Global Health – how to make a difference

Check against delivery

Ladies and gentlemen,

Today is 7 April – World Health Day. Congratulations!

It is a special pleasure for me to speak here again at the CSIS – and to be speaking on health.

A fair question from the audience would certainly be: “Why invite a Foreign Minister to speak on health? What does he know about medicine, health systems, health budgets, hospitals, mental health and diseases?”

The answer is not much, and certainly far less than any health minister, and – hopefully – far less than many of you.

But here is the point: While I was serving at the World Health Organization with Dr Brundtland from 1998, I discovered how much more there is to health – and global health – than the strict medical side of the issue. I did so by seeing, listening and experiencing, and by working with some extraordinary people from the global health community – a few of which are here today.

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I learned some very important lessons – and here are a few of them:

I learned that health is more than a budget expenditure. It is an investment in human dignity, human development – and thus in economic development and the welfare of people, communities and nations.

I learned that investing wisely in health was a powerful tool in the fight against extreme poverty. Poor health breeds poverty – that is something we have always known. But we are now much more aware than before that improved health leads to growth and development. The equation works both ways. This offers us a unique opportunity to both fight poverty and stimulate development.

I learned more about the amazing work that is carried out by health workers all around the world, from the modern and sophisticated clinics in Oslo and Geneva where my wife has given birth, to the primitive, local facility in an Indian village where a brave midwife helps a mother to save both her newborn baby’s life – and her own – because she gives birth there and not at home on a dirty floor.

I learned how much more we could accomplish by working differently, by reaching out to other partners beyond health – by assembling the evidence necessary for Dr Brundtland to call to presidents, prime ministers and finance ministers to tell them: “You too are health ministers. Your decisions have an impact on health. Get to work, get involved!”

I learned about the opportunities and complexities of the new partnerships and about the additional financial resources we could mobilise through creations such as GAVI and the Global Fund to fight AIDS, TB and Malaria. But also about the very complex landscape private–public interaction creates, and that sometimes leads to a lack of overview and unity of purpose.

Having foreign policy as my main field, I learned how much global health matters to foreign and security policy. How health tells perhaps the strongest story of globalisation, how the outbreak of a pandemic would immediately challenge our diplomatic and security systems, how modern states might be brought to closing borders, how the ownership of a virus quickly becomes a diplomatic struggle between the North and the South, how a polio immunisation campaign can offer the opportunity for a truce and perhaps be the first step towards a peace process.

And finally I learned what it takes to make a difference in health. Bill Foege explained this masterfully when he described all the efforts that have to fall into place to immunise a child – from the initial research in a laboratory, through testing, production, transport, establishment of a cold chain in a tropical country, to the training of the nurse at a local health station who gives the injection with a clean and safe needle – all of this and many more elements in a long chain that has to be in place before the lucky child can be protected for life against fully preventable diseases.

Dr Foege referred to the saying from Tanzania – which also became the title of a book by Secretary Clinton some ten years ago: “It takes a village to raise a child.” Dr Foege elaborated on that beautifully by stating: “It takes a whole world to immunise a child!”

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So this is me – a Foreign Minister who had the privilege of discovering the world of global health and the ambition to continue dealing with it – as an interested person and also as a Foreign Minister – with other colleagues and in settings not always accustomed to these issues.

And in this context let me add another thing that I learned, and am still learning: how important it is that professions break out of their boxes and dramatically improve their interaction. And this applies to health professionals in particular, if I may say so. Let me illustrate this be quoting a famous Norwegian public health official, Mr Karl Evang, who took part in the drafting of the World Health Organization’s constitution. He said that to him economists were worse than TB!

In these times of financial crisis he might perhaps have had a point. But another point, far more relevant I believe, is what the health profession and the economics profession can do by maximising their efforts and potential. I believe the report of the Commission on Macroeconomics and Health made a contribution to this by highlighting the potential of investing wisely and strategically in health as a strategy to fight extreme poverty.

Global health is therefore more than an “issue”; it has to do with managing complex international relations, important principles and major challenges of inequality and injustice. It involves changing economic priorities and establishing organisations and working relationships. In short: “We must reach beyond our grasp to fulfil our task.”

