Helen Clark: Speech at the 2013 Lambie-Dew Oration on “The World We Want: Health & Human Development in the 21st Century”
Helen Clark, UNDP Administrator
“The World We Want: Health & Human Development
in the 21st Century”
The 2013 Lambie-Dew Oration
For Sydney University Medical Society
Sydney University, Australia
I am pleased to join you at the University of Sydney for this year’s Lambie Dew Oration. My thanks go to the Sydney University Medical Society for inviting me to give this address.
In my lecture this evening, I will reflect on the intersection of health and development – a matter of great interest to me as a former Health Minister in New Zealand, and now as Administrator of the United Nations Development Programme and Chair of the UN Development Group.
Right now, governments, international organisations, and civil society around the world are discussing what the next global development agenda might look like. The target date for achieving the Millennium Development Goals (MDGs) is 2015, and there is general agreement that new objectives and goals should be set.
How health is framed in that agenda matters greatly, especially to people who are most susceptible and vulnerable to ill health: a pregnant woman in Africa who has neither pre-natal care nor a skilled birth attendant to assist delivery; a child anywhere who is exposed to second-hand smoke; or someone here in Sydney who may fear seeking an HIV test because of concern over how family or the health care provider might respond.
More broadly, the framing of health in the global development agenda matters to all of us. This agenda will help shape health priorities for years to come, informing how medicine and health care are practised, organised, and financed.
Health reflects the social, economic, cultural, and physical environments in which we are born and raised, and in which we live and work. Health reflects the choices we make collectively in our communities, our countries and our world. That is why health is inseparable from development.
These are the basic premises which underpin the contributions of my agency—the UN Development Programme (UNDP)—to health. While UNDP is not a specialized health agency, we do work in the health sphere, and we believe that health is central to development. Through our core work on human development—not least on governance, human rights, gender equality, and poverty reduction—we too can make significant and sustainable contributions to improving the health of the world’s most vulnerable people.
Health and Human Development
So what do we mean by “health”? What is “human development”? And how are they related?
The preamble to the Constitution of the World Health Organization (WHO), agreed in 1946, defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” That definition stands to this day. It reminds us that good health is built on broad foundations and denotes far more than the absence of illness.
Two years later, the Universal Declaration of Human Rights was agreed at the United Nations. It declares that: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family.” The right to health has since been enshrined in global and regional human rights treaties and in many national constitutions.
The 1978 Alma-Ata Declaration adopted at the International Conference on Primary healthcare, expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all people. It was the first international declaration underlining the importance of primary health care.
These documents unequivocally situate health as a universal human right. As such, health features prominently in the human development paradigm, the guiding framework for UNDP’s work. That paradigm owes much to the lifetime contribution to development thinking of Nobel Laureate Amartya Sen, who noted that health deprivation is the most central aspect of poverty.
The very first UNDP Human Development Report in 1990 declared that “people are the real wealth of nations”. It defined human development as the process of enlarging people’s choices, freedoms, and capabilities to lead lives they value. Human development aims to promote long, healthy, and creative lives.
This definition of development challenged the traditional thinking which had equated it with economic growth, as measured by gross domestic product (GDP). Neoliberal growth models had become received wisdom in many quarters – seeing health variously as a by-product of economic growth, health care as a private commodity, and frowning on state intervention. Such notions have less traction today. While their influence persists, they are unlikely to be serious inputs to current development discussions. Within the human development paradigm which we at UNDP champion, good health is regarded as both a precondition for exercising one’s choices and freedoms, and as an outcome of that freedom.
Evidence supports these conceptual foundations, demonstrating how profoundly health can impact human development. The HIV pandemic provides the starkest example. Even in low-level epidemics, the economic impacts of AIDS are devastating at the household level. A 2011 UNDP study in several south-east Asian countries provided evidence of how AIDS drives families into poverty. AIDS, like other chronic conditions, is a widespread cause of impoverishment, undermining human development progress. Beyond its economic impacts, HIV and AIDS continue to engender stigma and discrimination, which threaten human dignity, human rights, and human development.
