Ladies and Gentlemen,

Let me begin by thanking your Chairman, Jean Claude Faure, for asking me to address the Development Assistance Committee. I see it as a great privilege and a valuable opportunity.

As we look forward to new models of development co-operation, strengthening the ties between DAC member countries and key multilateral agencies is essential. We in WHO see these partnerships as crucial to ensuring the success of international efforts to reduce poverty, and to achieving the International Development Goals.

In preparing to speak to you today, I was interested to review the recent trends in Official Development Assistance for health. What do the figures tell us?

As our school teachers used to say: steady progress, but could try a great deal harder.

You are aware, I am sure, that total aid commitments for health have averaged about US$ 3.3 billion per year for the period 1996 to 1998. There has been real growth of about 3% per year. And this happened at a time when total aid volumes were in decline, so the share allocated to health has risen. This genuinely is good progress.

But the sentence in the report that caught my eye was this one: "Aid to health still remains low in relation to the contribution of health to increasing growth, and to reducing other manifestations of poverty. It remains even lower in relation to estimated needs."

Why should this continue to be so?

What will it take to change this situation?

How can we work together to realize the full potential that better health can make to improve dramatically the lives of poor people?

Let me be clear, this is not just a plea for more resources. It is much, much more than that. It is a plea for a shared vision of the future. A future in which we develop new ways of working together at global and national level. A vision which has poor people and poor communities at its centre. And a vision which focuses action on the causes and consequences of the health conditions that create and perpetuate poverty.

But let us start at the beginning. I would like to sketch for you a map of the new territory.

First of all let us look at the context in which we are working. The landscape for international health is changing rapidly.

The UN Millennium Summit, the meeting of G8 Heads of State in Okinawa and OAU leaders in Lome, the International AIDS conference in Durban, the malaria summit in Abuja, and the meeting of Health and Finance Ministers on TB in Amsterdam – at all these events, Heads of State from developing and developed countries called for a step increase in the response to the diseases most closely linked to people’s poverty. The two debates in the UN Security Council show – if further evidence were needed – the political, economic and social dimensions of the HIV/AIDS epidemic.

All the events I have mentioned have increased support for a number of global partnerships: Roll Back Malaria, Stop TB, the Global Alliance for Vaccines and Immunization, the campaign to eradicate Polio, and the International Partnership against AIDS in Africa.

International agencies have begun to respond to the call. In direct response to the Okinawa Communiqué, the European Commission has announced support for accelerated action against malaria, HIV/AIDS and TB in the context of poverty reduction at the recent international round table in Brussels. The World Bank is exploring more flexible approaches to funding work on communicable diseases, including HIV/AIDS.

And things continue to move at great speed. Take drugs, just as an example. In May this year, five pharmaceutical companies approached WHO and UNAIDS to initiate a dialogue about the possibility of increasing people’s access to life-saving patented drugs to combat HIV/AIDS and opportunistic infections – largely through reducing prices. Just six months later, we have the prospect of the European Commission taking on a leadership role and providing a forum in which countries north and south, along with all the other significant actors, can explore a much wider range of strategies that could dramatically increase the affordability of essential drugs.

There is a new political momentum. We have to take advantage of it.

But we must be certain we are standing on solid ground. Getting the facts straight. Building the case. Marshalling the evidence.

As you know, the reason I am in Paris today is that the OECD is hosting the third meeting of the Commission for Macroeconomics and Health. This Commission, chaired by Jeff Sachs, is just one element of WHO’s overall approach to providing evidence for health policy.

Our objective in convening a time-limited body, independent of WHO, was two-fold. First, we wanted a means of bringing together the best brains in the world and getting them to focus on the complex set of relationships that exist between health, economic development and poverty reduction. The Commission has six working groups that are currently tackling different aspects of this task – from modelling the impact of health on growth, to examining the impact of trade policies, incentives for research and development and new approaches to development assistance. This is the technical side of the work, and complements what is being done by other institutions, and what we are doing in-house in WHO.

But the Commission, on which the OECD is represented, also has a political objective. Including macro-economists and senior policy makers as members of the Commission certainly brings a fresh perspective to the technical work. But these eminent individuals also have the respect of other decision makers and opinion formers who may be less familiar with the world of health and development. Our Commissioners will become powerful advocates.

So what does the evidence look like so far? We have some way to go, but what we know is already very telling.

I will just touch on three things. Some points on what we know about the impact of ill health on people’s lives. What we are now learning about the true economic impact of disease, the potential economic benefits of better health. And the magnitude of the resource gap that exists between what is needed to redress current trends and what is actually available.

