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Speech

15 June 2006

Hilary Benn, Secretary of State for International Development

London School of Hygiene and Tropical Medicine

Meeting our promises in poor countries

Preamble

The Secretary of State spoke on a panel with Francisco Songane, the Director of the Partnership for Maternal, Neonatal and Child Health and ex-Minister of Health from Mozambique, and Fareed Abdullah, Director of Technical Support at the International HIV/AIDS Alliance, and representing the STOP AIDS campaign group and the UK NGO AIDS Consortium. The discussion was chaired by Andy Haines, Director of the London School of Hygiene and Tropical Medicine.

The Secretary of State later said

I’m very pleased to be able to speak here today at the London School of Hygiene and Tropical Medicine which has been a world leader for over a hundred years. And pleased too, to launch our new progress report on maternal health. I’m looking forward to hearing your views today, and those of my two friends here, Francisco and Fareed.

We all know that good health and education are the foundations upon which people can realise their hopes, make the most of their lives, and fulfil their true potential.

And we are seeing some success.

We have eradicated smallpox – I remember from the last time I was here – the plaque on the right that commemorates the eradication of smallpox, and polio is likely to follow in the near future. We have seen real progress in reducing the impact of many of the previously neglected tropical diseases – Leprosy, Lymphatic Filariasis, river blindness, guinea worm.

Over the past five years we have made huge efforts on AIDS, TB and Malaria, and on childhood immunisation. We are seeing child mortality falling in countries like Tanzania, Malawi, Ethiopia, and Mozambique.

And last year - during that extraordinary 2005 - Europe and the G8 agreed to $50 billion a year in new aid by 2010 – with half going to Africa. They agreed debt relief worth up to $50 billion, and the 1st nineteen countries are in the process of having this delivered. They agreed to support free basic healthcare; universal AIDS treatment. And I think it is a great shame that some still find it difficult or embarrassing to talk about HIV – how you get it, and how you can prevent it. Which is terrible, because embarrassment is temporary, while death is permanent. And an International Finance Facility for Immunisation was launched which will help us save 5 million lives over the next decade.

Now, while I see much that is positive, I also believe we have failed to deliver in many other critical areas. You all deal with these stark realities each day so forgive me if I am preaching to the converted.

In the developing world, pregnancy and childbirth kill a woman every minute – they die with no trained midwife or doctor to help. It’s an absolute outrage.

Four million children die each year in their first month of their short life. And half of all child deaths are the result of malnutrition.

Dirty water and inadequate sanitation kill 6,000 children each and every day.

Each year, every year, malaria kills one million people, tuberculosis 2 million people, AIDS 3 million people.

In all of this it is the poorest and most vulnerable who suffer most.

The real tragedy is that we have failed millions of people, not because we don’t know what to do, but because we haven’t done enough.

We clearly need to do much more, much faster, and in the countries that need it most, including those seen as fragile states – states where things do not work well or who are in or out of conflict. It is a very tall order

So what do I think needs to be done? I would like to highlight five key issues:

Let me start with Healthcare

We – developed and developing countries - have failed to invest enough in healthcare in poor countries.

In short, providing trained staff in the right place, equipped with the means to do the job, backed by reliable drug supplies, and led and supported by decent management. We have not made best use of communities in improving health, nor have we done enough to make sure we can properly monitor and improve performance, and above all to ensure there is accountability. Because if there is accountability then if you are not getting a decent service then people will have the chance to ask “…what are you going to do about it?”

This does not mean that governments need to provide all services. In much of Africa faith based organisations typically provide a third of care. In India 80% of out-patient treatment is provided through the private sector. So we need to do more to ensure that good regulation improves the quality of service.

Building better healthcare is a long term effort and there are obvious attractions in just dealing with elements of it; but not the whole.

I do believe the only way we can end all preventable deaths and the suffering of millions is to provide decent health care to all.

None of this should be hard. We ought to have the resources. We know what to do.

As the World Bank has pointed out, the Millennium Development Goals for health could be achieved if we ensured people had universal access to things that we know are possible – it isn’t a pipe dream, and which, in the most part, are very simple:

  • Clean water and sanitation;
  • Family planning;
  • Condoms to prevent HIV & STIs
  • A trained midwife and safe delivery;
  • Breast-feeding;
  • Childhood vaccination;
  • Mosquito nets;
  • Antibiotics for pneumonia;
  • Effective anti-malarial, TB and AIDS drugs, and of course
  • Better access to health information

And if everybody had these, then we would see a very powerful transformation for poor people.

