The contribution of primary health care to the Millennium Development Goals
Dr Margaret Chan
Director-General of the World Health Organization
Honourable ministers of health and foreign affairs, distinguished delegates, ladies and gentlemen,
First and foremost, let me thank the government of Argentina and its ministry of health for organizing this conference.
The topics being explored embrace some of the most pressing issues in public health today.
How can we realize the great potential of health to drive human development, as acknowledged in the Millennium Development Goals?
Obviously, if we want better health to work as a poverty reduction strategy, we must reach the poor. And we must do so with appropriate, high-quality care.
What role can primary health care play in this quest?
What are our prospects of reaching the health-related Millennium Development Goals?
More specifically, how can we overcome major barriers, such as weak health systems, inadequate numbers of health care staff, and the challenge of financing care for impoverished people?
You have been exploring these issues during the past three days, and I look forward to your conclusions.
When I took office at the start of this year, I called for a renewed emphasis on primary health care as an approach to strengthening health systems.
The experiences and recommendations coming from this conference are extremely relevant to public health today, both within countries and for the work of WHO.
Apart from the relevance of issues being addressed, the timing of this conference is most opportune.
We are near the mid-point in the countdown to 2015, the year given so much significance and promise by the Millennium Declaration and its goals.
These goals represent the most ambitious commitment ever made by the international community.
Their achievement would make the biggest difference in the lives and future prospects of impoverished populations in the history of humanity.
If the international community meets these goals, we will have the upper hand on ancient impediments to human development long considered intractable: poverty, ignorance, disease, unhealthy environments, and premature death from preventable causes.
This is our potential as we look towards the future, our unprecedented opportunity to build a better world in the 21st century.
Looking back, we are approaching the 30th anniversary of another historical set of commitments: the Declaration of Alma-Ata.
That document promoted primary health care as the key to attaining an acceptable level of health for all people in this world. This was the heart of the Health for All movement
Apart from its passionate call for equity and social justice, Health for All also launched a political struggle on at least three fronts.
First, it sought to make health part of the political agenda for development, to upgrade the profile of health and increase its prestige.
Second, it sought to broaden the approach to health, to move away from the narrow medical model of curative care. It acknowledged the power of prevention.
And it recognized that health has multiple determinants, including some in sectors other than health.
This meant that multiple sectors of government should collaborate, and pay attention to their impact on health.
At that time, different sectors were working in an isolated, fragmented way according to a hierarchy that usually put health near the bottom.
On a third political front, the Declaration of Alma-Ata argued that better health for populations should go hand-in-hand, in a mutually supportive way, with better economic and social productivity.
That meant viewing health as far more than a burdensome political duty, a bottomless drain on public funds.
These, then, were some of the political struggles surrounding a movement launched in the name of social justice, and for the good of our common humanity.
Ladies and gentlemen,
Let me try to capture some of the spirit of this movement with a quote. This is from a speech given by one of my predecessors, Dr Halfdan Mahler, to the World Health Assembly in 1979.
That was the first Health Assembly held after the adoption of the Alma-Ata declaration.
He said: “If human beings have the ingenuity to reach the moon and probe the planets, surely we will find the way to achieve our goals.”
He added: “What we need most of all is singleness of purpose, absolute determination to overcome obstacles, trial and error and retrial, and refusal to retreat in frustration if progress is slower than we would like.”
As Dr Mahler suggested, progress in improving the health of the poor, in reducing the great gaps in health outcomes, was indeed slower than we would have liked.
But the Health for All movement paved the way for the even more ambitious goals agreed on at the start of this century. The three political struggles were victorious, and this victory is embodied in the Millennium Development Goals.
First, the goals place health firmly at the centre of the development agenda.
Second, the goals make intersectoral collaboration a prerequisite for success. They attack the root causes of poverty and acknowledge that these causes interact.
Third, by making better health a poverty-reduction strategy, the goals move the health sector from a mere consumer of resources to a producer of economic gains.
In this sense, the Millennium Development Goals can be viewed as yet another legacy of the Health for All movement and the declaration that launched it.
The continuity is readily apparent. Both documents are visionary and set lofty goals. Both appeal to a set of fundamental human values.
