Global Health and the Foreign Policy Agenda

Based on a transcript of the speech.
Check against delivery.

This afternoon I would like to share with you what I would call a personal journey, which has meant a great deal to me and helped to shape some of the key ideas that we are working on now.

You might ask why a foreign minister has been invited here to talk about health. Surely we have health ministers for that. I will try to answer this question, and in doing so I will touch on some of the issues that Jeff alluded to in his speech.

I was brought into the field of global health in 1997, when Dr Brundtland, the outgoing Norwegian Prime Minister, decided to run for Director General of the World Health Organization. And I was invited in on her team.

In the autumn of 1997, we campaigned in Africa. It is quite a tough job running for the post of Director General of the WHO because you have to get enough votes in the executive board from all different parts of the world. While I was travelling in Africa with Dr Brundtland, I saw things that I had never really seen before. I saw that health issues had important implications extending far beyond the health sector. And how incredibly important human health, national health and global health were to so many of the dimensions of society.

I remember when we arrived in Botswana, a country that Norway has worked closely with for many years. We had just concluded our development cooperation with Botswana because the country had made so much progress. Life expectancy had risen to 70, which is quite sensational in an African context.

But while we were there, researchers from the University of Harare published new figures that readjusted average life expectancy in Botswana to 35 years. This was in 1997, when the first AIDS figures really started to make an impact.

And we could literally see and feel the consequences for the population, for the integrity of the state. What would happen to the teachers, the police, the army, the civil servants, the mothers and fathers?

Then we went on to Angola, which had a seat on the board of the WHO and was going to cast its vote. There we met with the Health Minister, and I discovered that the Minister was not in the Angolan cabinet, not in the inner circle of government.

I then developed my own thesis that there is a negative correlation between the weight of the health challenge and the influence of the health minister.

In my country, as in other developed countries with good health status, you win or lose an election because of health policy. Whereas in the poorest countries, health is all too often simply given low priority.

When Dr Brundtland was elected and took up her post in Geneva, one of the first things she said was that our main challenge is not to deal with health ministers – because they know the problems. It is to try to get through to presidents, prime ministers and finance ministers, and give them this simple message: you too are health ministers.

We need to find new ways of portraying health expenditures as more than costs, but also as an investment.

And we need to develop a new language and a new mindset that will enable us to reach and communicate with the real circles of power. Health professionals are too focused on their own field and have a limited ability to communicate with people in other sectors.

This is really an extension of conclusion of the Brundtland report, Our Common Future. We need to get to the core of the economic dimension and speak a language that people with power really understand.

We need to establish a link between investing in health and improving the health status of the population – of the productive fabric of society.

We need to convince political leaders that if we do these things, there will be more to share. If they fail they will be wasting their opportunity as a political leader.

This is in fact what brought us to Jeffrey Sachs. We wanted someone who could convene some of the world’s leading economists with experience in these areas to work on documenting what everybody could see – that if you are poor, you are more likely to have poor health. But it is less well documented that poor health in itself breeds poverty, creating a vicious spiral. So we were convinced that we had to get this down on paper and document it and its implications.

Jeffrey Sachs’ commission presented the report at the end of the year 2000. I am certain that the process we launched then contributed to the methodology used in devising the MDGs.

The study documented how appropriate, timely action can save 8 to 10 million lives a year.

That in itself would be a real humanitarian gain. But such action would also help to increase life spans, productivity and economic wellbeing, especially of the poor.

But the study also documented that this will not happen by itself. There has been a prevailing idea that as long as countries continue to develop, health will simply follow. This is not the case.

So there is a need to scale up the spending on health, by the poor countries themselves, and by better targeting development assistance for health. The report is particularly valuable because it demonstrated how affordable this operation could be. It documented the difference it would make if rich countries devoted one tenth or one per cent of their gross national income to health-targeted development assistance for specific interventions.  

That would be an investment that would be repaid many times and save millions of lives every year, and it would provide economic development and global security.

There were many who criticised this approach, which is a good thing because it stimulated debate. Many argued that there are too many vertical interventions, such as bed nets and vaccines. And that the approach to health care should be much more horizontal.

But these approaches can be combined. Unless we have a massive focus on what is literally on our own doorstep, we can forget about the horizontal process, and about making tangible differences in health.

Another conclusion of the report was the importance of partnership – which I believe is really a key lesson. Partnership is a simple word, but a very complex thing to practise.

The Sachs Commission concluded that more development assistance should be targeted towards health, while poor countries should allocate more money for health over their budgets.

