Address to the Regional Committee for the Americas
Dr Margaret Chan
Director-General of the World Health Organization
President of the 26th Pan American Sanitary Conference, honourable ministers and ambassadors, distinguished delegates, Dr Roses, ladies and gentlemen,
First and foremost, let me say how much I value the opportunity to address this Regional Committee.
I am personally grateful to you. This is the region that kept the torch for primary health care burning bright.
When the year 2000 passed, and talk about Health for All lost its place in the international health debate, this region maintained – even strengthened – its commitment to primary health care.
I am glad you did.
This is my fifth Regional Committee in as many weeks. I have been in office for nine months. Nearly everywhere I travel, nearly every meeting I attend, I see the values, principles and approaches of primary health care resurfacing. They are not always labelled as such. But they are there.
This is what I hear. Communities must be engaged. Health initiatives must be country-led and country-owned. The best help is self-help. Prevention is the greatest power of public health. The underlying causes of ill health must be addressed.
Medicines must be affordable and accessible. Universal coverage should be the goal. And perhaps most important: equitable health outcomes are the ultimate measure of a well-performing health system.
The Declaration of Alma-Ata, signed almost 30 years ago, was all about equity and social justice. The Millennium Development Goals are all about equity and social justice.
Primary health care was designed to achieve equitable and sustainable health development.
Health for All may not have achieved all of its goals, but the primary health care approach itself is sustainably relevant.
In fact, its elements almost have a life of their own, coming again to the surface, regaining their place at the centre of the development agenda.
Ladies and gentlemen,
Documentation before this Committee describes the Americas as the region with the greatest inequities in health.
The 2007 edition of Health in the Americas describes these inequities as “extensive and profound”.
In terms of income distribution, both within and between countries, your health agenda for the next ten years describes this region as the most inequitable in the world.
I find a noble principle at work here.
A region characterized by significant inequalities champions a renewal of primary health care – an approach specifically designed to promote equity. A concern with society’s most disadvantaged and vulnerable groups permeates health policy in this region.
This says something about governance. The way a government treats its most deprived citizens says something about the value society gives to each and every human life.
A commitment to primary health care is a commitment to equity in health outcomes, and a promise of solidarity and shared responsibility in its pursuit.
This is Pan-Americanism at its best.
It is also, quite simply, a smart move.
I agree entirely with documentation before this Committee. A primary health care approach is the most efficient and cost-effective way to organize a health system.
International evidence overwhelmingly demonstrates that health systems oriented towards primary health care produce better outcomes, at lower costs, and with higher user satisfaction.
Health is a foundation for prosperity. Pro-poor health policies contribute to stability. A prosperous and stable region serves the self-interests of every country.
Ladies and gentlemen,
When I discuss matters with Regional Directors and attend their Committees, I try to do two things.
First, I try to understand the problems being addressed in the region and see how activities at the international level might lend support.
Second, I look for regional lessons that can be applied internationally.
Let me start with some lessons from this region.
I congratulate Ministers of Health on their 10-year health agenda and also on the new position paper, Renewing Primary Health Care in the Americas.
This is a concise paper. It clarifies many concepts and misconceptions. It repackages the values, principles, and elements of primary health care to meet the unique challenges of this century.
This will serve us well at the international level, and I thank you.
The underlying premise of your Faces, Voices and Places initiative is absolutely true.
Progress in reaching the Millennium Development Goals will not be measured by national averages. It will be measured by improvements in life for society’s most miserable and least visible communities.
You have used a sophisticated methodology to find these invisible places and put them on the map. You are using participatory approaches to give these people faces, voices, and power.
You are building a menu of options, supported by evidence, of what works best under the worst possible circumstances.
Your strategies show a constant quest for greater operational efficiency. When your programmes tackle a problem, they aim to make that effort work for other problems as well.
You have adopted a region-wide strategy for integrated vector management.
This strategy works for dengue, for malaria, and for many of the neglected tropical diseases that cause such misery and disability in the poorest of the poor, especially women.
This region was the first to eradicate smallpox and polio, and has led the way forward in the elimination of measles and neonatal tetanus.
Right now, you are building on this success, with a region-wide initiative to eliminate rubella and congenital rubella syndrome.
At the same time, you are using this initiative to improve infrastructure in multiple sectors, to develop models for adult immunization and the introduction of new vaccines, and to promote a culture of prevention.
Your strategy for improving the quality of care and patient safety is absolutely vital for the renewal of primary health care. I am not surprised that this strategy gives priority to quality care in society’s most vulnerable groups.