Conversely, the impact of economic downturns on health can be similarly profound in many cases. The collapse of the Soviet Union was accompanied by a sharp and devastating decline in life expectancy. Increases in HIV infection and a resurgence of malaria followed Greece’s macroeconomic crisis and the response to it. ,
The relationship of economic status to health, however, is not always straightforward. In Africa, HIV disproportionately affects wealthier countries and wealthier individuals. Economic collapse and hyperinflation in Zimbabwe were accompanied by a decrease in HIV infection, not an increase. The current understanding of HIV dynamics takes us beyond absolute wealth and poverty as direct drivers of HIV outcomes, to a framing of AIDS as a disease of inequalities, with overlapping gender and economic dynamics which create fertile ground for HIV-related risk behaviours.
Framing AIDS as an issue of inequalities again brings one back to a broader definition of human development – a definition which explicitly takes into account not just wealth, but also how wealth and power are distributed, and how they interact with inequalities between men and women. Those who claim that the new pandemics of non-communicable diseases, such as diabetes and cardiovascular conditions, are solely the result of individual lifestyle choices are repeating the same mistake made in the early years of AIDS. Once we understand that choices themselves are inequitably distributed, we understand that the lack of social justice, combined with development deficiencies, create the conditions in which ill health can proliferate.
Economic growth has not, in itself, been a reliable predictor of health outcomes. Between 1960 and 2005, many of the world’s poorest countries, such as the Central African Republic, Haiti, and Madagascar, saw significant improvements in life expectancy, despite experiencing overall economic contraction. The implication is that many gains in life expectancy over recent decades have been driven by factors other than simply wealth creation, such as health-promoting policies, uptake of new technologies, and more and better investments in health.
Thus while economic growth which generates higher living standards and better services may be an enabler of health, it is not destiny. Policy choices matter across a number of issues and sectors – including finance, governance, trade, agriculture, housing, urban planning, education, and the law. These shape the extent to which health is prioritized, and how effectively and efficiently resources are transformed into health investments. They also shape the decisions people make about their lives, including about their health.
The nature of the link between health and development then will depend on the extent to which we choose to make health a development objective. This is one of the fundamental questions driving the framing of health in a new global development agenda, and also why these discussions are so important. If we want synergies between health and development to be optimized, we have to choose to make it so.
Health in the current global development agenda
The world did choose to include health in the current development agenda. The United Nations Millennium Declaration of September 2000 committed world leaders to combating poverty, hunger, disease, illiteracy, unclean water and poor sanitation, environmental degradation, and discrimination against women. The Millennium Development Goals, or MDGs, followed on from this Declaration. Each of the MDGs has targets and indicators. It is taken as a given that better health is central to human well-being, and that health contributes to economic and social progress.
Three of the eight MDGs explicitly address health outcomes. They are MDG 4 on infant and child mortality, with a specific target to reduce by two-thirds, between 1990 and 2015, the under-five mortality rate; MDG 5 on maternal health, with specific targets to reduce by three-quarters the maternal mortality ratio and achieve universal access to reproductive health; and MDG 6, on combatting HIV/AIDS, malaria, and other major diseases, which includes specific targets to have halted by 2015 and begun to reverse the spread of HIV, and have halted and begun to reverse the incidence of malaria, and other major diseases – with tuberculosis also specified in the targets.
The MDGs, with their time-bound, clear, and measurable targets, have succeeded in mobilizing action and directing resources to improve health and human development. In the context of HIV and AIDS, TB, malaria, and maternal and under-five mortality, the decline by nearly 32 per cent in the burden from these MDG-related disorders between 1990 and 2010 is considered to be greater than pre-MDG trends would have produced.
Child mortality, for example, has declined remarkably around the world—a 47 per cent decrease since 1990. A greater proportion of children survive to their fifth birthday than ever before.
The scale-up of HIV antiretroviral therapy has been unprecedented. A little more than a decade ago, practically no one in low- and middle-income countries had access to HIV treatment. At the end of 2012, 9.7 million people in these countries were on treatment.
In addition, preventive measures have got traction. Globally, HIV incidence has declined by 33 per cent since 2001, with a 34 per cent decline among adults in sub-Saharan Africa.
