Dr. Gro Harlem Brundtland
Director-General
World Health Organization |
Foreign Press Association, London
21 June 2000 |
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Presentation of the World Health Report 2000 |
Ladies and Gentlemen,
Over the past few months, global health issues have become a regular feature on the news pages and on the evening news.
At the turn of the year the UN General Assembly in New York, called for a more effective response to the HIV/AIDS pandemic. This was followed by a debate on AIDS in Africa in the Security Council. The first ever on a health issue. Some months later, the United States declared HIV/AIDS a national security threat. Three months ago the focus was on tuberculosis in Amsterdam. A month later, malaria in Abuja; tobacco in Bangkok. This month, health promotion in Mexico, women and health in New York, immunization in Oslo. Next month, HIV/AIDS again in Durban, and health and prosperity at the G8 Summit in Okinawa.
All over the world, Heads of State and political leaders - not just ministers of health - acknowledge that people's well-being depends on their enjoying good health. They recognise that investments in health, when properly focused, can contribute - directly - to people's ability to avoid and even emerge from poverty. Global health has become an issue of economic growth and of human security.
This may be part of the reason why we have seen such interest in the Report we are launching today.
But the effectiveness of health systems is also the subject of intense public debate all over the
world. The World Health Report plugs into this debate and, we hope, will help to shift the focus from opinion and ideology toward evidence and knowledge.
What makes for a good health system? What makes a health system fair? How do we know whether a health system is performing as well as it could?
Tough questions: and the answers, of course, depend on where you stand. A Minister of Health defending the budget in parliament, a junior doctor trying to find a bed for an acutely ill patient in the middle of the night, a news editor looking for a story, a mother waiting several hours to see a nurse, a pressure group lobbying for special services. All of them will have their different views. Which is why we in WHO have a responsibility to help all involved reach a balanced judgement.
Whatever standard we apply, it is evident that health systems in some countries perform well, while others perform
poorly. This is not due just to differences in income or expenditure. That performance in the UK exceeds that in parts of sub-Saharan Africa is hardly surprising. That there is a 25 year difference in life expectancy between two countries that spend similar amounts on health should, however, give us real pause for thought. The way health systems are designed, managed and financed affects people's lives. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair.
As you know by now, this year's World Health Report contains the first ever index of health systems
performance.
Using five different measures it analyses the extent to which health systems produce better health and the extent to which these benefits are distributed equitably. It examines the degree to which health systems respond to people's legitimate needs, and the fairness with which they are financed. These indicators are used to compare performance in 191 countries.
It is this aspect of the Report - using the information we have gathered to compare countries on the basis of what they could achieve, given the resources they have available - which is truly new.
It will also no doubt be controversial. We already know that some countries do not like what we have done. At the World Health Assembly in May some questioned our approach.
Some just don't like being compared to others. For some officials, their country's place in the list will be an uncomfortable reminder of imperfections. But I believe that few will be genuinely surprised.
WHO has a role in holding up a mirror, in which our Member States can see a reflection of their own performance. It is our responsibility to ensure that the reflection we present is as accurate as possible. The indicators on which we have reported are based on widely agreed principles. So what we are seeing here is WHO promoting accountability in practice. Providing information to strengthen democratic processes - and helping governments and civil society clearly address the challenges that they face.
We do know, and can be sure, that data analysed with care, and presented in ways that permit comparison, can help drive up the quality and responsiveness of services. This is our aim.
Some critics have queried the sources of our data.
In response to these questions, our position is crystal clear. We know the data are not perfect. But we also know that decision-makers cannot wait for the perfect data set - they have to act on the best information they can obtain. We have responded to this need and we are confident that we have made the most effective use of what is currently available. What we have done this year is a start. And to those who can do it better, we say: come and help us refine and improve the analysis next year, and the year after.
It is through work like this - that draws on our comparative advantage as a global body - that we can contribute to building societies that are fairer and that respond better to poor people's needs.
The tough message in this Report is that virtually all countries are under-utilising the health resources that are available to
them. For ministers defending their systems performance to the public, and to colleagues in government, such a message is not always welcome. However, very few ministers have had a real chance to develop, set up and implement a system from scratch. A critical light can help them move ahead.
Let me be clear, though, the purpose of this Report is not just to provoke criticism. On the contrary, I see this as a document of hope and progress. It lays out a path for the future. For governments. For development agencies. For NGOs. For all those who have a stake in making sure that health systems perform as well as possible. Not least, it is a document which will provide the basis for much of WHO's health systems work in the future.
The exciting thing for me is that the Report shows that significant improvements in performance are possible. We have done more work since the Report went to press. Having compared performance across countries, the question we have been asking now is: which factors are critical in making a difference?
Four appear to stand out: social inequality, total health spending below a critical threshold of about sixty dollars per capita, the magnitude of the HIV/AIDS epidemic, and the overall effectiveness of governments.
This is work in progress, but let me highlight three areas where we think that further work may be rewarding:
First, we need to look at what could happen if all countries improved their performance to the maximum possible -
without increasing resources. On a global basis, preliminary work suggests that disability adjusted life expectancy then could increase from less than 57 to approximately 70 years. In Sub-Saharan Africa, the potential for change could be even more dramatic - from 37.5 to 64 years of disability-free life - just through making better use of existing resources.
Second, the importance of government stewardship. Of the four factors that I just mentioned, the overall effectiveness of government seems to have a particularly strong influence on health systems performance. On the basis of some initial work, using a measure of government effectiveness developed by the World Bank, it seems possible that the health systems performance index of the least well governed countries could increase by up to 50% through better governance alone.
Thirdly, the issue of thresholds. The data in the Report suggest that good performance is really very hard to achieve if total health spending in a country is less than about sixty dollars per capita. This could be a finding of considerable significance. Not least in making the case for additional development assistance.
We estimate that forty-one countries (with a combined population of over 800 million) had expenditure below this threshold in 1997. To bring health spending up to this threshold would cost about six billion dollars a year. The potential pay-off - from what amounts to less than one quarter of one percent of total global spending on health - is an increase in disability adjusted life expectancy in those countries of about 8 years.
So, there is much that we can do.
The World Health Report this year provides both a road map and tool kit for improving health systems performance. It marks the start of a new endeavour in analysis and accountability - for WHO itself, and for Member States.
Reports such as this are not an end in themselves. They are successful only to the extent that they stimulate new commitment and action.
Over the next year we will improve our cross-country comparisons. Equally important, however, will be supporting countries in their efforts to collect, use and act on their own performance data.
We need to do more work to examine what it will take to improve health systems performance in particularly difficult environments - where there is little prospect of economic development, where new solutions are needed if we are to reach those most in need of health care.
We need to define priorities for action: not just in terms of better and more equitably distributed health outcomes. The choice of how to finance services is critical. The costs of health care can tip the balance from bare subsistence to real poverty. We learn too that providing services is not enough. Unless people are treated with dignity and protected from financial exploitation, they will not use services - and precious resources will be wasted as a result.
Let me conclude with one of the key messages of the Report. The ultimate responsibility for a country's health system - irrespective of public and private responsibilities for financing and provision - lies with government. The careful and responsible management of the well-being of the population - stewardship - is the very essence of government.
The health of people is always a national priority. I sincerely hope that this Report will help policy makers make wise choices. If they do so, substantial gains are possible for all countries, and the poor will be the principal beneficiaries.
Thank you.
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