By Kul C. Gautam
Deputy Executive Director, UNICEF
At Tulane University School of Public Health and Tropical Medicine
New Orleans, 25 November 2002
It is a great privilege to have been invited by this great institution of international health and development to deliver a lecture dedicated to the memory of a distinguished New Orleanian and my former boss and mentor, Harry Labouisse.
Labouisse was a great leader who, among his many acts of public service, helped pioneer a vision of how the benefits of modern medicine and public health could be brought to the doorsteps of even the poorest families of the poorest countries in the world.
Transforming “health for some” into “Health for All” was the vision of the primary health care movement launched at Alma Ata, Kazakhstan, in 1978. Along with the World Health Organization, UNICEF under Labouisse’s leadership became a driving force behind this movement.
All of us working in the field of international health and development are immensely grateful that the School of Public Health, and especially the Department of International Health and Development here at Tulane University, has been a training ground for so many leaders who have promoted PHC ever since the inception of that concept, and even before.
I want to pay a special tribute to the outstanding faculty and students of this great school who have fanned out across the world to promote the cause of “Health for All”.
Over the years, UNICEF has been a proud partner and a beneficiary of the talent and commitment cultivated for international public health here at Tulane.
The Seeds of a Child Survival and Development Revolution
The concept of primary health care as articulated in the Alma Ata Declaration 24 years ago is as relevant today as it was then. While the language might be more quantitative today, the priority considerations of modern public health were well reflected in the Declaration:
Maximising health outcomes and impact
Fostering national and local ownership and participatory development
Setting priorities based on burden of disease, cost-effectiveness, affordability and sustainability
Favouring universal coverage of an essential package of cost-effective interventions which build national capacity and contribute to sustainable health systems.
This philosophy of primary health care so passiontely advocated by Harry Labouisse was given a great boost by his successor at UNICEF, James P. Grant. Some of you might recall that like Labouisse, Grant was a recipient of an honorary degree at Tulane, and a frequent visitor to this campus.
Under Grant’s leadership, PHC got new traction as he promoted what amounted to a virtual Child Survival and Development Revolution as the cutting edge of the Health for All movement.
Though meant to be multi-sectoral, in the early years after Alma Ata, primary health care was generally seen as a health sector concern. What the Child Survival and Development Revolution did in the 1980s, was to put health issues firmly onto the world’s political and social agenda, cultivating ownership by mayors and governors, parliamentarians and civil society activists, the media and the academia, for the health and well-being of children.
Two major killers, diarrhoea and vaccine-preventable diseases were targeted to demonstrate that dramatic progress could be made to promote child survival. Millions of lives were saved with the low-cost and high-impact techniques of oral rehydration therapy and childhood immunization.
These interventions applied and elevated the concept of social mobilization as a powerful tool to promote health. I am happy to acknowledge that Tulane’s School of Public Health is one of the leading institutions in this field in the world.
Inverting the “Health for All” motto to “ALL for Health”, the child survival and development revolution saw everyone, from film stars to schoolteachers, heads of religious organizations to heads of states, actively involved in promoting ORT, immunization and other health and nutrition interventions.
Inspired by the success of the child survival revolution of the 1980s, UNICEF helped convene the World Summit for Children in 1990. This Summit, the largest gathering of world leaders until that time, adopted an ambitious agenda for further promoting child survival and development with relatively low-cost and high impact public health and nutrition actions at its core.
It is said that true leadership rallies different people to work together towards achieving common goals with clear time-bound targets. It was in that spirit that the World Summit for Children introduced the concept of universally agreed goals for the decade of the 1990s.
This simple concept of focusing on time-bound results has had profound influence on our modern development thinking. Through successive major international conferences and summits of the 1990s, as never before in the history of humankind, the international community has come to agreement on a common development agenda with clear goals and targets.
This goal-oriented approach to public health and development was a powerful complement to actions required to achieve the human rights standards and principles set by the Convention on the Rights of the Child, that also came into being just before the Summit.
The Convention, which quickly became the most universally ratified human rights treaty in the world, codifies children’s right to survival (Article 6), to basic education (Article 28) and to health care, nutrition and sanitation (Article 24).
It is now widely recognised that each child has the right to an essential package of health interventions. Programmatically, this translates into moving as quickly as possible towards universal coverage, a fundamental public health concept.
