Poverty is the number one killer in the world, and poor people bear a disproportionate part of the global burden of ill health. Health, poverty reduction and sustainable development are inextricably linked, and health issues are prominent among the Millennium Development Goals (MDGs). A strengthened focus on health has been evident for the last decade, from the publication of the World Development Report in 1993, Investing in Health, to the report of the Commission on Macroeconomics and Health (CMH) last year, which was commissioned by WHO. The UN, the World Bank, the G8 countries, the OECD/DAC, the OAU and the EU have all placed health high on their agendas. The linkages between poverty and ill-health in the context of sustainable development are also receiving increased attention in the preparations for the WSSD.

The right to health is recognized as a fundamental human right and is as such an end in itself. Better health is also an important development goal. The report from the CMH makes it clear that good health is also a means to achieve other development goals related to poverty reduction: that the linkages between health and poverty reduction are powerful and much stronger than is generally understood. Health in its broadest sense is a precondition for sustainable development. Good health contributes to economic development and poverty reduction through e.g. improved learning in childhood and adolescence, positive demographic changes, increased productivity, reduced household expenditure on treatment and medication, and increased saving and investment both at the household and national levels. As the CMH notes, investment in health must be accompanied by investment in education, water and sanitation and agricultural improvement to achieve health outcomes and poverty reduction.

Good health and its contingent development benefits are under threat from a relatively small group of diseases. In developing countries HIV/AIDS, malaria, tuberculosis, the cluster of childhood illnesses and diarrhoeal disease, which are often linked to nutritional deficiencies, account for most of the burden of disease, of which poor people bear a disproportionate share. The high levels of reproductive ill health and maternal mortality can be avoided. The CMH report estimates that by 2010 around 8 million lives per year could be saved - mainly in low-income countries - by essential interventions against infectious diseases and nutritional deficiencies. Other threats to health also loom large: tobacco-related ill-health, road accidents and unsafe environments account for an increasing share of the total burden of disease and premature death. Premature death and ill health attributable to environmental factors are now estimated to make up no less than 20-25 per cent of the total burden of disease in developing countries (reference is made to the Norwegian paper on health, poverty and the environment).

The main recommendation of the CMH is that the world's low- and middle-income countries, in partnership with high-income countries, should scale up the access of the world's poor to essential health services. Cost-effective measures do exist, but they do not match the need on a global scale and they do not reach those who need them the most: the poor. International initiatives such as Roll Back Malaria, Stop TB, the Global Alliance for Vaccines and Immunization (GAVI) and the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM), all of which are supported by Norway, seek to respond to these challenges and to mobilize fresh resources to combat the diseases of poverty. The CMH makes a strong case for substantial increases in support to health development. While increased spending by governments in poor countries is needed, it seems clear that the adequate development of basic health services in the poorest countries requires donors to make long-term and predictable commitments to financial support.

Increased funds are certainly welcome, but it is very important to consider some of the implications of increased financial commitments by donors and governments in developing countries on such a large scale. They require the simultaneous building of robust health systems, a clear and committed focus on the health needs of poor people, and adequate geographical outreach for quality services. The goal of poverty reduction through improved health can only be effectively addressed by means of a decentralized approach that ensures community empowerment, local institutional development, and promotion of good governance. Well-functioning health systems require incentives that attract qualified personnel, adequate infrastructure and information systems, and capacity for planning and effective leadership. Access to essential drugs at affordable prices, including patented ones, is also a precondition for the functioning of health systems. Together, these are essential conditions for the sustainability of health systems at country level. And it may be argued that sustainable health systems are an important condition for reaching the objective of sustainable development overall. In other words, robust health systems set up to respond adequately to the needs of poor people are necessary in order to make investment in health work for development.

Although the health sector clearly has an important role to play in promoting the health agenda, other sectors are often responsible for the action needed to mitigate risk factors. More comprehensive and innovative cross-sectoral cooperation between the health sector and environment and infrastructure authorities, bilateral and UN agencies, NGOs and public-private partnerships is needed. Public-private partnerships have proved useful in areas such as pollution control and waste disposal.

Suggested Norwegian initiatives

At the global level:

• contribute to a clear and committed focus on health in international fora and processes relevant to development cooperation
• continue to provide resources through the UN, the development banks and public/private partnerships such as GAVI and GFATM to support low-income countries' national efforts, plans and priorities in the health sector, in the framework of poverty reduction strategies
• contribute to a strong focus on environmental health and mitigation of environmental health risks in the preparation for WSSD/Rio+10
• contribute to the development of health financing mechanisms that aim to protect the poor

At country level:

• prioritize support for initiatives to strengthen the focus on prevention, affordable treatment and care in relation to HIV/AIDS, reproductive health, immunization, tuberculosis and malaria, and the reduction of environmental health risks
• contribute to the integration of health and the health sector in the development of national poverty reduction strategies and in PRSP processes in countries where PRSPs are being developed and implemented, and strengthen the negotiating power of health ministries vis-à-vis ministries of finance and the donor community
• increase support for strengthening the various components of health systems, including the capacity of relevant ministries for planning, prioritizing and coordinating the activities of the various actors in the sector and across sectors in order to ensure that resources are directed to the needs of poor people and are an adequate response to these needs
• encourage and contribute to the participation of civil society in general, and of poor people in particular, in information dissemination, planning and resource allocation processes
• support sector-wide approaches and harmonization of donor procedures
• contribute to the prioritization of the health and welfare needs of children and women