DEV/2741
Forum on Advancing
Global Health
AM & PM Meetings
WHO Head Warns World 'Dangerously Out of Balance' in Health Matters; Panels: Protection for Vulnerable; Building Resilient Systems; Enhancing Coherence
"We need to heed the call of our conscience, recognize that our interests are bound together, and act ‑‑ united ‑‑ with the urgency the times demand," United Nations Secretary-General Ban Ki-moon said today, as he opened a day-long forum on global health, in which representatives of Governments, United Nations agencies, the private sector and civil society explored ways to improve national health systems and maximize the impact of global health interventions.
In opening remarks to the forum ‑‑ entitled "Advancing global health in the face of crisis" ‑‑ he said the declaration of the first influenza pandemic in over 40 years was a reminder of our global vulnerability and the need for a global response. (Issued separately as Press Release SG/SM/12309-DEV/2742.)
"We cannot protect ourselves by working in isolation," he said. "This is as true for the recent outbreak as it is for the long-standing health challenges we face". From poor maternal health and weak health systems to the H1N1 flu, the current situation demanded strengthened efforts in mobilizing constituencies, coordinating action and prioritizing health issues that remained relatively orphaned.
The cost of cutting back was unthinkable, he said. Investments to scale up basic health services could bring a six-fold economic return: healthy people had improved life expectancy, went to school and were more productive. Across sub-Saharan Africa, controlling river blindness cost less than $1 per person, but delivered some $3.7 billion in productivity. In Ghana, United Republic of Tanzania and Uganda, studies had shown that each dollar invested in contraceptive services could save up to $4 in antenatal, maternal and newborn health-care spending. Such impressive numbers did not even begin to measure the value of lives saved.
He said he was most troubled by the costs of failed maternal and child health. The global impact of maternal and newborn deaths was an estimated $15 billion a year in lost productivity. Birth too often brought mourning when mothers and newborns died from a lack of care ‑‑ one every minute, which translated into over half a million tragedies each year, nearly all preventable.
Some progress had been achieved, he said. Official development assistance for health had tripled in the last six years, while new instruments ‑‑ like the Global Alliance for Vaccines and Immunization ‑‑ had shown that funds for health could be raised and disbursed in innovative ways. But, the needs were greater and growing: an estimated 50 to 90 million people in developing countries would move into absolute poverty this year alone.
"We have to move quickly," he said. Decisions made in the coming months would be critical to sustaining gains. With $60 billion already pledged to fight disease and strengthen health, he said honouring past commitments was ultimately political. But, sustainability was not just about securing predictable financial resources. It was about using opportunities provided by disease programmes to deliver health benefits. It was about training, drawing on the private sector and strengthening the untapped capacity of communities. Countless lives hung in the balance.
Echoing that call, Margaret Chan, Director-General of the World Health Organization, said the world was dangerously out of balance in matters of health. Differences within and between countries in income, opportunity and health status were greater today than at any time in recent history. While part of the world fed itself into obesity, the other part starved. While some lived into old age, others died from preventable causes. Such huge extremes were a precursor for social breakdown.
On top of that, she said the level of preparedness towards the current influenza pandemic was strongly biased towards wealthy countries. Many poor countries, where non-pharmaceutical measures had limited relevance, had been left empty-handed. She asked how, in sub-Saharan Africa, for example, home quarantine could be practised in the extended family, how social distancing could exist in a bustling market, or how hand hygiene could be expected in areas where millions lacked access to clean water and sanitation. The pressures of a pandemic, coupled with such crises and chronic disease, could cripple fragile health systems.
Transformational changes in policies that governed international relations were needed, she stressed. The Millennium Development Goals aimed to compensate for an international systems that had no rules for guaranteeing the fair distribution of benefits and provided the best chance to introduce greater fairness into the world ‑‑ but they did not address the root causes of inequity: those that resided in flawed policies. The financial crisis had ushered in a period of great soul-searching and leaders at the recent Group of 20 summit in London called for redesigning international systems to include a moral dimension.
She said a focus on health was the surest route to achieving that dimension and creating a value system that placed humanity's welfare at its heart. The market alone did not solve social problems. Public health, supported by evidence-based social policies could contribute.
The day also featured three panel discussions on protecting vulnerable populations, building resilient health systems and enhancing coherence.
Ann M. Veneman, Executive Director, United Nations Children's Fund (UNICEF), moderated a panel discussion on "Protecting vulnerable populations", involving Lesogo Motsumi, Minister of Health, Botswana; David Nabarro, Senior United Nations System Coordinator for Avian and Human Influenza; Thoraya Ahmed Obaid, Executive Director, United Nations Population Fund (UNFPA); K. Srinath Reddy, President, Public Health Foundation of India; Sam Zaramba, Director-General of Health Services, Ministry of Health of Uganda; Rajeev Venkayya, Director of Global Health Delivery, Bill & Melinda Gates Foundation; and Liya Kebede, the Liya Kebede Foundation.
The second panel discussion ‑‑ "Building resilient health systems: strengthening delivery from global to local" ‑‑ was moderated by Julio Frenk, Dean of the Harvard School of Public Health and former Health Minister of Mexico. It featured presentations by Richard Sezibera, Minister of Health of Rwanda; Ivan Lewis, Minister of State, Foreign and Commonwealth Office, United Kingdom; Joy Phumaphi, Vice-President, Human Development Network, World Bank; David de Ferranti, President, Results for Development Institute; and Ariel Pablos-Méndez, Managing Director, Rockefeller Foundation.
