The World Federation of Public Health Associations A NEW GLOBAL HEALTH RISKS AND CHANCES

1. The World Federation of Public Health Associations A NEW GLOBAL HEALTH RISKS AND CHANCES Ulrich Laaser WFPHA, President

2. FROM INTERNATIONALISATION TO GLOBALISATION I. THE INDUSTRIALISATION OF EUROPE & JAPAN IN THE 18TH AND 19TH CENTURY II. THE GREAT PANDEMICS esp. CHOLERA IN THE 2ND HALF OF THE 19TH CENTURY III. MANDATING OF LARGE INTERNATIONAL ORGANISATIONS (WHO, WB, IMF) > WW II IV. THE GROWING INFLUENCE OF NGO’s IN THE 21ST CENTURY (e.g. MSF, WFPHA)

3. GLOBAL FAILURES THREATENING OUR “SPACESHIP EARTH” I. GLOBAL WARMING – floods & deserts II. GLOBAL DIVIDES – poverty & hunger III. GLOBAL SECURITY – war & terrorism IV. GLOBAL INSTABILITY – financial crises V. GLOBAL HEALTH – a human right for all

4. GLOBAL DIVIDES

5. YLL, YLD, and DALYs by Region, 2001 (Mathers CD et al. 2006)

6. Distribution of health workers by level of health expenditure and burden of disease Source: Mullen F

7. Migration

8. Rural – Urban Migration Alleviates e.g. overpopulation, land shortages etc. of the rural areas. But costs through increased poverty, the rise of slum and squatter areas, extremely unequal distribution of resources, overburdening of the urban infrastructure and difficulties to supply mega-cities with the necessary resources such as air and water. Indeed, the urban poor are the main group affected by an unequal distribution of resources, and they have to live in quarters characterized by the worst environmental conditions like overcrowded slums and squatter settlements close to polluting industries or congested roads. Cornelius-Taylor B, 2001

9. GLOBAL SECURITY The modern concept of public health, the New Public Health (Frenk J, 1993) carries a great potential for healthy and therefore less aggressive societies. Development of the health systems has to contribute to peace, since aggression, violence and warfare are among the greatest risks for health and economic welfare (Laaser et al. 2002).

10. Estimated average annual military deaths in wars, worldwide, by century (Garfield & Neugut 2000)

11. Military Spending Global military spending in 2008 came close to 1500 billion USD the largest contributors being the United States with 48.5% and the European Union with 21.2%, followed next by China with 4.8%. Neither does the ranking of the top three US, EU, China changes if the calculation is based on purchasing power parity USD. However, expressed as % of GDP the US were at rank 27 in 2005 and China at rank 96 (2009), whereas the highest ranks were occupied by oil producing Arab countries and countries near conflict zones (e.g. Oman with 11.4 or Armenia with 6.5%). The growth rate of global military spending was 8.4% in 2007 and is forecasted to reach +33.9% since 2007 in 2012

12. Public expenditures per capita for selected countries (USD, 1990)

13. Comparative average US monthly spending for military operations and ODA for social services (As of 2003) • Sources of basic data: US Congressional Research Services; OECD-DAC • www.realityofaid.org

14. The Skopje Declaration on Public Health, Peace & Human Rights In the fall of 2001 the representatives of public health of South Eastern Europe gathered a in Skopje, capital of Macedonia, after a decade of civil war and ethnic cleansing in the wake of the dissolution of Yugoslavia, to engage the good offices of public health in promoting peace, preventing violence and contribute to the building of a more equal, stable and democratic world. The declaration of Skopje was later i.e. in 2003 adopted by the World Federation of Public Health Associations. http://www.wfpha.org/Archives/

15. The Skopje Declaration (continued) • Beyond their immediate professional domains public health professionals can contribute by: • Analyzing the causal interrelationships of violent phenomena • Curbing the determinants of armed conflicts and violence • Training health professionals in analytical, preventive and interventive skills • (Lever N, 2000)

16. GLOBAL INSTABILITY (Resetting Global Aid) The steep global gradient between rich Highly Developed Countries (HDL) and the poor Least Developed Countries (LDC) is well known. With a few exceptions the low GDP per capita goes hand in hand with limited access to food and water, low housing standards, incomplete educational coverage, high levels of (hidden) unemployment and high emigration. Not surprisingly also limited access to and low quality of health care services and population health measured as (healthy) life expectancy are running in parallel.

17. The Monterrey Consensus of 2002 “We urge developed countries that have not done so to make concrete efforts towards the target of 0.7% of their GNP) as ODA to developing countries” (art. 42). In addition there are serious imbalances between DAH and BoD (Ravishankar et al., 2009)

18. The Fragmentation of global aid One of the obvious reasons for imbalances is the extreme fragmentation and therefore ineffectiveness of international aid. East Timor: 1 study/1000 as compared to 1 physician/10.000 Vietnam: 2 donor visits/Working Day Tansania: 1500 projects with separate reporting & oversight Globally: 280 agencies, 242 multilateral funds, 24 Development Banks, 40 UN Organisations, and 1000ds of NGO’s

19. The value of international aid The temptation to accept international aid without conditions on the side of the beneficiary often disrupts national priorities. Loans – e.g. of the World Bank though at low interest rates – put often an underestimated burden on later years. Loans have two sides: Money is available now but has to be repaid later. In addition the money goes via expert fees and purchase of equipment mainly back to the crediting countries.

