International and Ecumenical Study Consultation Breklum, 25-30 September 2005

1. International and Ecumenical Study ConsultationBreklum, 25-30 September 2005 The overall health situation in the world Presentation by Louis J. Currat Former Executive Secretary Global Forum for Health Research

2. Outline • What are the main problems? • What are the main causes? • What are the resources to solve these problems? • Who are the actors in health and healing? • What are the objectives of the international community for 2015? • What would be the financial effort needed to reach these objectives? • Questions for any health or healing actor: my objectives? strategies? • How to select the right objectives and strategies? • A positive note: some major achievements of the past 50 years

3. 1. What are the main problems?

4. Burden of diseases(as % of total Healthy Life Years lost to diseases) 2002 2015 Infectious diseases+maternal/perinatal conditions 41.0% • Perinatal conditions 6.5% down • Pneumonia (ALRI) 6.1% down • HIV/AIDS 5.7% up • Diarrhoeal diseases 4.2 % down • Malaria 3.1% stable? • Tuberculosis 2.3 % stable? Non-communicable diseases 46.8% • Neuropsychiatric disorders (depression 4.2) 13.0% up • Cardiovascular diseases 9.9% up • Cancers 5.1% up Injuries 12.2% • Unintentional (road 2.6; falls 1.1; fires 0.8; drowning 0.7) 8.9% stable? • Intentional (self 1.4; violence 1.4; war 0.4) 3.3% stable? Total 100.0% Note: the total number of Healthy Life Years lost to diseases in the world in 2002 is estimated at 1’490 million years Source: For 2002 estimates: World Health Report 2004

5. Risk of becoming sickor injuredin low- and middle-income countries as compared to high-income countries • Communicable diseases, maternal and perinatal conditions 9:1 • Non-communicable diseases 1:1 • Injuries 2:1 Note: ratios are much worse for the poorer 20 % of people in each country! Source: Global Forum for Helath Research, 2004

6. 2. What are the main causes?

7. Proximate causes: selected risk factorsas % of total Healthy Life Years lost to diseases (1’490 million in 2002) • Malnutrition 15.8% • Water/sanitation 6.7% • Unsafe sex 3.7% • Alcohol 3.3% • Indoor air pollution 3.3% • Tobacco 3.1% • Occupational hazards 2.6% • Hypertension 1.5% • Physical inactivity 1.0% • Illicit drugs 0.5% • Outdoor air pollution 0.4%

8. Intermediate and Ultimate causes • Poorly functioning health services • Low education • Environmental risks • Bad governance • Internal/external conflicts • Violations of human rights • Laws are not applied fairly • Corruption is rampant • Poorly functioning Government institutions 5. Poverty

9. 3. What are the availablefinancial and human resourcesto solve these problems?And where are they?

10. Total health spending as % of GDP (2001) • USA 14.0 • Switzerland 11.0 • France 9.6 • Japan 8.0 • Chile 7.0 • Hungary 6.8 • Mexico 6.1 • China 5.5 • Russian Federation 5.4 • Morocco 5.1 • India 5.1 (OOP=75%) • Nigeria 3.4 • Indonesia 2.4 Observations: • The poorer the country, the less it spends on health as a proportion of GDP and the higher the out-of-pocket expenses (OOP) • The poorer populations in poor countries are hit twice: low expenditures on health by the Government and high out-of-pocket expenses  risk of falling into absolute poverty due to health expenses

11. Health spending per person by level of development HEALTH SPENDING PER YEAR PUBLIC DONORS PRIVATE TOTAL Least Developed Countries 6.0 2.3 2.7 11.0 Other Low-Income Countries 13.0 0.9 11.1 25.0 Lower Middle-Income 51.0 0.6 41.4 93.0 Upper Middle-Income 125.0 1.1 114.9 241.0 High-Income Countries 1356.0 0.0 551.0 1907.0 ISSUES: • MINIMUM NEEDED TO COVER ESSENTIAL INTERVENTIONS: $40/PERSON/YEAR (2001 Commission on Macroeconomics and Health) • THESE ARE AVERAGES; THE POOR DO NOT REACH THESE AVERAGES IN ANY CATEGORY OF COUNTRY

12. The human resource crisis in Africa Density of health workers (per 1’000 persons) • Europe and North America 10.0 • Western Pacific 9.0 • Middle East 7.0 • South America 3.0 • Asia 2.8 • Africa 0.8 Projection of health work force in Africa (2000-2015) 20002015 • Nurses and midwives 280’000 190’000 • Physicians 90’000 60’000 Source: High-level Forum on the Health MDGs, Abuja, 2004

13. 4. Who are the actors in health and healing? (see separately distributed sheet)

14. 5. Confronted with these problems, what are the Objectives of theinternational community for the coming years?

