Keynote address by Foreign Minister Jonas Gahr Støre at the World Health Assembly 2012, Geneva, 22 May 2012
Director General, Dr Chan,
Fellow Ministers, Excellencies,
Ladies and gentlemen,
First of all, let me congratulate Dr Chan on her nomination as Director General for a second term.
Dr Chan, you have shown strong leadership at a time when leadership is needed more than ever. You are recognised far beyond the circles of global health professionals for bringing health into the broader context of major global challenges.
I can assure you of Norway’s full support as you now take the WHO forward as the lead agency in global health.
It is a great honour for me to address you, health ministers of the world, who bear so much responsibility for the well-being and integrity of people around the globe – women and men, old and young, rich and poor.
For me, personally, I recall the fine years I had serving your extraordinary organisation as Chief of Staff of the Director General at the time, Dr Gro Harlem Brundtland.
Today, I stand here as a Foreign Minister of my country Norway, and the purpose of my address is to pledge support to your efforts to promote the health of people and communities across the world.
In this momentous task, you deserve strong backing from us, minister colleagues from other ministries. Not just because health is everybody’s business. And not just because the health sector often has to deal with consequences of modern life that come from various other sectors.
But because, in addition to all this, we all have a major stake in your success. Succeeding in local, national and global health ambitions requires the mobilisation of political will across and above the silos of political decision-making. We need to remind presidents, prime ministers and finance ministers – and even foreign ministers – that they too are health ministers.
We – your colleagues – need to fully appreciate that funding for health is much more than covering costs. It is an investment in human potential, in the strength of nations and communities, in the performance of the economy, and ultimately it is an investment in the security of states.
My ambition when I served at WHO was to learn as much as I could about health even though I did not come from a health profession. One of my ambitions as Foreign Minister has been to capitalise on that knowledge in shaping a modern foreign policy.
In fact, what I learned at WHO – and what I observe daily as Foreign Minister – is this: the interdependence created by health issues is perhaps the most striking illustration of globalisation.
National borders offer little or no protection against global health risks. National interests and national economies are highly dependent on local health conditions. Ultimately, states fail if the population’s health deteriorates – and states thrive if health improves.
There was a time when health officials regarded economists as “opponents”, since they saw funds allocated to health purposes as costs rather than an investment. Back in the 1950s, a prominent Norwegian public health pioneer identified economists as a greater threat to health than tuberculosis!
But times and approaches have changed. Modern economics now teaches us the value of investing wisely in health, demonstrating how this can create both human progress and greater value – for all.
Now, after almost seven years as Foreign Minister, I am more convinced than ever that improving health is crucial for achieving growth, development, equity and stability throughout the world.
Seeing contemporary security challenges through a health lens – as Norway did when we led the negotiations leading to the ban on cluster munitions in 2008 – may help change the perspective. It was precisely an emphasis on the unacceptable health and humanitarian costs of using such weapons that brought the ban about. I firmly believe that this is a vital perspective as we now seek to take concrete steps towards our goal of a world free of nuclear weapons.
We trade, we travel and we communicate more than ever and faster than ever. The trans-boundary forces of globalisation are affecting the health of individuals and populations more profoundly than ever before.
And this reality is here to stay. It will not go away. It will further widen and deepen as new centres of growth develop in the East and South, and a number of large emerging economies gain strength.
We will continue to witness a turbulent path of human and economic development, as states continue to experience crises and growth, progress and upheavals.
This is happening while the world is warming rapidly, against a backdrop of continued steep population growth, a rapid process of urbanisation and increasing competition for limited resources – in particular for water and energy.
In the face of this tide, we need to mobilise awareness of the right to health as a universal human right, a right that can protect both the individual and the community, a right that should guide the formulation of sound public policy, at national and international level.
The big picture for human development today is mixed, as I guess it always has been and will continue to be. Life expectancy is on average four to five years longer today than 20 years ago. Global GDP has almost tripled. We have made tremendous strides in dealing with a number of deadly diseases, in particular AIDS, tuberculosis, malaria and vaccine-preventable diseases.
Meanwhile, non-communicable diseases have become a major cause of death in many countries, particularly in areas where urbanisation is intensifying and people are embracing new lifestyles.
Development is still profoundly uneven and unbalanced. More than a billion go hungry to bed every day. And more than a billion are overweight – what a telling contrast.
Malnutrition used to mean not having enough food. Today, it often means getting too much of the wrong food. In many places, the cheapest food – or the most attractive for those who are gaining purchasing power – is high in calories and sugar, and low in nutrients.
The result is an epidemic of heart disease, cancer and diabetes. And the heightened expectations of access to health care of billions of people who are rising out of abject poverty are creating a tremendous financial and political challenge for governments in developing countries, which continue to face the so-called “double burden of disease”.
One fact remains unchanged: poverty continues to be the main cause of ill health.
