Professor of Medicine, Columbia University Medical Center
Deputy Executive Director, World Health Organization
Adjunct Senior Fellow for Global Health, Council on Foreign Relations
Nearly one year has elapsed since the seventieth World Health Assembly elected Dr. Tedros Adhanom Ghebreyesus as the new director-general of the World Health Organization. This meeting of CFR's Global Health Governance Roundtable Series examined the agenda of the seventy-first World Health Assembly, which took place during May 21-26, and provided an overview of the World Health Organization’s performance under Tedros’s leadership.
The featured speakers for this discussion were Ariel Pablos-Méndez, professor of medicine at Columbia University Medical Center and Werner Obermeyer, deputy executive director of the World Health Organization Office at the United Nations.
HUANG: Welcome to the Council on Foreign Relations. My name is Yanzhong Huang, for those who don’t know me. I’m an adjunct senior fellow for global health at the Council.
This is the fourth and the last meeting of this year’s Global Health Governance Roundtable Series. And today we’re going to address one—actually, two very timely and important topics—the WHO and the WHA, the World Health Assembly. Early this morning the World Health Assembly was kicked off in Geneva. And I just read the news that Dr. Tedros made a speech, but he said it was the call to better support interns at WHO that drew the loudest applause. (Laughter.)
And also, this year marked the first year of Dr. Tedros in office, when he became the WHO director-general. And this year also marks the 70th anniversary of the founding of the World Health Organization. And it is the 40th anniversary of the Declaration of Alma-Ata, the Health for All 2000, for those of who still remember what happened 40 years ago. Ariel and I, we were talking about this. Very fascinating stories, and how the health agenda was entirely politicized, you know, at that time.
And so with also Ebola back in the Democratic Republic of Congo, this year’s World Health Assembly sees the threat of major disease outbreaks. But in the meantime, it also witnessed the—Dr. Tedros, you know, bring to the meeting ambitious agenda for change, including the universal health coverage, or the UHC, and also the World Health Organization’s general program of work that centers the so-called triple billing targets. If you don’t know what triple billing means, Werner will explain that to you.
So we’re going to have a lot to talk about today. So what to watch at this year’s World Health Assembly? What has Dr. Tedros achieved in the past year? Are there any areas he could do differently? In the wake of the Ebola outbreak and also the changing landscape of global health governance, you know, how is WHO doing in providing leadership in this new world health era—that’s the term coined by Dr. Pablos. But we are fortunate here today to have two great speakers.
On my right, Dr. Ariel Pablos, who’s a physician, scholar, diplomat, and creative leader in global health. He’s currently professor of medicine at Columbia University Medical Center. He is seeing patients. He is also still continuing engaging in global health issues. He was a fellow working on MDR-TB—that’s another acronym, multi-drug resistant tuberculosis—in New York and around the world. He worked as—he was the director of knowledge management at the World Health Organization in Geneva and managing director for international health at the Rockefeller Foundation. In 2011, Dr. Pablos was appointed by President Obama to lead the USAID’s Bureau for Global Health.
On my left is Werner Obermeyer, who is the deputy executive director of the World Health Organization office at the United Nations in New York. In that capacity he was responsible for the negotiations that led to the adoption of the political declaration of the prevention and control of the non-communicable diseases, what we call NCDs. And he is also the focal point for resolutions on global health and foreign policy, health and the environment, as well as the post-2015 development agenda, among other things. Before joining the United Nations, he served as the South African deputy permanent representative in Kenya.
The speakers’ full bio is included in your handouts, so I’m not going to repeat them. After the two speakers’ remarks—we’re going to start with Ariel—we’re going to open up the floor to questions and discussions. And just to remind you, this meeting is on the record. I just had them sign the record release form. So now no Chatham House rules apply today. So, but please turn off your cellphones and, so, Ariel.
PABLOS-MÉNDEZ: Well, thank you. Thank you all for coming. And thank you, Yanzhong, for inviting me. And I guess also to Laurie also for inviting me the original time here—my connection with the Council.
And I’m an academic, so I have nothing to worry about what I say now. (Laughter.) But I guess it’s fair to state, as you noted, that I was a director at the World Health Organization. And I was part of the core campaign team that elected Dr. Tedros, and part of his transition team. But I no longer have any relationship with the WHO, and so I’m speaking on my own.
Global health, if I may, we used to be called tropical medicine in the first half of last century. And it was the more romantic period of missionaries, and Rockefeller, when he was the only player in town. And it was about eradication of certain diseases of poverty. It was such a time that—nonetheless, that period transitioned with the end of European colonialism after World War II, and into what we call international health. At this time, the U.N. was established. The WHO was established. The NIH was very well established. CDC very well established.
So there were many other institutional arrangements that, in a way, carried some of the early thinking about science and science for development. It was also a moment of the Cold War. So all the politics of the Cold War were at play. International solidarity was high on the one hand. Health was a social construct, primary health care, the Alma-Ata conference that we heard of right now. It was born of a time of a lot of political conflict. And that was sort of an issue for the World Health Organization leadership on the one hand, technically in positioning their agenda, but politically hampered subsequently in terms of what they could do with budgets and so on.