15. Objectives of the international community for 2015:«Millennium Development Goals » Goal 1: Eradicate extreme poverty and hunger - Reduce by half the proportion of people living on less than $1/day - Reduce by half the proportion of people who suffer from hunger Goal 2: Achieve universal primary education Goal 3: Eliminate gender disparity in primary and secondary schools Goal 4: Reduce by two-thirds mortality rate for children under 5 Goal 5: Reduce by three-quarters the maternal mortality ratio. Goal 6: Halt and begin to reverse the spread of HIV/AIDS, malaria and other major diseases Goal 7: Ensure environmental sustainability - Reverse the loss of environmental resources - Reduce by half the proportion of people without safe drinking water - Achieve significant improvements for at least 100 million slum dwellers Goal 8: Develop a global partnership for development - Trade, debt, development assistance, work for youths, access to affordable essential drugs, IT Note: the health MDGs are marked in red!

16. Do the MDGs cover all problems? MDGs represent a tremendous achievement, but there is general consensus that 3 more objectives should be added: • Non-communicable diseases (mental health, cardio-vascular diseases, cancer, etc.) • Violence and injuries • Reaching the objectives may represent only an improvement for the lower-middle class and not improve the situation of the absolute poor

17. 6. What would be the financial effort neededto reach these objectives?

18. Financial effort needed2001 WHO Commission on Macro-economics and Health(in billions of US$) Country financing 2001 2007 2015 • Least developed countries 7.0 11.0 16.0 • Other low-income 43.062.074.0 Total 50.073.090.0 Donor assistance to countries • To least developed 1.5 14.0 21.0 • To other low-income 2.0 6.0 8.0 • To middle-income 2.0 2.0 2.0 • For research and GPGs 1.55.07.0 Total 7.027.038.0

19. How to convince Ministries of Finance and foreign aid donors to invest more in health? (1) Bad health is very costly for the economy as a whole! • Irrecoverable losses in production due to absence of sick labour and relatives called upon to help the sick • Less well trained labour force • Loss of human and financial resources used to treat the sick • Higher labour force turnover and lower productivity in general • Less competitive economy • Lower profitability of enterprises • Lower tax revenues • In the long run, lower survival rates of less competitive enterprises • Lower attraction for foreign investments • Lower rate of growth and higher unemployment

20. How to convince Ministries of Finance and foreign aid donors to invest more in health? (2) Bad health increases poverty and social imbalance! • Disease of one member means an increase in malnutrition as a result of additional spending on treatment • Malnutrition increases the risk of unemployment • An already poor housing situation risks further deterioration • Opportunities for education and training are missed • Already low productivity of family decreases further • Access to health care, drinking water and social services become more precarious as a result of lower revenues and education • Poorer families tend to have more children (form of insurance) • Elevated risk of unwanted pregnancies • Sale of assets for survival and further economic deterioration • Increase in the powerlessness of the family

21. How to convince Ministries of Finance and foreign aid donors to invest more in health? (3) A few examples of rates of return! • Smallpox 1950: 5 mios deaths, 1 mio blind, 10 mios disfigured. Economic benefit of vaccination programme: $10 for every $1 invested. • Polio 1960: 500’000 permanently paralyzed/year. Result of Global Polio Eradication Initiative: 700 cases in 2003. Eradication expected: 2008. Return: several $ for every $ invested. • River blindness (itching, disfigurement, blindness): Control Program costs $1/person/year, covering 60 million people in 19 Sahelian countries. Prevented 600’000 cases of blindness and opened 25 mios ha. land which can feed 17 mios people. • Malaria: 300 mios cases/year and more than 1 mio deaths. Estimated loss of $12 bio/year for African economies. • HIV/AIDS: total of 60 mios cases, of which 20 mios have died. Five mios new cases/year. Cost of treatment: $500-1000/patient/year. Condoms cost $14/person/year. • Antibiotics for pneumonia are 90% effective and cost $ 0.12 per dose.

22. 7. Questions for any health or healing actor • What should ‘my’ objectives be (to have the greatest impact)? • What should ‘my’ strategies be (to have the greatest impact)? Note: An objective defines‘what’ has to be achieved. A strategy defines ‘how’ an objective is to be achieved Strategies are avenues, channels, ways or methods for reaching a specific objective. A strategy includes several ‘activities’.

23. What should ‘my’ objectives be? Decrease the burden of specific diseases? Perinatal/maternal conditions? Pneumonia? HIV/AIDS? Malaria? TB? Mental Health? Cardiovascular diseases? Cancers? Violence? • Decrease specific risk factors? Malnutrition? Water/sanitation? Unsafe sex? Alcohol? Tobacco? Illicit drug? Pollution? • Improve the functioning of health systems across the board of all diseases? • Improve the educational system? • Improve bad governance? Contribute to peace initiatives? To protecting human rights? To decreasing corruption? To upholding the rule of law? To more efficient and effective government institutions? • Focus on the specific health problems of the absolute poor? • Other objectives?