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Let me say a few words about the Norwegian approach:

Health has always played a major role in our development policy. Since 2000 we have scaled up. We have focused on taking the lead in three concrete initiatives:

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First there is GAVI, an alliance of major UN organisations, governments in developed and developing countries, the vaccine industry, and private actors such as the Bill and Melinda Gates Foundation. Prime Minister Jens Stoltenberg was the first prime minister to engage his government actively in this effort, and we have ever since been a staunch supporter of this effort with the ambitious vision of helping to immunise every child in the world. This is a new way of working, based on public–private partnership, focusing on performance and new incentives for partners to work together.

In my view, the results have been impressive: WHO estimates that between 2000 and 2008, some 3.4 million future deaths have been prevented through immunisation campaigns supported by GAVI. That is the equivalent to the number of inhabitants in Chicago and Washington DC combined.

So it has been successful, yes. But we must not be complacent. We must constantly look for improvements, be accountable and transparent and ready to adjust as we go ahead.

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Second, we have been actively engaged with the Global Fund to fight AIDS, tuberculosis and malaria – since its creation. As you know, the Global Fund is also made up of a creative mix of governments, private actors and support from WHO, UNAIDS and the World Bank.

We have seen a huge boost in treatment, counselling and prevention of HIV/AIDS. We have also seen the distribution of 70 million bed nets, the most cost-effective way of preventing malaria, the delivery of 74 million malaria treatments and the detection and treatment of 4.6 million additional cases of infectious tuberculosis. Today, we stand on the threshold of a real breakthrough in the battle against malaria – for so long at the core of global health efforts – and frustrations.

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And third, more related to methodology, we have pushed for more results-based management. Global health issues cut across traditional organisational structures in international affairs – and should be addressed accordingly. UNAIDS was set up to work primarily through its sponsoring organisations in the UN system, while also forming partnerships with a broad range of NGOs, governments and other actors. Roll Back Malaria and Stop TB are other partnerships that were formed, anchored in the World Health Organization – reaching out.

I repeat: transparency and accountability are key. And both may become more difficult to achieve in this new complex landscape. In order to keep the trust of both taxpayers and private investors, we must constantly improve our methods – how we spend and invest, how we monitor and report.

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There have been extraordinary results during this decade:

More than 200 million children have been vaccinated in low-income countries by vaccines previously not available to them.

Deaths from measles dropped by over 90% in sub-Saharan Africa.

More than 100 million bed nets have been distributed in sub-Saharan Africa.

We can expect malaria mortality to be rolled back by more than 90% by 2015.

The cost of treating an AIDS patient has been reduced from more than 30 dollars a day to less than one. More than three million people are on treatment as we speak.

To sum up in two telling figures: GAVI and the Global Fund alone may have saved 6 million lives based on an investment of some 9 billion dollars.

Then some have asked: “Isn’t there a risk that we could lose coherence in our effort to promote global health if we concentrate on just a few diseases at a time? And don’t we risk losing overview by having all of these complex partnerships operating together, with nobody having an overall coordinating function?”

I believe those are very valid questions. And no answer should attempt to cut that debate short. It concerns the matrix of horizontal versus vertical interventions – and the governance of global health now that voluntary contributions outstrip the regular budget of WHO.

Norway’s consistent approach – as we support new partnerships and new ways of working – is to keep focusing on the need to strengthen the UN and the World Health Organization – and to keep a strong WHO at the core as our standard-setting and normative agency.

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Let me move on to the Millennium Development Goals and make a few reflections on our progress. Norway has kept the MDGs as a guiding principle for its overall development cooperation efforts – the funding of which has now reached the historic goal that we set ourselves in 2005: 1% of GNI. Three of the MDGs are health goals, and this is where we have tried to maximise our contribution.

Important progress has been made on MDG 6, i.e. on halting and reversing the spread of HIV/AIDS, tuberculosis and malaria and making effective treatment available to all. The United States’ engagement has been essential for successes so far – and will be equally essential in future efforts.

There has been some success on MDG 4, on reducing the mortality rate of children under the age of five, primarily due to the immunisation campaigns. But the drama is still unfolding: far too many children still die of causes that are easy to prevent. This is not high tech. It is low tech.

In contrast to these relative success stories, we have failed miserably on MDG 5, on reducing maternal and infant mortality. The goal set in 2000 was to reduce maternal mortality by three quarters by 2015 and making reproductive health accessible to all.

Today, one mother and eight newborn babies die every minute – hardly any different to the situation ten years ago. These are terrible figures. It is still the case that the first day in a baby’s life is the most dangerous one. And for millions of women, nothing is more dangerous than giving birth.

On reproductive health there has been some progress as regards the availability of prenatal care, but the huge unmet needs for family planning undermine other goals.

