Minister Borst-Eilers,
Colleagues,
Ladies and gentlemen,

We are here to discuss how we can better set priorities for investments in health. I start with a focus on investing in health outcomes.

There have been extraordinary changes in global health during the last century. Life expectancy at birth of males in England and Wales was less than 50 years in the early 1900s but had risen to over 75 years by the end of the century.

Women in Chile could expect to live for less than 30 years 100 years ago but now can expect to live to almost 80 years.

Associated with this have been major improvements in living conditions and in education. But in addition, antimicrobials have been discovered and widely used, and the impact of many communicable disease agents - such as the small pox and wild polio viruses, the guinea worm, the leprosy bacillus and the onchocerca that lead to river-blindness - have been greatly reduced.

Yet, health remains a dominating concern for many, particularly the three billion people who live on less than two dollars a day.

For the mother who struggles to protect her children against malaria.

For the teacher who watches as tobacco marketing lures her students into a habit that will kill half of them.

For the prime minister who sees a substantial part of his country’s productive population ravaged by HIV/AIDS.

The levels of ill-health in countries constituting a majority of the world’s population pose a direct threat to their own national economic and political viability. They are thus a threat to the global economic and political interests of all countries. Global health inequities undermine human security and we cannot afford to ignore them.

We are working towards a shared vision of the future for health among all the world's people. A vision 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. Equitable health outcomes for all.

This vision directs us towards four strategic priorities for global health:

• we need to reduce the excess mortality of poor and marginalised populations;

• we need to effectively deal with the leading risk factors to health;

• we need to strengthen sustainable, fair and cost-effective health systems; and

• we place health at the centre of the broader development agenda.

I focus on the first priority: investing in a reduction of health burdens for poor people.

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.

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. 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 annual 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 noncommunicable diseases that is falling on poor communities. Noncommunicable 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 noncommunicable diseases, and to high rates of injuries.

There are numerous factors that influence this new "epidemic" of noncommunicable 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. Yet with increasing awareness of their importance, we are faced by demands to focus substantial resources on treatment and care of those who are affected by them. That increases the difficulty of focusing on health outcomes.

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 the enormous economic costs of ill health today. The better we can understand them, the more easily we can justify investments in effective action to promote well-being through better health. The political cost of sustained health inequities is being recognised. The present burden is compounded by the future impact on 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. Less well known are the new analyses – that good health can fuel the engine of human and economic development. An improvement in population health will add significant momentum to the forces of economic development and poverty reduction.

In a globalized world, this is as good news for people in Europe as it is for those in Africa. In our modern world, widespread poverty on three continents is a serious drag on all our economies. Investing in the health of people in poor countries is investing in the common future of all peoples.

Governments of poor countries cannot reduce the burden of disease with a per capita health spending which is often as low as $10. We have looked at the issues they face 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 halve malaria mortality 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. Yet such investments are essential are essential for the economic and human development of all our world.

The second approach recognizes that combating disease needs well-functioning health systems. Let me be clear. The health system is much more than the health care delivery system. It involves any activity designed to improve health, whether implemented "through poublic, private or voluntary sector channels. 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 the absolute level of resources is not the only issue. Our analysis shows that most 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 between need and spend. 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.

If we look at the global burden of disease twenty years from now, we will find a different, more complex picture than today. Communicable diseases will still remain important causes of death and disability globally, particularly in the poorest regions.

The traditional killers such as HIV/AIDS, TB and malaria, maternal, childhood and nutritional conditions are still expected to account for over 40% of the burden of disease in Sub-Saharan Africa in 2020, assuming countries’ economies will continue to grow at similar rates as in recent years.

But – as I have said – there will be increasing health problems linked to noncommunicable diseases and injuries, many associated with ageing and the tobacco epidemic will increase. Mental health, cardio-vascular diseases and road traffic accidents all in the top 5 predicted causes of the global burden of disease in 2020. And as I have already pointed out, tobacco is set to be the biggest killer of them all – causing more deaths than both malaria, HIV/AIDS and TB together.

To meet this challenge, investment in new systems that produce health is essential – in all nations and among all people. The ability to predict change and to transform our health systems in response to that change will determine whether people's health can improve.

In designing optimal policies for health investment, we need to remember that many of the major determinants of better health lie outside the health sector. Knowledge. Made available to people. Clean environments. Access to basic services. Fair societies. Fulfilled human rights. Good government. Enabling people to make decisions relevant to their lives, and to act on them.

For people to have the power to be healthy, they first need knowledge. Accurate, reliable knowledge about how to achieve good health, and about the risks to health that they face in their daily lives. They need knowledge that helps them to make the best choices and to implement them. They need to know how to achieve good health: how the family can stay healthy. As we see from the recent trends of reduction in heart diseases and cancers in several industrialized countries, up to date, applicable knowledge is a pre-requisite for better health.

Knowledge is necessary, but it is not sufficient. For people to have the power to be healthy, they must be in a position to choose better health. This means making the right choices, and putting them into practice. If people are not able to do so, the new knowledge leads to frustration. Hence our focus on healthy cities, healthy schools, healthy workplaces and healthy homes. Environments within which people can choose to be healthy, and implement their choices in their daily lives.

Yet, the combination of knowledge and a healthy environment is often not enough. Many people will still not feel that the power to be healthy is in their hands. The third element is their being empowered to make the healthy choices for themselves – and stick to them. This means local, national – and even international – policies that give them the freedom to do what they want, and need, to do.

