Minister of International Development Hilde F. Johnson

The Role of Global Health Research in the Fight against Poverty: Why do we need a new research programme on global health issues?

Bergen,22 September 2004

Check against delivery

The Ancient Greek physician Herophilus (335 BC-280 BC) once said that

“ When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.”

Herophilus and his colleagues became the founding fathers of modern medicine, and his words ring as true today as they did in ancient times. When health is absent, great potential is lost. This is why health research holds such a unique place in the fight against poverty, the fight to allow all people to use their potential to the fullest.

I am pleased to see so many of you here today, ready to discuss the link between poverty and poor health. This link seems obvious to us today – and has seemed obvious to the poor themselves for a long time. But until recently, it has been sadly neglected in mainstream development thinking.

Introduction: the link between poverty and poor health

In the World Bank study Voices of the Poor, where more than 60 000 poor people from all over the world were interviewed, health and ill health emerged as a central concern. A fit, strong body is an asset that enables poor adults to work and poor children to learn. A sick, weak body is a liability, both to individuals and to those who must support them.

Poor families in particular are concerned about the health of their breadwinner – when he or she dies, or needs expensive medical treatment, the costs can be devastating. The family may be thrown into a cycle of poverty from which it can never escape.

The study compares poverty to “walking a tightrope...without a security net”, and health is a critical and decisive determinant of how long one is able to keep one’s balance, survive without a security net.

This is why health is at the core of the Millennium Development Goals. Some of these goals are directly linked to health, such as reducing child mortality, improving maternal health, and combating HIV/AIDS. Other goals are indirectly linked, such as eradication of extreme poverty, empowerment of women and achieving universal education. Indeed, all of the MDGs are in some way linked to health issues, and none of them can be reached without a strong focus on aspects of health.

We know that ill health creates poverty, and that poverty creates ill health. If you are sick, you cannot generate income. You need to spend money on expensive medicine, and you need other people to care for you.

Poverty leads to ill health because of poor and polluted living conditions, poor nutrition, inadequate health services, lack of clean water, low education levels and lack of appropriate and accessible information.

The family’s productive capacity is reduced because members of the family have to spend time, energy and the little money they have caring for the sick. More often than not, the poor do not have access to insurance or other kinds of protection or assistance from public or private systems. Health problems in the family also limit children’s educational opportunities. It becomes a vicious cycle – and the effects can last for generations.

For the national economy, the consequences of ill health in the population are reduced productivity, higher expenses for treatment, and additional expenses to train a replacement workforce. In many developing countries, the AIDS pandemic has led to a situation where you have to educate two people in order to be sure that at least one of them makes it into the labour market. The pandemic may translate into a dramatic GDP drop in the most heavily affected countries.

Illness is expensive – for the individual, for the family, for the government, for the continent. Take tuberculosis, for example, which is still a common disease in many areas. On average, tuberculosis treatment costs the patient three to four months’ salary. Or malaria - the effects of malaria are reducing economic growth in Africa by 1.3 per cent a year. Some analysts even say that malaria is as bad for African health and economies as HIV/AIDS!

If we are to win the fight against poverty, it is abundantly clear that we need to reduce vulnerability to disease, and dramatically improve our response to health needs in the developing world.

There is ample evidence that investment in health has a high rate of return. This has been pointed out by the Commission on Macroeconomics and Health, and in subsequent reports from the OECD/DAC, WHO and the World Bank. Investment in health is likely to benefit not only the individual and the family, but the economy as a whole. In fact, the Commission turned the arguments around, and saw investment in health as an investment in economic growth rather than purely a government expenditure.

For this to happen, a range of conditions must be met, such as good governance of health services, a focus on prevention and targeting the poor.

The recent white paper on development policy reiterates the importance of the health sector as a Norwegian priority. Health issues must remain high on the international development agenda – in Norway, among other donors and in the developing countries. We need to substantially improve our knowledge and increase the availability of medicine and technology if we are to reach our ambitious goals by 2015. We need more resources – to spend on improving current tools and management, yes – but also to spend on new research. Successful public health campaigns will depend on this.

But we know that the global resources available for health research for the poor are far from sufficient. There is an enormous financing gap - what we call the 10/90 gap. This is one of the most glaring examples of global injustice.

