WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 105th Session Provisional agenda item 2 EB105/5 14 December 1999
Poverty and health Report by the Director-General
1. More than one thousand million of the world’s people have been excluded from the benefits of economic development and the advances in human health that have taken place during the twentieth century. At the start of a new century, WHO is committed to playing its role, within the United Nations Development Group and in partnership with other members of the international community, in mounting a global response to the challenge of reducing poverty. 2. Deciding how WHO can achieve the greatest impact, in ways that recognize the Organization’s strengths and limitations, is critical. This paper sets out the rationale for, and the main components of, a new approach which aims to focus WHO’s expertise and resources more closely on improving the health of the poor. It outlines a strategic framework, applicable to both the WHO Secretariat and Member States, and proposes a series of principles to guide country support. 3. The paper represents work in progress and is designed to stimulate discussion. Several unresolved issues concerning the implications of a poverty focus for the work of WHO are highlighted in the final section.
WHAT ARE THE CHALLENGES? 4. The basic facts are increasingly well known. About 20% of the world’s population, or 1300 million people, live in absolute poverty with an income of less than US$ 1 per day. Surviving on less than US$ 2 per day is a reality for almost half the people on the planet. Aggregate figures for economic growth disguise the fact that the number of people in absolute poverty is still rising. 5. Although poverty cannot be defined by income alone, the resulting inequalities in health outcomes are stark. To take some examples: those living in absolute poverty are five times more likely to die before reaching the age of five, and two-and-half times more likely to die between the ages of 15 and 59, than those in higher-income groups. Differences in maternal mortality are even more dramatic: the lifetime risk of dying in pregnancy in parts of sub-Saharan Africa, where almost 50% of the population live in absolute poverty, is one in 12, compared to one in 4000 in Europe.
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WHY IS BETTER HEALTH AN IMPORTANT COMPONENT OF POVERTY REDUCTION? 6. Ill-health is both a cause and a consequence of poverty. Illness can reduce household savings, lower learning ability, reduce productivity and lead to a diminished quality of life – thus creating or perpetuating poverty. The poor in turn are exposed to greater personal and environmental risks, are less well nourished, have less exposure to information, and are less able to access health care. They are therefore more at risk of illness and disability. 7. The other side of the coin – that better health can prevent or offer a route out of poverty – has been given less attention. Evidence now shows that better health translates into greater, and more equitably distributed, wealth by building human and social capital and increasing productivity. Healthy children are better able to learn, while healthy adult breadwinners are more able to work and provide for their families. The significance of these findings is clear: to move from a vicious, to a virtuous, cycle, means focusing resources on improving and protecting the health of the poor.
WHY DOES WHO NEED A NEW APPROACH? 8. There are many examples of how WHO’s work already benefits poor people: the campaign to eradicate river blindness, the strategy of directly observed treatment, short-course (DOTS) to combat tuberculosis, implementation of essential drug policies – to cite just a few. Neither is a concern for poverty and equity new in WHO. Promoting equity has been a cornerstone of health for all for over 20 years. Moreover, addressing inequities in health is central to the work of several WHO regions and features prominently in the health-for-all targets set by many Member States. These efforts are underpinned by a series of Health Assembly resolutions. In 1998, for example, when WHO recommitted itself to ensuring universal access to health services, resolution WHA51.7 emphasized the importance of reducing social and economic inequities by paying greatest attention to those most in need or affected by poverty. Resolution WHA52.23 (1999) requested the Director-General to strengthen the capacity of the health sector to participate in multisectoral efforts which address the root causes of ill-health, such as poverty. 9. Nonetheless, several factors argue for a new approach. Seeing health as a means of combating absolute poverty locates WHO’s work in the broader development context. It thus provides a clear focus within the framework of the Organization’s ongoing work on equity. In addition, a renewed effort recognizes that progress to date has been limited. Lastly, a focus on health in the context of human development will require new ways of working, and changes in the way WHO uses resources. It will require a collaborative effort with other partners. In other words, it will reinforce the wider process of WHO reform.
HOW HAS THE INTERNATIONAL CONTEXT CHANGED? 10. Over the past decade, the international development community has given top priority to poverty reduction. Commitments – summarized in the International Development Goals – have emerged from a series of international summits, including the United Nations Conference on Environment and Development (1992), the International Conference on Population and Development (1994), and the World Summit for Social Development (1995).