The Heads of State that met in Okinawa this summer did not exaggerate when they talked about how ill health has the power to reverse decades of development, and to rob an entire generation of hope for a better future. We are talking about a real crisis.

Infectious diseases alone account for 13 million deaths a year. In sub-Saharan Africa, life expectancy at birth - which rose to 59 years in the early 1990s - is set to drop to just 45 between 2005 and 2010. The situation is worse in those countries most severely affected by the HIV/AIDS epidemic, where an existing burden of infectious disease is compounded by an epidemic which as outstripped all past projections. Some of these countries act as a window on the future. They show what will happen unless urgent action is taken in those parts of the world where the epidemic is still emerging.

Among the 10.5 million children who died last year, 99% were from developing countries. Over 50% of these deaths are due to just five infectious diseases, made more deadly through malnutrition. Two million people a year die from TB – and 99% of these deaths are in the developing world.

We are increasingly recognizing that the full economic cost of disease within poor communities has been under-estimated. Even thinking about what is happening at present, the situation is daunting. HIV prevalence rates of 10-15% – which are no longer uncommon – can translate into a reduction in growth rate of GDP per capita of up to 1% per year. TB is estimated to take an economic toll equivalent to $12 billion dollars from the incomes of poor communities. What would Africa’s GDP be now if malaria had been tackled 30 years ago, when effective control measures first became available? Probably about $100 billion greater than it is now, according to a report on the economic consequences of malaria presented to African leaders in Abuja earlier this year.

We traditionally associate poverty with infectious diseases. But poor people are also affected by the rapidly growing burden of non-communicable diseases that is falling on poor communities. Non-communicable diseases can be a serious – even crippling - burden for poor countries. Their health systems have been designed and equipped to deal with infectious diseases and, therefore, need to be helped to respond to the added burden of cancers, heart disease, diabetes, epilepsy and other non-communicable diseases, and to high rates of injuries.

There are numerous factors that influence this new "epidemic" of non-communicable disease, but one is overshadowing all others: tobacco. The current annual toll of 4 million tobacco deaths world-wide will rise to 10 million each year by 2030. Seventy per cent of these deaths will occur in developing countries. Beside the terrible human cost, these deaths represent a huge economic blow to societies. Half of those who die do so in middle age, depriving developing countries of their most productive labour force. Most die after several years of suffering, reduced productivity and need for care.

Today, few developing countries have the resources to treat or care for the vast majority of those with cancer and heart disease, but as the middle-class in these countries develops, there will be a increasingly vocal demand to focus substantial resources on such expensive treatment and care, skewing health spending priorities.

Several World Bank studies have shown that whichever way you turn the figures, income associated with tobacco does not cover the costs of treating disease and loss of productivity.

To sum up, we are getting a better sense of economic costs of ill health today. They are enormous. But the true political cost of illness must take account of the future, of what happens to coming generations. Resulting from lost income. From teachers who die. From enterprises that fail due to workers’ ill health. From impaired ability to earn and learn. The list goes on and on. But it should not. It need not.

That poverty causes ill health is well known. But good health can fuel the engine of development and add significant momentum to the forces of economic development and poverty reduction.

It is at this point we need to turn to the issue of money. Poor countries cannot reduce the burden of disease with a per capita health spending which is often as low as $5-10. We have looked at the problem in two ways. The first is to assess the size of the gap between any reasonable estimate of need for tackling individual diseases, and the resources currently available. In the case of malaria, we estimate that to reach agreed targets in Africa is going to require an additional $1 billion a year. The gap in resources needed to combat the HIV/AIDS epidemic is even larger – probably in the order of $2.5 billion for prevention work alone. Add in the costs of care (which we must) and the costs rise even more dramatically.

The second approach recognizes that combating disease needs well-functioning health systems. In our analysis of health systems published in this year’s World Health Report, one of the strongest factors associated with the lowest levels of performance was a per capita health spending of less that $60.

Of course we know that money is not the whole story. Our analysis shows that some countries could get far more health for the money they currently spend. But for the poorest nations – whichever way you look at it – there is a huge gap. This gap can be partially filled by greater financial efforts on the part of countries themselves. But they face real constraints. Tackling the problems I have described will not be possible without a significant and, I emphasize, sustained increase in development assistance – including debt relief funds when they become available.

This brings me to my next point.