Less than 10 per cent of the resources invested in health research are devoted to the diseases or conditions that account for 90 per cent of the global health burden – the diseases of the poor. Less than 10 per cent! This is not only unfair - it is morally indefensible. And if 10/90 does not sound bad enough, let me give you something even worse, from my own country: 5/90. In Norway we spend only 5 per cent of our health research funds on diseases that affect the world’s poor. We – the richest and healthiest part of the world – simply cannot justify such figures. We have an obligation – and, I believe, also a self-interest – in addressing the global burden of disease. We cannot let narrow profit interests rule. We must make sure that research is in tune with reality. We must find the resources necessary to address world health problems – not only because it is the right thing to do, but also because it will benefit us all in the end.

The poor - health challenges

The inequality we see between developed and developing countries in the health sector is shocking. A woman in a poor country is over 100 times more likely to die during pregnancy and childbirth than her counterpart in a developed country.

Maternal mortality and morbidity and child mortality are also much higher among the poor than among the better off in the same country. And as in so many other areas, poor women and children are last in line for quality health care, and have to live – or die, as is often the case – with only the scraps that are left over when the men have been taken care of.

Even in rich countries, gender discrimination in health care can be a problem. But in the developing world, such discrimination is more often the rule than the exception - an enormous injustice on the global level.

We need a stronger focus on the health problems of particular concern to the poor. This means focusing on:

• High levels of childhood diseases as well as perinatal and neonatal mortality and morbidity
• Reproductive ill health, particularly maternal morbidity and mortality
• TB, malaria, HIV/AIDS
• Neglected tropical diseases.

We know why the poor are hit so hard by these diseases. Lack of access to health services because of distance or costs is one reason. Inability to take full advantage of existing health services is another. In three of these four areas, we have the means to help, but we are short on access and delivery. In other words, we know what the problems are – and they can be fixed, if we are willing to share the resources that are available.

We have the resources – but we need to re-think our priorities. As Mahatma Gandhi put it:

“There is enough for everyone's need but not for everyone's greed.”

The contrast between the health care available to citizens of rich countries, and that available in the developing world is stark. The poor cannot pay for health services and modern medication; they do not have access to transportation; and on top of it all they often feel unwelcome at clinics. They may prefer traditional medicine as it is cheaper and more readily available, and they may prefer the more welcoming attitude of traditional healers. These are understandable, but potentially dangerous choices – choices they should not have to make.

Access to and utilisation of appropriate health services are key factors in reducing morbidity and mortality - yet the tools to measure the coverage and use of services are woefully inadequate. We know far too little about the reasons behind the low utilisation rates. We need to learn more – through appropriate and adequate research conducted “on the ground”, in the real world, where real people are struggling every day.

One area of particular importance here is user fees. Out-of-pocket spending for the poor is high, and the money is often spent on low-quality or inappropriate treatment. The rural poor in India and China have to pay about 85 per cent of health care cost themselves - much of it spent on unnecessary or inappropriate drugs.

It is still too early to draw firm conclusions with regard to user fees. Many countries have introduced such fees as part of their health care reform, but we need more knowledge here.

We also need more context specific research on health systems, service delivery modalities, and on how best to set priorities in resource-constrained environments. This includes more and better information on health care financing, on personnel issues, on the implications of the AIDS pandemic for sustainable services, and on the role of the public sector. We need a sounder evidence base for stakeholder dialogue and decision making. And then we must find ways to translate research findings into effective policy – a complex, but crucial task.

Poor countries face particular challenges in building strong and sustainable health systems. Financial management and health personnel issues are key here – both severely affected by the brain drain problem, which is enormous. For example, 75 per cent of the nurses educated and trained in Ghana are now working abroad. More Ugandan doctors are working in South Africa than in Uganda .

In Malawi, one of Norway’s partner countries, only one in five of the nurses educated in 2003 started working in the public sector. The country has been unable to fill 64 per cent of the nursing jobs in the public sector. And on top of that, large numbers of the doctors and nurses who remain in their home country fall ill themselves, victims of HIV/AIDS.

Inadequate training systems, inadequate efforts to retain people, inadequate financing, inappropriate “stealing” of health personnel by rich countries - this all adds up to a pretty bleak situation for the developing world.

The situation is unfair – and unsustainable. We have to act, we have to look at our own role in improving the situation. These are common problems - and we need to find common solutions.

Knowledge gaps - where should we increase our effort?

We do not do enough - and we do not know enough. Let us take at closer look at where the main gaps are.