The third panel, on "Enhancing coherence: toward multi-stakeholder strategic partnerships" was moderated by Michel Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS). The panellists were: Aaron Motsoaledi, Minister of Health of South Africa; Michel Kazatchkine, Executive Director, the Global Fund; Ray Chambers, Special Envoy for Malaria; Julian Lob-Levyt, Executive Secretary, GAVI Alliance; Michael Joseph, CEO, Safaricom; and Tore Godal, Special Adviser to the Prime Minister of Norway on Global Health.
Statement by United Nations Secretary-General
United Nations Secretary-General BAN KI-MOON said the declaration of the first influenza pandemic in over 40 years was a reminder of our global vulnerability and the need for a global response.
"We cannot protect ourselves by working in isolation", he said. "This is as true for the recent outbreak as it is for the long-standing health challenges we face". From poor maternal health and weak health systems to the H1N1 flu, the current situation demanded strengthened efforts in mobilizing constituencies, better coordinating action, and prioritizing health issues that remained relatively orphaned.
"The cost of cutting back is unthinkable", he said.
By way of example, he said healthy people had improved life expectancy, went to school and were more productive. Across sub-Saharan Africa, controlling river blindness cost less than one dollar per person, but delivered an estimated $3.7 billion in productivity. Polio eradication would save $1.5 billion annually in vaccines, treatment and rehabilitation costs. In the United States, one dollar invested in a vaccine could save up to $27 in health expenses, while in Ghana, Tanzania and Uganda, studies showed that each dollar invested in contraceptive services could save up to $4 in antenatal, maternal and newborn health care spending.
Moreover, health bound the Millennium Development Goals together, and he was most troubled by the costs of failed maternal and child health. Birth all too often brought mourning, when mothers and newborns died from a lack of care. That happened once every minute, which translated into over half a million tragedies each year, nearly all preventable.
He said women wove the fabric of society, building stable, peaceful and productive communities. As such, maternal health must be a lens through which decisions and global health policies were made. Comprehensive sexual and reproductive health services must be integrated into global responses to specific diseases aimed at strengthening health systems. Women who received prenatal care were better able to protect themselves and their children from HIV, malaria and other diseases. The global community should apply its valuable experience of fighting AIDS and malaria to saving mothers' lives. When Governments, the United Nations, businesses and civil society joined forces, they had a powerful impact: "We can save lives," he said.
He said the world was reaching a tipping point and commitments had to translate into action. The United Nations and the Bill & Melinda Gates Foundation would jointly convene major players on maternal and child health to accelerate progress. Progress had been achieved. Official development assistance for health had tripled in the last six years, while new instruments -– such as the Global Fund and the Global Alliance for Vaccines and Immunization -– had shown that funds for health could be raised and disbursed in innovative ways.
While such efforts were tremendous, the needs were greater and growing, he said, with an estimated 50 to 90 million people in developing countries moving into absolute poverty this year alone. Inequities between rich and poor nations in health-care access would likely increase. One billion people suffered daily -– and often died -– of easy-to-control neglected tropical diseases. Gains in combating AIDS were fragile and must be protected. Such examples were some of the many hurdles that States faced and trends must be reversed, before millions more died from a lack of proper health care.
"We have to move quickly", he said. Decisions made in the coming months would be critical to sustaining gains. Noting that $60 billion had been pledged to fight disease and strengthen health, he said honouring past commitments was ultimately political and he called on the Group of Eight and the Group of 20 (G‑20) economies to stand by their promises. Sustainability was not just about securing predictable financial resources. It was about using opportunities provided by disease programmes to deliver health benefits. It was about training, drawing on the private sector and strengthening the untapped capacity of communities. Countless lives hung in the balance.
"In the twenty-first century, our fates are already intertwined," he said. "Now, we need to heed the call of our conscience, recognize that our interests are bound together, and act –- united -– with the urgency the times demand."
Statement by Director-General, World Health Organization (WHO)
MARGARET CHAN, Director-General of World Heath Organization, said today's forum sought to advance global health despite multiple crises. Last year, an imperfect world had delivered -- in short order -- food, fuel and financial crises. The world also had seen that the consequences of climate change had been seriously underestimated. Now, another contagion had emerged, with last week's announcement of the 2009 influenza pandemic.
Because of those multiple crises, some of the arguments and insights long made by health professionals were now being taken up by experts and leaders in other sectors, including those with far more clout than health. "Perhaps now our message will have some resonance," she said. "Perhaps now deaf ears will hear."
She called for continued momentum, noting that the world was in the midst of the most ambitious drive in history to cut poverty, and reduce the gaps in health outcomes. The price of failure kept getting higher. The crises were global, but consequences had not been equally felt. Developing countries would be hit the hardest and take the longest time to recover. More must be done for vulnerable groups. Health systems had to be strengthened, which required smart and strategic partnerships.
The trends were already evident. More people would sink into poverty, health status would worsen, life expectancy would shrink, and health systems would be overburdened to the breaking point. People in rich societies were losing their jobs, homes and savings; in developing countries, they would lose their lives. The pressures of a pandemic, on top of such crises and chronic disease, could cripple fragile health systems.
She said the risk factors for severe or fatal H1N1 infection were twofold: pregnancy, and underlying medical conditions such as asthma, diabetes and obesity. To make that point, she said 99 per cent of maternal mortality and 85 per cent of the burden of chronic diseases were concentrated in low and middle income countries. The pandemic would reveal, in a highly visible and measurable way, exactly what it means in life and death terms when health systems are neglected for decades. The world would see the consequences of the long-standing failure to ensure basic care during pregnancy and childbirth.
She called for fairness, which was at the heart of ambitions in global health. The world was dangerously out of balance in matters of health. Differences within and between countries, in income levels, opportunities and health status, were greater today than at any time in recent history. Part of the world fed itself into obesity while the other part starved; some people thrived into old age, while others died young from preventable causes. Such huge extremes were a precursor for social breakdown.