It is often said that in many UN conferences, goals are ever set but never met. That commitments on paper are rarely translated into action on the ground.
The systematic follow-up and monitoring that ensued the World Summit for Children, culminating in an end-decade review documented in this publication, We the Children, allows us to objectively assess the achievements and setbacks and the lessons learned for the future.
Predictably, the picture that emerges is one of mixed results. There has been real and significant progress in a number of areas – perhaps much more than people tend to acknowledge in a world fraught with cynicism and skepticism. But there has also been setback, and in some cases, real retrogression.
On balance, there has been net progress, and a good foundation has been laid for accelerating further progress in the coming decade to complete the unfinished agenda of the Summit for Children and to tackle some emerging issues that imperil the wellbeing of children in the 21st century.
On the positive side of the ledger, although total world population in 2000 was some 800 million higher than in 1990, 13 million fewer children were born and 4 million fewer children died at the end of the decade compared to the beginning. This is a remarkable testimony to the continuing progress in child survival and family planning.
Some 63 countries fully achieved the Summit goal of one-third reduction in under-five mortality, and over 100 achieved a reduction of one-fifth during the decade.
Diarrhoeal diseases, the number one cause of U5MR in 1990, was downgraded to number two at mid-decade. The goal of reducing diarrhoeal deaths by 50 per cent during the decade was achieved, saving the lives of 1.5 million children anually.
Vaccine-preventable child deaths were also reduced by a similar magnitude, thanks to the sustainability of immunization at a high level in most regions of the world.
Polio is on the verge of eradication, with 99 per cent reduction in the number of reported polio cases in the world this year compared to a decade ago.
After decades of precipitous decline, the time-honoured, life-sustaining practice of breastfeeding increased by a third in the 1990s.
There was dramatic progress in tackling the world’s major cause of mental retardation – iodine deficiency disorders – with 1.5 billion additional people having access to iodized salt, protecting 90 million new-borns world-wide from a significant loss in their learning ability.
As indicated earlier, there has been major progress in family planning. Today two-thirds of couples in developing countries are using modern contraception compared to barely 10 percent four decades ago, and total fertility rate has been halved from 6 to 3.
Regrettably, this progress has been uneven. And the poorest region of the world, Sub-Saharan Africa, has experienced considerable retrogression, as did most of the former communist countries of central and eastern Europe and central Asia.
Quite a few of the Summit for Children goals remain unachieved. Over 10 million children still die each year, mostly from readily preventable causes. 150 million children are malnourished. 120 million children are still out of school, a significant majority of them girls.
HIV/AIDS has grown into a catastrophic pandemic in several parts of the world in the 1990s. It is unraveling decades of positive progress in child survival and development in large swathes of sub-Saharan Africa, and is spreading like wildfire in other regions.
In many societies, HIV/AIDS is destroying the very people and institutions that are needed if there is to be sustainable development – or any development at all. In the most affected countries, up to 25 per cent of young people are HIV-positive. Last year alone an estimated 800,000 children worldwide were infected during birth or breastfeeding – 90 per cent of them in sub-Saharan Africa.
In an unprecedented reversal, the young generation of many countries in Africa today can expect to live a shorter life than their parents or grand-parents.
A dramatic illustration of the impact of HIV/AIDS unfolding right before our eyes is the food crisis that is engulfing southern Africa today. While drought is the apparent reason for this crisis, our assessment is that the gravity of the situation is attributable to the devastation caused by HIV/AIDS in people’s health, educaction and productivity.
The Summit for Children in 1990 was held at the time of the end of the cold war, amid high hopes for a peaceful world, where we hoped resources previously squandered in military expenditures might be available for development purposes. Unfortunately the decade since the Summit witnessed unprecedented levels of ethnic conflicts and civil wars, in which children and women have become either direct targets or collateral victims.
Perhaps more children have beome victims of armed conflicts and violence during the past decade than at any comparable period in history.
The increasing number and intensity of conflicts in the world is severely undermining children’s health and security. As stated by Graca Machel in her report, the Impact of Armed Conflict on Children, “conflict is a major public health hazard that cannot be ignored. Any disease that caused as much large scale damage to children would long ago have attracted the urgent attention of public health specialists. When armed conflict kills and maims more children than soldiers, the health sector has a special obligation to speak out.”
