31 January 2013

Africa: Helen Clark - 'Empowered Lives - Resilient Nations - Why Health Matters to Human Development'

Helen Clark, Administrator UNDP

Lecture at the Harvard School of Public Health Lecture

"Empowered Lives; Resilient Nations -

Why Health Matters to Human Development"

Boston, Massachusetts

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It is a pleasure to join you at the Harvard School of Public Health. My thanks go to Professor Ichiro Kawachi for inviting me to deliver this lecture on global health and human development.

This School's contribution to public health discourse is notable - as seen in research undertaken by faculty and students, including in the field of social epidemiology which Professor Kawachi has helped to define. I also acknowledge the participation of Dean Julio Frenk in numerous UN panels.

The United Nations Development Programme, the organization I head, is not a specialized health agency. Yet, our core mandate of helping countries to tackle poverty, promote gender equality, and achieve sustainable human development, is highly relevant to lifting health status. In that sense it can complement the work of the World Health Organization (WHO) and other specialized global health agencies.

That is because the conditions in which people live and work impact on their well-being. Disparities in health outcomes tend to mirror inequalities and inequities in the broader society. Therefore efforts by development actors to tackle inequality and inequity will have a positive impact on health status.

The reverse is also true: advancing better health is a gateway to development progress, lifting economies and societies. In Asia, for example, between thirty and fifty per cent of economic growth between 1965 and 1990 has been attributed to improvements in reproductive health and reductions in fertility rates and infant and child mortality.

At the most basic level, well-nourished and healthy children are better able to learn. Well-nourished and healthy adults will have more productive lives - and one hopes a better chance of attaining overall wellbeing.

Understanding this feedback loop between health and development reminds us why it is important for health and development actors to see each other's efforts as complementary. My lecture today therefore will focus on the intersection between the health and human development agendas, and on why it is important for actors in each to collaborate.

Examining the intersection between Health and Human Development

Defining Health and Human Development

The preamble to the Constitution of the World Health Organization, agreed in 1946, defined 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 is about rather more than the absence of illness.

Two years later, in 1948, 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 wellbeing 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.

These landmark documents provide a firm basis for advocacy for health as a fundamental right for all. As such, health features prominently in the human development paradigm, which is the guiding framework for UNDP's work. That paradigm owes much to the lifetime contribution to development thinking of Nobel Laureate Amartya Sen - who has written extensively on health equity - and his colleague Mahbub ul Haq.

The very first global Human Development Report published by UNDP in 1990 declared that "people are the real wealth of nations", and defined human development as the process of enlarging people's choices, freedoms, and capabilities to lead lives they value.

This definition challenged traditional thinking which had equated development with economic growth, as measured by GDP per capita. As the old saying goes, "man does not live by bread alone". Within the human development paradigm, good health is viewed both as a precondition for exercising one's choices and freedoms, and as an outcome of that freedom.

With each global Human Development Report, UNDP publishes the Human Development Index. Health is one of its three components alongside education and GDP per capita. Life expectancy at birth is used as the indicator for health and well-being.

Since 2010 the annual global Human Development Reports have included three new indices:

the Inequality-Adjusted HDI, which captures the loss in HDI because of inequality in each of the three dimensions of the HDI. Here intra-country disparities in life expectancy figure prominently;

the Gender Inequality Index, which captures the loss in HDI because of gender inequality; and the Multidimensional Poverty Index, which gives a more comprehensive picture of poverty than an income-only indicator can.

There can be no doubt that poverty impacts adversely on health, as do both inequality in general and gender inequality. To lift health status and make the right to health a reality, it is vital to tackle poverty and inequality in all their dimensions. That too places health at the centre of the development agenda.

The Alma Ata Declaration of the WHO's 1978 International Conference on Primary Health Care proclaimed that: "the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector."

As a young Health Minister almost a quarter of a century ago, I often thought I had been able to achieve as much, if not more, for public health in my previous role as Minister of Housing. Over almost three decades in public life in my country, including nine years as Prime Minister, I was acutely aware of the broader economic, social, and other factors which impacted on health status.

Now, as head of the UN Development Programme, the Alma Ata Declaration helps me to place health status in that broader developmental context. UNDP's own strategy for tackling HIV, "HIV, Health, and Development", is based on our understanding that "just as health shapes development, development shapes health."

