Statement on global health and foreign policy at the Campbell conference

(Transcription (excerpt) of the minister's statement)

Thank you so much for inviting me. I will try to explain to you how I come at this issue of evidence. I think the point of departure is that eleven years ago I joined Gro Harlem Brundtland, when she became the Director General of the World Health Organization. I was her chief of staff – in the election campaign, in the transition, and in the two first years of her tenure. And at that moment, as before and after, there was a lively debate about the role of evidence – in medicine, in health – moving on in academic circles, hospitals, health ministries, locally, nationally – all around most of the world.

In the WHO, the challenge we saw was that we needed to take this debate into the organisation. It is controversial – it is based on different evaluation of values, and evidence, and figures and norms, but it is better to have it on the inside -making the organisation a lively place, than making the organisation into an institution which is kind of - relating what happens at the outside.

From a policy point of view, the WHO, which I believe is a unique global public good, is there, but it has to argue its case. To win the attention of policymakers, beyond the health ministers. My first observation I made at WHO, was that health ministers is really not the problem. They basically agree. But they don’t necessarily decide. So we need to build an argument that can reach the presidents, the prime ministers and the finance ministers – arguing that they too are health ministers.

For that to happen, you have to find and present evidence in a way which argues the case for health. I think that was why I was brought into this. When I came into it, it really stuck with me.

So when I became foreign minister – I clearly saw that I can not do foreign policy and developing policy without a solid focus on health. Because I see the importance of health in so many of the key points that underpins conflicts. That it has to be an integral part of solutions. If we want to bring any of these policies forward, we need to cross sectors. Because that was the other thing I learned at the WHO – was that, unless you are able to cross sectors, engage other professions, we are not going too succeed.   

Our national director of health in 1948 in Norway, Karl Evang, who was a co-drafter of the constitution of the WHO, said at the time that “economists are worse than TB!” Well, some still are of that view, and that shows how serious both diseases are.

But I think it is interesting had Karl Evang, who was a progressive politician, been around these days - he would have felt encouraged. Because he could now have seen that economists can be the best advocates of wise health policies. Professions need to be able to cooperate. I have noticed that also as a foreign minister. Unless I focus on the health dimension, and have evidence for that health dimension, my policies has less potential to provide the results that I try to seek.

We have just presented the white paper on Norwegian foreign policy to parliament and we came into that interesting debate that foreign policy is really all about making domestic policy possible. And every foreign policy should have one purpose, namely to defend the national interests.  

But what we learned, of course, and I come back to the same thing as I did with health, so much of what matters to our interests is really beyond the foreign policy sphere.

My ambassador in Stockholm told me - and Sweden is our closest neighbour - that 80 percent of what he does is outside the realm of the Foreign Ministry. Because he had understood what modern diplomacy is about. It is not only taking signals from the Foreign Ministry, it’s also intermaking with culture, science, research – the whole public sphere.

And then again, defining national interests, the evidence for national interest in 2009 - it is a fascinating, but very complex task.  And what we have to explain to people in our public debate is that the notion “far away” it is a place which no longer exists.

If there is a flu outbreak in Mexico, if there is wider debate going on in Geneva, if there is a war in Afghanistan: It is far away, but it directly impacts our interests.  So we have to argue why we engage in all these processes, because it is in Norway’s national interest. 

Tax payers want to know. Norway under this government as reached the target of allocating 1 percent of our GDP to development cooperation. It is a lot of money. Twenty six billion NOK - four billion US dollars every year. Those are high figures.

But people ask to see the return of that money - see evidence of proper spending. And if we, for too long, cannot give you an answer to that question – we are in trouble.

In development cooperation, of course, there is the humanitarian dimension. When there is a crisis, a tsunami, or war or a national disaster, you intervene with tents and medicine, and food and water – and it costs money and you have to intervene.

The long term development aid is trickier. And that has brought us into the area –well it has brought Norway into  its emphasis on health. Because we believe that health both has remarkable stories and evidence of globalisation. If you talk to young audiences - at universities, high schools, and explain globalisation from the perspective of health, people understand. Viruses, travelling, interconnections and so on.

But it is also an area where we can demonstrate that development cooperation has an effect. That is why, over the last years, we have expanded our health effort – because we believe the evidence is good and the evidence is right.

Global health is more than an issue, it is about managing complex international  relations.

Let me mention a few examples:

When the new alliance for immunisation was formed –GAVI – the Global Alliance for Vaccines and Immunization - that partnership was in search of governance. I worked on this issue when I was at the WHO, then I joined government, and the Norwegian government supported that alliance.

Immunisation is an “easy” issue to support for the Norwegian society. Because all parents in this country immunise their children. It is something you can explain – every parent should have the right to do so.   

The prime minister, Jens Stoltenberg, thought about the initiative from three perspectives: “I am a father myself and I know that immunisation is something we take for granted. Secondly, I am an economist and I believe this is a good preventive strategy. And thirdly, I am a politician and I can do something about it”.

So we have invested significantly in the GAVI project and immunization. The WHO -figures estimates that between 2007 - 2008 some 3.4 million deaths have been prevented through immunisation campaigns.

