Keynote address at the International Seminar on Primary Health Care in Rural China
Dr Margaret Chan
Director-General of the World Health Organization
Honourable ministers, Dr Zhu, Dr Mahler, colleagues, ladies and gentlemen,
I will start with some straightforward statements about public health. I will then interpret these statements in the light of global trends that are changing the landscape of public health. I will explain the practical implications of these trends for health policies. I will then focus this discussion on the topic at hand: primary health care in rural China.
Let me begin with three overarching principles of public health.
First, the highest duty of public health is to protect populations from risks and dangers to health. This duty belongs to government. It includes the performance of basic public health functions, such as ensuring the quality of medicines and the safety of the food, water, and blood supplies.
It also includes a responsibility to ensure that populations have the information and the means to protect their health. Obviously, it includes regulatory functions and requires the investment of public funds.
Second, the highest ethical principle of public health is equity. This can be expressed in simple terms. People should not be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes.
Third, the greatest power of public health is prevention. Medicine focuses on the patient, but public health seeks to address the causes of ill health in ways that provide population-wide protection.
All of these principles are embodied in the primary health care approach.
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, I have had many opportunities to discuss health issues with ministers of health from around the world.
I have visited countries and viewed their showcase hospitals and research institutes. I have also viewed the struggle for health in their poorest communities. I have seen abundant evidence that health is an issue with a high political profile. Health is a priority concern at the international level. I have witnessed unwavering commitment to the health-related Millennium Development Goals.
Health has become a fruitful arena for foreign diplomacy. I have stood together with heads of state when they have launched global initiatives, and pledged financial support, for diseases or health problems virtually unknown within their own borders. I have observed the elevated status of health on the development agenda. Health is viewed as a direct route to poverty reduction, and thus as central to socioeconomic development. Health is no longer seen as a mere consumer of resources. It is also a producer of economic gains.
A doctor in Argentina, working on microfinancing schemes for women, said this most succinctly: “The human body is a unique tool for productivity that even the poor possess.”
These are all important steps forward. But I have also seen evidence of some disturbing trends. In matters of health, I believe our world is out of balance as never before. Gaps in health outcomes, both within and between countries, are actually growing wider. Life expectancies can vary by as much as 40 years between poor and wealthy countries.
Never before has medicine possessed such a sophisticated arsenal of tools and technologies for curing disease and prolonging life. Yet every year, more than 10 million young children and pregnant women have their lives cut short by largely preventable causes.
Something is wrong.
Progress in meeting the health-related Millennium Development Goals has stalled. In fact, of all the goals, those pertaining directly to health are the least likely to be met.
How can this be?
These are the goals that can make the greatest life-and-death difference for millions of people. These are the goals with first-rate tools – drugs, vaccines, and other interventions – to support their attainment.
Something is wrong.
All of these experiences have strengthened my position. I am now convinced that we will not be able to reach the health-related Millennium Development Goals unless we return to the values, principles, and approaches of primary health care.
Ladies and gentlemen,
No one questions the close two-way link between poverty and health. Poverty contributes to poor health, and poor health anchors populations in poverty. But better health allows people to work their way out of poverty and spend household incomes on something other than illness.
We know the problem. Globalization creates wealth, and this is good. But globalization has no rules that guarantee fair distribution of this wealth. You have seen this in China. Despite tremendous efforts to reduce poverty, China still has millions of poor rural farmers left on the margins of the economic boom.
As we all know, this world will not become a fair place for health all by itself. I believe that there is no sector better placed than health to insist on greater social justice and equity. In matters of health, equity really is a life-or-death issue.
In just the past decade, health has benefited from unprecedented attention and resources. Powerful partnerships have formed. The number of implementing agencies working in health is far greater than that in any other sector.
The number of funding mechanisms continues to grow, as does the size of resources they command. Health has never before received such attention or enjoyed such wealth. Today, health benefits from commitment, partnerships, resources, powerful interventions, and proven strategies for their implementation.
With so much working in our favour, we can see what is holding us back. It is this. The power of interventions is not matched by the power of health systems to deliver them to those in greatest need, on an adequate scale, in time.
Governments around the world have failed, sometimes for decades, to invest adequately in basic health infrastructures, regulatory frameworks, and the health workforce.
Sometimes the consequences of this failure go unnoticed until a crisis occurs. An outbreak is detected late or proves difficult to control. Or mass illness follows contamination of the food or water supply. Or dangerously high levels of pollution make urban air unfit to breath. Or counterfeit, expired, or adulterated drugs turn out to be the cause of unexplained deaths.
Then governments pay the price for this failure to invest. And that price can be extremely high.
In North America, the deliberate distribution of anthrax spores through the mail in 2001 forced a close look at the capacity of the public health system to cope with a bioterrorist attack. Grave weaknesses were revealed.
Fears that an influenza pandemic might be imminent caused a similar examination of public health capacities in a large number of countries. Again, grave weaknesses were revealed.
Apart from crises, a time-bound commitment to international goals can also reveal critical weaknesses in health systems. This has happened. As I said, progress in meeting the health-related Millennium Development Goals has stalled, and weak health systems are largely at fault.