For all these reasons it is vital to tackle health challenges on a cross-sectoral basis. Action in the health sector alone will not produce the gains in health status and development we all want to see. The final report of the Commission on Social Determinants of Health, established by the World Health Organization in 2005, reinforces the importance of cross-sectoral strategies and action.

In September 2011, the United Nations General Assembly held its first High Level Meeting on Non-Communicable Diseases, bringing together world leaders, and ministers, and other stakeholders within and beyond the health sector. The meeting issued a Political Declaration recognizing NCDs as not only a global health concern, but also as a threat to social and economic development.

The UN Conference on Sustainable Development in Rio de Janeiro in June last year weighed in along similar lines, stating in its outcome document that "health is a precondition for and an outcome of all three dimensions of sustainable development" - the economic, social, and environmental.

Health and the Millennium Development Goals

Health was placed at the very centre of the development agenda in the Millennium Development Goals promulgated by UN Secretary-General Kofi Annan in 2000. The MDGs focus on basic benchmarks of progress in human development. They set out to: reduce poverty and hunger; empower women and girls; reduce the incidence of specified diseases and maternal and child mortality; increase access to education, clean water, and sanitation; protect the environment; and forge strong global partnerships for development.

Three of the eight MDGs specifically target health outcomes. They are:

Goal 4 - Reduce Child Mortality: with a specific target to reduce by two-thirds, between 1990 and 2015, the under-five mortality rate;

Goal 5 - Improve maternal health: with specific targets to reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio and achieve universal access to reproductive health; and

Goal 6 - Combat HIV/AIDS, malaria, and other major diseases; with specific targets to a) have halted by 2015 and begun to reverse the spread of HIV/AIDS, and b) have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. The indicators under this second target focus on both tuberculosis and malaria.

While these goals and targets seek better health outcomes, action in the health sector alone will not achieve them. Achieving these goals is heavily related to progress on the other MDGs - not least through, variously, reducing poverty, improving nutrition, ensuring that children finish school, empowering women, and improving water and sanitation.

The UN issues an annual global report on the rate of progress on the MDGs, and many regional and national reports are also produced.

To me, there seems little doubt that the MDGs, with their time-bound, clear, and measurable targets, have succeeded in mobilizing action and directing resources to lift human development.

Last month, the Lancet published results from the 2010 Global Burden of Disease Study. Seven articles looked at different aspects of the study, including areas targeted in the MDGs: HIV/AIDS, tuberculosis and malaria; under-5 mortality; and, maternal mortality. Chris Murray and others, in their paper looking at Disability-Adjusted Life Years, suggest that the decline by nearly 32 per cent in the burden from MDG-related disorders between 1990 and 2010 is largely due to the increased global attention which was given to these priorities. While not all the health related targets will be achieved, the authors note that, on current trends, the burden should continue to decline further by 2015. They also note that under-5 mortality has dropped in all but three countries over the last two decades.

While progress has been encouraging on the health MDGs, many factors stand in the way of meeting them everywhere. The barriers to progress cannot be addressed by the health sector alone. Let me illustrate this by drawing on concrete examples of UNDP's work to support the achievement of MDG Goals 5 and 6, working with diverse partners.

Maternal Mortality

Progress towards the MDG 5 target to reduce maternal mortality has been very slow. The target will not be met within the timeframe set. Nor can it be said that universal access to reproductive health has been achieved.

Across the developing world, the number of maternal deaths per 100,000 live births is estimated to have been reduced from 440 in 1990 to 240 in 2010 on the figures used by the United Nations. That is well below the progress needed to achieve the MDG target. Significant regional disparities also persist, with maternal deaths occurring disproportionately in Sub-Saharan Africa and Southern Asia.

In tackling preventable maternal death, the health sector clearly has much to contribute - for example through the provision of antenatal care, attendance at birth by midwives or other health personnel, and access to full obstetric services.

But there may also be a range of social, cultural, and economic factors preventing women from exercising their reproductive and sexual health rights and accessing the health services they need. Those factors may include gender inequality; poverty; poor or little protection of the human rights of women and girls; food insecurity and poor nutrition; and inadequate infrastructure and services, including lack of access to energy or to transport to health services.

The complex relationship between such factors and maternal health status becomes apparent when work is done to identify obstacles in the way of achieving MDG 5. In 2010, UNDP developed the 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 lagging MDG targets. In a number of countries, the MAF is being used to address maternal mortality.