She said the global health system was a social institution that not only delivered pills or babies, the way a post office delivered letters. A health system striving for universal coverage contributed to social cohesion and stability. A failure to be fair in the systems that governed the way nations interact was one reason the world was is in such a big mess. Globalization did not turn out to lift all boats -– just big boats. It swarmed or sank smaller ones. Greed had ignited the financial crisis, which, in turn, led to an economic downturn and meltdown for poor nations. In terms of impact, the financial crisis had behaved like the economic equivalent of a "drive-by shooting", where innocent bystanders -– countries that had managed economically well -– also had been hit.
Taking up the influenza pandemic, she said the level of preparedness was strongly biased towards wealthy countries. Many poor countries, where even non-pharmaceutical measures had limited relevance, had been left empty-handed, such as in sub-Saharan Africa. How could home quarantine be practised in the extended African family? How could social distancing exist in a bustling African market, the heart-beat of social and economic life? How could respiratory and hand hygiene be expected, when millions lacked access to clean water and sanitation? In an out-of-balance world, the risk of failure rose.
She called for transformational changes in polices that governed international relations: the Millennium Development Goals operated as a corrective strategy, aiming to give a lopsided world greater balance -– in opportunities, income and health. They aimed to compensate for international systems that had no rules for guaranteeing the fair distribution of benefits. They provided the best chance to introduce greater fairness into the world. But, they did not address the root causes of inequities -- those that resided in flawed policies. In calling for policy change, public health had powerful support from the findings of the Commission on Social Determinants of Health, which issued its report just a month before the financial crisis began. The Commission's findings had greater relevance now.
The financial crisis had ushered in a period of great soul-searching and finger-pointing, she said. As economists and political analysts were quick to note, the crisis followed a failure of corporate governance and risk assessment. The April G-20 summit in London had heard calls for a reengineering of economic systems; the reign of Washington consensus was over. There was a clear call from leaders to give international systems a moral dimension, to redesign them to respond to social values and concerns. But when would the world finally see what most in public health had regarded as self-evident: that a focus on health as a worthy pursuit for its own sake was the surest route to that moral dimension -– the surest route to a value system that placed humanity's welfare at its heart. Greater equity in the health status of populations should be seen as a key measure of a civilized society.
The market by itself did not solve social problems, she continued. Public health, when supported by social policies that were evidence-based and based on equitable ways, could contribute.
Steady progress was being made with HIV/AIDS, tuberculosis, and malaria. The number of children dying from vaccine-preventable diseases was declining yearly. For the neglected tropical diseases, if the world stayed on course, it could eliminate some of those by 2015. Prime Ministers and Presidents had launched initiatives, and the commitment to the Millennium Development Goals remained high. At the G-20 summit in London, States pledged to keep their official development assistance commitments. More could be done. A levy on airline tickets was being used to purchase medicines for developing countries. World leaders and economists had joined forces to find innovative financing sources for health development.
Ministers of health from around the world were returning to the wisdom of primary health care, recognizing that it brought fairness and efficiency, and allowed health systems to reach their potential as cohesive, stabilizing institutions. She was seeing signs of goodwill and solidarity in response to the flu pandemic and the need to extend protection to the developing world. She thanked the Secretary-General for his invaluable support in that area to procure pandemic vaccines for developing countries, and making health development a top priority. She also thanked Member States for their interest in battling the health crisis.
Panel 1: Protecting Vulnerable Populations
Ann M. Veneman, Executive Director, United Nations Children's Fund (UNICEF), moderated a panel discussion on "protecting vulnerable populations", involving Lesogo Motsumi, Minister of Health, Botswana; David Nabarro, Senior United Nations System Coordinator for Avian and Human Influenza; Thoraya Ahmed Obaid, Executive Director, United Nations Population Fund (UNFPA); K. Srinath Reddy, President, Public Health Foundation of India; Sam Zaramba, Director-General of Health Services, Ministry of Health of Uganda; Rajeev Venkayya, Director of Global Health Delivery, Bill & Melinda Gates Foundation; and Liya Kebede, the Liya Kebede Foundation.
To begin, Ms. VENEMAN offered a series of hypothetical situations to illustrate how people's socio-economic situations led them to become vulnerable to health problems. She pointed out that there were intersecting factors at work. For example, in the case of people living on less than $2 a day, and where half or more of that income was spent on food, their children were not likely to receive enough nutrition. Children were put on the streets to work, where they faced the danger of being sexually exploited or trafficked.
She explained that 9.2 million children died before the age of 5 years, and that 93 per cent lived in Africa and Asia. Around 3 million died in the first 28 days of life. A woman in the Niger had a 1-in-7 lifetime risk of maternal mortality, compared to Ireland, where the risk was much lower ‑‑ 1 in 40,000. When searching for a solution, it was important that policy-makers understood the link between maternal and newborn health. For a start, adequate nutrition for the mother was key to good health in their babies. In turn, early childhood nutrition was important, because one third of deaths in children under 5 were thought to be caused by malnutrition. Poor nutrition also made a person more likely to die of diseases such as malaria, while lack of breast-feeding contributed to 1.4 million deaths.
She noted that pneumonia and diarrhoea were among the biggest killers among children –- diseases that were linked to HIV/AIDS, various tropical diseases and the flu. During a time of financial crisis, it was more important than ever to ensure that women and children, along with other vulnerable populations, had access to preventive and basic health services.
