Who: Dr Margaret Chan, Director-General of the World Health Organization
Ann M. Veneman, Executive Director of UNICEF
Dr Anatoliy Dernovoy, Minister of Health, Republic of Kazakhstan
When: Tuesday, 14 October 2008 at 17:00 pm Almaty time / 13:00 pm Geneva time /
11:00 am GMT time.
Where: Almaty Room, Intercontinental Hotel, 181 Zheltoksan Street, 050013, Almaty, Republic of Kazakhstan.
Moderator: ....entitled "primary health care, now ever. We've come to Almaty to launch this report on the eve of a global meeting of health leaders who are here to mark the 30th anniversary of 30th anniversary of the Alma-Ata declaration on primary health care. It was in this beautiful city in 1978 that a similar meeting of health leaders which actually lead to the Armada declaration. Then as now people everywhere were worried about protecting their health than the health of their families. They could not get the services needed and wanted and like today when services were available were not able to pay for them. Then as now the global health community wanted to ensure that everyone regardless of where they live whether they are rich or poor access to good quality and affordable health services. This years world health report makes the case for taking a primary health care approach to health systems strengthening. It is an important contribution to an ongoing dialogue around the world on primary health care which has been taking place for the last 20 months and is expected to intensify.
In addition to us in our Almaty today we are joined via the Internet by media all over the world as well as colleagues in offices in different regions and countries. We plan to spend the next 30 minutes or so listening to three keynote speakers Dr Margaret Chan director-general of the world health organization, Ms Ann Veneman executive director of UNICEF and Dr Anatoliy Dernovoy, Minister of Health, Republic of Kazakhstan. After that we will open up the floor from a few questions and I will be helped in the section by my UNICEF colleague Mr Sultan Khudaidergenov. We out further ado, and invite Dr Margaret Chan director-general of the World Health Organization to make a statement cave that.
Dr Chan:
Ladies and gentlemen,
Good afternoon, I am delighted to be here I arrived in this country about 12 hours ago, and I have been to meet Mr President and Minister of foreign affairs joining with Ms cinnamon and we have arrived here about an hour ago and nice to meet so many of you and I would like to thank the media members for joining us. I am asked to make a few comments. let me get through this comments then we will answer your questions.
Ladies and gentlemen I would like to share with you some of my thoughts. What I believe is that the world as it stands now is out of balance in matters of health as never before. This year’s World Health Report "Primary health care, now more than ever" supports my conviction.
Thirty years ago, in this beautiful city the Declaration of Alma-Ata launched primary health care as the route to health for all. This was a deliberate effort to tackle huge, and largely avoidable, differences in the health status of populations. Most of these differences are avoidable. The Declaration put health equity on the international political agenda for the first time.
Why was this so important? What does health equity mean? It means that people should not be denied access to life-saving and health-promoting interventions for unfair reasons, including those with economic or social reasons. Simply stated: equity in health is of life-and-death importance.
Globally, health has progressed remarkably over the past 30 years. On average, people are now living seven years longer. But if you look at individual countries or populations within countries, you get a very different picture.
Today, gaps in health outcomes, both within and between countries, are vastly greater than in 1978. Differences in life expectancy between the richest and poorest countries exceed 40 years. Can you believe it? We need to ask ourselves why. Annual government expenditure on health ranges from as little as $20 per person to more than $6,000.
Never before has our world possessed such a sophisticated catalogue of tools and technologies for curing disease and prolonging life. Yet each year, nearly 10 million young children and pregnant women have their lives cut short by largely preventable causes.
Something is wrong isn't it.
A world that is greatly out of balance in matters of health is neither stable nor secure.
Ladies and gentlemen,
The World Health Report this year looks at the way health care is organized, financed, and delivered and managed in countries around the world. It finds striking inequalities in health outcomes, in access to care, and what people pay for care. It also looks at the reasons and causes a. Many problems arise from the way health systems are organized and how resources for health are managed. The report documents these problems in detail.
All too often, people who are well-off and generally healthier have the best access to the best care, while the poor are left to fend for themselves.
Some of the greatest waste and inefficiency occurs when health is treated as a commercial commodity, to be bought and sold, assuming that market forces will somehow self-adjust to iron out any problems. This seldom happens. What you see instead is unnecessary tests and procedures, more and longer hospital stays, higher costs, and the exclusion of people who cannot pay.
When the emphasis is placed on specialized or commercialized care, providers have no incentive to invest in prevention. This is a failure with huge consequences. WHO estimates that better use of existing measures could prevent as much as 70% of the global disease burden. Why aren't we doing it?