With the end of the Cold War, we changed again. We became global health. And now it was a time for globalization, the private sector, trade, information technology was exploding. AIDS was a very important part of defining this period. Many NGOs jump in this space. New philanthropy, like Gates, came to the arena, public-private partnerships. The health system was not priority. That was really the period we’ve been in. In that period, as you can see here, there was an explosion of NGOs. Civil society became very important, in part because of AIDS and poverty alleviation, but in part because that was a time where governments were the problem, not the solution. Government was supposed to shrink—decentralization, privatization, globalization. And NGOs were part of the solution, together with markets, to solve all kind of problems.
And at the same time, private dollars took over development assistance dollars, big time. There were—development assistance was, like, 80 percent of the dollars in the ’60s, when USAID was established by President Kennedy. But by the ’90s, it had flipped. The majority of the dollars were private dollars, including remittances, but also foreign-direct investments, corporate investments, and so on and so forth. So private sector became very, very important in this era. And that was the money.
So I was at Rockefeller at the time. So we created many public-private partnerships that were not possible in the ’70s. It was not possible to have someone from the corporate world set foot in the World Health—in the WHO. That was just not possible. That changed. We were sort of pioneers at Rockefeller, bringing together—particular for areas where markets were failing, right? TB drug development, AIDS—price for AIDS in Africa. And it was an incredible, creative period because, again, there were so many entities created. I was directly involved from my TB background on these three: TB Alliance, which is now—(inaudible)—facility in Geneva, the Partnership to Stop TB, and so on. There were so many others.
And then the big guns emerged in the partnerships, with GAVI on immunizations, The Global Fund, and then with President Bush PEPFAR. And those really changed the landscape, the resources. We were in a totally new landscape. When I began in global health 30 years ago, $100,000 was a lot of money. And some people worried. I think that David Fidler, who is one of the fellows here, has called it the open-source anarchy. There were so many NGOs, so many players, so many private—like, people thought it was crazy. Some people missed the time when it was just WHO and UNICEF and Rockefeller and maybe the World Bank. And that world was gone. And but open anarchy has its risk.
And nonetheless, the MDGs provided a very solid foundation for everyone to be aligned. And that was a good thing. Actually, the U.N. did a good job in providing that framework and the world to more or less work together towards that framework. And some people may disagree with the priorities, but health did pretty well. We had three out of the eight priorities there, and it became a very important part of the work. And with that, money came. And there was more than a five-, six-fold increase in the total health expenditure from $5-6 billion a year to $34-35 billion a year. A third of that came from the United States—the United States government. And a third of that was for AIDS. But many others came to the fore, including, of course, Bill and Melinda Gates became quite a significant player in the global sort of higher-end—(inaudible)—countries, but mostly the global—the global space.
So that worked. It was an incredible formula. We have been privileged to have been part in the last 25-30 years of an incredible progress period for humanity—health—HIV incidence cut by half; TB deaths, malaria deaths cut by also nearly 50 percent; 50 percent fewer women dying giving birth; 125 million child deaths prevented. It’s been incredible. Family planning has empowered women, saved lives, brought demographic dividend to families and nations. This truly has been an unprecedented era, and from the lens of global health it has been incredible.
And I came from Mexico originally. And here I show the life expectancy in the 20th century, how did Mexico—that was the 1918 epidemic, a little dip, but Mexico pretty much is catching up in life expectancy with the United States. This grand convergence became, for me, a rallying cry. And we imprinted the Lancet Commission, led by Larry Center, on the idea that we can indeed achieve a grand convergence. That the rest of the world can catch up with the rich world in life expectancy, which depends statistically mostly on child survival. And child survival has indeed improved. When I was in Washington as the head of global health at USAID, I could—I wasn’t a maternal/child guy, but I was a physician, epidemiologist, global health historian.
And I noticed that in 1970s, there were 17 million deaths—child deaths. By 1990, 12.6, even though the world population had more than doubled. And when I arrived in Washington, 7.6. It is today probably about 5 or 5.5. And if the rest of the world catches up with the OECD countries, there will still be 2 million. But the point is we will achieve this end of preventable child/maternal death. We came from 17 to 12 to 6. We’re going to 2 by 2030, 2035. This is happening. The world will end preventable child/maternal deaths. And this is, again, an incredible gift of this generation to our civilization.
We also begin to talk with President Obama about the beginning of the end of AIDS. And that is happening in Asia already, where incidents is lower than mortality. And so the prevalence of HIV is shrinking in many countries now, with zero maternal-to-child transmission of HIV and so on. We’re not done. There’s plenty in Africa. And we have a huge mortgage to carry forward. But it was an incredible transformation. And I want to recognize Harold Armis (ph) because he was at the time where he was in Washington that so much—so much really helped us. And NIH had the credibility and science was required. Maybe this was very important, and a measurement became also very important to everything we did in global health.
And so, with that, we arrived to a new stage. The world has changed. It has changed because of the Great Recession in the rich world, but it also, and perhaps more importantly, has changed because of what I have called the economic transition of health in the rest of the world. And now, in this new world health, we have calls for national interests over globalism. We have political demands for social protection. Governments are supposed to address what markets failed us to do, because in 2008 we lost our homes, we lost our jobs, we lost our pensions. So some of the governments, where are you? And governments who do not respond are seeing a wave of populist elections, people who promise things they may or may not deliver around the world, from Brexit to many others.