Yet despite the progress on the health MDGs, the gains have not been uniform or in many cases fast enough to meet the ambitious targets which were set. Maternal mortality has declined by almost one-half since 1990, but change has not been fast enough to achieve the 2015 target of a 75 per cent decline. The world is also off-track in ensuring universal access to reproductive health. Only around half of all women in poorer countries receive the recommended amounts of reproductive health care. Similarly, at the current rate of progress, the goal of reducing child mortality by two-thirds will only be reached by 2028, according to a recent UNICEF report.
Global progress can mask worrying trends at country level. In Eastern Europe and Central Asia, HIV treatment coverage rates are the lowest in the world. In some countries in the region, new HIV infections have increased rapidly, especially among marginalized groups such as men-who-have-sex-with-men and injecting drug users and their sexual partners. In this region, as in others, we have seen some countries take steps which discriminate against these groups in their legal frameworks and perpetuate stigma around them. Apart from violating basic human rights, these steps have the unfortunate consequence of undermining HIV responses.
Worrying trends in policy environments are compounded by trends in funding to combat HIV. After an unprecedented decade of investments, external HIV assistance has flat-lined in recent years. The stagnation in funding is all the more grave because ambitions for treatment have been raised higher. Recent changes in WHO treatment guidelines have increased the number of people eligible for treatment from sixteen million to just over 28 million. At the same time, people who develop drug resistance must transition to the second- and third-line regimes, which are more expensive. Drug-resistant TB is alarming in some countries, and drug-resistant forms of malaria are appearing, too, particularly in South East Asia.
Any complacency around threats to health is dangerous. Reversals in progress are possible, and new diseases—and new forms of existing diseases—do not respect national boundaries. Therefore, how we sustain progress and address these concerns in a new development agenda is crucial.
Health in the post-2015 development agenda
A global conversation is under way on what a renewed development agenda should look like beyond 2015. UNDP has been an active contributor to and facilitator of these discussions, particularly by ensuring that the voices of the poor and marginalized are heard. To that end, we have worked with sister UN agencies to organize a series of consultations. Already, national consultations have taken place in 88 countries. Eleven global thematic consultations have been held on issues ranging from health, population dynamics, inequalities and governance to education, environmental sustainability, and conflict and fragility. Virtual platforms and social media are being used to include people far beyond official circles.
Feedback from the more than a million people engaged in the consultations is contained in a report launched recently, and is available both publicly to the Open Working Group on Sustainable Development. This group is comprised of representatives of seventy member states, including Australia, and is tasked with proposing a set of sustainable development goals next year for review by the General Assembly.
The broad contours of a post-2015 development agenda are taking shape. Some general principles have emerged—namely, that a new agenda builds on lessons from the MDG experience, maintains and accelerates MDG progress while addressing issues not explicitly covered by the MDGs, and includes a set of concrete, measurable goals. There is also broad agreement that a new agenda should be anchored in human rights principles, and should be universal—in other words, the agenda would apply to developed and developing countries alike.
While much debate remains to be had on the details of a new agenda, poverty eradication has emerged as a ‘central imperative.’ In his recent report to the UN General Assembly, the UN Secretary-General has called for the eradication of extreme poverty within a generation. This echoes similar calls by the World Bank, as well as by UNDP’s new Strategic Plan which directs us to support countries to achieve poverty eradication and to reduce inequalities and exclusion.
The Secretary-General’s report also calls for a focus on improving health in the new development agenda. This call echoes the priorities which people have expressed directly through the UN’s consultation process on the post-2015 agenda.
The more than one million people worldwide who engaged on future development priorities through the My World survey ranked good education and better health care as their top two concerns.
Within health, many of the key proposals to date have outlined a single, outcome-oriented health goal whose overarching objective is ‘ensuring healthy lives’. Such an orientation helps keep a focus on the ultimate objective—health and well-being—rather than on specific prescriptions on how to get there, while also allowing countries the flexibility to respond to their unique health priorities.