Ladies and gentlemen,
The World Health Report sets out a better way to manage and deliver health care. Primary health care is a people-centred approach to health that makes prevention as important as cure. As part of this preventive approach, it tackles the root causes of ill health, also in non-health sectors, thus offering an upstream attack on threats to health.
A primary health care approach is the most efficient, fair, and cost-effective way to organize a health system. It can prevent much of the disease burden, and it can also prevent people with minor complaints from flooding the emergency wards of hospitals. Decades of experience tell us that primary health care produces better outcomes, at lower costs, and with higher patient or user satisfaction.
Let me stress this last point: higher user satisfaction. I personally find this one of the most striking findings in the report. Social expectations for health are rising all around the world. People want care that is fair and people want care that is a efficient and affordable.
Studies show wide agreement. People surveyed in a range of countries believe that all members of society should have access to care and receive treatment when ill or injured, without going bankrupt as a result. When people are asked to name the top problems that they and their families face, financial worries usually head the list and I am sure that this is especially the case now that we are going through a financial crisis. The second issue they name after financial worries is a health. They attach a lot of important to that.
Political leaders would be wise to heed these findings of the survey.
Ladies and gentlemen,
Let me commend it the visionary thinkers who gathered in this city thirty years ago. All of them are still in the audience. They could not have foreseen an oil crisis, a global economic recession, or the emergence of a world-transforming disease like AIDS before they launched the Alma Ata declaration.
Today, we know where we stand. We face a fuel crisis, a food crisis, and a financial crisis. In a French it looks like history is repeating itself or "déjà vu". The effects of climate change, another global crisis, are already being felt. All of these crises have profound implications for health.
We must face these events with resolve. This is not the time to back away or buckle under. The bill for failing to protect and promote health always comes, and this is especially true at a time when chronic diseases, like heart disease, cancer, diabetes, and mental disorders, are on the rise worldwide.
In the recession that followed the Declaration of Alma-Ata 30 years ago, major mistakes were made in restructuring national budgets, with reductions in health and other fundamental social services. Health care has still not recovered from these mistakes, and the bill has been extremely high. This is especially true in sub-Saharan Africa, but also in large parts of Latin America and Asia.
If history tends to repeat itself, can we not at least learn from the past and avoid repeating mistakes?
Health is the very foundation of productivity and prosperity. Cutting investments in health is not a viable option. We have made that mistake before and are still paying the price.
Every health system in the world has inefficiencies. Well-documented ways of reducing these inefficiencies, through better management, through incentives, through primary health care, exist.
But health systems will not automatically gravitate towards greater fairness and efficiency. This world will not become a fair place for health all by itself. Deliberate policy decisions - policy makers starting with heads of government, heads of state, ministers of health and other ministers like ministers of education, ministers of transport, environment or other important leaders and decision-makers. They can make a difference.
The World Health Report documents the problems, but the World Health Report also shows what needs to be done. At a time of crisis on so many fronts, with so much at stake for health, let us all hope that this report has the impact it deserves.
Thank you for your attention.
(Moderator turns to UNICEF Executive Director Ann Veneman)
Ann Veneman:
Thank you very much and thanks to all of our friends in the media for being here today. A special thanks to Minister
Dernovoy the Minister of health of Kazakhstan and to his government for hosting us here in Almata and a special congratulations to Dr Margaret Chan my good friend and colleague and the WHO on this excellent and comprehensive flagship report. Earlier this year Dr Chan was the kind enough to join us as UNICEF with the state of the world's children report which highlighted the issues of child health, And I think that these two reports together are a very comprehensive and complementary.
The fundamental importance of primary health care has long been championed by both WHO and UNICEF. Our two organizations were at the forefront of the international conference that articulated the principles of primary health care in this city 30 years ago. The first world health report launched in 1995 focused on bridging the gaps in health, a theme that encapsulates the core objective of primary health care to make access to healthcare more equitable. The 2008 edition serves as a timely reminder of the need to develop health systems and achieve lasting improvements in the health of the country's citizens. The report's focus comes at the halfway point for the achievement of the millennium development goals. While many developing countries are making considerable advances towards the goals, others, particularly countries in Africa and in Asian are falling behind. In many of those countries that are not on track, basic health care services are still not an integral part of the system. Madagascar is one of the country's that is featured in a series of articles that informed 2008 world health report. In 1978, inspired by the Alma Ata agenda, Madagascar launched an ambitious primary health care programme. In the ensuing years the country has many notable gain in health. The average life expectancy for Madagascar child born in 2007 was 57 years which represents an increase of around 12 years on the 1978 level. Polio has been eradicated, and leprosy has been reduced to very low levels. And the rate of child mortality has fallen from 175 per 1,000 live births in 1980 to 150 per 1,000 in 2007. But primary health care agenda is far from complete in this island nation. In July I visited Madagascar to launch a tetanus immunization campaign with the government, to promote improved water sanitation and hygiene. Madagascar is one of the only countries in the world where maternal and neonatal tetanus has not been eliminated. Tetanus is entirely preventable through vaccination of pregnant women. It is the first immunization that a child receives as it is given even before birth by vaccinating a mother. Part of the reason for the low rate of tetanus vaccination in Madagascar is that only 60 to 70% of the population has ready access to primary health care.