And so I think we are in a different stage. And I’m calling this a new world health. The money’s flat. It’s been flat for the last 10 years. So that means, with inflation adjustment, we have lost about 17 percent of the buying power of the global health. And so even though we have been driving that peak and it’s not bad, the sense of growth that we had is stopped. The number of new partnerships—big partnerships with money, as we did a decade ago, has stopped. As you can see there, in this decade, very few—two or three—being created, and not given a lot of traction because of money. So it’s not happening, what we saw happening a decade ago.
But on the other hand, fortunately, the economics of the rest of the world is changing. Not only China and many other countries, but really around the world. Income per capita has grown in an unprecedented way in the last 50 years. And for half—more than half. More than half of the countries that were low income in the year 2000 are already middle-income countries—low-middle-income countries. And so that’s an incredible transformation for the countries themselves of their own economic capabilities. Whereas in the ’90s, they were collapsing under debts, now they are growing. Some of them, in Africa, at rates of 8, 10, 13 percent, the GDP a few years ago. So it’s a different world and it is changing.
There’s something that we have known for a while in OECD countries, and now we have data around the world. These are dots—are countries dotted against GDP and the total health expenditure. And it shows that as the GDP of countries grows, health expenditure grows pretty much along the line. The r-squared is 90 percent. Very, very high. And it’s actually—the income to demand is greater than one, meaning it’s not a one-to-one relationship. A 10 percent growth in GDP leads to an 11.5 percent growth in health expenditure. And this is a universal trend everybody pretty much is doing.
We know the U.S. is the yellow ball at the top growing faster. I made it in log scale to make it more dramatic. But you can see France and England and Canada following the same track. And China is coming. And this is, of course, a big headache for rich countries—although it shouldn’t be, but it is. That will be a different conversation. But for the poor world, this is incredible welcome news, because that means that a country like India, where, as you can see from 2000 to 2016. In 2000 in India, the dotted green line, India was spending $16 per capita in health, when it costed at the time $37—the red line—$37 to buy the essential life-saving interventions. Not like sophisticated New York care, just the essentials. India couldn’t afford that, even with all the donors, even with all their money. They just didn’t have the money.
And the money gets displaced. You want to give money? It just pushes other money to other sectors or to other bank accounts. But India’s economic growth means that the green line has now crossed by the red and the green—the black lines, which are estimates of the total cost including health systems costs to provide essentials. So India now has in their economy the capacity the provide health services. They just couldn’t in the year 2000. And of course, this has happened in so many countries around the world. And this is changing lots of things.
Now, most of that money is domestic. As you can see, the public domestic and private domestic money are now dwarfing—dwarfing—private dollars and development dollars. So it’s now the country’s own money. Even in Africa, which is where assistance is greatest today, it’s less than 20 percent of the total health expenditure. And it’s shrinking because their economies are growing, the health expenditure’s growing, while development assistance is flat. For those who tend to think of global health as development assistance health money, they’re in a shrinking paradigm. Right now that is a shrinking paradigm. And the rest of the world, we haven’t figured out a financial arrangement—even the United States hasn’t—to move towards cooperation.
What happens when we no longer work in Peru or Brazil? Well, we still need to work with them. We need to have—help with the change. But we have no budget for that sort of a change because they’re not linked to AIDS or to USAID priorities in Africa. So we will need to change those. This is USAID when I was there in 2015, a map of the countries that USAID has worked. In gray is countries USAID provided assistance to over the last 50 years. And we no longer provide assistance there. So it was, like, 100 countries or more, and now we have, like, 50 countries. And my guess is that by 2030 it’s going to be half of that. Only the poorest, more fragile countries will receive assistance.
So if global health is going to be defined by a shrinking footprint, we are in trouble. We need to figure out a new vision. We need to figure out new financing arrangements to look at the whole. And to today’s presentation on WHO’s World Health Assembly, I believe this is a time when now governments are having money and voice. It’s not like they were, again, in the ’90s, that perhaps an organization like WHO should get a better opportunity to lead into what is going to be a new era.
Now, there’s more money. That’s a good thing. But the money actually—as you can see when you move the bars from low-income countries to middle, lower-middle, upper-middle, high-income countries. You can see the blue part of the column, which is the government’s budgets, and then the light blue in the middle is donors’ money. The donors’ money shrinks. It gets diluted as the economies grow. I mean, the column is growing. But because governments do not grow fast enough to meet the growing demand that happens when economies grow, then the red happens. And you can see the growth in the red part is a ditch, I call it, is a ditch, a predictable, because you know a whole generation will now suffer paying out of pockets, which is inefficient, very regressive.
And in Africa, 50 percent of the total expenditure is paid out of pocket. In South Asia, 80 percent of the total expenditure paid out of pocket. And that’s pretty bad. So now in Nairobi, a woman who is bleeding after giving birth, can give to hospital. Her life will be saved. So that’s good. But now she will be kept in a private prison until the family sells their livelihoods to pay the medical bills. Paying for medical bills has become the number-one cause of impoverishment, going back into poverty, for countries that are moving to middle income countries level. And so this cannot be the future we’re trying to build for global health. So we need to find that as we move from survival to wellbeing and social protection, that we need to mind that also. Not only the reductions in mortality, we still have to continue, of course.