Picking up that thread, Ms. MOTSUMI said her country, Botswana, had been hard hit by HIV/AIDS in the 1990s, which led to a reversal of the country's economic advances. Nevertheless, political leaders felt called on to support funding and training for health care. The Government became candid about its needs and began engaging in partnerships with "everybody and anybody" willing to come to Botswana's assistance. The Government created a decentralized health care system, which was heavy on community participation, and was accessible to all at a cost of $0.70 per person. Health care was free for vulnerable groups, such as children under 12 years, orphans, the destitute, disabled persons, and people above 65 years. Health care was accessible to everyone within a 15 kilometre radius.
She said the Government had devoted 15 to 18 per cent of its budget to health care, with a large amount earmarked for AIDS. Even so, Botswana had had to make several difficult choices, for instance, on whether to fund infrastructure development or its antiretroviral programme. At the moment, antiretrovirals (ARVs) were available universally, with reduced waiting periods. The Government understood, as well, that unless it adopted a cross-sectoral and multisectoral approach, it would not win the war against AIDS. For example, there was a realization that the agriculture ministry must ensure "the maximum" food production, since ARVs were only effective in patients that enjoyed good nutrition. The Government was investing a great deal of money to ensure access to clean water, as well.
Mr. NABARRO remarked that, when he first began working in the area of international health in 1991, it had been difficult to get decision makers to "take health seriously". Now, health was understood to be a key contributor to the social, political and economic fabric of all societies. Vulnerability to ill health was seen as a major handicap. For example, in 2005, the Heads of Government of countries belonging to the Association of Southeast Asian Nations (ASEAN) voiced their worry over the possible socio-political impact of the H5N1 virus (bird flu). In response, the United Nations found itself creating a plan of action centred on a situation with many uncertainties, and for which it had to muster broad support.
That work involved intersectoral and interdepartmental effort, involving the military, regional organizations, the media, civil society and the private sector. With the advent of H1N1 flu, he said the United Nations took advantage of the work already undertaken for bird flu, always taking care to place the interests of vulnerable countries and communities at the centre of planning. There was also a need to deal with the world food crisis, since more than 1 billion people were identified as hungry and 50 million as malnourished. At least 50 countries were experiencing greater problems related to food as a result. The ability to maintain health in the face of disease was being endangered by the food crisis.
Ms. OBAID addressed the issue of maternal health. The well-being of women, which was already highlighted at the international level by Millennium Development Goal 5, must be seen as an issue of importance to individual nations. Pregnant women were more vulnerable to H1N1, which was a point that must be made clear. There was a need to focus on the 60 countries with highest rates of maternal mortality. Nations needed to collect robust data on health care gaps and to evaluate how "we move together". She noted that the World Bank was working with the private sector and civil society on such issues.
She added that women had a "weakened" life cycle. Access to clean water, sanitation and education all had an impact on prolonging a woman's life. Many that died during childbirth were first-time mothers, and often young unmarried women. That pointed to the need for more investment in family planning, which had been shown to be the most cost-effective intervention for saving mothers' lives. Other strategies could include removing cultural and social obstructions that worked against women's health, such as young marriage age, poor level of education, and so on.
Mr. REDDY said India's challenges were typical of low- and medium-income countries undergoing rapid transition. There was unfinished work on infectious diseases, on tackling nutritional deficiencies and on combating unsafe pregnancies. Chronic disease had become a public health challenge, and was "a public health emergency in slow motion", claiming the largest number of lives. Around 23 low- and middle-income countries accounted for 80 per cent of heart diseases, cancer, and respiratory diseases of people in mid-life. Some 46 per cent occurred to people below the age of 70 years, with heart disease depriving 9.2 million people during their most productive years (between 35 to 64 years). That number was likely to increase to 18 million in 2030. Death from those diseases propelled families into poverty, especially when they lost their breadwinner.
Developmental problems fed back into the inability to deal with public health problems, he said. In Kerala state, heart disease was rising fast, and 73 per cent of sufferers had had catastrophic financial expenditures in the process. A similarly high number was said to experience the same in China (71 per cent). The challenge of dealing with multiple health problems lay in finding solutions that did not detract from other causes. Some cost-effective solutions could include tobacco control and providing safer foods lower in salt and saturated fats. Another could be to realign a country's agriculture policy to provide more food and vegetables. Within the health sector itself, it could mean encouraging early detection of persons at risk, which could be provided at the primary health care level.
He said India had already embarked on a substantial plan of action along those lines. In 2003, it had enacted a strong anti-tobacco law, which was now being implemented. It had a national cancer control programme, and was about to launch a programme on heart disease, diabetes and strokes. Efforts to combat and control health challenges complemented existing programmes in infant and maternal mortality and improving child health. They were being integrated into national rural health programmes, as well as urban health programme targeted at the urban poor.
Mr. ZARAMBA took up the issue of neglected tropical diseases, such as sleeping sickness and river blindness, informing the meeting that there were 14 such diseases in total. They typically affected the poorest of the poor, and were ancient diseases. They were neglected by the international community and national Governments, with sufferers "forgetting to go for treatment". One billion people were said to be affected, and two billion were at risk. Most low-income countries were afflicted simultaneously by five or more of those diseases.
He said substandard housing and too few resources to eliminate the disease-bearing insects and other vectors of illness contributed to the problem. Those diseases resulted in severe physical pain and irreversible physical disabilities in their sufferers, with 500 million deaths every year. Many could be prevented and even eradicated using safe and effective tools. The international community was beginning to realize that it could not achieve the Millennium Development Goals without addressing neglected tropical diseases.
He thanked civil society organizations, such as the Carter Foundation, for their activism in that area, as well as companies that were providing free drugs, but more support must be given to countries experiencing those problems. There are many proven interventions that could be used to control those diseases, while effort could be spent on building the capacity of health workers. Providing medicines was not enough. There was a need to promote intersectoral cooperation ‑‑ such as the provision of clean water -- since many solutions lay in the hands of those outside the health sectors.
