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Strengthen global health security by investing in Universal Health Coverage

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Gro Harlem Brundtland addresses the World Leaders Forum at Columbia University in September 2019. (Photo: Columbia University / Eileen Barroso)

Our networked world means that we are only as strong as our weakest link. Gro Harlem Brundtland warns leaders to ensure resilience to epidemics by investing in health systems that are capable of meeting daily challenges.

This keynote speech was delivered at the World Leaders Forum: Global Health Security at Columbia University in New York, on 24 September 2019.


Ladies and Gentlemen,

It is a great honour to be with you here today to discuss such an important and timely topic.

As the leaders of the world are gathered in New York for the United Nations General Assembly, the issue of global health security should be uppermost in their minds.

I am speaking today as a medical doctor and someone who has spent decades in public life at a national and international level.

I am also speaking as a member of The Elders, the group of independent global leaders founded by Nelson Mandela to work for peace, justice and human rights.

When preparing for this speech, I was reminded of a powerful quote from Mandela that should underpin all our deliberations today:

“Health cannot be a question of income; it is a fundamental human right.”

By the same token, all global citizens have the right to live in peace and security, and it is the responsibility of politicians and health professionals to ensure that health security is maintained in an inclusive, fair and transparent fashion.

As a former Prime Minister and Director-General of the World Health Organization, I know the enormous constraints faced by politicians, including the perpetual challenge of budgetary restraints and competing agendas.

But I also know that leaders have to take bold action in the interests of their people and the wider world, and the centrality of political will to taking hard decisions that can be literally a matter of life and death.

We live in an age where a global security emergency that would endanger tens of millions of lives could be imminent. In days, a lethal influenza pandemic could spread across the world, halting trade and travel, creating widespread social chaos and leaving a hole in the global economy.

We can see today in the Democratic Republic of Congo how a lack of health security infrastructure – the result of decades of conflict and weak governance – exacerbates the impact of the Ebola epidemic to deadly effect.

Without a doubt, Ebola is a catastrophe: for the victims of the disease, their families and wider communities, and the countries and regions affected.

The way to avert this and future catastrophes is to invest in health security capability. And at its most fundamental level, this means investing in and promoting Universal Health Coverage, so all members of society – from the richest to the poorest and most vulnerable – have access to the healthcare they need without falling into poverty.

Yesterday, I spoke at the High Level Meeting on Universal Health Coverage convened by the President of the UN General Assembly. My message there was the same as it is today: unless leaders get serious about achieving UHC the world will never enjoy genuine or sustainable health security.

This means governments must take proactive steps to publicly fund healthcare, with a deliberate focus on preventive measures and primary health care so vulnerable and marginalised groups are covered.

Last month I visited South Africa with my fellow Elder, the former President of Chile, Ricardo Lagos, to learn more about the government’s plans to introduce National Health Insurance, that will cover ALL South Africans.

The reforms proposed by President Ramaphosa and his government are timely, ambitious and affordable; indeed, if implemented successfully, they could offer a model to the United States where, like in South Africa, the health system is dominated and distorted by inefficient and inequitable private health insurance schemes.

We know that weak governance, infrastructure and the lack of trust between people and their health services impedes efforts to fight diseases that are already identified and can be contained and overcome.

Countries that are already suffering other forms of fragility are the most at risk. This is as true today as it was a hundred years ago, when an outbreak of Spanish influenza killed more people than had died in the First World War; in part because that conflict had devastated public health and infrastructure across Europe. Meanwhile, today, we see the world’s worst outbreak of cholera in war-ravaged Yemen, where hospitals are deliberately targeted by military forces in contravention of the Geneva Conventions and the rules of war.

But it is dangerously complacent to assume that health security is a concern only for conflict-riven countries.

A new report by the Global Preparedness Monitoring Board, of which I am Co-Chair, together with my esteemed colleague Mr. Elhadj As Sy of the International Federation of Red Cross and Red Crescent Societies, warns that humankind is stumbling toward the 21st century equivalent of the 1918 Influenza pandemic.

In 1918 though, a virus could not travel the world in just over a day. Today, local epidemics can quickly become regional and global. Combined with increasingly complex social challenges, including eroding trust in institutions and the deliberate spread of misinformation, particularly via social media, this becomes a question not of ‘if’ but ‘when’ a deadly outbreak emerges and threatens to become a global pandemic.

This doomsday scenario need not be inevitable. We have developed many of the tools needed to prepare for an outbreak, but world leaders are not scaling them up. Where life-saving health technologies, including vaccines, drugs and diagnostics, are lacking, investment is needed to ensure that these are developed and that the communities that need them most get them.