In the face of growing poverty and inequity, certain trends of modern life, which in themselves can have benefits to societies and peoples, such as greater mobility, migration and urbanization, and have led to spread of diseases, and environmental hazards.
On the whole, if the goals of the World Summit for Children remain under-achieved, it is not because they were too ambitious, or were technically not feasible. It is largely because of insufficient investment.
With a few honourable exceptions, throughout the 1990s developing countries invested only 12-14 per cent of their national budgets, and donors allocated even less, only 10-11 per cent, of their declining aid budgets, for basic social services. These investments fell far short of the internationally agreed norm of 20/20 (i.e. that developing countries should allocate 20 percent of their national budgets and donors should allocate 20 per cent of their aid allocations) considered essential minimum to meet the most pressing needs of children to have aceess to primary health care, nutrition, basic education and sanitation.
In the larger scheme of things, the resources needed to provide for the basic needs of children are modest and affordable. With modest amounts of external support, even the poorest countries of the world would be in a position to afford basic social services.
The missing ingredient often is not resources but lack of vision, unwise priorities and commitment of leadership.
It is to summon such vision, commitment and leadership for the world’s children that the United Nations convened a new set of Summits in the past two years, in particular the historic Millennium Summit in 2000 and the Special Session on Children of the UN General Assembly in 2002.
The Millennium Summit and the UN Special Session on Children
The United Nations Millennium Summit in September 2000, which brought together the largest assembly of world leaders in history, agreed on a set of development goals, with measurable targets to be reached by the year 2015.
Many of the Millennium Development Goals are health-related and progress in health will be an essential precondition for their achievement.
The following are the 8 Millennium Development Goals:
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal heatlh
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
The specific targets and indicators for measuring progress towards the MDGs relate heavily to interventions in health, nutrition, safe drinking water and sanitation.
These goals and targets have been further elaborated in the outcome of the UN General Assembly’ Special Session on Children held in May 2002.
The UN Special Session on Children set out to formulate an ambitious agenda, aptly entitled “A World Fit for Children”. Like its predecessor, the World Summit for Children, the Special Session outlines what we hope will be the world’s agenda for child health and development for this decade and beyond.
The Major Health-related Goals of the WFFC
Promoting healthy lives is central to creating “A World Fit for Children”. And the Special Session on Children has adopted many very specific health and nutrition related goals to be achieved by the end of this decade.
I will not recite all those goals which you can find in this little booklet (World Fit for Children), and in the UNICEF website. Let me just mention a few for illustrative purposes:
• Reduce infant and under-five mortality by at least one third from 2000 to 2010 (and by 2/3 from 1990 to 2015)
• Reduce maternal mortality ratio by at least one third from 2000 to 2010 (and by 3/4 from 1990 to 2015)
• Reduce under-five child malnutrition by at least one third from 2000 to 2010, with special attention to children under two and reduce the rate of low-birth weight by at least one third by 2010
• Reduce proportion of households without access to hygienic sanitation facilities and affordable and safe water by at least one third from 2000 to 2010
• Access through the primary health-care system to reproductive health for all individuals of appropriate ages as soon as possible and no later than 2015
• Reduce by 2005 HIV prevalence among young men and women age 15 to 24 in the most affected countries by 25 per cent and by 25 percent globally by 2010
• By 2005, reduce the proportion of infants infected by HIV by 20%, and by 50% by 2010
To achieve these major goals, A World Fit for Children goes on to mention key strategies and actions needed. If we take immunisation for example:
• By 2010, we would aspire to ensure full immunization of at least 90% of children nationally with at least 80% coverage in every district
• Certify by 2005 the global eradication of polio
• Reduce deaths due to measles by half by 2005
• Eliminate maternal and neonatal tetanus by 2005
• Extend the benefits of new and improved vaccines to children in all countries.
Incidentally, the recent World Summit on Sustainable Development in Johannesburg has reaffirmed all the key goals contained in the World Fit for Children, giving these the strong political imprimatur of the world’s highest leadership.
The World Fit for Children also contains mortality and morbidity reduction targets for such major childhood killer diseases as diarrhoea, pneumonia, and malaria, and for nutrition interventions including promotion of breastfeeding and combating micronutrient malnutrition, such as the virtual elimination of iodine deficiency disorders by 2005.
While the MDGs and the goals of the WFFC are ambitious, we believe that they are achievable. However, the experience of the past decade makes it amply self-evident that with business as usual, we will not reach these goals.