It is only if this works together that it will make a difference. Partnerships between rich and poor, partnerships between the private and the public sectors.

Some said that this was going to be a great challenge for the UN. Why are we inviting the private sector in? Isn’t it the UN that has the mandate to do these kinds of things?

Remember that the idea of public-private partnerships still was quite new as it first emerged as an idea in the 1990s. We felt that in the WHO, working with Dr. Brundtland, the way she reached out to the private sector, was being criticised by those who said “it says in our mandate that we are the leaders in health”.

But let’s not forget that it was Kofi Annan himself who invited other sectors to join the global fund to fight AIDS, TB and malaria. To mobilise 10 billion dollars every year to make a difference.

So if the UN had not embarked on that course, I think the idea would have been marginalised. 

There were a number of other areas that started to attract attention. Vaccines for example.

A major effort by the WHO and UNICEF in the 1990s had brought coverage up to 80 per cent. A very high level. But since 1990, there has been stagnation and almost status quo.

How do we mobilise a new campaign for vaccines? How do we create new markets for malaria medicine?

At that stage, I left Geneva and went home to Norway. There was a new Norwegian government and I started to work with Prime Minister Jens Stoltenberg as his chief-of-staff. When the first Stoltenberg Government took office in March 2000, the Prime Minister decided that Norway would take on responsibility for providing vaccines for every child in the world.

So this was a “Norway–Gates coalition” in a way. Gates in the private sector and Norway in the public sector –investing in a specific alliance: GAVI, the Global Alliance for Vaccines and Immunisation.

I remember discussing this with Prime Minister Stoltenberg, and how easy it was to bring him on board – for three reasons.

First, because he was a father and he had had his children vaccinated. It is something you do for free in Norway. You don’t have to think about paying for it, you take it for granted. Because it is part of what the welfare state offers.

Secondly, he is an economist, and he saw that vaccination is by far the most cost-effective intervention you can make. You can prevent disease with two shots at a very early stage in life.

And, finally, he was a politician. So he could bring this into the realm of political action.

I believe that what happened around 2000, with the launching of the MDGs, was a response to the heightened awareness of all politicians, not just health ministers, of the link between health and development.

I would like to touch briefly on a few of the changes that have taken place since then.

Ten years ago, world investments in health aid totalled 4 billion dollars a year. This has more than tripled to 15 billion dollars today.

Around 2000 AIDS treatment was out of reach, and when drugs came on the market, it was at a cost of 40 to 100 dollars a day. A cost that neither poor people nor donors could afford.

Now it costs 4 cents a day to treat AIDS, and more than 2 million people are receiving treatment. That is far too few, but it is a beginning.

Malaria was and is the top priority of every African health minister. Today, tens of millions of bed nets have been distributed and new drugs have been made available on a broad scale. Where the majority of children sleep under nets, malaria wards stay empty.

As I said, there was great frustration about vaccination, with coverage stagnating and new vaccines not being introduced. This situation has now been turned around, and for example measles mortality has dropped by 90 percent in Africa.

Additional hundreds of millions of children are being vaccinated. The GAVI Alliance has saved between two and three million children from dying every year since it began its work.

Tobacco was another serious world health problem. Around 2000, it was predicted that tobacco would be the leading cause of death by 2020. That might still happen, but it is likely – thanks to the framework convention on tobacco control – that this prediction will not come true.

The process of developing the convention is quite another story, and I will not spend time on it here. But work on the convention started two months after Dr Brundtland took office, and was concluded two months before she left the WHO. It is modelled on the Kyoto Protocol. So it is another example of lessons learned across sectors.

Now I am getting close to the present day. These approaches gave rise to an ethics of politics. It is about engagement, it is about the political will to seize opportunities, it is about partnership, and it is about burden sharing.

And I believe that these approaches can be used to combat climate change, to promote health, not only in a number of development areas, but also in dealing with international conflict. And it coincides closely with what we are trying to achieve in Norwegian foreign policy.

In 2005, Jens Stoltenberg returned as Prime Minister and I became his Foreign Minister. And we scaled up our approach to health. Stoltenberg took the vaccine initiative one step further, and Norway pledged to make a real difference, not only in vaccinating every child, but also in fulfilling MDGs 4 and 5 – reducing child and maternal mortality.

And we are now investing 100 million dollars a year specifically for interventions in this area, not alone, but in partnership with the private sector and with specific governments.

Having worked with and been inspired by my countryman Jan Egeland and his work in the UN and elsewhere, and with Jeffrey Sachs, I saw that as Foreign Minister, I could deal with health differently than has been the case in the past.