Throughout the region, you have greatly strengthened preparedness plans for an influenza pandemic. At the same time, you have used these efforts to strengthen regional and sub-regional capacities to implement the revised International Health Regulations.
For HIV/AIDS, this region surpassed the goals for population coverage with antiretroviral therapy, set by my predecessor, Dr Lee’s, 3 by 5 initiative.
This is perhaps the most striking example of political commitment to equity and what this commitment can achieve. As we all know, it was countries in this region that showed the way forward for the rest of the world.
This region makes good use of evidence. Evidence has allowed you to map the most disadvantaged communities and municipalities, and concentrate efforts there.
Evidence has also allowed you to measure great progress, in just the past few decades, in reducing extreme poverty. You can be proud of this success.
But evidence also tells you to brace for new cases of HIV infection. Evidence tells you to brace for a continuing rise of chronic diseases.
And there are other problems that are not easily solved.
This region is experiencing one of the worst dengue outbreaks in decades, with all the attendant social and economic disruption. The threat of an influenza pandemic remains ever-present.
Chagas disease still does not have a safe and effective treatment or a simple and specific test for early diagnosis.
In this region, violence on city streets and in homes, mental illness, and discrimination are major concerns. Women, in particular, are often double victims: victims of violence, and victims of discrimination because of that violence.
This region has more than its fair share of natural disasters, and I extend my sincere condolences to the Ministers of Peru and Nicaragua for their major losses this year. The region has made great strides forward in preparedness, and you take another step forward with the new initiative on disaster-resilient health facilities. This will hold you in good stead for what we know is yet to come.
The science is overwhelming. Climate change is inevitable. Even if greenhouse gas emissions were to stop today, the climate will continue to change throughout this century.
The warming of the planet will be gradual, but the increasing frequency and severity of extreme weather events – intense storms, heat waves, droughts, and floods – will be abrupt and the consequences will be acutely felt.
Developing countries will be the first and hardest hit. Areas with weak health infrastructures will be the least able to cope.
This is yet another reason why we must reach the Millennium Development Goals.
Ladies and gentlemen,
In this region, as elsewhere in the world, all of us working in public health still have a long hard struggle ahead.
Let us turn to the international level. This region is concerned that gaps in health outcomes are growing wider. Unfortunately, this trend is global.
We all know the problem. Globalization creates wealth, and this is good. But globalization has no rules that guarantee fair distribution of this wealth.
No one questions the strong association between poverty and ill health. This world will not, all by itself, become a fair place for health.
All around the world, health is being shaped by the same powerful forces. Some of these forces intensify the health burden. Others tend to make inequities worse.
Unplanned urbanization is a global trend, as is demographic aging. Globalization of the labour market, and the increased health needs of aging populations, have contributed to an acute shortage of health workers, felt in this region and all around the world.
Changes in the way humanity inhabits the planet have disrupted the delicate equilibrium of the microbial world. New diseases are emerging at an historically unprecedented rate.
Old threats are resurging. The emergence of extensively drug-resistant tuberculosis, which is virtually impossible to treat, is a particularly ominous trend.
Globalization of the food supply, and globalized marketing and distribution channels spread lifestyle changes, and these speed the rise of chronic diseases.
Chronic diseases, long considered the companions of affluent societies, have changed places. These diseases now impose their greatest burden on low- and middle-income countries. In the Americas, chronic degenerative diseases are now the leading cause of morbidity and mortality.
With this epidemiological transition, another important shift takes place. Many of the underlying causes of chronic diseases – unhealthy diets, sedentary lifestyles, and tobacco and alcohol consumption – lie beyond the direct control of the health sector.
The health sector can, of course, manage these diseases once they develop. But the strain on already overburdened health systems is immense. The costs of chronic care can be catastrophic for households, driving impoverished families even deeper into poverty.
Prevention is by far the better option. But the prevention of chronic diseases demands a multisectoral approach. Once again, we return to the principles of primary health care.
Ladies and gentlemen,
All around the world, public health is engaged in the same basic struggles on three fronts.
First, we struggle to hold the constantly evolving microbial world at bay. Second, we struggle to change human behaviours. Third, we struggle for attention and resources.
This is nothing new, of course. But the challenges have grown enormously, on each of these fronts, in little more than a decade.
As I have stated, health increasingly has international dimensions. For each of these struggles, we are now aided by powerful international instruments and commitments.
These are expressions of our shared vulnerability, our common humanity, and our mutual responsibility in matters of health. Each is a call for collective action.
