Good afternoon,

I would like to thank you for inviting me to speak here today and to give me this opportunity to share with you the way the World Health Organization looks at global health in the coming decades.

Australia is the last leg of a very interesting two-week journey that has taken me through Thailand, Indonesia and East Timor.

In Bangkok, I opened an International Conference on Health Research. If we are to overcome the inequalities in health and make advances against the diseases that perpetuate poverty in the developing countries, we need new drugs and vaccines, we need to find better ways of using the interventions we know today, and we need to know more about how health systems work and can be improved in developing countries. To do this, we need more and better health research, and capacity building in developing countries.

More than 700 researchers from all around the world worked towards a new strategy of health research for development that will hopefully lead to increasing resources for such research.

One example of the new ways we are exploring to achieve results was the launch in Bangkok of the Global Alliance for TB Drug Development. This is a joint private and public sector venture capital fund that will finance research to develop new and much-needed drugs against tuberculosis. This is one of several such initiatives that have been formed over the past year to find new solutions to the problem of lack of new drugs and vaccines in the fields of malaria, tuberculosis and HIV/AIDS, diseases of poverty and lack of incentives for pharmaceutical companies to invest sufficiently. We need to overcome market inefficiencies and focus on where the real needs are.

I continued to Jakarta, where I met with President Wahid, Vice President Megawati and with health officials. Indonesia, is of course still struggling to recover from the political and economic turmoil of the past three years, and in my conversations I stressed the need to protect and even increase health spending to retain health levels as the country restructures.

There was understanding for such arguments among the Indonesian leaders, and the launch while I was there of the "Making Pregnancy Safer" Initiative was a clear example of this commitment. Maternal mortality is perhaps the condition most directly linked to poverty. Improving maternal health will have a direct positive effect on the economy and well-being of the poorest families.

From Indonesia, I went to East Timor, where the UN, in cooperation with the East Timorese leadership is building up a new country from scratch. It was shocking to see the destruction done by the militias and impressive to see the efforts to build up an entire country’s legal, political and physical infrastructure with very limited resources. Only 23 local medical doctors remain in the country, and most hospitals and health stations have been looted and destroyed. Despite this, there is now a functioning health systems in all but the most remote parts of the country. I had fruitful discussions with the East Timorese leader, Jose Alexandre Gusmao about how to structure a cost-effective and equitable health system.

Here in Australia, I will be attending the opening of the Paralympics, visiting the Flying Doctors and the Aboriginal Medical service and do a national launch of Vision 2020, a global campaign to prevent blindness.

In short, although they represent only a small part of WHO’s activities and responsibilities, these two weeks’ travel illustrate well how broad the global agenda for health is, as we enter a new century.

These are very exciting times for global public health. There is an unprecedented realization among presidents, prime ministers and other senior decision-makers, that health is crucial for maintaining human resources.

Although our work is first and foremost about preventing and reducing human suffering, I have always believed that only when we see the economic consequences will decision makers turn words into more decisive action. That was the case with the environment 20 years ago. Now, we are seeing a growing body of scientific evidence about the link between health and the economy.

During the early 1990s, the world began to accept that there is a complex, but close-knit relationship between health and poverty. Being poor is bad for your health. But being ill also reduces your chances of getting out of poverty.

There is new data about the extent to which ill-health is impacting on the economy of some communities and nations. Much of this data focuses on Africa but the trends are universal. We now know that a few diseases, such as malaria, HIV/AIDS, tuberculosis, the traditional childhood killers and reproductive health conditions, are directly biting into the economic growth of developing countries. Malaria shaves off as much as one per cent of GDP growth in the hardest affected countries. When HIV/AIDS reaches endemic proportions it can reduce growth by nearly half a percentage point.

There is an increasing recognition of the sheer difficulty faced by developing nations as they seek to counter these health threats. It is becoming clear that health systems which spend less than $60 or so per capita per year are not able to even deliver a reasonable minimum of services, even through extensive internal reform. It doesn’t matter how good the structure is – as long as you can’t afford to pay your doctors and nurses proper salaries and fill the shelves with essential medicines and vaccines, a health system will not be performing at a reasonable level.

But data also suggest an inverse relationship between health and economic development. As we saw in Europe at the end of the 19^th and beginning of the 20^th century, developing countries which invest relatively more, and well, on health are likely to achieve higher economic growth.

In East Asia, for example, life expectancy increased by over 18 years in the two decades that preceded the most dramatic economic take-off in history.

A recent analysis for the Asian Development Bank concluded that fully a third of the phenomenal Asian economic growth between 1965 and 1997 resulted from investment in people’s health.

But infectious diseases are not the only threat to the poor. Food borne diseases are annually affecting up to 10% of the population. The mishandling of food during its preparation by domestic food handlers, including care-givers of small children, is prevalent. We can all be affected.