I realised that health was not just the province of health ministers, finance ministers, presidents, prime ministers, but also of foreign ministers. Because health disasters are also a cause of conflict. They are a cause of environmental degradation and of collapsing and failing states.

We all know that threats to health do not respect national borders. So this is clearly a challenge for foreign policy.

We know that developing countries carry the heaviest burden as regards disease, but have the lowest capacity for prevention, treatment and control. So global health security is only as strong as the weakest link.

Are we prepared, as foreign ministers, to face a global health crisis?

Norway closed its border with Sweden for the first time in modern history during the outbreak of mouth and foot disease in 2000. And we were completely puzzled by the question “how do we reopen borders? When are you certain that the epidemic is over and we can do so safely?”

This is a foreign policy issue. It is easy to deal with Sweden, our neighbour, in such cases. But there can be other settings were this is more complicated.

As foreign ministers, we need to review government structures and systems and adapt them to better respond to global interdependence.

When I became Foreign Minister, I called six of my colleagues in different corners of the world and asked them to join me in an informal setting to address this issue. And to try to highlight what it means to be a foreign minister in an era where health problems are global.

I approached France, Thailand, Indonesia, South Africa, Senegal and Brazil. And they all responded favourably. We met at the UN in 2006 and appointed experts to work out an agenda, identify the problems and to advise us on a plan of action.

We came together in Oslo in March last year to adopt the Oslo Agenda, the Oslo Declaration and a plan of action. We singled out ten foreign policy areas where we need to take a look at the health implications.

Are health concerns being given the necessary priority? Are we applying the foreign policy tools at our disposal to get to grips with them?

Against the backdrop of an evolving health and development agenda, I believe we have something new emerging here. At the UN General Assembly last September, we were 30 foreign ministers who came together to discuss these fields.

In order for us to make these ideas workable, we need to continue take a broader view and work out new perspectives. We still take a very traditional approach in the debate on national and global health security. We discuss our own country’s perspective – with the main focus on protecting our own population. That is our responsibility as governments.

Even the threats of pandemic flu can be seen in this light. We buy drugs for our populations. But as we all know, viruses and bacteria know no borders.

So if we include the perspective of interdependence and shared vulnerability across nations and regions, we need to add a broader dimension to this debate. More than anything, it calls for solutions in which the benefits of preparedness are equitably distributed.

Because my insecurity does not depend on the Norwegian health system, it depends on systems far beyond Norway. All of this has to influence our development policy, our UN policy and also our Norwegian foreign policy.

As a final observation, one important insight of this group of experts is that health security cannot be interpreted narrowly. What we need is an understanding of the determinants of health.

Poverty is of course intuitively recognised as a core determinant even though we have failed to address it fully.

Two more direct determinants of health that are often overlooked are trade and intellectual property rights. In many countries, HIV and AIDS are overloading already weak health systems and having impacts on capacity, preparedness, human rights and movement across borders. This has foreign policy implications.

We also have to address how fragile states might collapse under what we call “the double burden of disease”. Poor countries struggling with the burden of infectious diseases are increasingly being burdened with non-infectious diseases – which often cripple a poor health system.

Another dimension is that rich countries are recruiting health workers from poor countries to take care of an aging population. This gives rise to a number of very serious, ethical and economic issues. These, too, must be brought into the foreign policy agenda.

I would like to conclude by mentioning a concrete example that I never thought I would deal with as foreign minister –¬ the issue of virus sharing.

Indonesia has been hard hit by avian influenza. Bird flu is widely considered to be one of the most likely sources of the next global pandemic. And global preparedness relies heavily on monitoring the outbreaks, particularly that which affect humans.

A year ago, Indonesia felt that it was being short-changed by the international community and asked bluntly why it should contribute to the production of a vaccine it will not be able to afford and would be unlikely to ever have access to by sharing its virus. – Good question.

I disagree with Indonesia’s decision to stop sharing the virus from local outbreaks, because I believe that Indonesia and all other countries should contribute fully to global preparedness. But I also understand and agree that we must make sure that the benefits of preparedness are shared equitably and sustainably.

One of the most shocking observations I was met with when I got to the WHO was that there is no opportunity to prepare malaria drugs, because where there is no money there is no market for these drugs. But for a disease that strikes somewhere between a half and one billion people each year, how can we say there is no market?

And if we accept that there is no market for malaria medicine simply because people can’t afford to buy it, that is also a market failure.

What this all adds up to is that this is a matter of political will, of knowledge, and of partnership.

Thank you for accompanying me on this personal journey.