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What are the main reasons? It boils down to discrimination against women and their unmet nutritional, social and economic needs – and the lack of available and reliable quality health services.

And even where health services do exist, they tend to be poorly adapted to women’s needs and out of reach in practical terms.

We have worked to find practical ways of addressing these issues – reaching the pregnant woman, following her through her pregnancy with enough assistance for her to make it safely to delivery. It doesn’t need to be all that complicated.

In India, together with the Government of India and selected local governments, we have focused on getting pregnant woman to deliver in a health facility – and not on some dirty floor. The method has simply been to give women a financial incentive, in short paying her to choose a health clinic rather than giving birth at home. Not an easy choice to make in many settings. 

We have established a partnership to promote maternal health. What we have seen is a ten-fold increase in the number of poor women delivering their babies in health facilities – from less than a million to ten million a year – achieved in just four years, simply by paying them to do so. And consequently we have seen a dramatic drop in the numbers of both babies and women dying.

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This was one concrete example. Now what should be the way forward?

Promoting effective and viable health systems is vital. We must provide accessible primary health care services, educated health workers, available and affordable medicines and diagnostic services, and a governance structure that is efficient and reliable. This isn’t news to you. It isn’t rocket science either.

To reach the Millennium Development Goals by 2015, we all need to do even more for women and children. Invest more, work more closely together.

I am encouraged to see the new US administration give high priority to maternal and child health. I was pleased yesterday to note how Secretary Clinton responded to my invitation for closer cooperation between Norway and the US on these issues.

One major challenge is money – especially now that we are in the middle of a financial crisis. Aid budgets and private budgets for these purposes are sure to be reduced – although it is highly regrettable. We need to protect the health sector as best we can.

In Europe, work is in progress to identify innovative financing mechanisms to help reach these goals. We need to develop new opportunities. Promising work is under-way. UNITAID is receiving additional millions from a modest tax on air tickets. We support new initiatives that could stimulate other innovative financial mechanisms – from governments and individuals alike.

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In addition – as I said at the start – we should see foreign policy in a broader sense through a “health lens”. At the World Health Organization I learned about all the links between foreign policy, trade policy and health.

In 2006, I invited six other foreign ministers, from Brazil, France, Indonesia, Senegal, South Africa and Thailand, to join me in declaring that global health was “a pressing foreign policy issue of our time”.

In March 2007 we adopted the Oslo Declaration that states that investment in health is fundamental to economic growth and development. Threats to health can compromise a country’s stability and security. Building capacity for global health security, facing threats to global health and making globalisation work for all – all of this depends on conscious use of foreign policy instruments – and on political will.

A similar point was made in 2007 by the then Senator Barack Obama, when he reflected on American national interests in global engagement (Chicago, April 23): “Since extremely poor societies and weak states provide optimal breeding grounds for disease, terrorism, and conflict, the United States has a direct national security interest in dramatically reducing global poverty and joining with our allies in sharing more of our riches to help those most in need.”

I agree.  I am encouraged to see this policy put in practice in the budget proposal from the US State Department, in which Global Health is a priority area – as I am encouraged by the potential for taking this forward after my meeting with Secretary Clinton yesterday.

The Foreign Policy and Global Health Initiative is all about engagement and outreach, building political alliances among states with different outlooks, different priorities and different geographic affiliations, but with a strong and consistent political will to promote global health as a common cause.

Our method of work is not to form a separate organisation or fixed structure, but to seize opportunities to make a political difference, where and when they arise, in respective organisations, boards and movements or in bilateral relations.

In January 2000, the UN Security Council devoted a session to HIV/AIDS as a threat to peace and security on the African continent. This was the first time a health issue was discussed in the Security Council.

Last autumn, the UN General Assembly put global health and foreign policy on its agenda.

Again: health is simply too important to be left to health ministers alone. I am not saying this because I underestimate health ministers, but to highlight that finance ministers, prime ministers, presidents, and foreign ministers, are needed as well.
The current global financial crisis is developing into a global economic crisis. We must now prevent it from developing into a social recession as well.

The social determinants of health are under increasing pressure also in poorer countries. This should be an issue for the G8, the G20, for finance ministers and heads of state and government worldwide.

Now we need to look ahead. We need creativity, new alliances.

We must find productive ways of promoting cooperation, forming alliances based on ideas and concrete issues.

The challenges on the health agenda are global. Our responses have to be global as well.

Thank you for your attention.