It’s in this setting that the concept—the policy idea of universal health coverage around the world—not to mention the United States—around the world has taken hold. And Laurie and I worked on a paper in 2008 that was published in the Lancet. The first paper, that it was called: All for UHC, leading the charge, Lori. And it was an important piece. And a clearly done map—because in global health we love maps to show evidence—and the evidence is imperfect. But the International Labor Organization had the only consistent source of data. And I used theirs. And it’s imperfect. And it still remains imperfect, measurement of coverage—effective coverage. But out of pocket expenditure is something we can measure much better now, and so on.
But this was the beginning of something. I was the head of health at the Rockefeller Foundation at the time. And again, how it was around—this was too crazy. But it’s been very successful at the policy level. It has become really a—the 2012 resolution we heard at the U.N., health for all, in December 12, which is now World UHC Day. The Japanese took an incredible leadership role as well. And the G-20—and, again, next year the G-20 in Japan will play a very important role at the U.N. General Assembly special session on UHC. So UHC makes sense, right? It’s social protection. It is government’s responsibilities. It’s domestic resources being organized. It fits into this new era. It’s not by chance that it’s been successful. And like health systems, which many people didn’t resonate with—politicians, heads of state resonate with the idea of universal health coverage.
And they have been embraced as part of the targets for the Sustainable Development Goals for health. And that’s a good thing. And of course, it is in this world that we have the election of Dr. Tedros last year, the first election by all member states and not just a subset of the secretary board. So that’s politically very powerful, at a time that it’s very important for organizations that member-state governments based. And so I was proud to be part of the efforts to elect also the first African ever to lead the World Health Organization. And so it’s a big opportunity for WHO. And I guess we will hear from Werner where WHO is stepping up to the plate or not. But it will be crucial, of course, that WHO provides the designation to provide technical assistance to member states, to declare public health emergencies in a timely fashion.
In Ebola, there was an unforgivable delay. Rethinking and modernizing surveillance systems, WHO has lost a very crucial normative role to a good job done by Chris Murray with the Institute for Health Metrics network. But that should have been something the WHO should have been doing. They need to do better. Member states trust WHO, and it’s also for standard (pre-qualifications, recruitment ?). All of these things are very important technical roles the WHO plays. Then providing guidance for the future of health systems and policies, with universal coverage as a prime example. And I offered the idea to Tedros, and he liked it, to expand coverage to 1 billion people. There is about 4 billion people who have coverage—that is, prepaid, risk pool financing for access to appropriate health services. So adding a billion dollars was a really—I have to confess, I didn’t do all the specifics of the math. But it was supposed to be done. But it hasn’t been done. But nonetheless, it’s now on the table for the World Health Assembly. Let’s expand coverage to 1 billion people. Let’s expand health security to 1 billion people. They like the 1 billion thing. And let’s expand better health for 1 billion people. So they like the 1 billion number. It’s a bold number for five years.
Now, SDGs, climate change will be important as well. And I think WHO and the World Bank, they do advocate that for poor countries, they still need development assistance. Those countries will still need additional assistance. I mean, better—perhaps we have learned a lot—but they still need the outside financing. There will be several countries that will not reach, as India did, that level of capacity to finance their own basics, even by 2030. But the majority will be close by then. And there will be also graduation of many countries. So how will countries—how do they learn to withdraw from the—to wean from the development assistance money? It’s not easy. Relationships, people, budget lines. But nonetheless, this is going to happen. Now this evolution, by in some places it does come as well, next year your budget’s cut in half.
But perhaps more importantly, WHO need to change internally. And that been and remains a big challenge, as Werner was just telling me. (Laughs.) But clearly, they need to do better at communications, as something important. And, I mean, the Ebola crisis was in part a failure of communication. But Dr. Tedros is a very tweeter. And that’s a good thing, but it’s not enough. You need to really leverage the whole organization around the world. Better roles and responsibility for headquarters, regions, country office. That remains a challenge. And he has not been as aggressive—he didn’t promise to be very aggressive in changing all of that. And nonetheless, that was also part of the complications during the response to Ebola.
Then you need very good technical staff, but you only need a few. WHO needs to leverage the world. There is a brain trust around the world. You don’t need to pay salaries in Geneva. You can reach out, you know, expert committees and collaborating centers and so on, that would be very happy to be affiliated with WHO for free. And so that’s something. And also better, because then there’s organicity and more impact to what you do. And then member states, perhaps what I view as one of the most important things in this year and next year, in particular, it will be the budgets. The WHO’s regular budget was frozen in 1983. And that means that the budget could only grow with voluntary money on the side.
That means that and today that’s 80 percent of the money is soft money. And you have to imagine you are the president of a country. And your ministers have to go passing the hat to foundations and to corporations to get money to run the department of justice or the department of—this is how WHO operates. And so when World Health Assembly meets and has solutions, they don’t control the money. This—USAID, and Gates, and this and that, the directors will go and, hey, they will dance to the tune of the dollar. And so this is a fundamental problem. And the quality—again, 80/20 is bad, it should flip. But the amount also—the amount of the budget of a—the whole budget of WHO in the regions and the countries is less than the revenues of the hospital where I work in New York. One hospital, a big one, but nonetheless, that the whole World Health Organization has a budget that’s less than one New York hospital. Well, we cannot expect a lot, also, right, if we don’t—if we don’t really put support.