Evidence from this exercise confirms that many of the obstacles to achieving MDG 5 do not relate to inefficiencies or problems within the health sector alone, but rather to a broader range of constraints. These may include:

overstretched governance systems, struggling to allocate and manage the limited resources available;

an inability to train and deploy skilled health personnel where they are most needed - more collaboration with education and other sectors is needed;

the breakdown of supply chains for equipment, drugs, and other supplies;

challenges in reaching remote communities - because of poor transport infrastructure;

persistent gender inequality.

In Uganda, one of the first countries to use the Acceleration Framework, practitioners and experts from the Finance, Planning, and Health Ministries were brought together with partners from civil society, multilateral organizations, and other development actors to identify the constraints on achieving MDG 5, and to agree on actions in a wide range of areas. They prioritized improving transport links and water supply to health centres, and putting in place incentives aimed at retaining health workers in remote areas.

Turning the tide on HIV

Significant prevention efforts, along with progress in science and technology, have contributed to slowing the rate of new HIV infections radically. A lot of the research has been done in the world's leading research institutions, like Harvard, and improvements in treatment continue. To complement this progress, however, initiatives outside the health sector are also critical.

In 2010 UNDP established and supported the work of a Global Commission on HIV and the Law. Its final report, released in July last year, showed that many of the inequalities and much of the discrimination which impede effective HIV responses are entrenched in laws and policies. For example:

laws which inappropriately criminalise HIV transmission, exposure, and non-disclosure deepen the stigma surrounding HIV/AIDS, and negatively affect both the taking up of 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;

punitive and discriminatory laws and law enforcement practices may prevent people who use drugs, men who have sex with men, transgender people, and sex workers from accessing HIV and health services;

where the age of consent for autonomous access to sexual and reproductive health services is higher than the age at which young people are sexually active, young people may be unable to access necessary prevention services; and,

trade law and policies may present barriers to expanding life-saving treatment for millions in need.

The Commission's report also notes that evidence-based laws and practices firmly grounded in human rights do exist in a number of countries, and are powerful instruments for challenging stigma, promoting public health, and protecting human rights.

Recently, Guyana rejected a bill criminalizing HIV transmission on the grounds that it was bad public health policy.

In 2009, Fiji removed its outdated 'sodomy law' from its penal code; the same year it requested UNDP support for a human rights-compliant HIV law. In August 2011, a law that met such criteria was introduced. Over the past couple of years, thanks to constructive engagement with government, civil society and networks of people living with HIV, Pacific Island countries are realizing the importance of human rights for a more effective HIV response.

Equally important to changing laws for better prevention and treatment is enabling men and women living with HIV to participate with dignity in daily life. In 2007, UNDP began work in India to expand the criteria of existing social protection schemes so that they were more HIV-sensitive and able to encompass marginalized groups, especially women and girls living with HIV. According to data from India's National AIDS Control Organisation (NACO), by the end of 2011, 35 state social protection schemes had started providing food, transport, housing, and pensions for people living with HIV. Close to 200,000 people living with HIV are now accessing such schemes.

Such policies can be important not only for persons living with HIV, but also for their families, and for ensuring that HIV does not force them into poverty-traps from which there is no escape. Evidence from a recent UNDP study in Asia, for example, suggests that children living in households affected by HIV were less likely to attend school than children in households not affected by HIV. This was especially true for girls, who were also more likely to have dropped out of school.

UNDP is an important partner of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. We act as the principal recipient of Global Fund grant monies in countries where capacity to receive and expend funding is low - for whatever reason.

In this capacity we are responsible for the delivery of some $400 million of Global Fund money each year, and for building the capacities of countries themselves to manage large-scale health programmes in the future.

In Zambia, for example, UNDP has worked with the Ministry of Health to strengthen national systems for managing funds, procurement, and supply chain quality assurance. This has enabled the Ministry to overcome recurrent shortages in the supply of life-saving commodities, and has improved the country's ability to attract funding from donors for tackling HIV.

The value UNDP brings to the partnership with the Global Fund includes its universal country presence and operational capacities, its experience of operating in complex emergencies and through political transitions, the existing legal and administrative agreements we have with host governments, our public policy expertise on tackling HIV and its social determinants, and our ability to harness the technical expertise and resources of other UN agencies and civil society.