Ladies and gentlemen,
Public health policy has not always been firmly rooted in evidence. Some assumptions that have guided policy decisions have proved false. Let us look at two.
First, many experts assumed that as economic conditions within a country improved, better health would automatically follow. To modify an old proverb, a rising economic tide lifts all boats. Experience has proved otherwise. Both within and between countries, the benefits of economic growth have not been equally distributed. The gaps have grown ever wider.
I am referring to the gaps between wealth and poverty, between good health and avoidable ill health. Gaps between the health status of privileged urban populations and that of marginalized rural populations. Gaps between households with health insurance and households driven below the poverty line by out-of-pocket payments for medical care.
In reality, the inverse care law, first put forward in 1971, continues to prevail. The availability of good medical care tends to vary inversely with the need for it. This means that the best care tends to go to those who need it least.
Here is a second assumption. Many experts believed that single-disease initiatives, such as those for HIV/AIDS, tuberculosis, and malaria, would somehow automatically strengthen health systems as interventions were delivered to large numbers of people. In fact, the opposite has proved true. Progress in delivering interventions has faltered because of weaknesses in service delivery, especially for those in greatest need.
The conclusions are obvious. Better health, especially for the poor, must be an explicit objective of development policies. The strengthening of health systems must be an explicit objective of health policies.
Progress in reaching the Millennium Development Goals will not be measured by national averages. It will be measured by how well health services reach poor and marginalized populations.
Evidence at the international level tells us two further things. First, a country’s income level is not an absolute determinant of health status in the population. The organization and management of health services are critically important.
Many low-income countries have, with efficient policies and high-level political commitment, achieved health outcomes comparable to that in much wealthier nations. Think of China in the 1970s. This country’s health achievements were legendary. The health system, achieving 90% coverage of a vast population, was the envy of the world.
Here is a second thing we know. Equity is extremely important as a policy objective. Low-income countries with policies that emphasize equitable access to essential care have achieved greater life expectancies than wealthy countries with no such policy objective. This gives us another obvious conclusion. Better health outcomes can be achieved when equitable access to care is an explicit policy objective.
A commitment to equity is also a mark of good governance. The political will to take care of society’s most vulnerable and deprived citizens says something about governance.
It also says something about the value a society gives to each and every human life, regardless of whether that value has religious, cultural, social, or economic dimensions. A commitment to equity is also a promise of solidarity and shared responsibility in the pursuit of better health
It is also, quite simply, a smart move, especially when equity is pursued through primary health care.
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 population benefits every government. A prosperous and stable China benefits every country.
Ladies and gentlemen,
The challenges China faces as it addresses the health needs of rural populations are by no means unique. The numbers in China may be vastly larger than elsewhere, but many of the challenges are shared around the world.
All around the world, health is being shaped by the same powerful forces. Some of these forces have increased the complexity of challenges facing public health. Others are giving many national health problems an international dimension. Still others are causing the current wide gaps in health outcomes, both within and between countries, to grow even wider.
Changes in the way humanity inhabits the planet have disrupted the delicate equilibrium of the microbial world. As a result, new diseases are now emerging at an historically unprecedented rate. Old threats have resurged, spread to new continents, or developed resistance to drugs. Mainstay antimicrobials are now failing at a rate that outpaces the development of replacement drugs.
The emergence of extensively drug-resistant tuberculosis, which is virtually impossible to treat, is a particularly ominous trend. As another example, a study released just two weeks ago in the USA shows that more Americans are now dying from drug-resistant bacterial infections than from AIDS.
Diseases spread internationally. Air and water pollution spread internationally. The effects of climate change are already being felt. Health costs are rising as technologies become more sophisticated and public demand grows, often fuelled by global information technology.
Societies are increasingly unwilling to accept large disparities in health outcomes. The financing of health care, especially for the poor, is an issue of universal concern.
Urbanization and demographic ageing are global trends, as is widespread population migration. Movement of the workforce from agriculture to the service sector is a global trend. Reliance on computers is a global trend, contributing to sedentary lifestyles.
International trade and globalization of the food supply, its marketing and distribution channels also spread lifestyle changes, and these speed the rise of chronic diseases. Once considered the companions of affluent societies, chronic diseases now impose their greatest burden on low- and middle-income countries. When this epidemiological transition takes place, another important shift occurs.
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 for households can be catastrophic, driving impoverished households even deeper into poverty.
Prevention is by far the better option. But the prevention of chronic diseases demands a multisectoral approach. The prevention of many infectious diseases, especially those spread by vectors or associated with agricultural work, requires a multisectoral approach. This likewise applies to the growing number of deaths and injuries arising from road traffic crashes.
Again, we see the relevance of primary health care, with its emphasis on prevention and multisectoral action.
Moreover, many of today’s problems can no longer be managed by any single government acting on its own. Fortunately, we now have international instruments that provide collective protection through shared responsibility for universally shared threats.
The Framework Convention on Tobacco Control has become one of the most widely supported treaties in the history of the United Nations. The greatly strengthened International Health Regulations came into force in June of this year.