A critical service that remains out of reach for almost 90% of the people in Madagascar and more than one third of the world's population is access to improved sanitation. Globally about 2.5 billion people lack access to adequate sanitation facilities and 1.2 billion have no access to sanitation facilities at all. The current rate of progress, the millennium development goals, but millennium development target of halving the number of people without access to improved sanitation facilities between 1990 and 2015 is likely to be missed by a margin of more than 700 people. India presents a particular challenge. It is home to one third of the world's population without decent sanitation facilities. In addition open defecation is practiced by more than 50% off India's population. Tomorrow is the first ever global hand washing day - a public/private initiative to promote improved sanitation and hygiene, particularly among children, mothers and health workers. Hand washing with soap can reduce the incidence of diarrhoeal diseases which kills almost two million children under five each year by about 50%. Many other risks to maternal and child health are also associated with an adequate sanitation and clean water and poor hygiene including pneumonia, sepsis, tetanus and under nutrition. Improving environmental health is not merely a technical challenge however or one that can be simply addressed by building more facilities. Making sustainable and equitable gains in water, sanitation, and hygiene requires the holistic and integrated approach to healthcare espoused in the world health report.
Community participation, equity and non-discrimination and gender equality, integrated approach and collaborative actions are the cornerstones of primary health care. The world health report has highlighted key areas for improvement in delivering primary health care which Dr Chan has eloquently stated.
An over arching theme of the report is the need to improve the effectiveness of health systems. Maternal and newborn survival in health key barometer of health system effectiveness. By these measures there is much to be done. Though falling, annual number of maternal deaths renamed stubbornly intractable above 500,000 per year. Each year almost 4 million children die within the first any day of life. The rate of neonatal mortality is falling but a far lower rate than be under five mortality. This is resulting in accounting for a higher share of the under five mortality.
As world health report emphasizes, health systems are better equipped to respond to the needs of communities when they are embedded within them. Re-training and incentivizing community health workers and skilled health personnel and promoting social mobilization and behaviour change are pivotal to accelerating progress. Just 10 countries account for two thirds of all maternal deaths. Particular attention must be given to India and Nigeria which together account for a third of maternal mortality globally. To this end UNICEF is focusing the next edition of it open a flagship report the State of the World's Children on the imperative of improving maternal and newborn health.
The world health report calls for inclusive participatory and negotiation based leadership to spur health system and development. Such leadership requires collaborative action among a wide array of partners including governments donors international agencies civil society that private sector and communities and families themselves. International health agencies including WHO and UNICEF are increasingly striving for greater unity and coordination in their actions.
At the 2008 G8 summit meeting, global health was the key issue that was discussed among the world leaders. At tomorrow's event here in Alma Aty, where we will commemorate the 30th anniversary of the declaration of Alma Ata, the world health report's call for strengthening primary health care will be central to the discussions. Concrete gains have been achieved in public health particularly in child survival since the last meeting. But there is clearly much still to be done to ensure equitable and extensive coverage of essential health care services. Primary health care must be scaled up especially for women and children who are so often the poorest and most vulnerable. Thank you very much.
Moderator: Thank you very much. Would like to invite Minister of health to come down to make his statement.
Dr Dernovoy: Your Excellency Dr. Chan, Mrs. Veneman, Ladies and Gentlemen, participants on radio and television today we are starting the first event within the framework of this common narrating conference. 30 year anniversary of Alma Ata declaration adopted by WHO and UNICEF on primary health care. V. Tele bridge is one of the important component of the events and here we have heard a wonderful presentation from the WHO director-general Dr Margaret Chan. It would not be an exaggeration to say that the whole world was listening very attentively to this wonderful presentation. Thank you very much distinguished Dr Chan for a substantive presentation, for an in-depth analysis, for an active stance and also the commitment of the W. H. O to further development and reform of the primary health care.
