Towards global health equity: opportunities and threats

On 29 August, 2011, I had the honour and pleasure to witness and facilitate the creation of the African Federation of Public Health Associations. It was a landmark event attended by all Ministers of Health of the African region, during which we committed to work together to support Governments and communities to address the public health challenges that we face at regional and country levels. Therefore, organizing the 13th World Congress on Public Health in Africa demonstrates the confidence that the World Federation of Public Health Associations places in the young African federation. I am assured that deliberations during the next 5 days will provide new insights and creative solutions to public health issues being faced by the world and the African continent in particular.1

The health of the population depends both on the provision of health care for the sick and the efforts organized by society to protect, promote and restore people's health. Since the dawning of civilization, humankind has made remarkable progress in advancing public health and improving people's health, but in many ways, we are facing intractable and emerging health problems. During the last 100 years, the application of scientific and technological breakthroughs in health has brought accelerated progress in control of communicable diseases in industrialized countries, but the fundamental success factors rested upon social and economic development that improved environment, housing, food, nutrition, education, water supply, hygiene and sanitation, and other key health determinants.

To date, developing countries, particularly in sub-Saharan Africa, are facing a double burden of communicable and non-communicable diseases, high infant and maternal mortality and recurring epidemics. This is further aggravated by the prevailing weak health systems, poverty and weak economic performance that pose serious challenges to health and development.

If we compare the key health indicators in the world, for example those related to the Millennium Development Goals, we are struck by the uneven distribution of health across countries, within countries, and between population sub-groups, e.g. rich and poor, men and women. There are differences between rural and urban areas in coverage of key health services, such as, skilled attendance at birth, immunization, and diagnosis and treatment of common diseases. These inequities can be avoided through adoption and implementation of relevant health and development policies that seek to minimize variation of health indicators associated with socio-economic status.

Available evidence shows a strong and positive correlation between health and wealth! That is why I think that the theme of the 13th Congress on Public Health – Towards Global Health Equity: Opportunities and Threats is very topical and appropriate. Public Health as a discipline is at the crossroads. There are major changes due in part to globalization, political and economic reforms, demographic and epidemiological changes, new technologies, open access to information and communication, and relatively high literacy rates among the population. These changes have brought both positive and negative effects in the way we perceive and manage health systems. Therefore, decision makers, managers, health professionals, and other relevant stakeholders should be prepared to address a broad and ever-increasing public health agenda, with new problems being assigned over time.

Over the last 30 years, life expectancy has increased globally. According to the World Health Statistics 2011, the average life expectancy at birth was 68 years in 2009, ranging from 54 in the African Region to 76 years in the region of the Americas 1. More than a billion of the world's poorest people are not benefiting from major advances in health care 2, and several countries particularly in sub-Saharan Africa have seen a decline in life expectancy due in part to the HIV/AIDS epidemic.

According to the WHO Global Burden of Disease, about 59 million people died in 2008, globally 3. Almost 18.6% of those deaths occurred in the African Region which shares about 12.1% of the world's population.

Communicable diseases represent 63% of total deaths in the African Region. HIV/AIDS, diarrheal diseases, malaria, tuberculosis, and childhood diseases cause 88% of those deaths. HIV/AIDS alone, accounts for 38.5% of deaths from communicable diseases and 15.6% of all deaths in the Region 3. Nevertheless, all these diseases are preventable!

Globally, the proportion of children under 5 years of age who were underweight declined from 25% in 1990 to 18% in 2005 despite the fact that prevalence in under-nutrition has increased in some countries, and globally stunted growth affects about 186 million children under 5 years of age. However, child mortality continues to decline in the African Region mainly due to concerted expansion in coverage of immunization programs and the Integrated Management of Childhood Illness – IMCI approach. Current statistics show that about 40% of deaths among children under 5 years of age are estimated to occur in the first month of life, reflecting poor attention to neonatal care. Let me emphasize that according to WHO reports, the greatest reductions in child mortality have been recorded among the wealthiest households and in urban areas 4.

The risk of maternal death is highest in the African Region where 620 deaths occur per 100,000 live births compared, for example, to 21 per 100,000 in the European Region 5. Maternal mortality is the indicator that shows the widest gaps between rich and poor, both between and within countries. In the African Region, maternal, perinatal, and nutritional conditions represent 12.2% of deaths 3. Unfortunately the African region is not on track to achieving the MDG5. Let us be reminded that in September 2010 the Secretary General of the United Nations launched the ‘Global Strategy for Women's and Children's Health’, with the goal of saving 16 million lives by 2015 in the world's 49 poorest countries 6. It is also very important to remember that the Heads of State and Government of the African Union debated on ‘Promoting Maternal, Infant and Child Health and Development in Africa’ in Uganda, 2010, and committed their countries on key actions to accelerate efforts to improve the state of Africa's women and children 7 8.