Most of the proposals for the components of a health goal cover the following themes to varying degrees: safeguarding and accelerating progress on the health MDGs; responding to new global health threats such as non-communicable diseases; achieving universal health coverage; and addressing health inequities and the social determinants of health.
Let me unpack each of these elements and describe the ways in which UNDP is making—and can continue to make—strategic contributions to advancing the health and development agenda.
1. Tackling the Unfinished Business of the Health MDGs
First, to my knowledge—and relief—no one is seriously considering dropping the objectives of the health MDGs. Most proposals retain some version of MDGs 4, 5, and 6 within a health goal. This is important – we have to maintain progress on these vital issues and avoid slippage. This is as true in Australia as anywhere else. On 5 July this year, the New South Wales Ministry of Health reported that in this state 409 new cases of HIV infection were recorded in 2012. This compares with 330 new cases in 2011—a 24 per cent increase. HIV is not just an issue somewhere else. It is an issue here, in my own country, and elsewhere, which requires on-going attention and action.
In 2010, UNDP developed an MDG Acceleration Framework which has now been applied with the support of UN Country Teams in more than forty countries. It drives efforts across sectors to overcome the bottlenecks preventing progress on reaching MDG targets. To date, the framework has been applied to the HIV targets in three countries: the Dominican Republic, Moldova, and Ukraine. These are prime countries for UNDP engagement, as the epidemic is concentrated among marginalized groups, and approaches based on improvements in law and policy and in human rights are critical to turn the tide on HIV.
In Moldova, for example, where rates of sexual transmission of HIV have increased from sixteen per cent of cases in 2000 to 86 per cent of cases in 2011, the acceleration action approach helped HIV resources to “follow the epidemic”, identifying opportunities to decentralize services to reach the most affected groups, such as injecting drug users and their sexual partners. The Framework also helped identify opportunities for sustainable national financing of the response through proposals to embed HIV services in the national health insurance scheme.
The MDG Acceleration Framework has also been extensively applied in countries to MDG 5 on maternal health. Evidence from this exercise confirms that barriers to reducing maternal mortality and providing universal access to reproductive health services lie both inside and outside the health sector. Within the health sector, these obstacles include overstretched governance systems which are struggling to allocate and manage the limited resources available; an inability to train, deploy, and retain skilled health personnel where they are most needed; and supply chains which break all too frequently.
In Uganda, the acceleration exercise identified the priorities of improving transport links and water supply to health centres, alongside the need for incentives aimed at retaining health workers in remote areas.
Maternal mortality rates are also generally highest among adolescent girls. Social mobilization is needed to emphasize the vital importance of girls’ finishing their schooling and not having children while they are children themselves.
With UNDP support, the MDG Acceleration Framework has been applied creatively to emerging health priorities not reflected in the current MDG agenda. Tonga, for example, is using the framework to develop innovative and prioritized solutions to address an epidemic of non-communicable diseases (NCDs), drawing links with poverty, nutrition, and gender—all elements of human development.
2. Prioritising tackling NCDs
Indeed a second key component of a future health goal must be responding to NCDs. Nearly eighty per cent of global NCD deaths are now estimated to occur in developing countries. The socio-economic consequences are striking. A report by the World Economic Forum and the Harvard School of Public Health suggests that over the next twenty years, NCDs will cause a cumulative economic output loss of US$ 47 trillion globally. As an estimated three quarters of health care spending is attributable to NCDs, many millions of people could be pushed below the poverty line if the cost of services is beyond their reach and if there is inadequate social protection.
Without doubt, addressing NCDs is a priority for all countries. In Australia, for example, if weight gain continues at current levels, by 2025, close to eighty per cent of all adults and a third of all children will be overweight or obese. In some countries, major NCD issues are already a reality: in 2010, 93 per cent of the people of Nauru were considered to be overweight and 71 per cent obese.