According to the 10/90 Report on Health Research 2003/2004, two types of knowledge gaps are of crucial importance:

Type 1 gap: The existing knowledge and technology in a variety of disciplines is not applied in a systematic, efficient or effective way.

Type 2 gap: The knowledge and technology do not exist, and new and more research is needed.

On the type 1 gap

The potential benefits of existing technologies are far from fully realised. Despite the availability of medicines that are relatively cheap and easy to deliver, there are still high levels of child and maternal mortality due to easily preventable diseases and complications. In order to change this, we need not only better access to health services, but also more extensive implementation and operational research.

There are still a number of unanswered questions related to health services for the poor. We must find out how to make services accessible, available and acceptable to the poor, the most vulnerable group in any society. Their voices must be heard – their urgent needs must be met. Funding for research is crucial.

The non-biomedical sciences play a crucial role in this area, and have been largely underfunded. Considering the potential they hold for improving access to health services and education, and for improving the environment, this is unacceptable. The social sciences can improve our knowledge of the most effective and efficient ways to promote health and encourage preventive action among the poor through education and environmental measures. This must be part of our comprehensive effort.

We also need more updated and appropriate health information with disaggregated data according to socio-economic status as well as gender and age. With the current health information systems, we actually have problems measuring development in indicators for the MDGs in many countries.

With the household data that is collected in national surveys in several of our partner countries, which includes baseline data, we might find new opportunities to strengthen monitoring and follow-up based on health indicators.

On the type 2 gap

Two of the most pervasive diseases in the developing world, malaria and TB, have until recently been sadly neglected. Fortunately this has changed in the last few years, and both funding levels and attention levels have increased. We still have a way to go to secure better and cheaper drugs, but we are making progress.

But the neglected diseases remain the diseases of the poor.

Tropical diseases such as Chagas disease and sleeping sickness remain virtually ignored in terms of research and drug development. These diseases are often limited in geographical scope, but affect a large number of people. The pharmaceutical industry, driven by market-based systems, clearly fails when it comes to neglected diseases like these. We have seen some promising steps in building public-private partnerships to develop malaria vaccines and microbicides, but the most neglected diseases remain outside the radar screen of regular pharmaceutical research. How can we address this problem?

• By appealing to the ethics/CSR of the pharmaceutical companies
• By increasing public funding
• By building public-private partnerships
• By improving policy coherence
• By improving access to cheaper medication (not only HIV/AIDS, malaria, TB)
• By introducing compulsory licensing (TRIPS Art. 31): Norway was one of the first countries to implement this decision.

And we need a stronger focus on women. About 70 per cent of the world’s poor are women – who are last in line for health research and political attention. If we are to succeed, it is imperative that we improve gender sensitivity in health research.

The need for joint efforts to strengthen research inNorwayon global health issues

The Government’s white paper on development policy underscores the dignity of every individual – a dignity that is universal and indivisible. Norwegian development policy is based on the fundamental principle that all people are equal, all people are entitled to the same respect, the same human rights. There are no exceptions – not for children because they are not adults, not for women because they are not men, not for the poor because they are not wealthy. Development policy becomes a human rights agenda.

A rights based approach to development recognises the right to health as fundamental. According to the Universal Declaration of Human Rights, everyone has the right to “a standard of living adequate for the health and well-being of himself and of his family”. Health issues are central to the MDGs – health issues are central to Norwegian development policy. The promotion of human resources development, health care and education will remain top priorities.

Health is also a policy coherence issue. We must ensure consistency between our national and our international actions, and make sure they align to improve conditions in developing countries. Policy coherence means that we must identify policy fields where international action is needed. But policy coherence also means that we must undertake policy changes in the industrialised countries to improve framework conditions for developing countries.

The white paper states that the Government will establish a research programme to enhance the efforts of public and private research institutions in Norway to resolve global health issues.

Funding the new research programme has to be a joint effort between the public and the private sector, between the funding agencies and the Norwegian research institutions, and between the different ministries.

The first major challenge is to build public-private partnerships (PPPs) in support of research on global health issues in Norway. In the past, the private sector in Norway has lagged behind the private sector in other OECD countries in funding for research and development in general, particularly with regard to funding for research outside their own corporations. The health sector is, unfortunately, no exception here.

The second challenge is to mobilise the resources of the Norwegian health research institutions, together with public and private funds. For the new research agenda on global health issues to succeed, the Norwegian research institutions themselves will have to contribute time and equipment. The projects submitted in the first, limited round of project applications for the new research programme earlier this year strongly indicate that the institutions are on board – that they are taking on this common challenge.