24. What should ‘my’ strategies beto reach these objectives? • Do advocacy work (conferences, publications) in support of these objectives? • Launch initiatives in support of specific objectives? • Join existing initiatives in support of specific objectives? • Engage in training of key personnel? • Help mobilize financial resources for institutions pursuing these objectives? • Be the Secretariat for a network of institutions pursuing these objectives? • Support the system of drug purchase and distribution? • Support the system of medical supplies and equipment? • Contribute to research work under these objectives and distributing its results? • Concentrate on a few countries particularly affected? • Other strategies?

25. 8. How to select the ‘right’ objectives and strategies?(among the almost infinite number of possible objectives and strategies)

26. How to select the ‘right’ objectives and strategies? • Identify the specific skills, knowledge, capacities of the WCC and each one of its member institutions, i.e. their ‘assets’. • Identify the objectives and strategies which correspond best to these assets, i.e. where it is estimated that the institution can have the largest impact possible. • The central idea is to gain as many healthy life-years as possible with the given (always limited) resources available (concept of cost-effectiveness: greatest impact for the given resources). • Importance of measuring results, i.e. using measurable indicators of performance. • Attempting to do everything is likely to mean dispersion of effort and little result. • Look for the best alliances/partnerships within and outside the institution. • Given the fact that each institution is differently endowed (different ‘assets’), their objectives and strategies are likely to be different, although within the same overall mission of the institution.

27. Need for international cooperationto solve world health problems • The magnitude of the problems • The efficiency argument • The interdisciplinarity argument • The synergy argument • The global public goods argument

28. 9. A positive note: Some major achievements of the past 50 years in international health cooperation

29. Some major achievements of past 50 yearsin international health cooperation • 1950: launch of systematic effort against cholera, plague, smallpox, typhus, yellow fever with considerably increased means • 1960: start of major international cooperation efforts in the field of technical assistance • 1974: launch of the Expanded Programme of Immunization (diphteria, pertussis, tetanus, measles, polio, TB, smallpox) • 1978: Alma Ata Conference promoting Primary Health Care and ‘Health for All by 2000’ • 1979: eradication of smallpox • 1988: launch of the programme for eradication of polio • 2002: launch of the Global Fund to Fight Aids, TB and Malaria • 2004: Tobacco Convention • ….. Hundreds of examples more….

30. Example of international cooperation:Tobacco Convention (1) • 4.9 million tobacco-related deaths/year (out of a total of 57 million deaths/year). No other consumer product kills as many people. Out of 1.3 billion smokers, half will die of tobacco-related causes. • Smoking: men 48%; women 10%; passive: 50% of children. • Idea for an international instrument for tobacco control was initiated in May 1995 at the World Health Assembly. • In May 2003… 192 States of the World Health Assembly unanimously adopted the world’s FIRST public health treaty WHO Framework Convention on Tobacco Control.

31. Example of international cooperation:Tobacco Convention (2) • The treaty requires countries to ban tobacco advertising, enforce labelling (30% of surface), protect from passive smoking, and prevent smuggling. • The treaty came into force (ratification by 40 countries minimum) in February 2005. • Today, 57 countries have ratified, representing 2.3 billion people. • The next step is now for each country to translate it into national laws (within a three-year period). • Governing body: Conference of the Parties (all countries that have ratified the Convention)

32. Health:Moving closer to the center of the development agenda • 1960s: basic infrastructure project (electricity, transport, telecommunications) • 1970s: + agriculture, industry, financial sector • 1980s: + global economic policies, education, health, social safety nets, fight against poverty  shift from focus on physical capital to a greater emphasis on human capital • 1990s: UNDP Human Development Index (health, education, standard of living) to be compared with GNP/capita • 1990s: concept of good governance (peace, basic human rights, strong civil society, rule of law, control corruption, effective management of public affairs)

33. The score on healthMDGs at half-time (1990-2002) • Goal 1 (target 2): Reduce hunger by half: Africa (35%33%); South Asia (25%22%); East Asia (16%11%) • Goal 4: Reduce by 2/3 child mortality: 11 mios children per year die under-5. Reduction has taken place in South Asia (126/100093). But in 16 countries (14 in Africa), under-5 mortality is higher than in 1990 (180/1000). • Goal 5: Reduce by ¾ maternal mortality: 500’000 women die every year in pregnancy or childbirth; death rate 1000 times higher in Africa than in high-income countries. • Goal 6: Begin to reverse HIV/AIDS, malaria and TB: some success stories. But HIV/AIDS has reversed life expectancy and economic gains in parts of Africa. • Goal 7 (target 10): reduce by half the proportion of people without access to safe water and sanitation: almost on target except in Africa. • Goal 8 (target 17): access to afordable essential drugs: very little progress. BUT CRUCIAL: movement and measurement have started!