But the nature of poverty is changing.
The greatest inequalities today are found within countries rather than between countries. Talking about rich countries versus poor countries gives little meaning.
Rather we see various degrees of wealth and poverty within every country. The largest number of people living in absolute poverty is now to be found in middle-income countries. This creates serious challenges in terms of equity and stability.
In addition to these urgent issues, you know – and the rest of us should know - that the causes of non-communicable diseases are not from within the health sector itself. They are due to complex aspects of society and human activity.
But the health sector is left to deal with the consequences. Health ministers and health officials even have to take the blame for shortcomings in an overburdened health sector.
So, the political focus needs to be broadened beyond the health sphere. We need to drive home the evident fact that prevention is far better than cure. WHO is taking the right strategic direction by highlighting chronic diseases as one of five priority areas, and last year the UN broadened its perspective on these challenges.
All of this is part of the complex picture facing decision makers and political leaders today. It is also part of the reason why health policy and foreign policy have become so intertwined.
In 2006 Foreign Ministers from France, Thailand, Indonesia, South Africa, Senegal, Brazil and Norway forged a network on foreign policy and health. We all came from different backgrounds, we had different experiences, but we had common interests and a shared vision.
In 2007 we adopted the Oslo Declaration on Foreign Policy and Global Health, setting out the direction for our work. We meet from time to time at ministerial level, but - more importantly - a network of experts has emerged from our foreign and health ministries, who are creating new bridges and interconnections between countries with different experiences, and are thus helping forge new consensus when this is needed in broader international contexts.
My experience is that fellow foreign ministers are becoming increasingly aware of these issues. On 1 June in Oslo, Secretary Clinton and I will host a conference on charting a new path in global health – more specifically on gender equality, and women’s and children’s rights and health. Similar focus can be noted across the world.
The underlying analysis is that the key challenge for political decision makers is to further broaden the perspective and address health issues in the context of other sectors in addition to the health sector itself.
As in other areas of international relations, we need stronger global traffic rules that take health properly into account rather than siding with other narrow interests. Let me explain.
My country, Norway, is generally faring well in comparison with other states. But we too need to mobilise efforts against the tide of chronic diseases.
For some time now, Norway has had a ban on advertising tobacco and alcohol products in order to reduce consumption.
Predictably, tobacco and alcohol companies have challenged these measures, citing provisions of trade and other international agreements.
As we speak, Norway, as well Australia, the UK and Uruguay, is facing lawsuits from tobacco companies seeking to limit the implementation of the Framework Convention on Tobacco Control, adopted by the member states of WHO some nine years ago.
When tobacco and alcohol companies try to force us to choose between respecting global trade agreements and protecting our people’s health, our answer is that we must and can do both. We must dismiss the notion that it is not possible to protect public health in a way that is compatible with our trade agreement obligations.
Because the purpose of trade is to enhance our economies. Not to harm the health of our people.
This conflict of interest is a familiar one to the global health community. And there are lessons to be learned when it comes to holding the commercial sector to account in relation to other products and production methods that severely affect public health.
In short, we need regulations that can match the forces of globalisation.
As ministers we cannot allow democratic policies to lag behind global market forces.
As we so often hear, we live in an interdependent world. The SARS epidemic, which erupted in November 2002, spread to over 25 countries during the course of a few weeks. It disrupted travel, trade and other activities. It created huge health policy challenges for individual countries. It reminded us of how closely knit our lives are.
In 2008, the World Bank estimated that a deadly flu pandemic could cost USD 3 trillion, and result in close to a 5 % drop in world GDP. In other words, we could face a global economic crisis even worse than the one we have experienced over the past five years.
I mentioned traffic rules. In recent years, WHO has contributed to the development of two major international instruments to improve health security: the International Health Regulations and the Pandemic Influenza Framework.
The transition period for implementing the core capacities established by the International Health Regulations is coming to a close this year, and a large number of countries have not yet implemented them. Progress in the implementation of the Pandemic Influenza Framework has also been slow.
Maintaining momentum on these two instruments should be a high priority for WHO and all its member states. In fact, these instruments reflect WHO’s unique role in protecting the health of our people.
If we fail to develop such vital traffic rules for our interconnected world, we will be failing in our responsibility as ministers.
We will then see how national, short-term and commercial interests constantly trump the common good and take precedence over sustainable, long-term solutions to supra-national problems.
Ladies and gentlemen,
From what I have said so far, it might seem that a partnership between health and foreign policy will only be a defensive one – a partnership to face serious threats.
Yes, there is a lot that needs to be defended. But the interplay between health, economic and foreign policy also offers real opportunities for economic and social progress.
In 1993, the World Bank published its paradigm-changing World Development Report Investing in Health. That report, together with subsequent findings included in the 2001 report of the WHO Commission on Macroeconomics and Health, provided strong indications of the link between improved health and increased productivity.