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11. The o verarching goal is to halve the number of people living in absolute poverty by the year 2015. This, and the other development goals – three of which are concerned with health1 – were reiterated as pledges in the closing statements of the annual meeting of the World Bank and the International Monetary Fund in 1999. The challenge now for the United Nations is to use its authority and influence to mobilize the whole international community behind the international targets for poverty eradication. To this end, the United Nations Development Group is preparing an action strategy to address poverty reduction, and the United Nations General Assembly (Geneva, June 2000) will review progress since the 1995 Summit. 12. In summary, there is now a strong impetus, and an important opportunity, not only for WHO to make health more central to economic and human development, but to provide leadership within the community of organizations committed to improving the health of the poor.
HOW CAN WHO INFLUENCE INTERNATIONAL HEALTH AND POVERTY? 13. WHO can influence international action to reduce poverty and promote health in several ways.
• As a knowledge-based organization with a global mandate. WHO is well placed to generate and disseminate information on the relationship between health and economic development; to document best practice with regard to improving and protecting the health of the poor; to examine the health impact of globalization and economic, trade or other development policies; and to design better measures to monitor health inequalities. Monitoring the performance of national health systems will add to the vital body of knowledge, necessary to inspire and implement change. • Through partnerships in the international community. In the context of development cooperation WHO is promoting the adoption of pro-poor health and public policies as part of the overall campaign to reduce poverty through mechanisms such as the United Nations Development Assistance Framework (UNDAF), the World Bank’s Comprehensive Development Framework, and the revised debt relief initiative; through sector-wide approaches; and through WHO’s growing network of relationships with the World Bank, the International Monetary Fund, regional development banks, the Commission of the European Communities, OECD, WTO, and other organizations of the United Nations system. • Through its relationship with Member States. WHO can catalyse action on the part of national governments to make the health of the poor a priority, collaborate with Member States to incorporate health strategies into poverty reduction policies, and promote pro-poor health and public policies.
WHICH HEALTH STRATEGIES ARE EFFECTIVE IN REDUCING POVERTY? 14. Selecting health strategies to reduce poverty requires a sound understanding of why the poor suffer greater mortality and morbidity. Interventions which rely on the health system for their delivery will be inadequate if the poor do not have access to organized services. Moreover, even if universal access to health services were possible, it is unlikely that this in itself would be sufficient. The reason is that many of the determinants of ill-health, and thus the means for bringing about significant 1 The health-related International Development Goals are: a two-thirds reduction in under-five mortality rate by 2015; a three-quarters reduction in maternal mortality by 2015; and reproductive health services for all by 2015.
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improvements in the health of the poor, will depend on developments beyond the health sector. An approach is needed which combines investment in health more broadly with better focused investment in health systems. 15. A health strategy to reduce poverty should include the components described below.
16. Acting on the determinants of health by influencing development policy. Equitable distribution of the benefits of economic growth is central to reducing poverty. Similarly, it should be WHO’s ambition to maximize the health benefits of policy for labour, trade, agriculture, micro-credit, environment and other aspects of development. Success will depend on strengthening the capacities of ministries of health to take the lead in cross-sectoral initiatives, and continuing to build on WHO’s widening network of relationships, at all levels of the Organization, beyond the traditional range of health sector partners. 17. Reducing risks through a broader approach to public health. The challenge facing governments is to improve the access of the poor to basic public health services, including safe and adequate food, clean water, and sanitation. Beyond the traditional domain of public health, however, the poor are more exposed to violence and environmental hazards, and are likely to suffer more during conflict and natural disasters. WHO’s experience in emergency preparedness, disaster management and the promotion of healthy settings (e.g. cities, workplaces, schools, homes) are particularly important in this regard. 18. Focusing on the health problems of the poor. A small number of conditions affect the health of the poor disproportionately. WHO can support governments by providing the tools and guidelines needed for implementing an optimal set of cost-effective health service interventions to tackle these specific problems. Information on the costs and benefits of interventions can also be used to influence the spending of national governments and development agencies. In the first instance, design of a set of core interventions would bring together work in such areas as immunization, integrated management of childhood illness, adult lung health, integrated management of pregnancy and childbirth, and reproductive health. 19. Ensuring that health systems serve the poor more effectively. Beyond assuring the capacity to deliver essential services, there are several other characteristics of a pro-poor health system. At a minimum, it is one which ensures access irrespective of income, and treats clients with dignity and respect. It protects poor people from unsafe practices and financial exploitation in both public and private facilities. It should also protect people who are not already poor from impoverishment due to the high costs associated with major illness. WHO has a role in advising governments on the reforms needed to achieve these objectives. In addition, there are several strategies, for example, targeting of services, improving outreach, and involving the poor in health care governance, in which analysis of different experiences across countries would be of particular benefit.