Both express conviction that the world needs to change, and is perfectly capable of doing so. Doing so, moreover, is a responsibility shared by all nations.
Both documents challenge the notion of a dog-eat-dog society, where survival of the fittest reigns.
Both focus on the underdog, the most vulnerable populations. And both aim to make these people fit to survive, fit to realize their human potential.
Above all, both documents are all about equity. People should not be robbed of opportunities to develop their human potential for unfair reasons, including those with economic or social causes.
Ladies and gentlemen,
We have come full circle. We have again embarked on an urgent mission aimed at reaching ambitious, time-bound goals.
We are again striving for equitable, comprehensive basic health care.
And again we make the same compelling humanitarian appeal: how can we morally afford to let so many people suffer and die from easily preventable or treatable causes?
But here is the difference between today and the situation in 1978. We are departing from a higher ground, on a way paved uphill by the struggle for health for all.
Those of us working in public health have many good reasons to be optimistic.
Today, health enjoys support from an unprecedented number of partnerships, foundations, and agencies implementing programmes in countries.
There are more actors in health than in any other sector.
The number of innovative funding mechanisms continues to grow, as does the size of resources they command.
There will always be unmet needs, but health has never before received such attention or enjoyed such wealth.
Yet despite this unprecedented commitment and momentum, we are still running behind.
In part, we are trying the catch up after years of inadequate investment in public health infrastructures.
More importantly, we are struggling against challenges that have grown enormously in their complexity.
The world did not face HIV/AIDS in 1978. Since then, many diseases, including tuberculosis and malaria, have dramatically resurged.
Globalization and rapid, unplanned urbanization have created new problems and intensified others.
New diseases are now emerging at the unprecedented rate, on average, of one per year.
In many developing countries, the health burden is growing at a time when public health is losing its capacity to respond.
The globalization of the labour market has contributed to the mass exodus of health workers from the countries that invested in their training.
WHO estimates that 4 million health workers are urgently needed to provide the bare essentials of care in more than a quarter of the world’s countries.
Chronic diseases, long considered the companions of affluent societies, have changed places. Low- and middle-income countries now bear the greatest burden from these diseases.
The rise of chronic diseases has created a heavy additional burden for health systems.
Moreover, the costs of caring for these diseases can be catastrophic for impoverished households, anchoring them even deeper in poverty.
Many of the world’s 1.3 billion poor still do not have access to essential interventions because of weaknesses in the financing of health care.
As a result of all these trends, the gaps in health outcomes are growing wider.
It is by no means certain that we will reach the health-related Millennium Development Goals.
Ladies and gentlemen,
We face a critical dilemma. Public health has effective interventions, proven strategies for implementation, and new sources of substantial funds.
We have unprecedented commitment.
But we are still not reaching underserved populations with sustainable, equitable, and comprehensive care on an adequate scale.
As I said, if we want better health to work as a poverty reduction strategy, we must reach the poor. Here is where we fail.
In the past decade, we have seen an enormous growth in the number of partnerships and initiatives implementing programmes in countries.
These initiatives are focused on delivering specific health outcomes. Outcomes depend on a functioning health system. Yet the strengthening of health systems is rarely a core purpose of these initiatives.
Here is where all this welcome momentum reaches an impasse. Health systems are not able to deliver interventions, on the necessary scale, to those in greatest need.
This is not just the view of WHO.
In 2005, the Millennium Project Task Force issued its assessment of the prospects for achieving the goals for child and maternal health.
“The health system that should make interventions available, accessible, and utilized is in a crisis. Only a profound shift in how the global health and development community thinks about and addresses health systems can have the impact necessary to meet the Goals.”
Let us look at the reality.
The biggest impediment to achieving universal coverage with antiretroviral drugs for HIV/AIDS is the absence of delivery systems and the lack of staff.
Numbers of maternal deaths will not fall until more pregnant women have access to skilled birth attendants and emergency obstetric care.
Child deaths from preventable causes will not drop until emergency care reaches neonates and children with acute respiratory infections.
Reduced morbidity and mortality from malaria depend on delivering interventions to hard-to-reach populations.