So that’s what I see the challenge is. And so my conclusions are that, first, the world health is changed already. It’s already changed and changing more and more. I mean, a lot of the budgets still carry on. So a lot of the old ways carry on, the old salary lines, everything. But the world is already leaving that behind. We are now looking at bold endgames for infection diseases, for maternal/child health, and a grand convergence in life expectancy is in sight. And we will also have to address NCDs, injuries too. And the Global Health Security Agenda has reached prominence, and that will remain important. After the Great Recession the global health budgets have plateaued, and the world is now leveraging the economic transition of health and domestic resource mobilization, with greater captive ownership towards equitable sustainable developments. It’s going to be a different way the money will move. And a newer health is taking shape with growing demands for social protection and reforms towards a progressive realization of universal health coverage and shifting development assistance of health to global public goods and the very, very poor countries.
I believe that all of this is a setup of opportunity for leadership by the World Health Organization as a member state organization to change the world, to really take on this role. And we’ll see this World Health Assembly let us know if we are going to or not. Thank you.
HUANG: Thank you, Ariel.
OBERMEYER: Thank you. And thank you all for attending today. I don’t have the academic freedom that Ariel has. (Laughter.) But if he does not mind, I’ll borrow from what he said. The World Health Organization was created just after the Second World War, 70 year ago. And as you’ve heard we are not going anywhere soon. It provides, as Ariel has mentioned, guidance and norms on many different areas, from air quality and quality of water and food safety, standards for developing and use of medicines and vaccines. There are a long, long list of technical work and achievements that the organization has been involved in.
And it’s governed by the World Health Assembly, which is meeting this week in Geneva. It consists of 194 countries, about 4,000 people come and attend it every year. I’m not going to go into all the details of it, because it’s likely to bore you. There is an executive board which governs the work of the assembly. It meets in January every year to set the agenda for the assembly. It does the preparatory work, and then it meets immediately after the assembly has met in May, this week. So the board will meet next week to take forward the decisions of the assembly.
Much of the technical work I think the WHO has been doing over the last seven decades have been vertical in nature, so disease specific. But there has been a shift since 2000, since the adoption of the Millennium Development Goals, to look at a more integrated and horizontal approach. And as you have heard from Ariel, there has been tremendous progress in many different areas. Life expectancy has increased, and child mortality declined. Many of the major communicable diseases are contained and on the path towards eradication. But despite the progress, there are always new threats to global health, and new threats to vulnerable and poor people in any country and in every society.
So one of these are the uptick in non-communicable diseases and specifically mental health disorders. That it’s shown that higher life expectancy does not necessarily mean healthier life expectancy. We have seen also growing challenge with anti-microbial resistance. And as you’ve seen in the news the last couple of days, there are always outbreaks of epidemics that are man-made, but also caused by nature, and obviously affects economic stability and human security—health security. We have seen also increase in climatic-related disasters for health, and one big, big challenge which people tend to overlook is the trend of migration, with almost a quarter of a billion migrants and 20 million refugees that are adding to the burden that health systems face everywhere.
So the situation is often also made worse by poor health literacy, not only in developing countries but also in developed countries. This is made even worse by weak health promotion policies in all countries. And that results in poor health choices. Key determinants of health obviously are found outside the health sector. And that is why we have started moving towards Alma-Ata and beyond to a whole of government and whole of society approach to health. So in WHO, in the last year or so specifically, there has been a move towards transforming the work of the organization to a people-centered approach that will help counties build systems to ensure that health is an indicator and outcome of sustainable development.
So let me quickly go the assembly, which is now meeting. It will have many strategic issues under consideration. Probably the most important is the general program of work, which this time runs for five years, from 2018 to 2023, and not a two-year cycle like before. Specific issues which will be considered tomorrow and the day after relate to health emergencies, polio eradication, health and the environment or climate change, access to medicines and innovation, intellectual property, and, of course, preparations for the high-level meetings in the General Assembly this year on non-communicable diseases and TB.
There are also obviously routine issues that are taken up every year or every couple of years. The budget is very, very important because we are looking at a multifaceted budget envelope over five years to fund the general program of work, or GPW as we call it. You may have seen on the agenda of the assembly there are issues related to heart diseases, snake bites, and so on, which are more technical discussions. But the main focus in terms of the GPW is linking the work of WHO to the sustainable development agenda, and how to use this agenda to attain the highest standard of health and wellbeing for everyone.
So this vision that Dr. Tedros and the organization has determined should be based on a mission statement which includes the promotion of health, keeping the world safe, and serving the vulnerable. So those three approaches are then the guidance for ourselves, our roadmaps so to speak, those priority areas around which we want to ensure healthy lives. And this is where the 3 billion scenario comes into play. So the aim, firstly, is achieving universal health coverage with 1 billion people—more people benefitting from such coverage. Then to address health emergencies with 1 billion people better protected from such emergencies, and promoting healthier populations, with 1 billion obviously having—enjoying better health and wellbeing.