Colleagues,

The governments of many countries struggle to reach a minimum acceptable level of health system spending. The are also struggling to deal with ballooning costs of activities undertaken within their health systems – many of which are ineffective at producing health..

Sweden, New Zealand, and – indeed – the Netherlands, are among a number of countries which have gone new ways to systematically consider how to balance the limits of spending with the best possible health services.

The point of departure for this year’s World Health Report has been the basic assumption that in order to improve efficiency and set priorities, one needs to accurately assess the current performance of health systems.

Only with a clear vision of the goals of the health system, as well as evidence about current goal achievement, can countries start to assess priorities based on evidence. These priorities must be linked to ways of improving goal attainment and health system performance.

WHO has identified three main categories for assessing health system performance: health attainment, responsiveness to expectations, and fairness of financing. These criteria for performance can also form a basis from which priorities are set. We hope that the consensus on goals for system performance will make it easier to judge what interventions to focus on.

Most importantly, countries need to compare system performance and their experiences with attempted improvement. They learn from each each other. When, as this year’s World Health Report has shown, countries with similar health expenditures can have as much as 25 years difference in healthy life expectancy, there is a substantial scope to pick up best practices and cost-effective solutions from other countries and adapt them to local settings.

The World Health Report ranking of health system performance is meant as a contribution to this process of looking beyond national borders for solutions.

One of the many interesting findings of this year’s Report was that no health system exploits its resources to its full potential. Our estimates of health system performance showed that health systems within almost a third of all our Member States were achieving less than 60% of their potential given current levels of expenditure.

In other words, they could improve their goal attainment by 40% or more without investing additional resources.

One example is the way in which systems respond to people with chronic illness. Existing health systems in most countries do not take fully into account the rising share of patients with long-term illness as a proportion of the total demand for health care. Systems are responding to a growing proportion of people with noncommunicable diseases, and an increasing number affected by infectious diseases - such as HIV infection - in need of long-term care. There is a profound mismatch between the care needs of long-term patients and the way health care is organized, managed and financed. In the usual acute care-centered health system, the average health care cost of a patient with long-term illness is three times bigger than that of an patient with acute illness.

We are all aware that of the evidence that many systems implement interventions that are not cost-effective at improving health. But with the increased international attention on health outcomes, these efficiencies must be addressed by those who advocate investments in health.

For example, in the mid 1990s, the Harvard Life Saving Project showed that many interventions that were not fully implemented in the US cost less than $10 per year of life saved.

Reallocating the resources committed to primary prevention from cost-ineffective to cost-effective uses in the United States was shown to have the potential to save an additional 600,000 years of life annually for the same level of investment.

Colleagues,

Let me summarize: We need to invest in health because improving health is a concrete, measurable way of reducing poverty and inequity – both in and between countries. Investments in health are investments in human potential which we have seen is the greatest resource for development.

We need to do this through ensuring that people know about proven, effective interventions. They must be able to access and to benefit from them. Insecticide-treated mosquito nets to reduce malaria mortality. Legislation to prevent the promotion of tobacco to young people. Effective treatment for those with multi-drug tuberculosis, whether or not they are imprisoned within a penal system. We need new relationships between trading practices and the public health, so that that those who need them have access to the drugs and vaccines they need. We need policy decisions that empower people to make healthy choices. And we need better health systems that are cost-effective, responsive and fair.

None of this can happen without clear and strong stewardship by the world's governments and, particularly, their Heads of State. Over the last two years we have seen a growing commitment, but implementing the commitment to the benefit of poorer people calls for sustained and effective government action.

We are at the end of a decade that has seen a political move towards less involvement of government in society. I will argue that what we need is not less government but better government.

The importance of the stewardship of investments in health, by well-informed and responsive governments, is critical. This means governments taking responsibility for the careful management of resources that are used to promote the well being of an entire population. This emphasis on effectiveness and equity is the essence of good government.

This means getting priorities straight in the public sector.

But health systems mean much more than government-provided health care. In many countries – in particular developing countries, the private sector makes up the majority of health system.

So, good stewardship also means harnessing the energies of the private and voluntary sectors to better achieve the goals of the system – to use appropriate health interventions and technologies; as well as to reduce waste.

Stewardship is concerned with the oversight of the entire system. On examining its performance and determining ways of improving it. It does not mean turning a blind eye to its failures.

Stewardship means setting clear directions based on evidence and a basic set of values. And it means leading and taking responsibility but not necessarily by being dominating. Instead it means being able to manage and encourage a wide number of partners and collaborators in a way that all contribute their best.

Our job, as professionals committed to health outcomes, is to ensure the proper stewardship of resources for health. We need to make sure that they are adequate for the tasks expected, that they are wisely used, and that their impact is properly monitored. Only then will we see a difference in health outcomes for all.

Colleagues,

My message is that we must invest more resources in world health, but we must invest wisely. In many countries, much more money is needed to ensure that the health system develops in a sustained way that makes long-term planning and better access for all a reality. At the same time, in all countries, the priority is to ensure that we gain more health outcomes among more people given the resources that are invested. This means cost-effective actions to produce health, more responsive to people’s needs, made available in ways that are inclusive and fair.

These are complementary goals. They are difficult. But we all have a vital role in making sense of the challenges faced as we strive for their achievement. It is a noble challenge – nothing that we do could be more worthwhile.