Mr. VENKAYYA spoke on the role of technology in tackling illnesses. The first dose of the "RTS,S" malaria vaccine, which had shown promise in trials, was injected into a child just last week, while the WHO Group of Experts had published a recommendation that the rotavirus vaccinebe used for children in African and Asia. There was a drive to provide companies with incentives to produce such vaccines, and, in fact, there were already six vaccines for tuberculosis, and a few for diarrhoea.
At the Gates Foundation, it was understood that the world had a "chequered past" when it came to vaccination. A vaccine for hepatitis B had been available since 1992, yet 27 years later, one third of the population in sub-Saharan Africa did not have access to it. That type of intervention required a well-functioning health system to be in place. At present, 26 million children were unvaccinated. Nevertheless, the Foundation was not deterred by the world's poor track record of transmitting existing technologies to such places. For example, it was active in examining the "barriers to uptake" of existing technologies, by studying the decisions being made in the product development lifecycle ‑‑ the impact of cost, presentation, cold chain and logistic requirements ‑‑ that affect whether countries could "take up" those technologies.
He said countries needed to be able to translate evidence into policy, and to use such evidence to inform trade-off decisions ‑‑ whether to choose one intervention over another, or whether to make human resources decisions over infrastructure decisions, and so on. The Gates Foundation was focused on developing new technologies while improving delivery of existing technologies.
Ms. KEBEDE, who was also WHO Ambassador of Newborn, Maternal and Child Health, spoke on the need to prioritize maternal health around the world. She urged donor countries to continue donating to the cause, and for developing countries to place it at the top of their agendas. Most deaths during childbirth were preventable. She had given birth to her children in the United States, but had she been elsewhere, her life was likely to have been at risk. Most people did not realize the extent of the problem, and did not know that the most common cause of death among women in developing countries was pregnancy-linked.
She related a story about a 17-year old Ethiopian girl who walked one hour to the nearest clinic during her pregnancy. The community offered no blood tests or birthing classes. At the birth of her child, she had been asked to pay for the gloves, sheets, water and syringes to be used in the birth. She did not have money for those items, but a photographer ‑‑ who happened to be present to document the birth for a publicity campaign ‑‑ paid for her safe delivery.
Ms. Kebede described the typical health provisions that a poor woman in a developing country might have access to: holding up a birthing kit, she showed participants that it contained a piece of soap, gloves, some gauze, a set of sheets and a cord, all of which cost $10. A kind of birth kit in Senegal was even simpler, and consisted of three pieces of cloth ‑‑ one to lie on, one to clean the mother after birth, and one to bundle the baby in. If that was the extent of the health system in those countries, then international funding was absolutely necessary to improve the situation. Local non-governmental organizations also had a role to play –- for example, in educating girls on the risks of early pregnancy, or teaching them that starting families a little later would enable them to complete school and provide a better life for their baby.
Several representatives of Member States spoke, some stressing that it was not a time for the developed world to step away from the cause of maternal and child health, but to redouble their efforts in that regard. Health was an economic, social and human right issue, not to be viewed with a narrow focus. Some speakers emphasized the importance of regional cooperation in tackling health problems. They emphasized the need to act quickly and with a clear purpose, and praised efforts by the World Bank, World Health Organization and others to harmonize international child and newborn health policies with those at the country level.
Some speakers described advances being made in their countries to provide vaccines, or to step up disease preparedness plans. For example, the representative of India said three private sector vaccine producers were ready to begin production as soon as WHO made certain materials available. The representative of Luxembourg, who was also Chair of the Economic and Social Council (ECOSOC), said the Council would devote its session this year to global health issues, in which it was prepared to discuss the multisectoral character of public health. She said ECOSOC was in a unique position to mobilize all the stakeholders.
Other speakers were from the United Kingdom, Chile, United States, Czech Republic (speaking on behalf of the European Union), Canada, Colombia, Nicaragua, Philippines, Cuba, China and Malaysia.
Mr. NABARRO responded to some of those speakers, saying the United Nations was working to ensure that needed vaccines and medicines to combat the flu pandemic were affordable and accessible to poor countries. He added that the Organization was also discussing "the right kind of action" at the border, based on guidance from the WHO. Those were difficult issues, which the Secretary-General and Director-General of WHO were currently addressing. Ms. VENEMAN ended the discussion by calling for action on "a basic package" for women and children around the world.
Panel 2: Building Resilient Health Systems: Strengthening Delivery
From Global to Local
The second panel discussion ‑‑ "Building resilient health systems: strengthening delivery from global to local" ‑‑ was moderated by Julio Frenk, Dean of the Harvard School of Public Health and former Health Minister of Mexico. It featured presentations by Richard Sezibera, Minister of Health of Rwanda; Ivan Lewis, Minister of State, Foreign and Commonwealth Office, United Kingdom; Joy Phumaphi, Vice-President, Human Development Network, World Bank; David de Ferranti, President, Results for Development Institute; and Ariel Pablos-Méndez, Managing Director, Rockefeller Foundation.
Launching the panel, Mr. FRENK said the high-level Task Force on International Innovative Financing for Health Systems was a major development. While progress had been made in recent years, a lack of resources was a huge constraint. The Task Force found that health spending in low-income countries was about $25 per capita annually, most of which was from domestic sources. Development assistance was at $6 per capita in low-income countries; more than half of which was directed at big communicable diseases like HIV/AIDS and malaria, leaving $2.25 per capita for everything else. About $10 per capita was out-of-pocket expenditure. That was the worst way to finance health expenditure.
"We need more money for health and more health for the money," he stressed. Delegates had gathered today to guarantee additional investment in health that would foster the best possible outcomes. There was huge variation among countries ‑‑ those with the same level of health spending had achieved widely different outcomes. Why was that happening, and what could be learned from others' success to achieve more health for the money?