Instruments such as these provide protection from some global threats, but much remains to be done within countries. And many needs fall under the direct responsibility of governments.
Ladies and gentlemen,
This brings us, full circle, back to those three overarching principles I mentioned at the start.
The duty of governments to protect populations from risks and dangers to health now has international dimensions. This duty now also feeds into the larger objective of socioeconomic development. It depends increasingly on the engagement of multiple sectors.
Equity in access to health care comes to the fore as a way of holding globalization accountable, of channelling globalization in ways that ensure a more fair distribution of benefits.
The pursuit of equity has become a driving force for policy at the international level. The Declaration of Alma-Ata, which launched the health for all movement almost 30 years ago, was all about equity.
The Millennium Declaration and its Goals are all about equity, but this time in the context of a globalized society. As the declaration states: The central challenge we face today is to ensure that globalization becomes a positive force for all the world’s people. The underlying principle is clearly stated: “Those who suffer or who benefit least deserve help from those who benefit most.”
Prevention likewise comes to the fore as, quite possibly, the only viable option for keeping the costs of health care manageable – for households, for health financing schemes, and for governments.
Ladies and gentlemen,
The problems facing rural health care in China are well known, and this meeting has been convened to address them. At the request of the Chinese government, WHO submitted a proposal, in April of this year, on health system reform in China. The report makes 17 specific recommendations. These recommendations respond directly to well-documented problems. Let me name just a few.
Health indicators have not improved at the same rate as economic indicators. The discrepancy between health outcomes in rural and urban areas is wide. Health in some rural areas is deteriorating.
The cost of health care is rising, with prices across the whole spectrum of care outstripping the growth of average per-capita incomes. The share of household spending that goes for health care is highest among the rural poor.
Increasing costs, combined with lack of adequate financial protection, mean that more and more rural households are experiencing catastrophic illness. The rise of chronic diseases adds to the problem.
From 30–50% of the rural poor indicate that ill health is the root cause of their poverty, because of reduced earning capacity and ruinous medical bills. The payment of providers through fees charged for services has commercialized health care, compelling providers to focus on profitable rather than cost-efficient health services.
Given the pressure to generate revenue, providers over-prescribe drugs, use expensive but unnecessary tests and procedures, and keep patients in hospital longer than necessary. Health education and preventive services are neglected, as these activities do not generate income.
First-level care fails to provide comprehensive basic services that are easy to access, of good quality, and affordable. Through self-referral, problems that could have been treated at the primary care level flood into hospitals. As a result, simple conditions are often treated in a high-cost environment.
Low levels of health literacy mean that farmers cannot question the practices of providers or hold them accountable for delivering good value for money.
When ability to pay determines access, many rural residents will not seek care until a disease has reached an advanced stage, when treatment is more complex and costly, if not impossible.
In short, the health system in rural areas has been given multiple incentives to operate with great inefficiency. As a result, the Chinese government receives very little return, in the form of improved health outcomes, for its investment in health care.
Internationally, there are few examples of sustainable rural health schemes that do not have strong support from government. China has the most important perquisite for change in place: high-level political commitment.
I want to commend the government of China for this commitment. I want to commend the Ministry of Health for convening this meeting. I want to commend, most especially, its emphasis on primary health care.
Ladies and gentlemen,
I have mentioned the importance of the way health services are organized and managed. I have referred to evidence about the efficiency of a primary health care approach.
Primary health care is the best system for reaching households with essential and affordable care, and the best route towards universal coverage. It is also the best gatekeeper for ensuring that simple conditions receive appropriate and affordable care, at an appropriate and cost-effective level of the health system.
Primary health care promotes the use of essential medicines. It creates space to integrate traditional Chinese medicine with Western medicine. Above all, it gives priority to health education and preventive care, and to individual and community participation in efforts to improve health.
A primary health care approach allows a return to rural farmers of decision-making power and control of their own health. A community’s mutual concern for the welfare of others is a vital form of social capital, and primary health care is well placed to tap this resource. As abundant evidence shows, communities have great ingenuity and managerial capacity, especially when health literacy is improved.
I am glad this meeting gives such a strong emphasis to the role of primary health care – as a route to equity, prosperity, and social stability. These are the larger rewards of better health.
As I conclude, let me comment more specifically on the significance of this meeting.
Time and time again, we have seen how political commitment at the highest level of government can turn the tide for public health. China has expressed this commitment.
Public health owes the notion that prevention is better than cure to China and the Huangdi Neijing, the most important book of ancient Chinese medicine.
During its three thousand year history, traditional Chinese medicine pioneered interventions such as diet, exercise, awareness of environmental influences on health, and the use of herbal remedies as part of a holistic approach to health.
These are historical assets that have become all the more relevant under the unique conditions of the 21st century.
China’s past spectacular successes in public health – in smallpox eradication, in the control of schistosomiasis – led to a favourite saying at WHO, which is part of the Organization’s historical lore.
“China can do anything it decides to do. China can meet any goal it sets.”
The world is watching closely. How China addresses the health needs of its vast rural population will almost certainly serve as a model for many other countries.
I wish you every possible success.