Chronic diseases including mental disorders represent about 60% of the current global disease burden. Worldwide about 37 million deaths are attributable to non-communicable diseases (NCDs); that is, 63% of the total number of deaths. Available estimates in the African Region show that 3.0 million deaths annually are attributable to non-communicable diseases 3.

The rapidly increasing burden of NCDs is affecting poor and disadvantaged populations and disproportionately contributing to widening health gaps. Most chronic diseases are associated with major risk factors such as tobacco use, unhealthy diets, physical inactivity and alcohol abuse. Needless to say, the untapped potential of public health approaches such as health promotion, disease prevention and specific protection, could make a significant difference in reducing the level of exposure of individuals and populations to these modifiable factors.

The alarming growing trend of NCDs has been the subject of intense global debate. In September 2011 a Resolution of the United Nations General Assembly, adopted the Political Declaration on the prevention and control of non-communicable diseases 9. In October 2011, the World Conference on Social Determinants of Health held in Rio de Janeiro, Brazil, offered an excellent opportunity for debate on issues of governance for health, community participation, equity in health, and finally adopted the Rio political declaration on social determinants of health that makes a resounding call for global action toward policies needed to achieve both sustainable development and health equity through action on social determinants 10.

To respond to the huge disease burden, disabilities and premature deaths due to communicable and non-communicable diseases, the unfinished agenda of reducing infant and maternal mortality, and addressing emerging and re-emerging diseases; the World Health Organization provides in its 11th General Programme of Work (2006–2015), seven key orientations (2):

• Investing in health to reduce poverty;

• Building individual and global health security;

• Promoting universal coverage, gender equality, and health-related human rights;

• Tackling the determinants of health;

• Strengthening health systems and equitable access to health care;

• Harnessing knowledge, science, and technology to improve health; and

• Strengthening governance, leadership, and accountability in health.

In this context the African region has highlighted: WHO normative and policy guidance; health systems based on the primary health care approach; the health of mothers and children first; accelerated actions on HIV/AIDS, malaria and tuberculosis; prevention and control of communicable and non-communicable diseases; and accelerated response to risk factors and key determinants of health 11.

Achieving the highest possible level of health implies addressing current and emerging health problems. Progress toward achieving health Millennium Development Goals is unequal throughout the world. Some parts of the world are doing better than others. In the African Region for example, very little progress was made toward MDGs 4 and 5. Therefore, the world has to tackle both the intractable public health problems and new ones.

New threats to public health are commonly associated with socio-economic and demographic factors (e.g. population growth rates, international trade, poverty, urban migration, international travel, social disruptions); individual and collective human behavior (e.g. diet, illicit drug use, sexual practices, and outdoor recreation); environmental aspects (e.g. use of pesticide and antibiotics in crop and livestock management, changes in food processing, inadequate coverage of potable water, and sanitation); and health systems issues (such as the use of technologies, availability and use of human resources, and financing) among other determinants 12.

The global recognition of new public health challenges is of particular significance in the African region. I see, for example, some issues we need to collectively address:

• Adaptation to climate change: the recent droughts in the horn of Africa and the Sahel have resulted in environmental distress that impact negatively on food security, nutrition, and health of people.

• Urbanization in Africa is rapidly evolving with overcrowding, urban sprawl, and pollution, which may lead to outbreaks, violence, and other negative effects on people's health.

• Changes in the interface between wild-life and human settings are creating interactions between animal and human health and is increasing the risk of new pathogens and diseases.

• Emergence of germs that are resistant to common antibiotics such as resistant strains of pathogens related to AIDS, tuberculosis, and malaria.

New public health challenges create increased demands on health systems to detect and mitigate them.

Addressing the public health challenges in the 21st century requires a new health systems thinking. Health systems are subject to powerful social and economic influences that often pull them from their intended goals. We need sounder health policies underpinned by the primary health care values and principles, and I am especially appealing to equity. We need reforms that redesign health systems in a more holistic manner, in which public health is a shared responsibility that recognizes the important role of individuals and communities.

Strides Towards global health equity require, in my view, a more critical approach to health systems, within which Public Health as a theoretical framework incorporates a broader range of individual and societal issues, and identify interventions that are relevant to different contexts and environments.

The World Health Organization remains committed to promoting public health based on scientific evidence. We have been working with the World Federation of Public Health Associations and currently the WHO Regional Office for Africa is providing support in view of consolidating the African Federation of Public Health Associations.

Health in all policies is a must to tackle health determinants and risk factors. Intersectoral collaboration, multidisciplinary actions, and partnerships are important requirements of public health. It is in this context that I would like to highlight the important role of National Public Health Associations, the regional federations, and the World Federation of Public Health Associations. Together we can achieve better health for our people! We need to act together! And we need to act now.

Luis Sambo

Regional Director of WHO Regional Office for Africa

Brazzaville, Republic of Congo

[email protected]

Notes

¹Keynote Address by Dr L. G. Sambo, Regional Director of WHO Regional Office for Africa at the 13^th World Congress on Public Health Addis Ababa, Ethiopia: 23–27 April, 2012.