Central to all of this is trained staff. This is perhaps the greatest barrier of all to making progress. In Zambia, a country of over 11 million, two thirds of places for nurses and doctors lie vacant. So now in Zambia, one third of all rural health facilities are run by unqualified staff. And well funded AIDS programmes pull away some of the staff that remain.

If we don’t do something, this crisis will only grow. Worldwide 4 million additional health workers are urgently needed, with over 1 million in Africa.

Imaginative approaches are being tried. Pakistan has almost reached its target of 100,000 Lady Health Workers to bring healthcare to the doorstep. And I met a group of these women when I visited Pakistan a few years ago who were doing a remarkable job. But 80% of women still give birth with no skilled attendant.

In Malawi we are helping with a £100 million emergency programme over 6 years, part of which aims to double the number of nurses and triple the number of doctors, provide better training, and pay them better. This support is already making a difference. But we need to see this in almost 60 countries.

And we need to pay more attention to fragile states, without which we won’t meet our promises on health. Child mortality is two and a half times higher in fragile states than in other poor countries; the malarial death rate is 13 times higher than elsewhere in the developing world. This needs more innovative approaches – like we are using in Afghanistan where the government has asked NGOs to provide basic healthcare because it can’t – and which the London School is helping us with.

Second, we must ensure that Global Health Initiatives and Funds help to strengthen healthcare and do no harm

The Global Fund was created primarily as a way to urgently fight AIDS, and as a way to raise additional money. Overall funding for AIDS programmes has risen to over 1.7 billion a year, a 5 fold increase on the years up to 2001.

The prices of antiretroviral drugs have fallen by 98% and treatment in poor countries has grown from near zero, to 1.3 million currently, and set to rise to 3 million by 2007.

Six African countries report a drop in HIV prevalence of over 25% in young people. Global funds, as well as raise money and provide treatment, have forced us to focus on issues that are stigmatised, or taboo or that we may find politically challenging to address. They allow us to help people in countries where we do not have programmes.

And we have made other progress too. In Tanzania the number of children sleeping under treated mosquito nets has increased by three-quarters since 1999. The result ? Reported fevers have fallen by a third.

And yet, we have to be honest, these targeted approaches can come with a cost attached, and we have to be careful that prioritising one disease or issue, doesn’t mean that we neglect others.

There are now up to a hundred issue based global health initiatives. One study in Tanzania showed that a District Medical Officer spent 20% of their time accompanying missions from such initiatives, and the same time again writing reports.

Now part of the challenge we face – is how to manage all this good will – so people can do the work and provide the healthcare.

So we must also think about what all this can do to national health priorities and budgets. The Zambian health budget this year is $159 million but PEPFAR is providing $149 million in the same period, and overall donor funding to AIDS is around $400 million a year! This can’t be right – it pulls attention, staff, and other resources away from all the other health problems Zambia faces.

Our permanent secretary, Suma Chakrabarti, is visiting Zambia with Peter Piot this week, and I hope to learn more from them.

But we know that the major constraint to achieving Universal Access to AIDS prevention, treatment and care is poor healthcare systems. We need more health workers, and more drugs, and more clinics if we are to keep all of our promises on health.

Third; we need to invest more in research and global public goods

Only 10% of the $70 billion spent each year on health research is devoted to diseases responsible for 90% of health problems.

So we are supporting the development of vaccines, drugs and microbicides for HIV/AIDS, Malaria, Tuberculosis and other neglected diseases; funding research on how to scale up treatment and prevention; and more work on how to further reduce drugs prices, as well as to help countries use TRIPS better.

Exciting things are happening – for TB we may get a new diagnostic test by the end of next year, a new drug by 2010 and a new vaccine by 2012.

And we have launched the Advanced Market Commitment initiative to give incentives to companies to develop vaccines that deal with the diseases that affect poor people in poor countries

Fourth; we must the remove barriers that stop people from getting health care, including by abolishing user fees

Health services can only improve health if people can reach and use the services.

In Ethiopia a third of all rural people have to walk more than 10km to reach a health service. I met a man in Arba Minch who had left home at four in the morning, and he would have to walk back for four hours to get home. And that’s half a day lost that could be spent working on the farm. That’s lost income. And when they get there, they have to pay.

We have got to eliminate user fees for basic public health services.

I believe that charging people for basic health care at the point of delivery, is a very bad idea; first of all it’s unfair, and secondly it doesn’t help improve their health. It can’t be right to take money from poor people when they are sick, and when they can’t afford it.

