Poverty, Health and the Human Future
Mr. President, Director-General Dr. Margaret Chan, Excellencies, colleagues and friends:
We stand at a moment of exceptional possibility. A moment when global health and development goals that long seemed unattainable have moved within our reach. A moment, also, when dangers of unprecedented magnitude threaten the future of humankind. A moment that calls us to shed resignation and routine, to rekindle the ambition that has marked the defining chapters of global public health.
A generation must rise that will drive poverty from the earth. We can be that generation.
A generation must rise that will end the scourge of inequality that divides and destabilizes societies. We can be that generation.
A generation must rise that will bring effective health services to every person in every community in every country in the world. We will be that generation, and you—members of this Assembly—will lead the way.
Yes, I’m optimistic. I’m optimistic because I know what global health has already achieved—what you have achieved.
In 2011, global average life expectancy reached 70 years, a gain of six years since 1990. The global child mortality rate has fallen 40 percent in the same period. In the ten years since Dr. LEE Jong-wook announced WHO’s commitment to support countries in scaling up antiretroviral treatment for AIDS, 9 million people in developing nations have gained access to this life-saving therapy. These are just a few of the milestones of recent progress.
I have another reason to be optimistic. I know global health is guided by the right values.
Thirty-five years ago, the Alma-Ata Conference on Primary Health Care set powerful moral and philosophical foundations for our work. The Declaration of Alma-Ata confirmed the inseparable connection between health and the effort to build prosperity with equity, what the Declaration’s authors called “development in the spirit of social justice.”
Alma-Ata showed the importance of primary health care as a model of health action rooted in the community; responsive to the community’s needs; and attuned to its economic, social and cultural aspirations. Alma-Ata set the bar high. But we continue to struggle to provide effective, high-value primary health care to all our citizens. Unfortunately, none of WHO’s 194 Member States has yet built the perfect health care system. We can all get better and we know it.
But in the grand spirit of Alma-Ata, we must focus again on the link between health and shared prosperity. And, this time, we must turn our loftiest aspirations into systems that build healthier, more productive, more equitable societies.
For what Alma-Ata did not do was provide concrete plans or effective metrics for delivering on its admirable goals. In many cases, frontline efforts inspired by Alma-Ata lacked strategy; evidence-based delivery; and adequate data collection. This shouldn’t have been surprising, and I’m certainly not criticizing global health leaders of that time. Indeed, many of the architects of Health For All are my heroes to this day.
Today, we have resources, tools and data that our predecessors could only dream of. This heightens our responsibility and strips us of excuses. Today we can and must connect the values expressed at Alma-Ata to strategy and systems analysis; to what I have been calling a “science of delivery”; and to rigorous measurement. And we must actually build healthier societies.
The setting for this work is the growing movement for Universal Health Coverage.
The aims of universal coverage are to ensure that all people can access quality health services, to safeguard all people from public health risks, and to protect all people from impoverishment due to illness: whether from out-of-pocket payments for health care or loss of income when a household member falls sick.
Every country in the world can improve the performance of its health system in the three dimensions of universal coverage: access, quality, and affordability. Priorities, strategies and implementation plans will differ greatly from one country to another. In all cases, countries need to tie their plans to tough, relevant metrics. And international partners must be ready to support you. All of us together must prevent ‘universal coverage’ from ending up as a toothless slogan that doesn’t challenge us, force us to change, force us to get better every day.
The good news is that many countries are challenging themselves, measuring outcomes and achieving remarkable progress. Turkey launched its “Health Transformation Program” in 2003 to provide access to affordable, quality health services for all. Formal health insurance now covers more than 95 percent of the population. The health reform is one of a bundle of factors that have contributed to Turkey’s health gains. Between 2003 and 2010, Turkey cut its infant mortality rate by more than 40 percent.
Thailand’s universal coverage reform dates from 2001. The program has substantially increased health care utilization, especially among the previously uninsured. And, as of 2009, the program had already reduced by more than 300,000 the number of Thai people suffering catastrophic health care costs.
And let me acknowledge that Thailand launched its universal coverage program against concerns over fiscal sustainability initially raised by my own institution, the World Bank Group. Thailand’s health leaders were determined to act boldly to provide access for their whole population. Today the world learns from Thailand’s example.
Many other countries are also advancing. And the growing momentum for universal health coverage coincides with a new chapter in the global fight against poverty.
Last month, the organization I lead, the World Bank Group, committed to work with countries to end absolute poverty worldwide by 2030. For the first time, we’ve set an expiration date for extreme poverty.
And we know that fighting absolute poverty alone is not enough. That’s why we’ve set a second goal. We’ll work with countries to build prosperity that is equitably shared, by nurturing economic growth that favors the relatively disadvantaged in every society. We’ll track income growth among the poorest 40 percent of the population in every country and work with country leaders to continuously improve policy and delivery, so countries can achieve economic progress that is both inclusive and sustainable – socially, fiscally, and environmentally.