This covers as you can imagine communicable, non-communicable, and other disease burdens and health threats. There is a need also—I think member states often overlook to invest in community-based health services, and specifically to invest on the area of trained health professionals. There are tremendous shortages, up to 40 million being forecast over the next 5-10 years. So it is an area where we need to do much better work. We also probably need to do much better in not only strengthening health systems, but also looking at improving effective service delivery in an integrated manner. That’s essential, obviously, for achieving an increase in access to quality health care, and to achieve universal health coverage.
The next two years will be very crucial time for WHO, not only in terms of the budget but also in terms of how we will see financial support for the organization and political leadership on global health issues. And the two meetings taking place here in New York on tuberculosis—which you all know is an ancient, curable, and preventable diseases. Causes the most death in the world from infectious agents every year. That meeting is taking place on the 26th and—followed by a high-level meeting on noncommunicable diseases on September 27th.
We are hopeful and have set a target of having at least 35 to 40 heads of state attend each of these meetings, particularly noncommunicable diseases at the third high-level meeting. It causes most deaths, 72 percent of deaths, every year in the world; 41 million people die prematurely because of noncommunicable diseases.
And outcome of these two meetings will hopefully project us and build momentum through a Global Health Summit, which Germany is hosting in October. Many other global events will take place in the lead-up to next September, 2019, when there will be a high-level meeting at head-of-state level on universal health coverage. So we will have lots to talk about over the next two years.
HUANG: Thank you, Werner.
OK, we have, like, 18 minutes left. So it’s kind of—sorry for all that. So I’m going to—well, initially I was thinking of asking two questions, but I’m going to ask only one that will make it provocative, although I don’t think it will be as provocative as Laurie’s, which I’m sure will have one—(laughs)—coming. It’s about WHO reform, because as we can see, actually, from Ariel’s presentation, right, talking about internal challenges that require the WHO reform internal management, you know, governance.
And we know that the WHO reform was on Margaret Chan’s agenda as early as 2010, right. And actually the Ebola outbreak in 2014 highlighted the need to reform the internal structure of the organization as well as the need to beef up its abilities for emergency response. But that WHO reform, in my humble opinion, seems to be completely dropped from Dr. Tedros’ agenda.
Is that true? Any comments?
OBERMEYER: (Laughs) I’ll turn to you.
PABLOS-MÉNDEZ: I don’t think that the reform agenda has disappeared from WHO. Perhaps it is not called reform. What Dr. Tedros has embarked upon is called transformation.
HUANG: OK. (Laughs.)
PABLOS-MÉNDEZ: One good example—
Q: (Inaudible)—all the keywords in your Google search. (Laughter.)
PABLOS-MÉNDEZ: —is the senior management now. For the first time we have achieved gender parity. All regions of the world are represented in our senior management. That is one HR transformation which is visible and tangible.
And I think, in terms of the work—general program of work that’s been developed over the last 12 months, the deliverables built into that program will show just how truly the organization will be transformed going forward.
OBERMEYER: I think that he has done a few good things. And there’s a lot more women in the leadership cadres, including the director general; better representation geographically. The Brits are wonderful, but we have too many of them, and now there’s better geographical representation in the organization.
But those are not, like, profound transformations to sort of the strategic work and direction of the organization. He might eventually get us there. But the crucial thing is when Ebola—there was an issue as to the coordination of information between Geneva and the regional office and the country office, and sort of tiptoeing around that hierarchy instead of acting with more bold resolve.
And so that’s an issue, whether that—it’s not easy. All these things are very complicated. The member states are on both seats. And it’s up to them, really; not so much up to Tedros, although leadership is about making the case.
And I also believe the budget will be paramount. And the conversation is gearing up for next year. And I think there’s been some seeds planted for that. It is my hypothesis that the conditions are ripe for an opportunity. But if the organization doesn’t move and provide confidence to the member states, then that may fail. And if that fails, then a lot of things will fail.
HUANG: Thank you.
Any questions? Laurie.
Q: No, I think Harold preceded me.
HUANG: Oh, all right.
OK, go ahead.
Q: Very gracious of you, Laurie. Thank you.
So you both placed a lot of emphasis on the idea of increasing the number of—the amount of universal health coverage, and possibly even having a billion additional people on it. Can you be a little more nuanced about what you mean by universal health coverage? How is that concept changing as a result of the new interest in noncommunicable diseases, for example? What is the coverage? Who’s going to pay for it? How many people are covered now? Give us a sense of how steep a hill this is to climb.
OBERMEYER: Right. Universal coverage is defined as three access. It’s access for all to appropriate health services without financial hardship.
Q: So not the United States. (Laughter.) Seriously.
Q: Well, it should be on the list.
OBERMEYER: So it’s access for all.
Q: I mean—(inaudible)—have access.
OBERMEYER: The access—that everybody has to have access to some services is paramount. The fact that you have to do that without paying out of pocket in a way that you get impoverished by it is also paramount.
And the first is simple. How many people have access? And you can measure that. We have surveys and so on.
The other—the third is also more or less straightforward. It’s complicated in the economics.
But the out-of-pocket expenditure is measurable. And, as I said, in Africa it’s 50 percent. In South Asia it’s 80 percent out-of-pocket expenditure. Pooling of those resources is a good thing and is a central part, obviously. It should be less than 20 percent. In OECD—
Q: So roughly how many people have UHC now?