When staff numbers are inadequate, directly-observed treatment for tuberculosis is compromised, promoting the emergence of drug resistance, including extensively drug-resistant disease.
Ladies and gentlemen,
When I think about this dilemma, I reach two conclusions.
First, in matters of health, I believe our world is out of balance, possibly as never before in history. We have never had such a sophisticated arsenal of technologies for treating disease and prolonging life.
Yet the gaps in health outcomes keep getting wider. Life expectancy can vary by as much as 40 years between rich and poor countries. This is unacceptable.
An estimated 10.5 million children under the age of five die each year. At least 60% of these deaths could have been prevented by just a handful of inexpensive measures. This is not fair.
Nor is it fair that more than one million people still die each year from such an easily preventable disease as malaria.
I am sure Dr Mahler would agree. A world that can put a man on the moon should be able to put more children under bednets.
My second conclusion relates directly to the topic of this conference. I do not believe we will be able to reach the Millennium Development Goals unless we return to the values, principles, and approaches of primary health care.
Again, we turn full circle.
Decades of experience tell us that primary health care is the best route to universal access, the best way to ensure sustainable improvements in health outcomes, and the best guarantee that access to care will be fair.
Having said this, I want to commend PAHO and its member states for their enduring commitment to primary health care.
Ladies and gentlemen,
I would like to suggest four principles that can guide us as we explore ways to achieve equity-based comprehensive health care and look at the contribution of primary health care.
First, we must maintain our commitment, determination, and above all, our sense of urgency. As Dr Mahler stated almost 30 years ago, our determination must be absolute. We must refuse to retreat.
A similar reminder of the urgency of our mission was made just three weeks ago, when Gordon Brown, the new Prime Minister of the United Kingdom, made his first address to the United Nations.
In that speech, he expressed dismay at the lack of progress in meeting the Millennium Development Goals.
As he stated: “It is time to call it what it is: a development emergency which needs emergency action.”
I agree. This is indeed an emergency. And this should be a time of tireless action and sleepless nights for all of us with a leadership role in health.
Second, we must hold our politicians accountable for the promises they make, whether to their voting constituency or at international summits. Promises should not be broken.
Third, if we want politicians to make the right promises and keep them, we must provide solid evidence. Evidence gives health arguments persuasive power at the policy level.
Primary health care is not cheap. It is not a bargain-basement way for governments to fulfil their duty to protect all citizens from risks and dangers to health.
We need a better body of evidence demonstrating costs and benefits, best practices, interventions that work best in specific situations, and the impact of these interventions on health outcomes.
We need proof of programmes, and proof of progress. As I have said, what gets measured gets done.
Finally, we must never underestimate the power of human ingenuity. This power goes hand-in-hand with resolute determination to reach a goal.
As one example, determination to reach the Millennium Development Goals has stimulated the creation of innovative funding mechanisms.
In just the past year, we have seen the launch of UNITAID, a drug purchasing facility which draws revenue from a tax on airline tickets.
We have also seen the launch of the International Finance Facility for Immunization. Borrowing an approach used in financial markets, this facility is frontloading 4 billion dollars to fund the immunization, by 2015, of 500 million children.
Again, we can do things in grand ways, on a grand scale.
As my last remark, I believe that, when we talk about primary health care, we must also acknowledge the great ingenuity of communities.
Human nature has certain commonalities that transcend differences of place, race, religion, and culture.
Compassion in the face of suffering and a desire to help is one common trait. Aspiration for a better life is another.
Time and time again we see how, when communities are given opportunities they want and programmes they can own, they are empowered to achieve the lives they desire.
Given a hand up, they can indeed lift themselves out of poverty and improve their health.
We see this with microfinancing schemes for women. We see this with programmes where communities take charge of disease detection and drug distribution, with rapid and sustainable improvements for health.
Ladies and gentlemen,
This, then, is part of our common humanity, as expressed in the Millennium Declaration. These are our shared traits of compassion, inspiration, aspiration, and great ingenuity.
Our common humanity gives us reason to care. It is why we must act with urgency in the face of an emergency. It is also why we have so much to gain, in the name of social justice.