I would say this is extremely symbolic that are important WHO report was voiced in Almaty, because it is the homeland of the primary health care declaration and it was done on the eve of the opening of the conference. This telebridge has enabled us to broaden the audience of this meeting. Thanks to this tens of thousands of specialists from all over the world might be a part of it. Jumping ahead I could say I could say at this summit and again at this high level of forum we shall be again demonstrating the advantages of further development and improvement of primary health care it is one of the most cost effective and efficient types of medical care and we are going to look at some of the best practices in this area suggested by many countries of the world and discuss our actions for the future. With the development of health care system shows how important it is to focus on primary health care and how important it is to employ general practitioners that will enable us to cover up to 80% of our population with effective health service. Qualified Primary health care reduces at the need for a long-term hospitalization and also increases the overall efficiency of medical assistance and health care bringing down costs. That is what was mentioned by distinguished Dr Chan. I would say that the outcome of the conference would be the record nation of the need for a reasonable combination of the primary health care reform and the hospital sector reform. I would say it is very important for everyone to know how the Alma Ata declaration ideas are being followed up in its home country Kazakhstan. I would say that Kazakhstan has made a pretty uneasy way we've been face 30 years old a developed Soviet system of health care to a very sophisticated period of Kazakhstan formation in the 90s because we have seen some real priorities being given to primary health care. As an example primary health care promotes further access to such services as immunization, medical assistance as care for mother and child, providing high-quality water and basic elements of sanitation. Also the Enlightenment and awareness raising on some of the major healthcare related ground and also some of the major medication. Let me give you some of the facts.
First of all for primary health care facilities and outpatient clinics and medical points will started implementing the residents programme don't in the region of our country fell off the standard rural outpatient clinics equipped with medical vehicles. Within the last two years, we have also started establishing new health facilities so called primary health care facilities. We are trying to pay attention to segregate polyclinic, outpatient clinics and inpatient clinics. We are providing more services to rural areas since 2005 introducing telemedicine. By 2011 it will be acceptable in all the rural areas. Altogether I would say that Kazakhstan has completed percentage of any state health care development programme for 2005 to 2007 that was adopted and approved by the presidential decree and it was about giving more attention and giving more investment to this area this sector and providing more equipment and technology. Right now we are at the second stage covering 2008 2010 and we shall be looking at the quality factors in the health sector including first for primary health care. We are very excited about achieving all the goals of the WHO in order to achieve the global objective of health in the 21st century.
Journalist: Question for Dr Chan. Dr Chan, both you and Ms Veneman mentioned infant and maternal mortality. How can primary health care and health systems tackle this problem and more broadly how can they tackle all the millennium development goals?
Dr Chan: I am very pleased to hear from you, you use maternal health and infant health you are using women's health as an entry point to the question you want to ask.. As a woman and also because we are very biased to women and children's health. Honestly, if you look at all the millennium development goals collectively the world has made progress, and has good achievements. Unfortunately the progress and the achievements are not even, between countries and within countries. You will know from statistics the facts and figures, the groups in the countries in the sub Sahara Africa are lagging behind. Whereas in other countries they are making good progress. And even within a big country like India and China, you will see certain groups of people doing better than others. So we need to ask the question "what is wrong?". We can learn from the past experiences that these services meaning the services to women's health, let me use that as an example, is perhaps fragmented. They deal often with the problem rather than the whole person. Maybe women have difficulty in accessing services. And does not come as any surprise, that the status of women, the financial capacity of women has an impact on their ability to access health care services. For an 20 years we failed to make a dent in improving the health of women through better and more comprehensive sexual and reproductive health.
How can primary health care and make a contribution? Instead of looking at a fragmented issue, a woman who comes because she is pregnant, a woman who comes because she wants to do family planning, we should look at what kind of comprehensive and holistic service we can provide to women. If a woman is pregnant we should not forget about whether she is anemic or not. We should not forget whether she is getting the proper nutrition and diet, and we should not forget whether or not she has the money even to pay the bus to get to the clinic for antenatal checkups.
So the primary health care approach which we are revitalizing is, the whole notion is the organization of service, the financing of service, the delivery and management of service should start with patient-centred holistic care. You need to organize the services in such a way that you involve other sectors as well.