Combating Non-Communicable Diseases

Non-communicable diseases were not covered in the MDGs, but are increasingly recognised as a very significant health problem in developing countries. Indeed, nearly eighty per cent of global NCD deaths are estimated to occur in developing countries.

NCDs have striking socio-economic impacts:

At the macro level, morbidity and mortality related to NCDs sap productivity among working age populations. China, India and Russia were estimated to lose USD 23-53 billion per year between 2005-2015 because of heart disease, stroke, and diabetes alone.

For low-income countries, managing NCDs can be very expensive, and puts a severe strain on already overburdened health systems.

At the household level, NCDs can push families into poverty when adequate social protection measures, such as health and disability cover and access to services, are not available.

Evidence suggests that policies which directly target the use of tobacco, alcohol, and obesogenic food and drinks, through taxation, production, and advertising restrictions, can have a positive effect on NCD prevention and control. The UN has been supporting Ministries of Trade and Health in the South Pacific to review import tariffs on unhealthy foods, because we believe that reforming such laws and policies can help reduce the incidence of NCDs.

Public policy in other areas as wide ranging as sport and recreation, transport, urban planning, the environment, access to clean energy, and more could also help tackle the NCD burden.

In March 2012, Margaret Chan, Director General of WHO, and I wrote to the UN Development System's Country Teams of diverse agencies worldwide, asking them to support holistic strategies and multi-sectoral action to tackle NCDs in the wake of the Political Declaration on NCDs agreed at the UN General Assembly's High Level Meeting the previous September.

The post-2015 development agenda and emerging development challenges

Debate is now underway on what the global development agenda should look like beyond the 2015 date set for the MDG targets. There is no question that health should feature in the agenda: the question is what form it should take.

UNDP and its partners in the UN Development Group are leading a large number of national and global consultations on how the agenda should be shaped.

Some advocate having targets for universal health coverage. A resolution passed last month in the UN General Assembly: "Recommends that consideration be given to including universal health coverage in the discussions on the post-2015 development agenda in the context of global health challenges".

In Mexico, the expansion of health coverage - an effort which began in 2004 when Dean Frenk was Minister of Health - has led to significant declines in maternal and infant mortality as well as mortality in children under five years old. In Thailand, the expansion of universal health care increased inpatient care use by poor people by between eight and twelve per cent over a period of five years.

Universal health coverage, however, desirable as it is, will not in itself deliver higher health status. Action on a much broader front is needed, including on tackling the socio-economic determinants of health. That is because various forms of stigma, discrimination and marginalization, rooted in laws, policies and economic, social, cultural, and other factors, have profound impacts on health status, and on whether people will access health services even when they are readily available.

A broader chapeau for a health goal could be envisaged - possibly around "universal health", or maximizing "healthy life" - beneath which specific targets could be set; for example, for progress towards universal health cover and on tackling the drivers of disease. Outcome indicators could relate to life expectancy, premature mortality, and other factors.

Health in the broader context of sustainable development - including the environmental dimension

Achieving sustainable human development becomes very difficult as the world moves towards the edges of its planetary boundaries. This can be most clearly demonstrated with respect to climate change, which is now recognised as a significant threat to development. Its health consequences need to be more widely acknowledged too.

The Intergovernmental Panel on Climate Change has concluded that increases in extreme weather events are already a discernible trend. There is broad agreement that without urgent action the world will move beyond what have been termed its 'planetary boundaries' for climate and on other dimensions. The impacts of that would include the depletion of natural resources; more frequent natural disasters, from flooding to heat waves and droughts; and radical changes in ecosystem dynamics.

These 'environmental' impacts have real economic and social repercussions, including some directly related to health outcomes. Evidence suggests that climate change:

threatens food security and livelihoods, which can increase malnutrition; alters ecosystems, influencing disease distribution through exposure to new pathogens and expanding the influence of existing ones such as malaria; causes natural disasters, contributing directly to injury and death, and to disease related to the destruction of critical infrastructure; and leads to an increase in the incidence of natural resource-related conflicts both within and across borders, particularly with respect to fresh water, with populations being displaced.

Climate change therefore is an environmental, a developmental, and a health challenge. Those groups and individuals already disadvantaged are the most at risk.