20. Funding channels of DAH (% share) Ravishankar et al. 2009

21. National coordination As has been outlined already, specially in developing and transitional societies coordinative capacities and competences are limited vis a vis a complicated and time consuming process of implementing international and bilateral aid efficiently. In addition international and even more bilateral aid very often is disrupting coherent national development plans and priorities.

22. The Sector Wide Approach (SWAp) • The national coordination deficit became more known in the nineties and proposals to cope with were developed. One of the most promising - however rarely implemented - concepts is the • Sector-Wide Approach. • (Cassels1997)

23. THE MILLENIUM DEVELOPMENT GOALS • We have been moving too slowly to meet our goals… • The numbers of people going hungry and living in extreme • poverty are much larger than they would have been had • progress continued uninterrupted (Ban Ki-Moon 2009). • In fact it is unlikely that the other seven goals can be achieved sustainably if poverty remains as widespread as it is today. A closer look reveals in addition that the improvements up to 2005 are grossly different between continents.

24. MDG 1, Target 1: Halve, between 1990 and 2015, the proportion (%) of people whose income is less than USD 1 a day (here 1.25 USD is used)DR Developing Regions; SSA Sub-Saharan Africa; Southern Asia; SEA South Eastern Asia; EA Eastern Asia; LA Latin America; SEE South Eastern Europe

25. MDG 4: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. MDG 5, target 1: Reduce by three quarters the maternal mortality ratioDR Developing Regions; SSA Sub-Saharan Africa

26. A dim outlook for the MDG’s achievement In summarizing it can be said, that the health related MDG targets for Goals 1, 4, 5 and 6 are unlikely to be achieved in spite of some sluggish progress made. Also it is obvious that the economic growth of 4% in the developing regions between 2000 and 2007 did not translate directly into better population health. The low correlations between growth and MDG achievements show that growth is necessary, but not sufficient for a sustainable MDG strategy. It has to be complemented with the appropriate sectoral policies (Bourguignon et al. 2008).

27. GOOD GOVERNANCE AND A NEW GLOBAL HEALTH Health systems have a broader scope since they incorporate the population dimension inherent to public health and all relevant social and political determining factors (i.e. incl. global factors). (Council of Europe, 2009)

28. Ethical governance The main health systems in Europe – variations of Bismarckian social insurance and the Beveridgean national health service models – rely on administrative, financial and professional accountability. It is taken for granted that health services, despite the diversity of systems, should be based on principles of universality, equity and solidarity. Health and healthcare are not ordinary commodities. They are seen as public/social goods. There are several principles that are more generally applied to the whole range of public services and administration. These include transparency or openness, accountability, public participation, effectiveness and efficiency, and quality and safety.

29. CONCLUSIONS I. To improve global health will not become possible without a strong involvement of the civil society. Already by now about 25% of the DAH is channelled through NGOs and is on the increase. However NGOs are not only accountable to their clientele but should be to an open society in general. Therefore a code of conduct for NGOs is a first main recommendation and demand.

30. II. Unchecked demographic growth, poverty, the burden of disease, and violent conflicts are interconnected. The demand for basic needs like shelter, clothing, provision of safe food and water, access to adequate (primary) health services and to education, and last not least security in daily life for all populations does not seem to be an extraordinary or unjustified one. A renewed major effort of the UN community therefore is to be initiated to achieve the MDGs as planned. To simply continue as so far will certainly not be enough!

31. III. Resetting global aid has to become part of such a renewed effort towards the MDGs. As of today aid is highly fragmented, bilateral and donor dominated with enormous transaction costs, and not given according to priorities in the recipient countries. It also frequently lacks planned integration and coordination. In fact most of the financial support is channelled back to the donating countries (via dept repayment, purchase of technical equipment and international expert charges). The concept of sector wide approaches (SWAp) has to be further developed and made practical to put the receiving governments into the “drivers’ seat” on the condition of improved governance.

32. IV. The migration towards Highly Developed Countries - especially of qualified professionals - cannot simply be stopped without violation of basic human rights. However, there should be an agreed mechanism to compensate the "sending" countries for basic investments into upbringing and education.

33. V. Military conflicts and violence in many forms are a major cause of mortality and morbidity and of excessive waste of scarce resources. The developments towards regional peaceful cooperation in Europe, the Pacific region,in the Americas and elsewhere, is to be enhanced. Public health professionals can contribute by 1) analyzing the causal interrelationships of violent phenomena at all levels of society, 2) curbing the determinants of armed conflicts and violence, and 3) training health professionals in analytical, preventive and interventive skills.

34. VI. The deficit of all good will proposals and actions is a mechanism of enforcement at the global level. However, a good global government is still behind our horizon. Nevertheless a global awareness in the sense of a New Global Health is a first and essential step on this path and a participatory approach is the only way open to us.

35. The Istanbul Declaration 2009 www.wfpha.org NOW IS THE TIME To revive human values To renew political will To change direction To acknowledge Public Health as the first public good To achieve global cooperation on global health To unite the public health workforce