We saw 4 billion cases of diarrhoea last year from food. One billion people lack adequate water supplies. Three billion people lack hygienic sanitation facilities.

Air pollution is another major contributor to death and disability – in particular among the poor.

The woman bending over her oven, inhaling hazardous smoke from the wood she is burning – her child suffering as she sits on her mother's back. Its impact in developing countries is much greater than that of ambient air pollution.

It is simple, really. Human health and the health of ecosystems are inseparable. The focus on how reduction in a few infectious diseases can drastically improve the well-being and prospects for the poor does of course not mean that we should ignore the wider determinants of ill health. Improvements in environment, in work conditions and in safety must go hand in hand with the fight against HIV/AIDS, malaria and tuberculosis.

Another important finding from recent research is that the way health systems are designed, managed and financed seriously affect people’s lives. The performance of a country’s health system is as important as the absolute amount of money spent.

Whatever standard we apply, it is evident that health systems in some countries perform well, while others perform poorly. 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 cause for thought. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair.

As we look ahead to the coming two decades, we see a clear shift in the global burden of disease.

Non-communicable diseases, mental disorders and injuries will make up a dominant share of the total burden. The change will be particularly rapid in developing countries, which to a large extent will have to deal with a "double" burden of disease, since their health systems still will be occupied with the traditional infectious diseases. Therefore, the challenge of prevention and control of injuries, of heart diseases, diabetes and cancers and of mental disorders are enormous.

Take injuries. Work-related injuries and diseases are responsible for the death of over 1 million people every year. 250 million accidents and 160 million new cases of work-related disease occur every year. The cost to the economy has been estimated at 4% of the world's gross national product.

The rapid rise in the magnitude of these problems represents one of the major health challenges to global development in the 21^st century and threatens the lives and health of millions of people.

Changes in lifestyle and environment are among the reasons for this shift. But the single largest factor in the growth of non-communicable diseases in the developing world is tobacco.

We are facing an emerging epidemic. World-wide mortality from tobacco is likely to rise from about 4 million deaths a year last year to about 10 million a year in 2030. In public health terms, this is comparable to the HIV epidemic. Over 70 per cent of the deaths will be in the developing world.

The implications are obvious. Tobacco is not only a human tragedy. Tobacco also burdens our health systems. It costs taxpayers money. It hampers the productivity of our economies. We have seen this happening in the U.S. and in Europe. But now, these burdens are hitting developing countries, countries which need all their resources to build their social and physical infrastructure. As you know very well, developing countries have no extra money to spend on the unnecessary costs of a man-made epidemic.

As we look into the future, we see the outlines of a world where the main infectious diseases can be controlled given the wise use of substantial extra resources. We see a world where tobacco-related diseases, injuries and mental disorders will demand considerably more resources of health systems than they do today, and we see a world where developing and rich countries alike must focus on using the resources at their disposal better to deliver more cost effective and fair health services to their populations. In the industrialized countries, which already spend substantial amounts on health, we are talking about more health for the money rather than more money for health. In the developing countries, we need to spend more on health, but we must do so in a cost-effective, result oriented way.

WHO sees the need for concerted, global action in order to achieve these tasks. We have therefore decided to take a more active approach to health questions, by pointing out the political implications of global health, the resource needs and the possible strategies needed to make progress with the main health issues of the coming years. This has perhaps been an unexpected turn of events, and WHO has certainly become more involved in controversy, but it is a direction our Member States have appreciated. They expect this leadership from WHO, and they wish WHO to be an Organization that gives advice on the difficult health issues all countries face.

What does this mean in practice?

First of all, anyone who is concerned with the social and economic development must place health centrally in their thinking. Health is becoming an important issue for finance ministers, prime ministers, planning ministers – and indeed for law-makers.

Secondly, we have an increasing amount of firm scientific evidence that can help decision-makers to make educated choices for health based on what works, what is most cost-effective and what are the most equitable solutions. This means we must let knowledge take precedence over ideology .

Thirdly, new ideas are emerging. We have a number of health interventions which dramatically reduce mortality from the main infectious killers. A number of health interventions can dramatically reduce mortality from the main killers. Supervised medication regimes for TB; nets impregnated with insecticide against mosquitoes, and wide distribution of malaria treatment among children and pregnant women; prevention programmes for HIV/AIDS – or access to care programmes that can substantially slow the mortality among those living with HIV.

They have in common that they have proven effective on a local or national level. Quite simply, if we can take these interventions to scale - and by that I mean to a global scale - we have in our hands a concrete, result-oriented, and measurable way of starting to reduce poverty.

We also know that such action is crucial if hard-won health gains – and in the extension of these, social and economic gains – are to be sustained.