Taking the floor next, Mr. SEZIBERA called for improvements in health facilities, equipment, people and processes. For its part, Rwanda's health system had seen gains: malaria mortality and morbidity was down 60 per cent, and per capita use of health services had increased between 2005 and 2008. But, for Rwanda to achieve Millennium Development Goals 4 and 5, it would need an additional $30 per capita in the next five years.
He said Rwanda had created performance-based financing for health, and money that followed those changes had performed better. Health systems must be approached from a system perspective: it made no sense to invest in HIV/AIDS and pay no attention to the rota virus. Systems had to be based on six pillars, including pro-poor health-care financing. Human resources for health must be given due attention, while more should be invested in training and professional development. Investment in health infrastructure and equipment should also be improved. The physical barriers to care must be addressed, and high-impact interventions in family planning services scaled up. Finally, he urged countries to build strong evidence on what worked and what did not. Increased political commitment and resources were essential.
Speaking next, Mr. LEWIS said the British Prime Minister had emphasized that now was the time for the developed world to redouble its efforts towards the developing world. Health exemplified the importance of global social justice. In whatever was agreed, health had to be a country-led approach that addressed specific challenges and opportunities. In terms of innovative finance, he said there was no doubt that more and better resources were needed. Health spending had to be increased from $31 billion to $6 billion per year by 2015. While innovative financing mechanisms identified thus far had the potential to raise $10 billion per year, they could not replace existing commitments made by donors.
He said innovative development finance involved the untraditional use of official development assistance. The Task Force recommendations included strengthening Government capacity to secure better performance of investment from organizations, including faith-based organizations. Among other recommendations, the Task Force urged that the allocation of funds be more efficient, and requested that the Organisation for Economic Cooperation and Development (OECD) undertake a review of technical assistance.
Finally, he said three groups of countries needed to make progress on Goals 4 and 5 ‑‑ some had health systems and simply were not delivering; others could build health systems that would lead to rapid progress between 2010 and 2015. But, what about those countries with no prospect of developing health systems in the foreseeable future? A specific approach was needed, as they could not be left behind. Money alone was not enough. The highest levels of Government needed to care about health and, equally, about the links between health, access to clean water and education. Without ensuring better use of existing resources, countries would not have enough funds to reach health-related Goals.
Ms. PHUMAPHI said the high-level Task Force created an environment conducive for global stakeholder consultation. She focused on the essential role for countries in taking charge of their health systems. For maternal and new born health, Governments must start with family planning, notably by addressing unsafe abortion and both prenatal and post-natal care. In those efforts, they must ensure that the most vulnerable populations were reached. Maternal and newborn health-related Goals were key determinants of the success of other Goals.
A Task Force outcome noted that strengthening health systems required pro-poor financing that was efficiently used. The public sector and civil society must work together with development partners to ensure that each intervention was results-based. The Task Force had worked with the Norwegian Government on results-based financing and launched an initiative in Africa with the World Health Organization. In addition, the Task Force would organize a meeting withthe Global Alliance for Vaccines and Immunizationand the Global Fund to focus on streamlining resources for health systems.
Describing her work as chair of a maternal and newborn health partnership, she said country-specific analyses of financing gaps were being developed in India, Indonesia and Papua New Guinea, among other countries. Partnerships started and ended with communities. All stakeholders had to ensure that comprehensive support to those communities was aligned under a common agenda. She did not wish to see another mechanism created to deploy resources to developing countries. Existing mechanisms should be strengthened, not weakened by making them compete with another mechanism.
Mr. DE FERRANTI focused on the ingredients for strengthening governance, saying that effective stewardship was multidimensional. It was the Government's role to be a steward for the whole health system, rather than focus on specific services. Several countries ‑‑ including Thailand, Colombia, Mexico and Chile -- had achieved success in that transition and offered lessons for success.
He said, in all cases, leadership was essential. Leaders in Government and those with whom they cooperated had to see the breadth of activity in any given country. Second, leaders needed information to monitor progress, and financing to deliver critical services. Further, extensive outreach to everyone was essential. Health system purchasers, licensing for providers and suppliers, and accreditation were all needed build a comprehensive approach. Successful countries had tried things that were new and eventually scaled them up to achieve comprehensive outcomes.
Mr. PABLOS-MENDÉZ said health systems included technology, human resources, financing and governance. In those ways, they were similar to most other corporate structures. Participants in today's forum had heard about the importance of universal health coverage and global social justice, both of which required the commitment of national leaders. The global economic crisis only increased the need for social protections. Money alone was not enough. The challenge was to use information technology beyond its role in financial stewardship. Use of information and communications technology to improve health covered primary care informatics and public health informatics.
He said the health sector was a laggard in picking up information technology. A decade ago, many were worried about the digital divide. Today, a market-driven expansion of cell phones in the developing world had changed many sectors, including health. Many African countries had 80 to 90 per cent cell phone coverage ‑‑ better coverage than that found in New Jersey. In the United States, systems applications were incompatible, but compatible systems were needed. The situation required awareness, as well as national e-platforms and frameworks, such as the e-platform being developed in Rwanda. New global partnerships were forming and, in that context, he noted the United Nations Foundation had led the "mHealth Alliance".
In the ensuing discussion, representatives of Member States stressed that health threats knew no borders and required a collective response. At the same time, they emphasized that national ownership of any health programme was essential. Governments had to account for money that flowed into a country and needed to be transparent about where it was going. It must not flow into individual pockets, Botswana's representative said. She also noted that while e-health was "the in thing", countries in Africa often lacked basics, such as roads to transport equipment and medicines. Other comments centred on the need for effective policy coordination across all sectors and the difficulty of implementing international law in occupied territories.