OBERMEYER: About 4 billion or so. You simply—again, yeah, about 4 billion people. So that’s—and the WHO and the World Bank have joined in developing a measurement framework for UHC in which they are looking at impoverishment. As opposed to the out-of-pocket percentage of the total, they’re looking at households who are impoverished, to decrease that to zero by 2030. Today there are about 100 (million) or 120 million families that are impoverished, meaning they spend more than 40 percent of their household income in health. And so that’s measure, and we have data to progress that.
The other is whether they have access to services, because, you know, you may not pay anything because you have no money, and there’s no access. And so out of pocket doesn’t look—looks good, but there’s no services. And so they are—for that they have the final list of the essential services, and which are the traditional public-health, global-health priorities.
I have to say that—that includes blood-pressure control and so on—that what is appropriate health services varies according to the economies of countries. It’s not only what they can afford. This is what they can buy from the demand side, but also what they can offer from the supply side.
Q: And it depends on also—
OBERMEYER: And Rwanda has a universal coverage scheme, based on the mutual community-based insurance that supplements the government expenditure. And it’s very nice idea for a very poor country that was just coming out of genocide.
And so there’s no point Rwanda say that they will not cover sophisticated neurosurgery. They don’t have sophisticated neurosurgery in the country. So they don’t have to—that they have to ensure that you will have access to a physician or a nurse or you have access to the service, immunization. All of those things are covered. And that’s what universal coverage is.
Q: Just a quick question to either of you who feel comfortable about it. What did you think of the memorandum? (I leaked it ?) this weekend, but it’s been out pretty widely, the Merkel—Germany-Ghana-Norway joint memo calling for a restructuring of all global health and complete restructuring of everything, with a deadline of October at the Berlin summit for agreement.
HUANG: Any of you? Comments?
PABLOS-MÉNDEZ: Well, the letter has been around for some time. The letter calls for health to be the driver of the 2030 agenda, not only the targets that are captured in the goal for health. It does not really call for a major restructuring in terms of the governance architecture, although, of course, that will be part of the discussion.
Dr. Tedros has written to the secretary-general to inform him, and the letter has now been circulated to the senior leadership in the U.N. system. But this letter actually affords an opportunity for us to move much more coherently towards universal health coverage and the drive to achieve it, culminating in the high-level meeting next year.
Just to mention quickly that we measure through household surveys how many people are impoverished because of health expenditure. It’s around 100 (million) to 110 million a year that have to sell assets in order to pay for health. So this is a problem that can be solved.
Q: That’s the entire world, not just the developing world.
PABLOS-MÉNDEZ: Entire world. It is a problem that can be solved obviously not through donor support. It needs to involve domestic-resource mobilization. Otherwise we will not be able to achieve it.
Q: But can I just say, from my read of that letter, the final paragraph, it calls for restructuring so that GAVI—The Global Fund, et cetera—would be under WHO. In other words, it puts WHO back in the driver’s seat, in a position it has not been in since the great surge of money and the creation of these new silos. And I thought that was very clear. And it’s causing quite an uproar in social media.
And I also just want to say the UHC figure of, you know, between 100 (million) and 100 million people bankrupted or placed into poverty by health, my read of that is that it’s incredibly low, because it actually is not accounting for wealthy countries. And so this country alone, we have a very substantial number of people. It’s the number one cause of family bankruptcy in the United States. So the numbers are just not right.
Q: Oh, so it does include the advanced countries, where the numbers should be most reliable?
Q: Yeah. So I don’t believe that figure. I think it’s really low.
PABLOS-MÉNDEZ: You are right. The number is low. But we used the benchmark that the U.N. determines for poverty levels. If we use the ILO benchmark, the number may be higher.
Q: Oh. Well, by that benchmark, then a homeless person in Los Angeles is not in poverty.
HUANG: So we still have—we only have, like, seven minutes, so—but we have four—
PABLOS-MÉNDEZ: Laurie, this is radical part of your question, if I may. I mean, clearly, UNAIDS, that’s relatively straightforward, to bring—to be brought back into the fold. It’s not going to be easy. It’s not going to be very publicly discussed. But that seems to be a reasonable thing. GAVI and The Global Fund, more complicated. Could they be merged? That’s going to be very tricky, because the financing comes from people that are not controlled by the World Health Assembly or by Germany, and so on and so forth. So the restructuring even of those global entities that very much depend on global resourcing is tricky on its own. My sense is going to be dilution, but it’s going to do it, as opposed to radical revolution.
HUANG: I’m going to collect two rounds of the questions. First is Jim’s and Jeff (sp), and then Brian (sp), Craig. How about that? Please keep your questions and answers as brief as possible.
Q: One of the most dramatic changes that was described on the screen was the shift from public financing to private-sector financing. To what extent is the current agenda on public health being shaped by corporate sources of funding, drug companies, others? How much are they now shaping what’s being decided, and how?
HUANG: And Jeff (sp).
Q: Thank you, Yanzhong.
Forgive me for putting America first, but what has been the change, if any, registered in Geneva of the arrival of the Trump administration and its priorities vis-à-vis what WHO has been doing? Our new presidential national security adviser has been a bitter foe of the Millennium Development Goals a dozen-odd years ago, and presumably hasn’t warmed up to them under SDG guise. Is there any sense that the—that, as we go into this World Health Assembly, that the U.S. is going to be a positive and engaged cooperative player? Or does it have an agenda either in terms of forcing the budget down or other things that might put it at odds with the membership—with others in the membership?