WHAT PRINCIPLES WILL GUIDE WHO’S COUNTRY SUPPORT? 20. To implement the strategy described above, the support WHO provides to countries will be guided by certain principles. • Ensuring nationally led and owned policies, adapted to the local context. Although the broad principles and strategies for improving the health of the p oor are common to many countries, entry points, terminology and approaches need to be country specific.
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• Working in partnership. WHO will achieve little by working in isolation. Partnerships with different parts of government, with development partners, nongovernmental organizations and civil society will be essential. Furthermore, health can be an effective component of a national poverty reduction strategy only if it is part of a coordinated multisectoral effort. UNDAF, UNDP’s approach of sustainable livelihoods, the World Bank’s Comprehensive Development Framework, and discussions about the use of funds freed up by debt relief, provide ways of coordinating the work of governments and development partners in which WHO will actively participate. • Drawing on the resources of “one” WHO. Several regional and country offices have considerable experience of providing support to governments in their efforts to tackle problems of poverty or equity. Drawing together that experience to facilitate learning across WHO will be an important step in further developing poverty-reducing health strategies. • Integrating gender and human rights perspectives in strategies. Poverty affects men and women differently and these differences must be reflected in the approach to be adopted. Human rights instruments will also be useful for gaining support for poverty-reducing health strategies. • Listening to the voice of the poor. The poor have assets and capabilities that can be built upon to sustain their livelihoods, and opinions on the most effective approaches to development. WHO will encourage governments to use approaches which foster greater participation of the poor, or their representatives, in the design of policies and programmes.
STRATEGIC ISSUES 21. Devising a poverty-reducing health strategy raises a number of strategic questions, set out below. 22. Focusing on absolute poverty. Most development organizations have started to concentrate their resources almost exclusively on the reduction of absolute poverty. Given its global health mandate, the situation for WHO is somewhat different. Contributing to the eradication of absolute poverty is an important new priority, but it must be located within a broader concern about the health consequences of relative deprivation and inequity in all parts of the world. The strategic question, therefore, is how and to what extent should WHO give priority to the health of the poorest in the world? 23. A strategic balance. The four components of the strategy outlined above, all of which are essential in addressing the health needs of the poor, are consistent with the four strategic directions in the proposed corporate strategy for the WHO Secretariat.1 The question, however, is how WHO should allocate its resources between the four components – given the Organization’s present capacity, its advantages compared to other organizations, and the roles and responsibilities of headquarters and regional and country offices. WHO’s traditional strengths lie in the design of technical interventions and the promotion of p ublic health. But to address the key determinants of health of the poor, WHO also needs to strengthen its ability to influence economic and development policy, the main thrust of the first component. 24. Focus within the health sector. Balance among the components more directly concerned with the health sector is also an issue. WHO has developed a clear competitive advantage in the design of 1
Document EB105/3.
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cost-effective core interventions. Technical support for such interventions should increasingly become the focus of WHO’s work in countries. Experience has shown, however, that advice on cost-effective interventions alone has limited impact on the way governments design systems or allocate their own resources. The question is how to ensure that attention is given, first to other strategies for influencing government and donor spending and, second, to a range of other health systems issues that determine whether the poor have access to quality services. 25. Assessing WHO’s performance. The International Development Goals provide an overall measure of progress toward a healthier world. However, two issues arise with regard to the way they are used. First, there is the concern that the Goals are not sufficient as indicators for WHO or for Member States because the health targets do n ot focus on improving the health status of the poor. Second, they represent a target for governments and development organizations acting collectively. If poverty reduction through better health becomes a key component of the proposed corporate strategy for the WHO Secretariat, yardsticks will need to be determined by which to measure WHO’s contributions. 26. Clarifying roles across WHO. WHO has conducted research and analysis of health inequalities between rich and poor at both global and regional levels. At the same time, it has invested resources at different levels to support Member States in determining targets, policies and strategies to reduce those inequalities. Greater synergy could be achieved by identifying the roles and activities best suited to each level in view of their strengths, and by integrating planning and programming throughout the Organization.
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