The third challenge is to mobilise funds from the budgets of several ministries. I mentioned earlier the 5/90 situation that we have in Norway, which is worse than the international average. We need to spend more of the resources allocated over the national health research budget in Norway on global health research, particularly on the diseases of the poor.

But if we are to rectify the 5/90 gap in Norway, a new research programme on global health issues must draw on resources beyond the development co-operation budget. We will make a substantial contribution, but we cannot carry the burden alone. So far, we have allocated 6 million kroner (3 million in 2003 and 3 million in 2004) to the new research programme over the development co-operation budget. This is a start: the seeds of bigger things to come. Research on global health issues cannot be improved overnight – it must be consistently given priority over time. In order to succeed, we need other ministries to step up and at least match the funds already on the table.

Our comparative advantages in health research

And we have something to build on.

Norway has a number of competent researchers who are knowledgeable in areas of research relevant to fighting the poverty diseases and addressing key global health issues.

Two of our universities, in Oslo and Bergen, boast highly competent health research teams. Research in Norway on health and diseases in low-income countries has so far been concentrated at these two universities. At both universities, there is a strong tradition for building research programmes across academic disciplines, particularly as regards research on development issues and the South.

The University of Bergen has (in collaboration with the Haukeland University Hospital) succeeded in establishing a very strong and dynamic environment for international health research, the Centre for International Health at the Medical Faculty in Bergen. The Centre is well known for its teaching and training programmes, and co-operates closely with policymakers and researchers in our partner countries. A similar centre has also recently been established at the University of Tromsø.

We also have much to offer in health systems research. The newly established Competence Centre on Health Services is an important addition that will further enhance our knowledge in this crucial area.

There is no doubt that the rapid progress needed in meeting the MDGs in the health field is greatly hampered by weak, poorly functioning or, in some cases, non-existent health systems. In some important respects, the situation in the health field today resembles the challenges posed by environmental issues a few decades ago.

We know quite a lot about the problems. We know much about the technical solution to problems. But we understand far too little about the obstacles to implementing sensible policies. Much is known about the barriers or constraints on greatly increasing and ‘scaling up’ health services. But remarkably little is known about how best to relax these constraints, whether through reformed service delivery strategies, different human resource management policies or new organisational structures.

Norwegian health researchers and health system professionals in general are highly skilled in communicating their views to policymakers and officials in the central administration. Some would call you the top political lobbyists among Norwegian professional interest groups. An interesting challenge would be to see if an analysis of these processes of formal and informal interaction between health professionals and policymakers in Norway could generate useful knowledge for health system analysis in the South.

Capacity building in low-income countries is an essential element when we allocate financial resources to research and higher education over the development co-operation budget. We have a long tradition of research collaboration between Norwegian institutions of higher education and research, and their partners in developing countries, first and foremost through the NUFU programme. Health research and co-operation in advanced training for the health sector remain priorities for the NUFU programme.

Norway supports international health research through a number of international initiatives, funds, networks and organisations. In all these efforts, we emphasise the need for partnerships with health professionals in the South in order to enhance research competence and capacity-building in our developing partner countries. The new research programme on global health issues must also build on strong partnerships with developing countries. Norwegian health researchers who are engaged in research to fight poverty-related diseases in developing countries must work in solidarity and partnership with health researchers in the developing countries. Only then can we make sure that the poor will gain lasting benefits.

Norway should be in an excellent position to contribute scientifically and technically to reducing the 10/90 gap by starting at home – by making a major effort to overcome the 5/90 gap in our own health research.

I believe we can meet the challenges of the MDGs - provided we make a concerted and sustained effort to achieve policy coherence and to meet the health targets we have set.

Richard G.A. Feachem, Chair of the Global Forum for Health Research, said that:

“Without a quantum change in health research and a re-orientation of research towards the key health priorities of the world, we will not win the war on poverty, we will not reach the Millennium Development Goals by 2015, and we will not succeed in the fight against AIDS, tuberculosis and malaria”.

This conference is an important step in bringing us forward. I would like to thank you all for taking part in out common quest for a better, fairer and healthier world, and to wish you every success in you future efforts.

I would like to close by quoting an Arab proverb:

“He who has health has hope, and he who has hope has everything.”

Let us do everything we can to bring hope to many more around the globe.

Thank you.