| Hôpitaux Universitaires de Genève Thank you for inviting me to
address you this morning to speak to you on an issue of increasing importance for all
committed to the cause of public health: How do we set our priorities?
When taking office at the World Health Organization I gave this question a lot of
thought. We need priorities. When resources are scarce – and they always are - we
need methods to define what is more important.
In the case of an international organization devoted to public health, the question of
priorities is particularly complex. When the media ask: What are your priorities? –
they will not have patience for more than two or three.
I never accepted that tabloid logic. As incoming Director-General I answered: If WHO
can reform, adapt its structure and focus its work – then this is my answer: The
World Health Organization is my priority. A WHO that can engage where the needs are
greatest. A WHO that is trusted to maximize its resources. A WHO with excellence. A WHO
that can truly make a difference as the lead agency in health.
We are taking decisive steps towards that goal. Guiding us in this work of reform we
are studying how we really can make a difference – above all for those who are most
in need.
If we look across countries and compare their health achievements and the resources
that they spend on health, there is a real mismatch. Some countries spend nearly one out
of every seven dollars on health care, but achieve much worse health status than countries
that spend much less.
At all levels of income per capita, some countries outperform other in terms of health
achievement and the extent of health inequalities. The lesson is clear: What matters is
not simply how much we spend on health, it is what we do with the resources we spend. What
matters is the decisions we make about how we promote health, and which types of services
to provide - preventive and curative medical services, public health services and
rehabilitation.
To raise the performance of health systems, we need to bring attention back again to
the major health challenges that explain the gap between countries and the gaps between
the advantaged and disadvantaged in countries. We need to identify and deliver the public
health and curative interventions that really will make a difference.
Many health systems are undergoing major reforms. In the face of intense pressures to
change the financing and delivery of health care, we must not lose sight of the content of
health care and of priority actions to improve health.
To focus attention on health during health reform, we need to have a comprehensive and
objective view of health challenges. We need the evidence on what works to improve health
and what it costs and we must organize health systems to deliver critical health
interventions for priority health problems.
Developed through the Global Burden of Disease Study, the purpose of the burden of
disease concept is to provide comprehensive assessment of health challenges to help inform
public debate on the priorities for health action. Too often - in too many places - public
attention is captured by the most vocal advocates. Large numbers of people suffering from
serious problems are often ignored because they do not have good advocates.
The burden of disease approach will help us address this problem and is founded on six
principles.
First, the magnitude of health problems needs to be evaluated based on the best
available evidence, not simply on the claims of vocal advocates. The basis for assessing
health problems needs to be as objective as possible, bringing to bear all the available
information.
Second, it will provide the best available information on the magnitude of health
problems. Decision-makers must make decisions even where the evidence is not ideal. Where
a problem has not been studied well, its magnitude should still be estimated as best as
possible in a transparent and scientifically credible manner.
Limitations of existing information can help motivate future efforts to get better
evidence, but in the meantime public policy cannot ignore death and suffering simply
because ideal studies have not been completed.
Third, health is much more than survival. Public debates on priorities for health too
often focus only on the number who die. In the burden of disease approach, non-fatal
health outcomes, morbidity and disability, are also evaluated.
By giving morbidity and disability comparable attention to premature mortality, these
critical components of health can be included in decisions about priorities. Measures such
as Disability-Adjusted Life Years provide a way to facilitate comparisons of the magnitude
of fatal and non-fatal health problems. Only then will the historical neglect of disabling
conditions such as many neuro-psychiatric conditions be addressed.
Fourth, the burden of disease approach allows decision-makers to focus on inequalities
by revealing whether particular vulnerable groups in society have much poorer health
outcomes than others.
Fifth, the magnitude of premature mortality and disability is examined not only in
terms of diseases and injuries, but also in terms of risk factors. Risk factors can be
physiological factors such as hyper cholesterolemia, hypertension or diabetes, individual
behaviours such as tobacco use, physical activity or diet, or social factors such as
education, poverty or employment.
Sixth, for some critical decisions we need to anticipate future health trends.
Decisions about research and development, medical training or investments in hospitals and
clinics should all take into account future health patterns. Projections of alternative
scenarios are an integral part of the analysis.
Finally, any assessment of health problems raises many ethical issues. A key component
of the burden of disease approach is to make the ethical values underlying an assessment
of health priorities transparent and available for public debate.
The Global Burden of Disease Study was the first implementation of the burden of
disease concept at the global and regional levels. The study demonstrated that this
approach is feasible. The large number of National Burden of Disease studies that have
followed also indicate the demand for such comprehensive views of health problems.
The results of these studies show that the effort at comprehensive assessment can yield
many surprises.
Perhaps the most surprising is that neuro-psychiatric conditions cause 10% of the
global burden of disease. This is not just an issue for rich countries. Just under 10% of
all disease burden in developing regions is due to these conditions. Depression alone is
the fourth leading cause of the global disease burden.