Over the last 20 years, we have built up an impressive body of evidence about the role of health as a driver of economic growth and social development.
Today we know beyond doubt that – together with investments in education – wise investments in health provide impressive returns in the form of increased productivity, reduced absenteeism, reduced turnover of staff and greater ability to attract investment.
Inspired by the progress they have achieved in controlling epidemics, immunising children and reducing mortality through effective and affordable treatment regimes, several middle-income countries have significantly boosted their health spending in recent years.
In fact, the success of emerging states in increasing their public health budgets – look to India, China, Brazil and South Africa, to mention just the largest countries – is a telling illustration. And - yes – a number of the poorest countries have also improved public health to a remarkable extent in relation to their growth rates and aid levels.
These achievements are not a coincidence.
There is no inexorable link between growth and improved health and welfare.
It is politics that drives history, not inevitable laws of economics.
Furthermore, we know beyond doubt today that extreme inequity leads to social tension, conflicts and instability.
We know that it impedes the productivity of a population, we know that it undermines democracy, and we know that it causes a population’s health to deteriorate, not only in poor countries, but also in the richest among nations.
For some decades, principles such as equity and fairness have been associated with a certain political approach. That may still be the case. They certainly figure prominently among the ideals of my social democratic political family.
But now research and other compelling evidence is showing how countries with greater equity – less difference between rich and poor – generally fare a lot better.
They make better use of human potential, they are able to build on and enhance social capital, and they are showing the way towards the most noble of all WHO objectives – health for all.
My point is this: sustainable development is increasingly a question of equity, of good governance and national priorities that protect all the citizens in a country and provide for their basic needs – health ranging prominently among them.
It is in this context that we also need a new perspective on research and innovation and access to life saving medicines. Market forces will not fix global equity “by magic”. I note that new, fresh ideas have been put forward. Let them inspire our sense of purpose and common resolve.
Central to any effort to combat inequity and enhance the potential of a population is the empowerment of women.
Again, in recent years, there has been growing evidence of the link between the empowerment of women and economic growth and development.
Extending educational and employment opportunities to women can improve the health and educational outcomes of entire families.
My country, Norway, is a prosperous country today. A hundred years ago, however, we were one of Europe’s poorest.
One of the main reasons for our progress is that we have succeeded in mobilising all our human resources and putting them to good use.
This has not come without a political struggle on the part of pioneers - and first among these are brave women. Today, we can look back and see that every time our country has enacted a major piece of legislation to empower women – from universal suffrage a century ago, to the universal availability of day care for children, and the requirement for 40 % of corporate boards to be made up of women just a few years ago – a long-term benefit to the economy has followed.
Three out of four women are employed in the formal labour market in Norway. This is one of the highest rates in the world.
Since the early 1970s, women have doubled the pool of human resources in the workforce. They have created new jobs and generated tax revenue, enabling us to continue to invest in welfare and opportunities for all. The same is true for the other Nordic countries.
I believe the key political lesson is this: strengthening women’s empowerment is a high-return investment in better health – for women themselves, yes, but also for their families and for society as a whole.
And just as this cause must be fought politically in every country, it must also be raised internationally – pointing to the evidence, and supporting effective advocacy.
This is why I have initiated, together with the World Bank, WHO, UN Women, the Bill and Melinda Gates Foundation and the medical journal The Lancet, a project to address gaps in our knowledge about the importance of investment in female health as a major driver of sustainable economic development.
I am particularly grateful that Dr Chan has agreed to take part in the reference group for this project together with the Executive Director of UN Women, Michele Bachelet. The outcome of the project will be presented in The Lancet in just over a year from now.
Ladies and gentlemen,
Let me conclude with a couple more reflections on the way ahead for global health.
The last decade stands out as a leap forward in global health, with remarkable achievements both in substance and method. We - who work outside the health sector - need to learn from these successes and find inspiration for new initiatives in other areas of development.
Between 2000 and 2010, a number of serious – and sometimes catastrophic – trends in global health were arrested and reversed.
AIDS, which a decade ago was out of control and threatening to devastate whole continents, is being managed through a remarkable demonstration of international solidarity and ingenuity.
Child mortality, which was around 12 million per year in the 1990s, has been reduced by more than a third thanks to improved vaccination rates, a dramatic improvement in malaria control and AIDS treatment and prevention.
In recent years, enhanced efforts to improve maternal mortality are having an impact on the ground. From barely budging for decades, the number of maternal deaths has shown a significant decrease in the past couple of years.
However, we cannot accept a world where close to 1000 women die every day in connection with childbirth.
We cannot accept a world where, in spite of substantial progress, 20 000 children die every day from preventable causes, and where – in poor countries – only one in four women gives birth with proper medical assistance, only one in three children with severe diarrhoea receives lifesaving fluids, and over 200 million women do not get the family planning help they need.