Other speakers were from Italy, Syria and Indonesia.
Responding, Mr. LEWIS said that, in the context of the economic crisis, there had never been a more important moment for Governments to get results from money spent on health. He welcomed comments on the centrality of systems, and hoped the next G-8 agenda would include the importance of innovative financing for health.
He agreed that any approach to health must be country-led, a fact often forgotten in current discourse. Achieving health outcomes had to do with access to services: roads; transport; and modern technology. Investing in systems must relate to the fact, for example, that women often could not reach a hospital because road networks were not "up to scratch". A far more holistic approach was needed.
Panel #3: Enhancing Coherence: toward Multi-Stakeholder Strategic Partnerships
The third panel, on "Enhancing coherence: toward multi-stakeholder strategic partnerships" was moderated by Michel Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS). The panellists were: Aaron Motsoaledi, Minister of Health of South Africa; Michel Kazatchkine, Executive Director, the Global Fund; Ray Chambers, Special Envoy for Malaria; Julian Lob-Levyt, Executive Secretary, GAVI Alliance; Michael Joseph, CEO, Safaricom; and Tore Godal, Special Adviser to the Prime Minister of Norway on Global Health.
Opening the discussion, Mr. SIDIBÉ said the economic crisis had demonstrated the reality of global interdependence in a visible way. Interdependence had resulted in a plethora of partnerships in the health sector, resulting in an architecture that was "messy". The challenge was to generate consensus among stakeholders, for which practical and moral leadership was needed.
The first panellist, Mr. MOTSOALEDI addressed the issue of sustainability in the context of South Africa's attempt to reduce the incidence of HIV. It was not only a Government goal, but one taken by many stakeholders through an AIDS body chaired by the Deputy President and encompassing civil society, Government and business. The strategy was targeted at those using public assistance. In addition, the President had instructed the ministries to consider ways to establish public-private partnership on a massive scale. Mr. Motsoaledi commented that such partnerships should be able to demonstrate a real transfer of skills in areas such as finance, information and communications technology and infrastructure, so that society could continue to benefit from the fruits of those partnerships.
Mr. KAZATCHKINE said the last few years had seen significant progress in malaria, tuberculosis and AIDS due to efforts by the Global Fund, which was "raised vertically" and "spent horizontally". Its investments were mainly in prevention and treatment, but also in health systems. Progress was measured in lives saved and bednets distributed. In terms of its work with health systems, the Global Fund focused on infrastructure, health-care workers, procurement, and supply chain management. Aside from that, it was also active in strengthening the capacity of civil society to deliver preventive interventions. Demand for funding from the Global Fund had quadrupled in recent years, because of its success in helping applicants to scale up their programmes. For example, in 2002, Lesotho applied for money to treat 3,000 people; this year, it was asking for money to treat 50,000.
Mr. CHAMBERS said his goal had always been to approach the challenge of malaria from a business perspective. He discovered that a $10 bednet could prevent malaria. With 700 million people facing the risk of malaria, he said that thus far 350 million nets had been distributed to combat the disease. He was confident that the goal of covering 700 million people could be reached by 2015, bringing the number of deaths to zero and possibly saving $40 billion in lost gross domestic product (GDP). The initiative to provide bednets brought the private sector, World Bank, UNICEF, WHO and the Global Fund together under one plan. Celebrities brought publicity to the cause, as did the United States White House, which hosted an event on the issue. The television show American Idol also hosted events. Attention was concentrated on the seven countries that comprised 66 per cent of malaria deaths. He said it was stunning to think that the world could actually bring the incidence of malaria down to zero.
Mr. GODAL touched on the issue of "poor donor syndrome", where donors did not have the money to finance the very plans they had paid others to develop. The GAVI and World Bank were working together to develop a platform to provide consolidated financing for health services. But, the challenge was to do so without creating unnecessary bureaucracy. He then moved to the issue of power structures in society, which handicapped women. One programme in India paid women to deliver their babies in clinics. Offering them such cash transfers had the effect of empowering them, giving them a bargaining chip when discussing the birth with their husbands and mothers-in-law. In that context, giving women cash was a transforming event. He stressed the importance of results-focused work, saying that, while the health sector raised funds vertically, the ability to spend horizontally depended on the ability to produce a tangible outcome.
Mr. LOB-LEVYT, speaking on how to create and manage a sustainable fund, said the key was the ability to examine previous successes and to uncover the ingredients of the success. In Italy, six Governments committed themselves to providing $1.5 billion to tackle pneumonia and finance immunization. Those efforts were built on partnerships, and were based on accountability and results. Around 75 per cent of the children were immunized in sub-Saharan Africa, rivalling the situation in some areas of Europe. Part of their success was due to rigorous attention to accountability and the complementary roles played by the agencies involved in the partnership. Also, good coordination meant that individuals played to their strengths. As the world moved forward, it must explore other forms of innovative finance. The changes in the health system architecture over the last 10 years had created significant opportunities in that regard. The World Bank, GAVI and others were involved in seeking joint finance to improve health systems over the long-term.
Mr. JOSEPH, addressing the issue of innovative technology to address bottlenecks, said the developing world's infrastructure ‑‑ roads, good medical facilities ‑‑ were limited or non-existent. The mobile phone network he operated had 85 per cent coverage, and enabled the Government of Kenya to reach many people. Through his high-speed data network, it sent messages to women who had just given birth on how to look after their babies; the Ministry of Health monitored patients, making sure they took their medicine at the right time and in the right order. The network enabled the transfer of "social payments", so that people could buy medicine or birth control pills. There was also a system for people to pay for clean water through their mobile phone. In addition, people could receive HIV counselling through an 800 number, as well as obtain information on where to get antiretrovirals when their usual supply was disrupted.