Doctors writing in the British Medical Journal estimated that over 230,000 children’s lives could be saved if fees were abolished in 20 African countries.

It’s the right thing to do.

We have helped Uganda do this. Ending fees increased demand - increased funding for more health workers and drugs helped increase supply. The result? Attendance at health facilities more than doubled, as have immunisation rates, which are now over 80%. And we are also helping Zambia do the same. And we will help other countries do so too.

I think the other thing to appreciate is politics – which is also about supply and demand! You’re all health specialists – I’m a politician, so you might think I would say this - but getting rid of the one real barrier people face is a major political signal that you are serious about trying to address their concerns. That you have listened. That you care. This is politics - the debate and discussion that helps determine what society wants, and how to go forward.

And on the back of this momentum, governments can undertake the other more costly but vital reforms necessary to improve the quality of healthcare.

And finally we need to think ahead to what the world will be like in five or ten years time.

What are the new problems that we will face?

The world is changing fast. Urbanisation first in Asia and then Africa will mean that most people will live in towns and cities within two generations. Climate change will have a huge impact on poor countries – countries that didn’t cause it but will feel its worst effects.

Tobacco will be killing 10 million people a year in 5 years time. Indoor air pollution kills 1.5 million people annually. Diabetes, heart disease, cancer. Or road traffic deaths - believe it or not, the second highest killer of young people in the world after AIDS – and if unchecked, is set to become the biggest, but where we have all the answers.

We need to plan for tomorrow’s problems today.

It is relatively easy to diagnose the problems. The real challenge is to make all of this happen.

Until recently the additional aid needed to reach the health MDGs was estimated at between $20-25 billion a year, including expanding services to achieve universal access to AIDS treatment. But the AIDS estimates alone are now $22-30 billion. For TB it’s $31 billion over the next nine years. That does not leave much room for much else.

African governments promised to increase health funding from around 8% to 15% of their budgets at Abuja in 2000. But 15% of a small budget is not enough.

The only long-term way these budgets can increase is if there is more money – look at our own history and how we have been able to pay for what we now have. Developing countries are going through that process right now – but where there remains a gap we need to help countries finance it.

And if economic growth increases, and jobs are created, then this will mean more money too. And an investment in health is a vital part of increasing growth – little is possible without a healthy workforce.

But in the interim it will mean that donors – through aid and debt relief - will have to help poor countries meet the finance gap between current spending and the $35-40 a person recommended by the WHO to get a good quality service.

And the only way we can do all of this is if we are all more ambitious.

What should we do?

I think all of us – poor countries, donors, UN agencies including the WHO and the World Bank, the EC, the Global Fund, GAVI, NGOs and others need to urgently make a major global effort to expand health care in poor countries.

WHO play an important role. Let me take a moment to mention the very sad loss of JW Lee, enormously experienced and greatly respected, and whose leadership helped agree the 3 by 5 initiative – a brave and bold step. Did we achieve it? No, but we made great progress. It’s this kind of vision and courage that we need now.

And I think this will need three things.

First, a foundation built on ambitious 10-year country plans – led by Ministries of Health and made more of a priority by Ministries of Finance - plans to fight the major causes of ill health, to provide AIDS treatment for all, to build clinics, to employ doctors, nurses and frontline carers and to remove barriers including user fees.

Plans of the right quality to both improve peoples’ health and to be endorsed and backed by the international community. Twenty two countries in Africa are doing this now for education.

Because if they come up with the plans then they challenge us to come up with the money.

Second, long-term and predictable support from donors and funds that will provide poor countries with the security of knowledge that they can make long-term investments, abolish user fees for basic services if they wish to, and meet the costs of salaries, drugs, infrastructure and training without which things won’t change.

Aid is extremely variable – it has gone up and down over past years – if this was a salary for a job, you’d say “…this is going to be difficult, I’ve got commitments.” Well countries have too – if you’ve got people on treatment, you can’t just turn off the tap.

And of course much better aid, we have got to get donors to work together more effectively in support of government efforts.

Finally we need to combine all of this effort, and build on the goodwill last year.

So, there we are.

This is not about having to make a choice between doing things quickly or improving healthcare overall. For me it is about doing both at the same time so that we achieve all of our health goals.

And your research – here at this school and with others - will help us do things better, and that in turn will help make our money work better, and will ultimately help change poor people’s for the better.

We need to get on with this, and we need to do much more of it, and we need to do it now.