I am increasingly convinced that merely pointing to the size of the gap and requesting those with the deepest pockets to help fill it is not good enough. We, as development and health professionals, have to convince our parliaments and our governing bodies that we know what we are doing. We need to be able to demonstrate results. We need to show that we have learnt from past experience. We have to be able to build consensus around genuine partnerships.

Increasingly, this has become one of our major preoccupations in WHO. As the leading technical agency in health, we have a responsibility to respond to the calls of the international community, and to signpost the way forward. What will it take to scale up the response to the most serious health problems that drive poverty? The shorthand we are using in WHO when we refer to this work is the massive effort. For this is what it will take – a truly massive effort. We know now that we cannot expect to reach the health-related International Development Goals if we just continue with business as usual.

Let me outline some key points in our thinking.

First, we must be clear about priorities – and focus on the health conditions that most affect poor people’s well-being.

Next, we must be clear about what works – identifying the most effective health strategies in different settings – and have a clear idea about the costs and constraints that have to be overcome in working to scale.

We must use all effective channels to ensure that poor people have better access to the services, the commodities and the information that they need. This means good government stewardship: to get the best out of the public sector, and to fully harness the energies of private, voluntary and community organizations.

We need independent systems for monitoring progress.

We cannot always let the urgent displace the important. By which I mean that we must not forget the broader determinants of ill health, and the factors in society that increase people’s vulnerability to disease. To do so is the equivalent of cleaning up oil spills as the mainstay of environmental policy. The need to promote healthy public policies – in employment, in housing, in trade, in education, to name just a few areas – must be kept firmly in view.

We need to work through nationally-driven development processes. We are working to ensure that health plays an increasingly prominent role in national poverty reduction strategies, and specifically in Poverty Reduction Strategy Papers. We are supporting sector-wide approaches, and ensuring that they focus on health outcomes as a measure of their success.

Increasingly, we need to link work at country level with enabling actions globally. In today’s world, we can no longer see these two domains as being separate. The success of national programmes depends on many local factors, but also on international policies which influence the price of essential pharmaceuticals, and the incentives which govern research and development world-wide. We need new vaccines, better drugs, new diagnostics – and we need policies and systems that will create markets for these products.

Globalisation – as it affects the flow of products, people, services and information – must be made to work for the poor. One example of this is the work to assist developing countries in defending themselves against the onslaught of international tobacco companies. These countries need technical assistance in formulating legislation and in enforcing such laws in order to reduce or ban advertising, drastically raise taxes and effectively combat smuggling. But they also need the support an International Framework Convention on Tobacco control will provide. Support for the work on the Framework Convention is support for preventive health in developing countries.

Finally, a word about development assistance. As I said at the outset, the international response is currently only a fraction of what it should be. I only have to listen to Ministers at the World Health Assembly and our Regional Committees to realise that the present system leaves much to be desired. They tell me, for example, that international systems for financial transfer are slow and inefficient. That resources do not get to where they are needed. That transaction costs for projects and programmes are disproportionately high. These problems are often mirrored in their own national systems, but too often the tendency on the part of international agencies is to by-pass, rather than to strengthen, national institutions.

We need an international system that can do more, that can really help national partners go to scale. We need to be much more effective – by a factor of 10, at least. To gear up the system in this way is a huge challenge – but the alternative is to accept that our development goals will remain unrealised, that lives will continue to be blighted, and that the scourge of poverty will remain.

Colleagues,

I would like to end on a practical note, and say a few words about present and future collaboration between the OECD and WHO.

About a year ago, we developed the first Framework for Co-operation between our two organizations. This has been a fruitful and mutually enriching partnership. I would particularly like to mention the work on national health accounts as it is helping to bring methods of accounting between developed and developing countries more into line – and thus advance our ability to carry out international comparative analyses of health systems.

From these early beginnings I would like to find ways of increasing the scope of our work together. For example, I would like to se OECD member countries work closely with us on the Framework Convention on Tobacco Control. I hope after today’s meeting, for instance, that we can find ways of working more closely with the Development Assistance Committee itself.

In WHO we have been particularly impressed by the high quality of the work that has gone into developing the Guidelines on Poverty Reduction. In the first instance we have made a contribution on health to the chapter on sector support. However, we realise that the main purpose of these guidelines is to focus on process and ways of working, without going into detail on the specifics of each sector.

I sense that now is an opportune time to think about next steps. Health is already one of the most important areas for development assistance. I am convinced it will become an increasingly prominent component of assistance from all agencies in the future. I therefore suggest, Mr Chairman, that we explore ways in which we in WHO can work closely with DAC Members and the Secretariat in making health a real force for poverty reduction.