The greatly strengthened International Health Regulations came into force in June of this year. The revised Regulations move away from the previous focus on passive barriers at national borders, to a strategy of pro-active risk management.
This strategy aims to detect an event early and stop it at source, before it has an opportunity to become an international event. This strategy greatly strengthens our collective security, and raises the preventive power of these Regulations to new heights.
We must never again allow a disease such as HIV/AIDS to slip through our networks for surveillance and early containment.
In our struggle to change human behaviour, we also have a powerful international instrument. The Framework Convention on Tobacco Control has become one of the most widely embraced treaties in the history of the United Nations. This is preventive medicine, on a global scale, at its best.
Next year, the Commission on Social Determinants of Health will issue its report. This will be another powerful tool as we seek to address the complex social factors that influence health, and strive for greater fairness in health outcomes.
In our struggle for attention and resources, we have the Millennium Declaration and its Goals. They represent the most ambitious commitment ever made by the international community.
These goals have at least two major implications for health at the policy level. First, they recognize health as a key driver of socioeconomic development. This elevates the status of health. Health is no longer a mere consumer of resources. It is also a producer of economic gains.
Second, by making health a poverty-reduction strategy, they give clear direction to international policy. For example, if we want health to reduce poverty, we cannot allow the costs of health care to drive impoverished families even deeper into poverty.
This has implications for health financing, especially when the poor rely on out-of-pocket payments. I know this issue is being given high priority in the Americas.
As another obvious example, if we want health to work as a poverty reduction strategy, we must reach the poor.
Here is where we fail.
Midway in the countdown to 2015, we have to face the reality. Of all the Millennium Development Goals, the health-related goals are the least likely to be met.
How can this be?
These are the goals that make the greatest life-and-death difference for millions of people. These are the goals with first-rate tools – vaccines, drugs and other interventions – to support their attainment.
For the first time, public health has commitment, resources from new sources, powerful interventions, and proven strategies for their implementation.
But here is the reality: the power of these interventions – vaccines, drugs and others – is not matched by the power of health systems to reach those in greatest need, with comprehensive care, in time.
Of all the health-related goals, those set for reducing maternal and child mortality pose the greatest challenge globally.
This should come as no great surprise. The determinants of maternal and child health are especially broad, and very closely linked to social and economic factors.
One could argue that our ability to reduce maternal and child mortality is a sensitive indicator of performance in meeting the Millennium Development Goals in their totality.
To reduce maternal and child mortality, the need for a well-functioning and equitable health system is absolute.
To reduce these deaths, we need to return to the values, principles, and approaches of primary health care.
Ladies and gentlemen,
When I gave my acceptance speech in November of last year, I called for a return to primary health care as an approach for strengthening health systems. Since then, my commitment has deepened.
During the international conference on health for development, held in August in Buenos Aires, I expressed my conviction that we will not be able to reach the health-related Millennium Development Goals unless we return to the primary health care approach.
As I said, I do not believe this world will, all by itself, become a fair place in matters of health. I believe there is no sector better placed than health to insist on greater equity and social justice.
The argument is easily expressed. No one should be denied access to life-saving and health-promoting interventions for unfair reasons, including those with economic of social causes.
For health, inequities really are a life-and-death issue.
I mentioned earlier the need to see how events at the international level can lend support to regional efforts.
Health leaders in this region have many reasons to be optimistic. Heads of state are increasingly engaged in health initiatives, often for diseases that have little significance within their borders. One example is the US President’s malaria initiative.
The recent summit of heads of government of CARICOM on chronic diseases is an historic landmark.
Last month saw the launch of new international health initiatives, supported by Canada, France, Germany, the Netherlands, Norway, and the UK, aimed at accelerating progress in reaching the health-related development goals. These initiatives fully recognize the importance of investing in health systems, putting countries in charge, and making aid less cumbersome and more effective.
I want to thank the countries in this region for their contribution to the Intergovernmental Working Group on Public Health, Innovation and Intellectual Property.
I want to thank heads of state in this region for their leading role in many of the initiatives I have just mentioned.
Self-sufficiency in this region is growing, and this has international implications. Countries in this region with strong manufacturing capacity are changing the dynamics of the global market for public health vaccines.
I want to thank south-south collaboration, coming from Brazil and Cuba, for helping African countries meet an emergency need for meningitis vaccine.
I also appreciate the region’s support, with qualified and experienced human resources, in the last battle for a polio-free world.
Above all, let me repeat an opening statement. This is the region that kept the torch for primary health care burning bright. You have my deepest gratitude.