Another surprise is the importance of injuries in all regions. Injuries caused 15% of
the global burden of disease and injury in 1990. And in some parts of the world, this is
closer to 20%.
Social and economic development is not a guarantee for containing health gains. There
can be abrupt reversals. The alarming decline in male life expectancy in Eastern Europe,
described by the Global Burden of Disease study, reminds us that we cannot take good
health for granted.
It is very clear that ill health is often caused by more than one disease. The
importance of some diseases, such as Hepatitis B, diabetes and several blinding
conditions, increases dramatically when the full burden associated with these conditions
is examined.
The findings on risk factors for health are alarming. We now know that under-nutrition
causes one-sixth of the global disease burden. Tobacco, alcohol and unsafe sex each cause
3% of the global disease burden, equivalent to the burden from tuberculosis or measles.
The projected changes in disease burden are guides for action. Unless we control
tobacco use, tobacco will cause 10% of disease burden worldwide by 2020. China has
revealed through a comprehensive study that one out of three Chinese men under 30 today
will die from tobacco use. Not in old age but in middle age,
The world is getting older and this will mean that the burden of noncommunicable
diseases will rise. In broad terms we are living through a transition from communicable
diseases towards a growing burden from non-communicable diseases. That will have major
implications for the organization of health systems – for the training of health
workers and the financing of health services.
Barring unexpected shocks, the burden of communicable diseases is expected to continue
to decline. But we cannot be complacent. The HIV epidemic is projected to rise
dramatically over the next decade or so. This is an unprecedented reversal of human health
progress. The HIV epidemic underscores the potential for other new diseases to emerge or
known diseases to reappear.
Even without any real changes in risk, the burden of neuro-psychiatric conditions will
rise simply because of demographic changes. The number of young and middle-aged adults at
highest risk is expected to increase by 50% by 2020.
Life expectancy is expected to rise and significant gains should occur in poorer
regions. Gains of 10-13 years are projected by 2020. But if we are not successful in
controlling the two major causes of disease burden that are increasing sharply - tobacco
and HIV - these gains will be much less impressive.
WHO is committed to periodic revision of the Global Burden of Disease Study to provide
the world with up-to-date comprehensive assessments of health challenges. More
importantly, WHO is also committed to assisting countries that wish to apply this concept
at the national or sub-national level.
An important innovation at WHO is the creation of the cluster on Evidence and
Information for Policy. Refining and further elaborating the Global Burden of Disease
Study will be an important task of this cluster. I see this as making available a global
public good. All governments will need better evidence for their decisions. We need to
share experiences – good as well as bad. WHO has the vocation of being a centre where
the evidence is gathered and made available for all.
Decision-makers - whether primary care providers, district health managers or national
authorities - need much more than good information on the size of health problems. They
need to know what works to improve health and how much it costs.
Great strides have been made through the evidence-based medicine movement to provide
decision-makers with access to the evidence on clinical efficacy. The Cochrane
Collaboration, for example, makes systematic reviews of more than 500 interventions
available to the medical community. These efforts are important but we need many more.
We need to understand how to get from the results of clinical trials in ideal
circumstances to what happens at the community level. We all know that there can be a huge
gap between the results in trials and the real effectiveness of an intervention in a
population.
Grappling with the gap between clinical trials and community effectiveness means
understanding how to deliver high quality health services, how to encourage patient
adherence and how to respond to co-morbidity.
We must also know the costs of different health interventions. Only the very rich can
purchase every possible health intervention. In the face of scarcity, we must focus
attention on the interventions that will generate the most health and reduce inequalities
in health for the resources available.
Many countries use or plan to use cost-effectiveness information to help prioritize
health interventions. But for most countries, the information needed, clinical efficacy,
costs and the likely effectiveness in real communities can be difficult to obtain. WHO has
a critical role in ensuring that countries, communities and health care providers have
access to this important information.
When I speak about health interventions, I do not just mean curative and medical
services. I mean actions that improve health whether they are public health, curative,
rehabilitative or even in other sectors such as road safety.
Armed with a balanced assessment of health problems and their distribution, and the
best evidence on what works to improve health and how much it costs, we can then ask the
question how should health services be organized to ensure health gain.
For WHO in the coming years – this will be key: How can we tailor what we do in
such a way that it strengthens the health sector at a national and community level? I have
told the Executive Board of WHO that if what we do does not contribute to a strengthened
health sector – we should consider not engaging. From 1 January we will initiate a
project called Partnership for Health Sector Development – aimed at pulling the whole
of WHO around this goal – to help the health sector define their priorities and to
help them sustain their activities according to available resources.
The burden of disease approach helps bring into focus the major health problems,
whether or not they have vocal advocates.
It brings health more fully into public debate on the priority-setting in public
policy, nationally and internationally.
Thank you. |
