Global action to strengthen health systems
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, distinguished delegates, colleagues in public health, ladies and gentlemen,
I must begin by addressing what is almost certainly the top concern internationally at levels from heads of state to heads of households. We are meeting at a time of crisis. We face a fuel crisis, a food crisis, a severe financial crisis, and a climate that has already begun to change in ominous ways.
All of these crises have global causes and global consequences. All have profound, and profoundly unfair, consequences for health.
A time of crisis is a time for decisive action, but reasoned action, not rash action, and cautious decisions. It is a privilege for me to address this distinguished audience. Public health needs your guidance and support.
I want to thank the G8 for its history of leadership in health and its willingness to engage in some of the most challenging health problems of our time. I want to thank, in particular, the government of Japan, not only for hosting this conference and many previous high-level events, but also for bringing the issue of health security to the forefront of international concern.
I am further gratified to see that health has gained in stature as a fruitful, and a friendly, arena for international diplomacy. Health security truly is one of the issues that we need, as an international community, to address with great urgency.
Health system strengthening, the focus of this conference, is one of the surest routes to health security, nationally and internationally.
We are not in a secure situation when the difference in life expectancy between the poorest and the richest countries exceeds 40 years. We are not in a secure situation when annual government expenditure on health ranges from US$ 20 per person to well over US$ 6000.
We are not in a secure position when more than 40% of the population in sub-Saharan Africa is still living on less than a dollar a day. We all know the links between poverty and ill health. A dollar a day will not keep the doctor away.
Medicine has never before possessed such an arsenal of sophisticated treatments and procedures for curing disease and prolonging life. Yet each year, nearly 10 million young children and pregnant women have their lives cut short, largely by preventable causes.
Our world will not become a fair place for health all by itself. Economic developments within a country will not automatically protect the poor or guarantee universal access to health care.
Health systems will not automatically gravitate towards greater fairness and efficiency. International trade and economic agreements will not automatically consider the impact on health. Deliberate policy decisions are needed in all these areas.
Let us look briefly at the food crisis. Poor households spend up to 80% of disposable income on food. Food choices are highly sensitive to price increases. The first things that drop out of the diet are usually the healthy foods, which are nearly always more expensive – like fruits, vegetables, and high-quality sources of protein. Processed foods full of fat and sugar become the cheapest way to fill a hungry stomach. The health consequences are well-documented.
When something so fundamental to life as food is priced beyond the reach of the poor, we know that something in our world has gone terribly wrong.
Let us look briefly at climate change. All the experts tell us: developing countries will be the first and hardest hit. They also tell us, in no uncertain terms, that countries with robust, equitable health systems will be best able to cope with the shocks of climate change and a drastic increase in extreme weather events. The experts give us another important conclusion. As the Intergovernmental Panel on Climate Change states: protection from the social factors that place poor and deprived populations at special risk is far more important than structural protection.
The direction set by the Millennium Declaration remains the right way forward. In seeking the right foresighted policy decisions in a climate of extreme uncertainty, we must not lose this sense of direction.
We must stay on course. We must not falter in our drive to alleviate poverty and reach the health-related Millennium Development Goals. This is our insurance policy for many other crises looming on the horizon. This is our route to health security.
Ladies and gentlemen,
Since taking office, I have repeatedly stressed the need to strengthen health systems. At this year’s International AIDS Conference in Mexico, I addressed the question of whether single-disease initiatives have weakened health systems or distorted health priorities. This is not a valid conclusion.
AIDS, malaria, and TB are high-mortality emergencies that require a targeted response to bring the disease burden down. Increasingly, they are doing so in ways that strengthen fundamental components of the health system.
Health systems are weak because of decades of failure to invest in basic health infrastructures, services, and staff. These weaknesses have become much more visible because of the unprecedented drive to improve health. We see now what holds us back.
We have powerful interventions for reaching the health-related Millennium Development Goals. What we lack are the systems for delivering these interventions to those in greatest need, on an adequate scale, in time.
As I have said before, I am 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.
Last month, WHO released its annual World Health Report. This year it focused on primary health care and is subtitled “now more than ever”. In a wide-ranging review, the report found striking inequities in health outcomes, in access to care, and in what people have to pay for care.
Data set out in the report are indicative of a situation in which many health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet the needs and expectations of people. As the report notes, conditions of “inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability”.
To steer health systems towards better performance, the report calls for a return to primary health care. Decades of experience tell us: a primary health care approach is the most efficient, fair, and cost-effective way to organize a health system. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of health for the same investment.
This is a people-centred approach to health that makes prevention as important as cure. As part of this preventive approach, primary health care tackles the root causes of ill health, also in non-health sectors, thus offering an upstream attack on threats to health, an upstream way to improve health security. As the report notes, better use of existing interventions could prevent 70% of the global disease burden.
Such lessons take on critical importance at a time of global financial crisis. Indeed: “Now more than ever.”
Ladies and gentlemen,
Let me again express my gratitude for the attention you are giving to global action to strengthen health systems. The financial crisis comes at a time when commitment to global health has never been higher. This crisis comes in the midst of the most ambitious drive in history to tackle the root causes of poverty, reduce the great gaps in health outcomes, and ensure that the benefits of social and economic progress are more evenly distributed.
As I said, a fair, efficient, and affordable system of health care is our best insurance policy, our best route to health security. Investment in health systems and services is investment in human capital.
Healthy human capital is the very foundation for productivity and prosperity. Equitable distribution of health care and equity in the health status of populations is the foundation for social cohesion. Social cohesion is our best protection against social unrest, nationally and internationally. Healthy, productive, and stable populations are always an asset, but most especially so during a time of crisis.
Ladies and gentlemen,
I have one final remark. Our world has never before been so closely connected and interdependent. The financial crisis has unprecedented dimensions. The most experienced economic analysts in the world cannot tell us, with any degree of certainty, what lies ahead.
In this volatile, uncertain time, the health sector has one distinct advantage. We can speak with a great deal of authority. We have the scientific method on our side. We have rigorous methodologies to measure things, prove things, produce estimates, and issue evidence-based conclusions.
At the end of last year, we reached a landmark. Nearly three million people in low- and middle-income countries are now receiving antiretroviral therapy for AIDS. Again, let me thank the G8 for its contribution to this achievement. But if funding dries up in this or other areas, the health sector can produce some fairly precise estimates of what this means as measured by the number of lost lives.
Human suffering and misery are not so easily calculated, but our common humanity should make us care on this count as well.
I personally believe that when the G8 takes on a health issue, you give a human, if not a humanitarian, face to the political leadership that our world so greatly needs. In the final analysis, the net result of all our international policies, from the food supply, to energy use, to the rules of our financial and trading systems, should be to improve the quality of life for as many of the world’s people as possible.
In matters of health, I personally believe that greater equity in the health status of populations, both within and between countries, should be regarded as a key measure of how we, as a civilized society, are making progress.
Strengthened health systems, ideally based on primary health care, are indeed the route to greater efficiency and fairness in health care, and greater security in the health sector and beyond.