I foresee 5 major challenges ahead, if these goals are to be achieved:
-The Challenge of mobilizing “All for Health”
-The Challenge of Global Interdependence
-The Challenge of Going to Scale
-The Chllenge of Mobilizing Resources, and
-The Challenge of Leadership
Let me share with you some of the specifics under each of these 5 challenges:
1. The Challenge of Mobilising “All for Health”
It is often said that health is too important to be left entirely to the care of medical professionals. Of course, we all need and value enormously the expert advice and treatment by dedicated physicians. But each one of us, no matter what our profession, ought to take greater responsibility for our own health and the health and wellbeing of our loved ones.
Health establishments, whether hospitals, clinics or Ministries of Health, all play an important role in combating diseases and promoting health. But their effectiveness is greatly enhanced if they can mobilise support from sectors outside health.
In her address to the World Health Assembly a few months ago, my boss, the Executive Director of UNICEF, Carol Bellamy called upon all Ministers of Health to become Ministers of Health Outcomes. This is an important point. The high burden of disease in the world’s poorest countries coupled with severe resource constraints of ministries of health means that while the health sector can and must be strengthened, achievement of better health for the vast majority of the world’s poor cannot be left to the health sector alone.
From the point of view of child health, the number one health worker is the mother. The more we can do to empower her with basic knowledge, information and skills in good infant feeding practices, care and stimulation of the young child, hygiene and sanitation, better birth spacing, etc. the better the health outcomes of her child. Good maternal health and nutrition too are, of course, of paramount importance.
One of the best ways to promote this is actually through action in the education sector. As we know, girls’ education is probably the most effective of all health interventions. An educated girl marries later. She can better protect herself from diseases, including HIV/AIDS. She has reduced fertility, lower infant and maternal mortality. Her children are likely to be better nourished and healthier. They are more likely to go to school and perform better. And as they become adults, they help break the intergenerational cycle of ill health and poverty.
Teachers are another group of potential health workers that we tend to underestimate. Most children spend many years as a captive audience of their teachers. If teachers, especially at primary and pre-primary level were better informed about psycho-social stimulation and development of children, if they had the basic knowledge of nutrition, hygiene and sanitation, and if they were empowered to impart such knowledge to their students, they could make an enormous contribution in bringing about good health outcomes.
Alas, at present most schools in developing countries tend to be breeding grounds for sicknesses and malnutrition. Millions of school age children are infected by worms and parasites, which leads to malnutrition, anaemia and retards their physical development and learning capacity. Lack of safe water, and sanitary facilities in schools is a major impediment to good learning outcomes in schools, particularly for girls.
That is why UNICEF’s key message at the World Summit on Sustainable development in Johannesburg was this: that in the course of this decade, every primary school in the world should be equipped with separate sanitary facilities for girls and boys – and should have a source of clean and safe drinking water. That would be a major contribution for both education and health outcomes.
In partnership with WHO and many other organisations UNICEF has produced this little booklet called “Facts for Life”. It has now been published in 215 languages and over 15 million copies are in use worldwide. Containing advice on safe motherhood and breastfeeding, child development and nutrition, diarrhoea and malaria, HIV/AIDS and prevention of injuries, it is a primer for health promotion aimed at ordinary people – parents, teachers, health workers and community leaders. We believe that if fully utilised, the messages contained in this little booklet could do more to promote public health than all the hospitals in the world.
It is said that the greatest reductions in infant and child mortality in the 19th century in Europe were attributable, not to medical breakthroughs but to dramatic progress in potable water and sanitation. Water and sanitation in many countries are not in the domain of ministries of health, but those of ministries of public works. An effective public works department can therefore be a very good contributor to good health.
Similarly, in most countries, nutrition is in the domain of ministries of agriculture. And effective working of the agriculture sector can therefore be of great significance to health outcomes.
And in today’s world, mass media and communication can be a great provider of good health information or a promoter of unhealthy life-styles. The communications media, both public and private, can therefore be the greatest ally of ministries of health in their mission of health promotion.
Indeed, if we look at the great success stories of health improvement in recent decades, from the campaigns to eradicate smallpox and polio, to promotion of oral rehydration therapy against diarrhoeal diseases, salt iodisation against iodine deficiency disorders and the good examples of HIV/AIDS prevention work in Uganda and Thailand – and recently in Cambodia and Senegal – the key to great success has been action by other sectors, complementing that of the health sector.