In addition to making better use of existing interventions, we must focus on ways to best make drugs and vaccines that exist but are not widely available affordable to as many as possible. This is in particular true for access to care for those living with HIV. WHO is working with UNAIDS and other UN agencies to facilitate a dialogue between five major pharmaceutical companies and individual countries to drastically lower prices on anti-retroviral drugs and drugs against opportunistic infections.

WHO is also advising countries on how best to gain access to the cheapest possible essential drugs for other conditions than HIV/AIDS and to improve import regimes and distribution systems in order to make drugs available to those who need them.

The world must also increase our efforts to produce new drugs and vaccines. We are fighting against time to achieve the best results possible with the drugs that exist as they slowly are becoming less effective due to microbial resistance. We need new drugs for malaria, TB and a range of other diseases. Like the Global Alliance for TB Drug development which was launched last week.

We also need to work on new vaccines. The Global Alliance for Vaccines and Immunization, GAVI, has already disbursed its first batch of funds for countries, less than eight months after its launch. It will continue its work to scale up and widen the immunization coverage of children world-wide. But it will also support the development of new vaccines. Let us take inspiration from the campaign against polio. Some decades ago, a polio vaccine was just a dream. Today, thanks to scientists and public health workers, the world-wide eradication of polio is within reach.

To overcome the challenges against the main infectious diseases, we will need a global, long-term commitment. In short, we will need a Massive Effort. Current estimates suggest that an additional $1 billion dollars annually will be required to combat malaria effectively. The situation with TB is similar. Another billion dollars annually spent on drugs - linked to work on health systems - could result in a 50% drop in mortality over the next five years. With HIV/AIDS, we need even more. Sums in the order of $2.5 billion dollars annually are needed for prevention alone. Add the cost of care, and the figures rise dramatically.

In July, the G8 leaders committed themselves to support step-by-step improvements in health outcomes among poor communities. They committed to targets set by international fora for reducing the toll from HIV, malaria, and TB by 2010.

The European Commission has shown a strengthened push to fight HIV/AIDS, malaria and tuberculosis. It has adopted a policy framework to increase access for poor people to essential health goods and services; aims to reduce prices of vital medicines and commodities; and to create incentives for strategic research to develop new and more cost effective products for prevention, diagnosis and treatment.

Australia, as an important player in the east Asian, and of course, Pacific region, can play a crucial role in such an effort. Both in your bilateral assistance and in your diplomacy, Australia can play a very constructive role in promoting equitable development through health.

The fourth conclusion we can draw from today’s world is that health systems make a difference.

The effectiveness of health systems is the subject of intense public debate all over the world. This year’s World Health Report plugged into this debate. It contained the first ever index of health systems performance. The aim of compiling this index was to shift the focus of the debate 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. This is why we in WHO have a responsibility to help all involved reach a balanced judgement.

The tough message in this Report was that virtually all countries are under-utilizing 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.

Not surprisingly, the Report led to wide-spread discussions both in national and international media and among health professionals about how to assess health systems, as well as a more fundamental debate about what makes a good health system.

This debate is good. Discussion about the concepts and analyses in the World Health Report has given us all new insights. To continue the global dialogue on how to get the most out of health systems, we will work closely with Member States to make better uses of existing data sources and where necessary to collect new information so that the annual assessments of health systems performance are based on the best available evidence.

In response to numerous requests, WHO will be working closely with a number of Member States in an Initiative to Enhance the Performance of Health Systems to apply the new WHO assessment framework at national and also sub-national levels; to use this analysis as an aid to national policy formulation; and to work together to facilitate positive change.

The fifth conclusion is that we need to make policy decisions in the near future that will determine the disease burden in the decades to come. For most noncommunicable conditions, there is a lag between exposure to risk and visible outcomes, but policy decisions to deal with this shifting burden of disease are required now.

This is true for all non-communicable diseases and injuries. During the next 12 months WHO will be looking particularly at mental health.

No country and no community is immune to mental disorders and their impact in psychological, social and economic terms is huge. Yet, societies raise barriers to both care and the reintegration of people with mental disorders. What makes our task doubly urgent is that there is no reason for inaction - much less exclusion. World Health Day on April 7 2001, the World Health Assembly in May that year and the World Health Report 2001 - all will focus on mental health. Together, we will find solutions and strive to make the necessary changes.

Tobacco, of course, is another area where today’s decisions will determine the mortality figures in twenty or thirty years’ time.

Yesterday, negotiations began in Geneva on an International Framework Convention on Tobacco Control. The treaty will provide an international framework to address both national health policies and to control the global reach of the tobacco companies. It will set standards that countries can adopt to control advertising, prevent smuggling and facilitate the global exchange of knowledge. That support for health is also a support for justice, equity and solidarity.

I hope and trust that Australia will play an important role in helping us craft the Framework Convention on Tobacco Control.