I mention in some countries women have no transport to access health facilities because they don't have money or there is no road. So in that situation ministers of health, need to negotiate and discuss with the minister of road and construction to make sure the clinics are accessible. I am pleased to hear that in my meeting with Mr President this morning, he mentioned that the Government is investing in building more health facilities. That is good news. The whole support facility needs to go with the clinic or hospital - do they have the roads to access them - do they have medicines or when people get to the clinic, does the clinic have trained qualified nurses or doctors to take care of them are? The whole notion of primary health care, let me go back to the principles and values. To sum up if you have a service that is equitable in access , properly financed which is affordable, universal coverage, you have got it made. Every county can start now, it is never too late to start and in fact in the past 30 years, many countries have success stories to tell us and I would like you to take a look at the report when you have time. Look at some of the success stories whether or not those experiences can be emulated in other countries and of course we must emphasize that it is important - every country need to design its own model having considered the historical, cultural and political conditions, perhaps I shall leave the question here. If I have not answered everything, I shall be happy to come back. I would like to invited Ms Veneman to comment.
Veneman: Thank you very much and certainly I agree with everything you have said. Just a couple of things I would like to add particularly with regard to the MDGs. I think that one of the things that we know was that we really need community based integrated approaches to address the issues of maternal and child health and that we have to understand the interlinkages, not only between maternal and child health but among the other MDGs as well. So the health of the mother is inextricably linked to the health of the child. A mother who is underweight, who does not have proper nutrition, is too young, is likely to have less a less healthy child. And so you start with the health of the mother. That relates to the health of the child and then having that basic health care centre again helping to provide preventative care and let us assume first of all that you also want as many of those women as possible to have access to not only prenatal services but also to have attended deliveries, a health care worker at birth. The next important thing is to tie in MDG one which involves proper nutrition and that the most important thing there is the mother breastfeeds for the first 6 months of life exclusively. This has been shown to save so many lives but directly again related to nutrition. Making sure then that the children get proper immunizations we have seen tremendous increase in coverage of immunization since 30 years ago. The new issues, particularly HIV/AIDS, in southern Africa particularly making sure the mother is tested for AIDS and HIV status before she delivers that baby so hopefully we can prevent the transmission of virus from mother to child. Looking at some of the issues I have talked about, the interlinkages of water and sanitation to the health of the mother and health of the child. Of course HIV, AIDS and Malaria, but even the issue of gender education and equality as Dr Chan said, the women is so often the uneducated one, the one who is not given the equal opportunity and who suffers and her children and her children are less likely to have the opportunities if she doesn't have those opportunities to provide for the family. Other issues are, we have to look at culture and tradition, why is in some places like Sierra Leone where I visited earlier this year that the rate of breast feeding is only 8%. They feed babies rice water there, and it has the highest child mortality in the entire world, 264 child deaths for 1,000 live births. SO I think that you have to look at that, you must look at violence against women particularly young women, many of whom get pregnant or AIDS and look at the impact on their health, of some of the practices that go on continuously. I think that when you look at health care you cannot ignore all of the issues that play into it.
Journalist: Do you think that implementing the findings of the report involved only proper policy measures or should it involve movement of resources from developed countries into the developing world.
Dr Chan - if you look at the resources for health in the last 10-15 years actually that has increased tremendously and so that it the good news. There are many partnerships development partners who are contributing in the interests of solidarity to support developing countries. But there is always greater need than money available, this is the reality. But let me also emphasize, including African countries, they have committed themselves to invest more resources for social services and especially for health, because health is seen as very important to people, very dear to people, so you have heard our discussion, we don't look at health as in health sector alone, what is more important as a health person is a doctor, I myself, it is I want to be very honest with you. It is a very humbling experience for us to admit, the contribution to good health from the health services itself is rather modest. Are the services, like good and safe water proper sanitation, good nutrition proper housing, education of women are very important and if you also look at those dimensions, collectively together with the health service, you can make huge benefits and the synergy of all these coming together is greater than the sum of all these parts, and that is why we are talking about health equity or health in all policies. This morning when I was meeting with Mr President, we were very happy that Minister of Health was joined by the minister of Science and Technology because there is a huge relationship there and this is what we are advocating. The leadership of governments and of course the leadership of ministers of health help people at all levels must make a very strong case to say how important it is to make all these linkages.
I talk about the roads, Ms Veneman talks about water and sanitation, and the list goes on. I give you another example. Why is the Minister of Health at the receiving end of all the car crashes or car accidents when the road is not properly done, when the person chooses to drink and drive and speed, whether the country has speed limits, seat belt limit, would all contribute towards prevention. And if we move, we can convince government to move upstream to do more prevention, people will benefit and that will reduce the health care costs.