In 2000, the commission of microeconomics and health - led be Jeff Sacks – noted the economic impact of saving lives through these strategies. This is evidence reached finance ministers, the presidents, prime ministers – beyond the health ministers.

Then of course, we have the Global Fund to fight AIDS, tuberculosis and malaria, in which we have also been engaging ourselves. And we have pushed for more results-based management at UNAIDS, and at other organizations.

Let me say that, unless you are able to demonstrate that you make a difference, support will erode. But if you can demonstrate that you make a difference, not only will support for that specific intervention increase, it will increase for the whole area of health. Because we know off course that health is development.

When we talk about health capacity, training the right people, then it is more difficult to demonstrate immediate impact compared to the number of vaccines that we distribute. But I believe that immunisation serves as a very good marker to explain why these other services have to be put in place.

Evidence of impact of our health initiatives is compelling:

The number of children being vaccinated, number of death from measles dropped by over 90 percent in sub-Saharan Africa. You know many of you these results; we need to bring them out to offer hope and inspiration.

But then there are of course critics. Vertical versus horizontal intervention. My view has always been that you should not prefer the one over the other, you have to do both. And I think one can promote the other, and vice versa. So if you do these vertical interventions in the right way, you can also contribute to the broader systemic part of the way we do global health.

By the way, I think that in this world competing for resources, WHO was put into a   very strange position because it was a public organization, which should according to the book be financed by public money, so it would serve the common good. When I was there, ten years ago, we were in the position that we reached the 50-50 state. Fifty percent regulatory contributions and fifty percent voluntary contributions. Now I learned, I spoke to Director General Chan that they had 80 – 20 - Eighty percent voluntary.

Now, on the one hand – it is a great thing because regulatory contributions has not gone down, it is the voluntary has gone up. WHO has been able to demonstrate that they can deliver, and that is a good thing. The questionable thing is that you risk a biased approach to global health – money is put where investment yields highest return - and you will not get that broad consensus decision making only the WHO can deliver. But that is part, I think, of the challenge.

We are also engaged actively in two of the Millennium Development Goals - 4 and 5 put together and 6.

Important progress has been made on MDG 6 on halting and reversing the spread of HIV/AIDS, tuberculosis and malaria. Some success on MDG 4, on reducing child mortality. In contrast, we have failed on MDG 5, on reducing maternal and infant mortality.

But there again, I think that these new tools of health interventions give us a lot of lessons learnt and have improved our ability to come up with new approaches and policies. We see now examples of what we do with Indian government, in some areas – that target and support to pregnant mother – making her go to the clinic and not give birth at home - has reduced mortality for both mothers and children in a way that is quite impressive and we should bring with us to other areas.

I believe that this way of working on the issue of global health – taking it into development policies, taking it into foreign policy, making it part of that broader cycle of policies we need to see more of.

With the new American administration I have noticed a willingness to focus more on health in its foreign policy agenda. I met Secretary Clinton last April, and we decided to increase our cooperation on child health, maternal health, women’s health. And to bring that issue – not only into the health sector, but also into the human right sector. As Norway and the US now has joined the Human Right Council. So it is a new way of making these policies interventions into other areas, where they did not use to belong.

When the foot and mouth disease broke out in Britain in 2000 it spread half around Europe. Norway closed its borders to Sweden, for the first time since 1814. I remember at that time, I was working with the Prime Minister, the decision to close the border was easy. But before we did it we said that opening it would be very hard. Because then you have make sure that you can say that now everything is completely safe. Let me also mention the SARS epidemic: When Dr. Brundtland issued travel advices concerning strategic cities around the world, it was a highly sensitive issue. It illustrates how health all of a sudden can come to the table of foreign ministers.

When I became foreign minister, I wanted also to se foreign policy through a “health lens”, and in 2006 I invited colleagues from six other countries – which were strategically chosen – France, Brazil, Indonesia, South Africa, Senegal and Thailand. We had all regions present. And we tried to create a network on foreign policy and health. Since then, we have had one big meeting at the UN General Assembly – with around fifty foreign ministers, coming from all over the world to discuss these themes, and the experts of these seven countries are meeting regularly to study more in depth how foreign policy makers will meet issues of health in their daily work.

And we can do that because we have more evidence of what is happening. Right now for example, at the World Health Assembly, the virus sharing issue is there - a very key issue. God knows it is foreign policy related, it is security related. Because those countries who refuse to give up their viruses to a greater common good, they don’t do it because they simply want to sit on it, but they want their share of the value.

I think it is a highly appropriate issue to address. But it is being cast into something which is foreign security policy and we have to look into it.  

I think finance ministers should take a broader approach to health issues, not only seeing health as an expenditure, but as an investment. But to do so, they need to have the right evidence. So let me conclude simply by saying that when you discuss evidence during this seminar you will, and you should, focus on the right evidence for interventions and for public policy in health. And I think you are leading the way both in a very important and complicated complex methodology issue.

What I try to bring to the discussion is to say that others, outside the health sector per se need that evidence as well. We need a cross sectoral approach, and we need to approach evidence from a very broad perspective in the way we formulate our policies. I am grateful that the health sector has led the way and that you are inspiring other sectors.

Thank you for your attention.