PABLOS-MÉNDEZ: Thanks. I mean, the role of private corporations was very important; was particularly important, I think, in the global-health era. Today is going to be different. It’s not going to be about some discrete partnership between some corporations that donate drugs or access to this and that, as we did, and then we give it from the rich to the poor countries.
No, today is going to be shaping markets. In Africa, all of the dollars, all of the dollars—USAID, bilateral, multilaterals—when it comes to health commodities, drug vaccines, account for about $5 billion in Africa. The markets of those commodities in Africa already are $25 billion, and they’re expected to go to 40 (billion dollars) or $50 billion by 2030. Clearly, 50—5 billion (dollars) was significant 10 years ago. It’s not going to be significant in 10 years. So—but those are markets.
So how do we work to shape those markets to ensure deficiency for the markets and the innovations that we want are welcome? But also quality and equity, because there will be all sort of companies. Not all are great. And there’s no lens to looking at this transformation of the markets in Africa.
When it comes to universal health coverage, big debates. Should private insurance play a role? There are different views on that. I’m of the view that you can organize UHC in so many ways. The Swiss have Obamacare at the national level; in Singapore have President Bush’s idea of health spending accounts for everybody, and it works very well. So you can do lots of different approaches, as long as you are pooling and doing some—(inaudible). Insurance is logical. (Inaudible)—is always political.
So those are—those are things where corporate sector will play an important role. They are employers and they care for their employees. And so there will be many other new dimensions. They have to be involved with the policy shaping of those countries, as opposed to simply how do we donate a drug or a vaccine. That’s going to change, is my view.
The Trump administration—I mean, I was a member of the—former member of the Obama administration, and I was very proud of that being what I call the golden era, because it’s been a golden era. And that is no longer the case, right? We just have the Admiral Ziemer, who used to work with me and was in the National Security Council, has been demoted. The position has been eliminated. So that speaks a bit about the commitments of the administration to global health.
But I will say, remember, America is bigger than the U.S. government, and the U.S. government is bigger than the White House. All of the budgets that I enjoyed, because my budgets kept going up, as also—(inaudible)—kept going up, were determined by the Congress.
In the six years I was there, the Congress was Republican. And the Republican Congress owns the budgets. They understand. They believe. They know why those are important. And so the Congress remains right now—it is a battle, of course, like all budgets for all things. And we have a lot of champions among Republicans also in Congress to defend the global-health budget. I mean, there’s pride from the Bush administration on PEPFAR and what it has accomplished.
There’s a lot of champions, I tell you. I always remember Congressman Smith, Chris Smith from New Jersey, who I—I mean, he has his views on abortion, but on child survival, he’s a champion. And I say how many votes did he earn for supporting budgets for child survival in Africa? He cares. And there’s a lot of people like that in Congress.
HUANG: OK. Brian (sp) and Craig.
Q: I’ll pass, in fact.
HUANG: Oh, OK. Brian (sp). OK, the last question, then.
Q: Thank you. My question is I just learned that this morning Taiwan was blocked outside of WHO again because of one-China principle. But what I can—what I’m concerned is, under WHO, there is international health regulations, under which regulations each country should report case to these regulations. But no, last year, in 2017, in October—(inaudible)—Taiwanese got (topical ?) losses. He is in a—he is one of passengers on airplane, and IHL report its case to China. But China let Taiwan know; that’s five months later. To what extent (can ?) IHL regulate China? It’s just that 15 years ago that has also happened in China. And it took many, many days Taiwan to know that. It caused huge cost.
So here is my question. What’s the—
HUANG: Are there any comment?
Q: —(sense at ?) IHL? Thank you.
HUANG: You’re a diplomat. Do you know—(laughs)—do you have a diplomatic answer?
OBERMEYER: I just want to make two quick points on the previous questions. On the private sector, there has to be private-sector involvement. Most of the money going to research and development obviously are not from the public sector. In India, more than 55 percent of patients visit private institutions for health care, not public. So the private-sector role is crucial.
Just to echo what Ariel has said, we have had a very positive relationship with the administration in Washington. Dr. Tedros has visited several times and received very strong support from both sides of the aisle.
In terms of TB, very strong support also for the high-level meeting this year. The USA is the largest international donor for tuberculosis. Obviously, each country have their own priorities. So those that may support TB may not be supporting noncommunicable diseases. In some countries, industry have a bigger influence than others. So this is the reality of the political landscape.
The international health regulations apply evenly to all countries, and each country has an obligation to which it becomes a signatory when it enters into the application of the regulations. WHO does not have the capacity to judge, but we have the capacity to build. So each country, obviously, are not able equally to apply the regulations. So we are working towards this. It is going to be a work in progress for quite some time.
HUANG: Thank you, Werner.
OK, for those—Craig and Lindsey (sp), you didn’t have the chance to ask questions. I apologize.
But thanks to our two speakers for giving us the very informative—(applause). Thank you.
And I hope you enjoy the beautiful afternoon today.
This is an uncorrected transcript.