The good news is that these trends are not irreversible. Different policy choices can be made. Australia, for example, led the way in the war on tobacco when it passed the world’s first plain-packaging laws, and then fended off a hard fought battle with the tobacco industry, which mounted a vigorous challenge to the law in the High Court. Yet the fight over plain-packaging of tobacco here is not over. Other legal challenges have been mounted through the World Trade Organization, and under a bilateral investment treaty with Hong Kong. Australia’s courage, however, can embolden others to take such measures. As Minister of Health in New Zealand more than two decades ago, I well recall the entrenched opposition I encountered when we enacted progressive anti-tobacco legislation, and that battle continues today as New Zealand aspires to tobacco free status by 2025.
Along with sister UN agencies, UNDP is supporting countries to implement the Framework Convention on Tobacco Control— particularly with respect to assisting Parties to the Convention to develop multisectoral, national tobacco control strategies, establish national co-ordinating mechanisms, and reduce tobacco industry interference in setting and implementing public health policies with respect to tobacco control. UNDP can work with actors outside the health ministry, such as customs and import duties officials and ministries of finance regarding tobacco taxes; intellectual property specialists to address trademark concerns; law enforcement officers to implement laws on smoke-free places; and civil society organizations to promote transparency and accountability in policymaking.
In the South Pacific, UNDP and WHO have supported assessment of the impact of trade agreements on rates of NCDs and their risk factors. Health and trade officials came together to identify strategies to align trade agreements with public health needs. Encouraged by this process as well as the implementation of the MDG Acceleration Framework, Tonga has recently raised its excise rates on carbonated drinks and tobacco.
3. Universal health Coverage
The third feature of how health is being framed in a new development agenda is universal health coverage, or UHC. The goal of UHC is to ensure that all people obtain needed health services—educative, preventive, curative, and rehabilitative—without financial hardship. Universal health coverage helps us think beyond vertical disease silos and towards strengthening health systems to deliver quality, affordable health services.
Universal health coverage is also a critical investment in human security and development. Some 150 million people are pushed into poverty each year because of out-of-pocket health care costs. This is avoidable – Mexico’s national health insurance programme for example, contributed to significant declines in maternal and child mortality, while also reducing out-of-pocket spending, especially for the poorest households. If the aim is to eradicate extreme poverty – as I hope it will be – universal health coverage will be a central means of doing so.
One way in which UNDP is already contributing to universal health coverage is through its role in a number of countries working with the Global Fund to Fight AIDS, TB and Malaria. We help strengthen the capacities of health systems in a number of countries around reducing rates of HIV, TB, and malaria, and providing treatment to all who need it.
Yet universal health coverage cannot be a panacea for addressing the many health challenges that the world faces. Affordability and access to health services must be addressed, but so must be the social determinants of health.
4. Addressing the Social and Economic Determinants of Health
This is the fourth and final key feature of how health should be framed in a new development agenda. Health inequities are found everywhere—within countries as well as between countries. They follow social gradients, such as income, education, occupation, sex, race and ethnicity. These gradients are driven, in turn, by economic and social policies and political choices. These choices create conditions in which people engage in risk behaviours, such as smoking or poor diets, and in which they struggle to access health care. While the structure of a health care system is an important input into the level and distribution of health, health inequities persist even when health care is free and available.
People affected by poor health or at high risk of poor health may face, for example, difficulties in securing or maintaining suitable employment or housing. Pension schemes and various forms of insurance may be out of reach, especially those that exclude people deemed “high-risk”—or that fail to provide adequate benefits in the face of early illness or death.
Ultimately what determines the distribution of health is beyond the health system, or outside what we consider as ‘medicine’. The biggest gains in life expectancy in the twentieth century occurred before the widespread availability of such biomedical wonders as vaccines and antibiotics. For most of human history, TB was conceptualized as a disease of deprivation and poverty, not as a problem of a lack of medicines. In England during the Industrial Revolution, one in four deaths resulted from ‘consumption’. The setting was conducive to a sustained epidemic, as a result of overcrowding, poor nutrition, and an absence of workplace health and safety regulations. It was not until those conditions improved that the tide turned. Two-thirds of the decline in TB mortality occurred well before the introduction of effective treatments.