To end poverty and boost shared prosperity, countries need robust, inclusive economic growth. And to drive growth, they need to build human capital through investments in health, education and social protection for all their citizens.
To free the world from absolute poverty by 2030, countries must ensure that all of their citizens have access to quality, affordable health services.
This means that, today as never before, we have the opportunity to unite global health and the fight against poverty through action that is focused on clear goals.
Countries will take different paths towards universal health coverage. There is no single formula. However, today, an emerging field of global health delivery science is generating evidence and tools that offer promising options for countries.
Let me give just one example. For decades, energy has been spent in disputes opposing disease-specific “vertical” service delivery models to integrated “horizontal” models. Delivery science is consolidating evidence on how some countries have solved this dilemma by creating a “diagonal” approach: deliberately crafting priority disease-specific programs to drive improvement in the wider health system. We’ve seen diagonal models succeed in countries as different as Mexico and Rwanda.
Whether a country’s immediate priority is diabetes; malaria control; maternal health and child survival; or driving the “endgame” on HIV/AIDS, a universal coverage framework can harness disease-specific programs diagonally to strengthen the system.
As countries advance towards universal health coverage, there are two challenges we at the World Bank Group especially want to tackle with you. These two areas are deeply connected to the goals on poverty and shared prosperity I described a moment ago.
First, let’s make sure that no family, anywhere in the world, is forced into poverty because of health care expenses. By current best estimates, worldwide, out-of-pocket health spending forces 100 million people into extreme poverty every year, and inflicts severe financial hardship on another 150 million. This is an overwhelming form of affliction for people, as the anguish of impoverishment compounds the suffering of illness. Countries can end this injustice by introducing equitable models of health financing along with social protection measures such as cash transfers for vulnerable households.
Second, let’s close the gap in access to health services and public health protection for the poorest 40 percent of the population in every country. Improving health coverage and outcomes among the poorer people of any country is critical to building their capabilities and enabling them to compete for the good jobs that will change their lives. We have to close health gaps, if we’re serious about reducing economic inequality, energizing countries’ economies and building societies in which everyone has a fair chance.
The issue of point-of-service fees is critical. Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services. This is both unjust and unnecessary. Countries can replace point-of-service fees with a variety of forms of sustainable financing that don’t risk putting poor people in this potentially fatal bind. Elimination or sharp reduction of point-of-service payments is a common feature of all systems that have successfully achieved universal health coverage.
Now let me tell you five specific ways the World Bank Group will support countries in their drive towards universal health coverage.
First, we’ll continue to ramp up our analytic work and support for health systems. Universal coverage is a systems challenge, and support for systems is where the World Bank Group can do the most to help countries improve the health of your people.
I was recently in Afghanistan, where the Bank Group has been working with the government and other partners to rebuild the country’s health system. In Afghanistan, this abstract term ‘health system’ quickly becomes personal. Let me tell one story. Several years ago, Shakeba, a young woman from Parwan province, gave birth at home, because there was no health center she could go to. She developed complications and lost her baby. Earlier this year, Shakeba gave birth to another child—in the delivery room of a recently-opened health center, with modern equipment and skilled personnel. Shakeba and her new baby are thriving. Improving health systems literally means life or death for many mothers and children.
The number of functioning health facilities in Afghanistan grew more than four-fold from 2002 to 2011. During this time, the country reduced under-five mortality by more than 60 percent.
Middle-income countries may face very different challenges. Many middle-income countries I visit are suffering from an epidemic of hospital-building. In some countries, I’ve seen brand-new, ultra-sophisticated emergency facilities where specialists are preparing to treat, for example, complicated emergencies like diabetic ketoacidosis. But when patients are released from these facilities, they can’t get adequate support in the routine, daily management of illnesses like diabetes, because the primary care system has been starved of financing. It makes no sense to pour resources into responding to downstream complications, without investing in upstream prevention and disease management that could often keep those complications from happening in the first place.
When countries anchor their health systems in robust primary care and public health protection, health care costs can be controlled. We will work with all countries to do just that.
Our second commitment is that we will support countries in an all-out effort to reach Millennium Development Goals 4 and 5, on maternal mortality and child mortality.
Reaching these two MDGs is a critical test of our commitment to health equity.
We must continue to focus on the MDGs, even as we prepare for the post-2015 development agenda. The MDGs have given energy and focus to everyone in the global development community. We have not finished the job. Now is the time to do it.
Last September at the United Nations General Assembly, I announced that the World Bank Group would work with donors to create a funding mechanism to scale up support for MDGs 4 and 5. Since then, we have been expanding our results-based financing for health, focusing on the maternal and child health goals. Our results-based financing fund has leveraged substantial additional resources from the International Development Association, IDA, the World Bank Group’s fund for the poorest countries. This has been an unquestioned success: the trust fund has multiplied resources for maternal and child health. Over the past five years, we have leveraged $1.2 billion of IDA in 28 countries, including $558 million for 17 countries since last September alone. Now we are working with Norway, the United Kingdom and other partners to expand this effort.
