, to “leave no one behind”.
It’s an idea we all agree with.
But how can we make it a reality, and not just a slogan?
Forty-one years ago, the world came together in Alma-Ata to commit to achieving health for all.
Despite the sincerity of the commitment, despite the efforts that were made and despite the progress that was achieved, that vision was not realized.
In Astana last year, we came together once again to reaffirm that primary health care is the foundation of universal health coverage.
How can we make sure we do not fail again? How can we make sure that we realize the vision of health for all? How can we make sure no one is left behind?
Our starting point must be to know who is being left behind, where and why.
Too many people are not counted and not reached.
Traditionally, we have always looked at familiar measures like gender, income, or geography.
These are important measures, but they are insufficient.
In today’s world, we also need to consider other reasons people are left behind, like migration or internal displacement, conflict, marginalization and discrimination.
Disaggregated data is vital for painting a more accurate picture of where services are needed and where gaps must be closed.
Which brings me to my next point: how can primary health care help us to achieve equity?
Primary health care is about building a health system from the ground up.
It is about providing care in the community and making sure that health services are accessible.
We still have a long way to go to ensure that everyone has access to sustainable, high-quality health services.
A 2016 WHO report estimated that all countries must meet a minimum “threshold” of 45 health workers per 10 000 population to meet the SDGs.
Few countries meet that threshold, and the shortages in developing countries are particularly acute. Niger, for example, has only 1.6 health workers per 10 000 population; Mauritania, the best-resourced of the G5 Sahel countries, has only 8 per 10 000.
No country can build a health system without health workers.
But to be successful, those primary health care professionals need to know and engage with their community.
Some simple examples:
In my own country, we rebuilt the health system around the model of health extension workers. To date, 42 000 health extension workers have been trained to provide basic health care to their communities.
As a result, more than 95% percent of Ethiopia’s population has access to primary health care within a distance of 10 kilometers.
This expanded access to PHC services -- as part of the national health strategy -- has been a key factor which, along with other interventions, contributed to a 55% reduction in HIV-related deaths and a 70% reduction in the number of people living with HIV.
Samoa is tackling its crisis of non-communicable diseases by taking awareness campaigns and testing to the community.
As a result, 92% percent of the population in the 7 villages included in a pilot phase of the programme have been screened for NCDs.
And in Niger, government policies that established free health care for pregnant women and children under 5 -- in conjunction with nutrition programmes -- helped contribute to a 57% decrease in under-5 mortality in less than 20 years.
A common thread in these success stories is that when health care professionals are actively engaged in their communities, more people – particularly those who are hard to reach – connect with the health system.
If we are to be successful in reaching marginalized populations, a commitment to primary health care is essential, because PHC expenditures are more pro-poor than any other type of health spending.
But countries need to do even more to strengthen their primary health care systems.
This means addressing several important factors.
First, there is the question of financing at the country level.
When countries provide adequate funding for primary health care, they can make high-quality, sustainable services available to all.
By re-prioritizing budget allocations and increasing the share of public spending dedicated to health, countries can reach an additional 1% of GDP by 2030 for primary health care.
Kazakhstan, for example, has set a goal of 5% of GDP allocated to health by 2025, with 60% of that money dedicated to primary health care.
We estimate that expanding health care services in low- and middle-income countries will require new investment of 134 billion U.S. dollars annually, increasing to 371 billion dollars a year by 2030.
These additional investments could prevent 97 million premature deaths worldwide, including 50 million premature deaths among children under 5.
About two-thirds of this investment would be for health infrastructure -- water, electricity and connectivity -- and health workforce.
Globally, there will be a shortage of 18 million health care workers by 2030. This is a gap which will be felt most acutely in developing countries.
We need to find ways to attract more people into the caring professions and provide them with high-quality education and an attractive career path.
We also need to address the issue of access to quality medicines and products.
We have made progress globally in addressing the underlying causes of stock-outs and supply chain problems. But more needs to be done.
And we need information. We need to support countries in developing information systems that will provide comprehensive, disaggregated data which can be used for evidence-based decision-making.
Advancing equity will require actions beyond the health sector as well.
It will require work that is perhaps best done in, with and by communities.
Leaving no one behind is not just about ensuring that every baby gets vaccinated, or that every village has a health worker -- as important as that is.
It also means ensuring that the creation of health strategies is inclusive.
It requires that diverse population groups are reflected in the development of a situation analysis or a policy dialogue, in the budgeting process, or in monitoring and evaluation.
This means working closely with civil society, with the private sector, and with other stakeholder groups.
We also need to ensure that all population groups are included and accounted for in the design and delivery of services.
Forty-one years ago in Alma-Ata, the world established four principles for health for all: equity in health; use of appropriate technology; cross-sector collaboration; and community engagement.
Those principles are as relevant today as they were in 1978.
The Astana Declaration reaffirmed the world’s commitment to primary health care. Now it is up to us to make it a reality.