As we pursue the millennium development goals and look forward to the next wave of revolution in health outcomes, I have no doubt that effective inter-sectoral collaboration will be the key to the kingdom of better health in the 21st century.
2. The Challenge of Global Interdependence:
We cannot be healthy in an unhealthy world. Unlike people, diseases do not need a passport or visa to travel. No amount of border controls in today’s world can effectively seal a country from the stealthy, unannounced transmission of diseases.
Epidemiological surveillance at the international level, analysis of global health trends, dissemination of international best practices in disease control and health systems, and technical cooperation among countries to combat diseases and to promote health must therefore be considered global public goods.
Campaigns to eradicate or eliminate diseases such as smallpox, polio, guinea worm disease, etc. are the classic examples of global public goods with mutual advantages for all parties concerned. But the same can be said, even more so, for HIV/AIDS, tuberculosis, malaria and myriad other diseases.
In fact, efforts to give priority to combating or eradicating certain diseases can only be justified if they are considered global public goods.
Let us take the example of polio. The number of cases of polio has dwindled to such level now that it would seem cost-ineffective for a country that is severely strapped for resources to continue to invest in polio, instead of, say, malaria or pneumonia, which affect far more people and cause far more damage to its economy.
Yet, eradication of polio is one of our cherished global goals, that merits high priority as a matter of international solidarity.
Eradication of polio benefits not just the poor, polio-endemic countries of the South, but it benefits all countries, including the rich industrialized countries of the North. Although the rich countries have been polio free for many years, at present they have to spend hundreds of millions of dollars every year to vaccinate their children, because until polio is eradicated everywhere, children are not safe anywhere.
But once polio is eradicated, the world will save $1.5 billion every year. The United States alone will save $350 million. Europe and other industrialized countries will save $500 million, and the rest of the world will save $650 million per year. And these gains will keep accruing for many years to come.
Thus investment in programmes like polio eradication, and other health, education and environmental measures can truly be a win-win proposition for all.
3. The Challenge of Going to Scale:
The health development map of the world is littered with small scale pilot studies and demonstration projects. While some of these are useful for innovation and replication, others tend to be of greater interest and benefit to researchers, donors and their local counterparts than to the intended benficiaries.
To be really useful, development programmes should attempt to take action on a scale commensurate with the problems that they are trying to tackle.
For most of the major causes of mortality and morbidity affecting children and women in developing countries, we do have proven, cost-effective interventions. The challenge is to take such interventions to scale.
Tonight only one percent of African children will sleep under a treated mosquito bednet which costs less than $4 and can provide significant protection against malaria.
Half of Africa’s children do not receive routine childhood immunizations that are cheap and widely known to public health officials.
Two thousand children in the world will die today – and three-quarters of a million this year – from measles, because they have not received the readily available vaccination against it.
And 4,000 children will die today – and 1.5 million during the course of this year – from simple diarrhoea because of lack of access to oral rehydration salts costing less than a quarter.
Examples abound of low-cost and high impact interventions crying out to be taken to scale.
We already have globally approved goals and targets and agreed strategies and actions. Scaling-up will require simple and focused plans, strong partnerships, competent and motivated human resources, essential supplies, strong monitoring and evaluation, and sufficient funds.
4. The Challenge of Finance:
The WHO Commission on Macroeconomics and Health, led by Professor Jeffrey Sachs estimates that the financial resources required for a set of essential interventions against infectious diseases and nutritional deficiencies that could potentially save 8 million lives per year in low income countries would cost around $34 per person per year.
The Commission estimates that the magnitude of additional resources needed from donors for country programmes, research and development for the poor and for the provision of some of the global public goods would be of the order of $27 billion a year by 2007 and $38 billion a year by 2015.
This would amount to an increase in donor country ODA of about 0.1 per cent of their GNP. As the average total ODA now stands at only 0.22 percent of donor countries’ GNP in 2000, well below the agreed international target of 0.7 per cent of GNP, a 0.1 per cent increase in ODA for health is eminently feasible, leaving ample room for growth in other sectors such as basic education.
In fact, 4 countries, all European, currently exceed the recommended 0.7 percent of their GNP for ODA. This demonstrates that development aid of such magnitude is entirely feasible if the world’s richest countries were to fulfil the already agreed aid targets.