Following the panel discussion, several delegates took the floor, including the representatives of Egypt, Thailand, Japan, Peru, Republic of Korea, Qatar, Iceland, Israel, Brazil, France, Vanuatu (speaking on behalf of the Small Island Developing States), Austria and Venezuela.
A number of speakers expressed support for health as a human right, with some invoking the right to physical and mental health. Others brought up the right to food. A few speakers raised the issue of global regulations on the pharmaceutical industry, and ensuring access to medicines by striking a fair balance between intellectual property rights and global public health needs. Some speakers talked of conferences and summits hosted by their countries, which focused on specific diseases such as AIDS, or on broader issues such as ways to strengthen the health system and empower communities in the area of health.
On the subject of partnerships, the representative of Thailand suggested that developed countries consider entering into a trilateral arrangement with developing countries, with the Global Fund playing a third role. The representative of the Republic of Korea described the outcome of a successful partnership in which his Government produced a vaccine against cholera in partnership with the Governments of India, Sweden, Kuwait and Viet Nam and the Gates Foundation. The representative of France encouraged developing countries to take ownership of health programmes, in situations where they relied on developed partners to jump start the process. While developed countries provided training to their developing partners, it was just as essential to find ways to ensure that the trainees could earn a good salary at home and could enjoy a good working environment.
The Permanent Observer of the Holy See also spoke, stressing the important role played by faith-based organizations.
Each of the panellists then offered a sentence or two in response, with Mr. MOTSOALEDI saying that the goal of reducing the incidence of HIV/AIDS was achievable with the right partners. Mr. CHAMBERS said programmes could bring success if they were well thought through, and he reiterated a suggestion by Mr. GODAL that Nigeria could be used a laboratory to see how Millennium Development Goals 4, 5 and 6 could be achieved with the right combination of assisting partners. Mr. LOB-LEVYT took the opportunity to remind everyone that pneumonia killed more children that malaria, HIV and tuberculosis put together. Mr. KAZATCHKINE said it was possible to reach all the health-related Millennium Development Goals by scaling up interventions and building partnerships, through a "raise vertical, spend horizontal" spending policy. Mr. JOSEPH said much could be achieved with the aid of technology.
In closing, Mr. SIBIDE said, given the lessons learned from the effects of the financial crisis on the poor and vulnerable, the international community should create a rapid response surveillance system, based on a broad partnership, to assess the crisis's impact on health. Also, the world needed a new paradigm that would take the AIDS movement out of isolation, perhaps by setting up a partnership between the AIDS movement and the movement on other Millennium Development Goals, so that results could be delivered by 2015.
Closing Remarks
In closing remarks, United Nations Secretary-General BAN KI-MOON congratulated delegates on a productive and challenging discussion. The day had started with a strong message from the World Health Organization that "we are in the midst of the greatest drive against poverty ever". The price of failure kept getting higher, a reality brought into the spotlight by the current influenza pandemic. Improved health outcomes were needed to achieve the Millennium Development Goals. "That means we need to up our game because we don't have much time left," he said.
More than ever, it was critical to avoid any reversal of progress made in global health, he continued. Throughout the day, three overarching questions had been examined, which would form an important agenda for action going forward: who do we need to protect as our first priority? How do we better define and build resilient systems to deliver health services for all? What are the opportunities for building partnerships that would enhance cooperation? Indeed, it was easy to ask questions and even to propose solutions. But today's meeting had gone beyond that, as delegates, in determining what must be done, had made concrete pledges of action.
On the issue of vulnerability, he said that, despite progress, many people were being left behind. Nowhere was that more evident than in the staggering number of women who suffered or died because of poor sexual and reproductive health in pregnancy or during childbirth. Maternal mortality was the largest health inequity: 99 per cent of maternal deaths were in poor countries. Half of all of them were in Africa.
He said an immediate focus should be in understanding where the gaps were ‑‑ and where the system was failing to address barriers that prevented women from getting the care they needed. Neglected tropical diseases impacted women and children the most, afflicting the poorest in the developed and developing world alike. Controlling such diseases was among the most low-cost of all interventions. Pandemic preparedness provided an example of successful cross-sectoral and intergovernmental cooperation, and lessons could be applied in moving forward on both H1N1 and a range of other health challenges.
To build resilient health systems that worked for the poor, he called for training midwives, community health workers and health system managers alike. New technologies must be integrated and decision makers must listen to those in need. In that regard, the International Health Partnership had provided a framework for supporting country-led plans. While the current financial climate was a reminder of the cost-effectiveness of coordination, significant new funding was still needed to meet health-related Millennium Development Goals and innovative financing mechanisms could help fill those gaps. Indeed, the world had moved beyond traditional vertical approaches, and he welcomed new directions being taken by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Global Fund.
He said improved coherence called for new ways of working, new strategic partnerships and ‑‑ importantly ‑‑ making space for new actors. Although those here today had come from a range of backgrounds and professions, all were united in a common goal. The crisis reminded everyone that the response to global interdependence was, quite rightly, enhanced multilateralism. Meeting the Goals meant that stakeholders had to be clever. "We must listen to what young people ‑‑ the leadership of tomorrow ‑‑ might teach us," he said. People affected had to be at the heart of collective efforts. The explosion of mobile phone coverage in the developing world provided huge new opportunities. To take advantage of that, countries needed inter-operable e-health systems. Forging the right partnerships now would save money and lives.
In closing, he challenged participants to bring their partnerships to the next level; to be strategic and accountable under enlightened leadership. He hoped all would leave today with a clear sense of purpose. Ensuring that every health Goal was met was not what ought to be done ‑‑ it was what must be done.
For information media • not an official record