As the poor disproportionately rely on access to natural resources for their livelihoods, their economic and social wellbeing is directly impacted by inaction on climate change. Similarly, as women and girls in developing countries often bear the responsibility for collecting fuel and water, the extra burdens when these resources become scarcer and lie further away from home are inequitably distributed. This can mean less time for girls to be in school, or for women to pursue income generating activities which could lift their family's living standard.

The poor also carry a "double burden" of exposure to environmental risks which impacts on their health. They are simultaneously exposed to risks in their immediate home environment, including air and water pollution and lack of sanitation, and to global climate trends such as extreme weather hazards, rising sea levels, and related injury and death, as they often reside in more precarious housing.

The WHO estimates that preventable diseases directly linked to contaminated water and polluted air claim the lives of around three million children under five years of age each year, with these fatalities concentrated in Africa and South Asia. It is sobering to think that this number equates to the size of the entire under-five population of Austria, Belgium, the Netherlands, Portugal, and Switzerland combined.

The UN's Office for Disaster Risk Reduction (UNISDR) estimates that over the past twenty years 1.3 million people have been killed and 4.4 billion have been affected by disasters caused by natural hazards. Climate change is making weather patterns more volatile and extreme events more common. In 2011 alone, almost 30,000 people were killed in 302 disasters, and 206 million people were affected, including 106 million by floods, and sixty million by drought - mainly in the Horn of Africa.

Deaths and injuries from natural disasters are not randomly distributed within countries, or across them. Adverse impacts from these disasters are disproportionately concentrated in poorer countries with weaker governance. Ninety-five per cent of disaster-related deaths occur in developing countries.

While the risk of being killed by a cyclone or flood is lower today than it was twenty years ago, under two per cent of global deaths from cyclones occur in countries with high levels of development, while more than half of all cyclone deaths occur in least developed nations.

Within countries, certain communities may be marginalized and made particularly vulnerable to injury because poverty, lack of legal rights, or ethnic or other affiliation, has led them to reside in precarious informal settlements.

For all these reasons, we need to hear the voice of the global health community on the threat to human health and development posed by climate change.

Conclusion: A call for a stronger public health advocacy and research agenda around current development challenges

How can public health research support policy-making to tackle emerging development challenges with health implications?

The theoretical and conceptual groundwork for doing such research has already been set, particularly through the social determinants approach. The methodological tools are constantly being refined to allow for more credible causal inference.

Multi-level modeling, familiar to researchers at this institution, can contribute to a better understanding of the structural factors which make certain populations and individuals more vulnerable to poorer health outcomes. It is important to take a broad range of factors into account, including the environmental, legal, and political factors which have been studied less.

More research on the links between policies which touch on the core business of development actors - such as employment, housing, and labour conditions; increasing access to health and education; setting urban development and environmental policy; and supporting inclusive social protection programmes - and health outcomes,should be encouraged.

From a life-course perspective, inter-generational perpetuation of disadvantage can have important implications for the future prospects for individuals - including for their health, and for the sustainable economic and social development of communities and countries. Life-course epidemiology can therefore contribute to current debates around sustainable development.

At UNDP we recognize that there are opportunities to support health interventions in settings like schools, workplaces, community meeting places, and public sector institutions. Intervention studies could offer evidence of what could work best, and also of how to use innovation in technology in support of better health outcomes. Examples of the latter include:

the WHO and the International Telecommunication Union (ITU) are testing a mobile phone solution for supporting people in managing their NCDs in Africa, by offering guidance through text messages.

the Clinton Foundation's "Global Alliance for Clean Cookstoves" aims simultaneously to save the lives of women and children currently exposed to indoor air pollution, improve livelihoods, empower women, and combat climate change.

Community-based research being conducted in the Harvard School of Public Health, including the randomized worksite studies for cancer prevention, can also offer tools for combating NCD risk factors.

The remaining challenge then, is to put research into action at the scale needed to see a real impact on population health.

Development and health practitioners share the same goals of tackling inequality and improving the well-being of individuals and communities; yet, they often lack the common language or approaches to find solutions together. This gap is an artificial one, and should be bridged through dialogue and inter-institutional partnerships.

Now more than ever, health and development actors need to work together. The global financial crisis has placed significant constraints on funding for health and development. New and innovative partnerships are needed to prevent human development progress stalling.

At UNDP we welcome all opportunities to link with health sector counterparts: the challenges we tackle in health and development are so often two sides of the same coin. If we tackle those challenges together, we are both more likely to succeed in our missions.

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