Health systems need to be managed efficiently and transparently, and fully integrated into the global health and governance architecture.

In this regard, there is much that I learned from the experience of the SARS epidemic of 2002-03 when I ran the WHO.

This was a sudden outbreak of a new disease. It was not predicted, and it took some time to identify and contain. International organisations faced particular challenges in balancing the imperative of clear and precise public messages with the political reality of engaging with particular regimes with an embedded culture of secrecy and authoritarian control.

But successful international collaboration between governments, health organisations and scientists meant it was possible to both understand and contain the disease, and ultimately prevent what could have been an international health disaster.

One of the lessons that the WHO drew from that experience was that transparency and open communication is absolutely vital – first to report and identify disease, and then to be able to issue global alerts and travel screening measures.

An essential factor undoubtedly was the clarity of the WHO constitution, and the authority and respect for leadership it gave us. We managed to assert authority and won respect among the world’s governments as well as other key international institutions and stakeholders.

The WHO and its partners have also in many ways significantly improved their response capabilities since the 2014-2016 West African Ebola outbreak, including the use of breakthrough vaccines, medicines and innovative technologies.

Yet the current outbreak in DRC is taking place in a far more complex environment, where communities suffer from severe and longstanding insecurity and lack of trust in authorities and health care workers.

Understanding community needs and ensuring that they are fully engaged in planning and accountability mechanisms is essential. Solutions can no longer be solely focused on health, but must involve all parts of society, including the security sector.

Heads of governments need to do much more to protect the health security of their people. There is a significant weakness in all countries’ defences when it comes to epidemic preparedness, because the reality of our networked world is that we are only as strong as our weakest link. In cost terms, investing in preparedness is excellent value for money.

The same logic applies to Universal Health Coverage, which is the surest way of strengthening all the links in the global health security chain.

Investment in health equals investment in the economy as a whole. This was the conclusion of the Commission on Macroeconomics and Health that I established as Director-General of the World Health Organisation in 2001, and which was led by Professor Jeffrey Sachs. In fact, not investing in health is the very definition of a false economy. A Lancet Commission chaired by the Harvard economist Larry Summers has estimated that the economic returns to investing in health will be at least 10 times the outlay of public spending. These findings have been endorsed by over 350 of the world’s leading economists.

Nevertheless, given the scale of existing challenges, there is some understandable scepticism within governments, about the relevance and importance of preparing for acts of bioterrorism that might take place in the future.

When resources are scarce, they would rather address the health issues that their countries are already coping with today. The need to deal with the conventional challenges that already exist, as well as emerging threats, must be borne in mind as we seek ways to bring different international and local actors together to address the challenges of health security.

Yet there can be a win-win approach. Resilience to epidemics and deliberate biological threats must be firmly rooted in a health system that is fit for purpose for the challenges it faces every day. States should meet this responsibility to their citizens by fully implementing the International Health Regulations and providing sufficient public funds to ensure universal health coverage. This will improve the resilience of individuals’ health, of the system of health infrastructure and delivery, and, crucially, of the trust between citizens and the state.

Data from the World Bank and WHO show that most countries would only need to spend on average between US $1-$2 per person per year to reach an acceptable level of health emergency preparedness, representing a return on investment of ten to one or higher. Wealthier countries should also invest more to fill the gaps for lower-income countries because ultimately the world is fully interconnected and threats to one are threats to all.

We need to assert this spirit of solidarity if we are to enhance the capabilities of the global health security system and avert catastrophe. This means upholding and strengthening the principles of multilateralism and a rules-based international system, to better withstand the threats of isolationism and the politics of cynical, short-term horizons.

Diseases know no borders and cannot be kept at bay by walls or barbed-wire fences. It would truly be a catastrophe if our vision of “security” becomes so distorted by the discourse of bellicose nationalism that it dehumanises people seeking shelter on the shores of prosperous states.

Separating families and keeping children in cages is not the hallmark of a civilised society. Nor is it the hallmark of a healthy society. If refugees, migrants and other marginalised and vulnerable groups are left in squalid and dangerous conditions, from the Rio Grande to Cox’s Bazaar in Bangladesh, the health security of all our societies will be threatened.

To conclude, we need to recognise the scale of the challenge facing us. It can be tackled with innovation, ingenuity and investment, deploying technological advancements to improve the resilience of health systems and health security infrastructure.

But ultimately, we will only deliver health security for all if we understand it as a matter of human rights and dignity, drawing on the legacy of ethical leaders like Nelson Mandela to build a better, safe, healthier world for our children and grandchildren.

Thank you.

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