Results-based financing is a smart way to do business. It involves an up-front agreement between funders and service-providers about the expected health results. Payment depends on the delivery of outcomes, with independent verification. Results-based financing also allows citizens to hold providers accountable. It puts knowledge and power in ordinary people’s hands.
These programs all have rigorous impact evaluations. In Rwanda, the impact evaluation showed officials that performance incentives not only increased the coverage and quality of services, but also improved health outcomes. The study found that babies were putting on more weight, and that children were growing faster.
Our third commitment is that with WHO and other partners, the World Bank Group will strengthen our measurement work in areas relevant to universal health coverage. In February, the Bank and WHO agreed to collaborate on a monitoring framework for universal coverage. We’ll deliver that framework for consultation with countries by the time of the United Nations General Assembly in September.
We don’t have enough data. For example, we don’t yet measure the number of people forced into poverty by health expenditures in every country each year. We will work with countries and partners to make sure we get better data so countries can achieve better outcomes.
Fourth, we will deepen our work on what we call the science of delivery. This is a new field that the World Bank Group is helping to shape, in response to country demand. It builds on our decades of experience working with countries to improve services for poor people. As this field matures, it will mean that your frontline workers – the doctors and nurses, the managers and technicians – will have better tools and faster access to knowledge to provide better care for people.
Distinguished ministers, as you move towards universal coverage, tell us where you’re hitting barriers in delivery. We’ll connect you and your teams to global networks of policymakers and implementers who have faced similar problems. We’ll mobilize experienced experts from inside and outside the World Bank Group, including from the private sector, where much of the best delivery work happens.
Fifth and finally, the World Bank Group will continue to step up our work on improving health through action in other sectors, because we know that policies in areas such as agriculture, clean energy, education, sanitation, and women’s empowerment all greatly affect whether people lead healthy lives.
Mexico has done an impressive job in this respect. Mexico’s Seguro Popular, for instance, works in concert with the Oportunidades cash transfer program. Oportunidades has increased poor people’s spending capacity and reduced the depth of poverty. It has also raised school enrollment and access to health services among the poor. Meanwhile, Seguro Popular has reduced out-of-pocket health care payments and catastrophic health expenditures, especially for the poorest groups. All countries can’t match Mexico’s resources. But promising options for similar types of action exist for all countries.
When ministers of health seek to integrate expanded health coverage with efforts to reduce poverty, the World Bank Group’s policy advice, knowledge resources and convening power are at your disposal. For instance, we can help facilitate discussions with ministries of finance. We saw promising steps in this direction at the meeting of African health and finance ministers in Washington last month.
But specific actions from the World Bank Group must be part of a wider change in how we work together as a global health community.
The fragmentation of global health action has led to inefficiencies that many ministers here know all too well: parallel delivery structures; multiplication of monitoring systems and reporting demands; ministry officials who spend a quarter of their time managing requests from a parade of well-meaning international partners.
This fragmentation is literally killing people. Together we must take action to fix it, now.
Aligning for better results is the approach of the International Health Partnership, or IHP+. And it’s gaining momentum. Earlier today, Director-General Margaret Chan and I took part in an IHP+ meeting. It’s inspiring to see more and more countries taking charge, setting the agenda based on strong national plans, and making development partners follow the lead of governments.
We are reconfirming our shared commitment to IHP+ as the best vehicle to implement development effectiveness principles and support countries driving for results. But, honorable ministers, we must hold each other accountable. We all have to be ready to pound the table and demand that we stop the deadly fragmentation that has hindered the development of your health systems for far too long. The stakes are high and the path will be difficult, but I know we can do it.
Together, we face a moment of decision. The question is not whether the coming decades will bring sweeping change in global health, development and the fundamental conditions of our life on this planet. The only question is what direction that change will take:
Toward climate disaster or environmental sanity;
Toward economic polarization or shared prosperity;
Toward fatal exclusion or health equity.
Change will come—it’s happening now. The issue is whether we will take charge of change: become its architects, rather than its victims. The gravest danger is that we might make decisions by default, through inaction. Instead, we must make bold commitments.
Since the turn of the millennium, we have experienced a golden age in global health, shaped by the achievements of the leaders in this hall. But will history write that the golden age expired with its hopes unfulfilled, its greatest work barely begun? That it sank under the weight of economic uncertainty and leaders’ inability to change, to push ourselves beyond our old limits?
We know what the answer must be. The answer that the peoples of all our nations are waiting for—those living today and those yet to be born.
We can do so much more. We can bend the arc of history to ensure that everyone in the world has access to affordable, quality health services in a generation.
Together, let’s build health equity and economic transformation as one single structure, a citadel to shelter the human future.
Now is the time to act.
WE MUST BE the generation that delivers universal health coverage.
WE MUST BE the generation that achieves development in the spirit of social and environmental justice.
WE MUST BE the generation that breaks down the walls of poverty’s prison, and in their place builds health, dignity and prosperity for all people.