Again, this harms us as a human family. And it challenges our political decision making processes far beyond the health sector itself.
Today, we are calling for a massive effort to eliminate the tragic and preventable deaths that these statistics lead to. Because it can be done. This is not high-tech rocket science – it is low-tech human endeavour.
Over the last two years, we have seen an unprecedented increase in the focus on women and children, such as: the launch of the UN Secretary-General’s “Every Woman Every Child” initiative; the US Government’s Global Health Initiative, including “Saving Mothers Giving Life”; and President Obama’s Emergency Plan For AIDS Relief (PEPFAR). In addition, the UK and the Bill and Melinda Gates Foundation are planning a summit in July to address the gap in family planning, and UNICEF – together with various partners – is planning a high-level event on child health in June.
Today, Norwegian Prime Minister Jens Stoltenberg will chair the new UN Commission on Life-saving Commodities for Women and Children in New York, which will provide recommendations to all countries and stakeholders on how we can make such commodities available to all who need them by addressing trade and distribution problems.
Most of the progress we have seen in the past decade has quite simply been due to a significant increase in health investments.
In absolute terms, these increases have been modest – a single-digit billion dollar figure per year spread over nearly 150 countries.
But the fact that this has led to such a dramatic leap in terms of lives saved shows just how cost-effective health investments are.
We can achieve much more by investing wisely and maintaining focus on innovation. We need to tap into new opportunities, such as the widespread presence of mobile phones even in the poorest and most remote settings.
The progress of the past decade has created a tremendous momentum for positive change.
We cannot allow this momentum to be lost, particularly in these times of financial crisis, when public budgets are being cut.
As governments, we need to live up to our commitments to finance the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is emerging from a reorganisation process that will hopefully make it even more effective.
We need to maintain our support for GAVI, WHO and Unicef’s vaccination efforts.
We need to strengthen investments in the Secretary-General’s “Every Mother Every Child” initiative, with particular focus on the goal of no more children being born with HIV by 2015.
We need to strengthen and support a reformed WHO that can play an even more important role in the years to come in setting global health policy, and norms and standards for global health governance.
I can assure you that Norway will maintain its focus on global health, both as a funder and as an engaged partner. The Prime Minister is deeply committed, as are my colleagues the Minister of Health and Care Services – present here today – and the Minister of International Development, as well as many more, as this engagement cuts across many sectors. And in a few days, the Norwegian Parliament will debate the first ever white paper on global health.
The growth period in global health that emerged at the turn of the century was partly due to WHO’s ability to reach out. Yes, WHO is the lead agency in health; this is spelled out in its constitution. But leadership is not a birthright – it must be earned.
I believe WHO will preserve and enhance its pivotal role by continuing to reach out and build broader momentum for change.
It is in the field of health that we have seen – and must continue to see - initiatives for involving civil society, the private sector and research communities in decision-making and planning.
It is in the field of health that we have seen – and must continue to see - more cost-effective programmes based on measurable results and the mobilisation of new sources of financing.
The Global Fund, UNITAID, GAVI, and a large number of other public–private partnerships have bolstered efficiency, innovation and progress in health. Many more sectors can benefit from a closer study of lessons learned – positive as well as negative.
Against this backdrop of activity and innovation, it is still unclear how all this has affected the governance landscape of global health. It can seem chaotic at times. Who are the key players? And are they singing the same tune?
In order to get some clear answers to such questions, Norway has helped establish the independent academic Commission on Global Governance for Health. The aim of the Commission, announced last November, is to draw up a roadmap for the protection and promotion of health in the many global governance processes affecting health.
The University of Oslo, and the Harvard Global Health Institute, assisted by The Lancet, are leading this work. I am confident that the Commission’s report will be a catalyst for discussions and debates, and lay the foundation for a second stage of consultations and deliberations in international decision-making forums.
We are quickly approaching 2015, the target year for the Millennium Development Goals. The process of looking beyond 2015 is starting as ministers prepare to gather in Rio, 20 years after 1992.
We must ensure that health retains a central place on the post-2015 agenda. We look forward to working with Prime Minister Cameron who will chair the UN’s work on this important issue.
Ladies and gentlemen, fellow ministers,
I am honoured to be speaking to the World Health Assembly from this podium, and recall the meeting in 1998 when Dr Amartya Sen was the first external invited speaker to address the WHA. His message was crystal clear:
Health is crucial for development, not only for economic reasons, but also because improved health promotes freedom and quality of life.
He stressed how an informed public debate and the availability of democratic tools are crucial for a country to set the right priorities and ensure that sufficient resources are allocated to health.
We need to bear Dr Sen’s words in mind as we get to work to create a better, more equitable and healthier world.
This noble task cannot be confined to a single sector of politics. It needs the full mobilisation of us all.