We see similar examples today in the fight against HIV. Recent studies in various sub-Saharan African countries have provided compelling evidence that giving modest cash transfers to poor girls can reduce their risk of contracting HIV significantly, possibly by reducing the incentive for “transactional sex.” This impact, at least in the short-run, is on a par with the impact of male circumcision – which the WHO estimates can reduce the risk of heterosexually acquired HIV infection in men by around sixty per cent.
Overall, action on the social determinants can change risk behaviours which lead to poor health, and can also help people access health services. In 2010, UNDP established and supported the work of a Global Commission on HIV and the Law. The Commissioners, who included the Honourable Michael Kirby of Australia, released their report in July last year. It showed that many of the inequalities and much of the discrimination which impede effective HIV and AIDS responses are entrenched in bad laws and policies.
Laws which criminalize HIV transmission, exposure, and non-disclosure deepen the stigma surrounding, and negatively affect both testing and treatment services and the relationship between patients and health service providers. Laws which fail to protect women from domestic and sexual violence contribute to women’s greater vulnerability and risk of HIV infection.
The Commission also noted that evidence-based laws and practices firmly grounded in human rights are powerful instruments for challenging stigma, promoting public health, and protecting human rights. Recently, for example, Guyana rejected a bill criminalizing HIV transmission on the grounds that it was “bad public health policy.” In Pacific Island countries, thanks to constructive engagement between government, civil society, and networks of people living with HIV, we are seeing a realisation of the importance of human rights for more effective HIV responses.
Addressing the social determinants of poor health requires multisectoral action which complements efforts in the health sector. For example, in many contexts, large infrastructure projects can create conditions in which HIV finds new footholds. The construction and operation of mines, dams, and roads, for example, create opportunities for labour migration and expanded sexual networks. Working with partners in East and Southern Africa, UNDP is helping to co-ordinate multiple sectors to reduce the negative HIV, health, and gender impacts often associated with large capital projects. Together, UNDP and partners are supporting Ministries of Environment to mainstream these issues into social and environmental impact assessments.
How do these broader considerations of health and human development affect people here in Australia and more broadly?
Human development is not something to be advanced only in poor countries. It is relevant wherever poverty, inequity, discrimination, and exclusion persist, and wherever some groups experience disproportionate burdens of disease.
Partnerships are vital in tackling the health dimensions of human development. Health is impacted by what happens across many sectors.
Health outcomes result not only, or often not even, from individual choices, but rather from collective choices relating to economies, the environment, social and cultural norms, and much more. These factors also shape the conscious and subconscious choices people make about their health: whether they smoke; how much alcohol they drink; whether they can afford fruits and vegetables; whether they have adequate knowledge; or what their sexual relationships are like. These broader choices and circumstances have profound health consequences from Sydney to Shanghai and South Sudan.
Those here tonight who are perhaps in the early phase of a health career, will almost certainly face challenges unimaginable to previous generations. Globalization and increasing interconnectedness, for all their benefits, do expedite the spread of deadly new diseases. New viral and bacterial strains will continue to emerge, and some of them will be stubbornly drug-resistant. The global food and drugs trade has already challenged existing oversight and enforcement mechanisms at national and international levels, as tainted goods have sickened those who consumed them—sometimes halfway around the globe.
Climate change too poses tremendous health challenges worldwide, far beyond those associated with escalating weather hazards and rising sea levels, which disproportionately affect the poor. Studies suggest that climate change could expose an additional 2 billion people to dengue fever transmission by the 2080s. Malaria, which is strongly influenced by climate, is already responsible for the loss of almost 700,000 lives annually, and is projected with global warming to spread its range further after decades of contraction, while rates of malnutrition and under-nutrition, which contribute directly to child mortality in developing countries, are also expected to worsen. According to WHO, global warming since the 1970s caused over 140,000 extra deaths annually by 2004, while the direct costs to health could reach US$2-4 billion by 2030.
These challenges are great, they are growing, and they do not respect national boundaries. They will demand expanded partnerships across multiple sectors, governments, development partners, and others to be tackled. More than ever before, we need to unite health, development, and broader government actors if we are to sustain the human development and health advances of recent decades.
At UNDP, we believe that by working collaboratively with others, and by keeping health close to the heart of our mission, we can be a contributor to tackling these challenges.