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Depar tm ent o f EU In te rna t iona l

Rela t ions and D iplom acy St ud ies

EU Dip lom ac y

Papers

1 / 2007

Global Answers to Global Problems:Health as a Global Public Good

Jorge Sampaio

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EU Inte rna tio na l Relations and Dip lom ac y Stud ies

EEUU DDiipplloommaaccyy PPaappeerrss

11 / / 22000077

Global Answers to Global Problems:

Hea lth as a Global Public Good

Jorge Sampaio

© Jorge Samp aio 2007

Dijve r 11 | BE-8000 Brugg e, Belgium | Tel. +32 (0)50 477 251 | Fax +32 (0)50 477 250

E-mail ird.info@co leurop .be | ww w.co leurop e.eu/ ird

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Jorge Samp aio

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About the Author

Jorge Sampa io is the United Nations Sec reta ry-Genera l's Spec ial Envo y to Stop

Tub erculosis and former Preside nt o f Portug a l.

Jorge Sampa io gradua ted in Law from Lisbon University in 1961. In 1979 he was

elec ted to Parliament as a me mb er of the Soc ialist Pa rty. He w as a lso a

member of the European Human Rights Commission of the Council of Europe

(1979-1984). In 1989, he was elected Mayor of Lisbon and re-elected in 1993. In

1996, Jorge Sampa io was sworn in as Preside nt o f Portug a l, and he was re-

elec ted five yea rs la ter. During the last d ec ade, Jorge Samp a io has ma de

important c ont ributions to seve ra l issues rela ted to Europ ea n a nd g lob a l affa irs,

includ ing HIV-AIDS, d rugs, child ren, human rights and the ind ep end enc e fo r

East Timor. In 2006 UN Sec reta ry-Genera l Kofi Anna n a ppointed him a s the first

Spec ial Envo y to Sto p Tub ercu losis.

Editorial Tea m:

Nike Bönnen, Ma thieu Briens, Sieg lind e Gstöhl, Diete r Ma hnc ke, Kevin O'Co nne ll

Dijve r 11 | BE-8000 Bruges, Belgium | Tel. +32 (0)50 477 251 | Fax +32 (0)50 477

250 | E-mail ird .info@coleurop .b e | Website w ww .c oleurop e.eu/ ird

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EU Diplom ac y Papers 1/2007

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Introduction1

My analysis about Global Answers to Global Problems – Health as a Global

Public Good is mainly about Europe. But instead of taking a 'domestic'

European viewpoint as is usually done, I would this time rather start at a global

level and then reac h the Europ ea n standpoint. I do b elieve it is a mo re

c ha lleng ing wa y of repo sitioning Europ e in our Globa l Age.

I will divide my presentation into four main points: I will begin by outlining the

progress made regarding the assumption of responsibilities in global health,

pa rticularly in the fight aga inst infec tious d isea ses like HIV-AIDS, Ma laria and

Tub ercu losis in rec ent ye a rs.

Sec ond ly, I will foc us on the shortfalls in ac hieving the Millennium Develop me nt

Go a ls (MDG) on Hea lth.

Third ly, I would like to address several strategies that could better ensure a

susta inable hea lth polic y reg a rd ing its huma n c om ponent in order to me et the

MDG.

Fourthly, I will turn to the European Union a nd foc us on its main responsibilities in

designing a nd impleme nting a Europ ea n Glob a l Hea lth Stra teg y.

First po int: The g oo d news – progress made in a ssuming g lob al responsibilities in

health – a m ajor ac hieveme nt: hea lth is pa rt of the g loba l age nda

I think everybody would agree that, today, health issues are clearly on the

global developm ent ag enda and they are mo re a nd m ore seen as a g loba l

public goo d . In a n increasingly globa lised wo rld , ma rked by migrations and fast

mo vem ents of p eop le w orldwide , pub lic hea lth issues indeed c all for dom estic

policies but also require international measures and an integrated regional

approach, since events overseas affect each country’s health. Communicable

diseases are a most obvious example of these externality aspects of public

1 Address on the occasion of the 8th Hendrik Brugmans Memorial Lecture to

celebrate the 100th anniversary of Hendrik Brumans, sponsored by the College ofEurope, the Madariaga Foundation and the Alumni Association of the College of

Europe, Brussels City Hall, 14 Dec ember 2006.

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hea lth. Tha t is, no single c ountry c an a lone p reve nt or co nta in c om munica b le

d isea ses in orde r to p rotec t the he a lth of its pop ulation.

This inc rea sing awarene ss of c ross-borde r and g lob a l hea lth issues is a lso

expressed in the growing a ttention p aid to hea lth b y non-hea lth sec tor entities,such as the United Nations, the World Bank, the European Union or the G8, as

well as by private, corporate and charity sectors, such as the Bill and Melinda

Gates Foundation, the Clinton Foundation and the Global Business Coalition

Initiative.

Another important point has to do with the progress made in mobilising

resources. Apart from commitment to further support for the Global Fund to

fight AIDS, Tuberculosis and Ma laria , the internat iona l co mmunity is eng aged indeve lop ing innova tive financ ing me c hanisms suc h a s the Interna tional Financ e

Fac ility and the UNITAID, which is an Inte rna tiona l Drug Purchase Fac ility be ing

established by some countries, funded by an international air-ticket solidarity

levy.

Despite some outstanding problems, I do think these examples are obvious

indicators of health issues moving up the global agenda and thus being

c onsidered p a rt of a minimum for a d ec ent w orld . Therefore, in my view , wehave good reason to be optimistic: at the international level there is clearer

political commitment and stronger public awareness, and more resources are

availab le. These bette r c ond itions lend renewe d impe tus to the fight aga inst

infectious diseases, but also create added responsibilities with a view to

p rod uc ing b etter results.

That wa s the g oo d new s. Now , the ba d new s.

Sec ond po int: The b ad news – lac k of steady prog ress in ac hieving the

Millennium Develop me nt Goals (MDG) on Hea lth

The b ad new s is tha t, de sp ite a ll the p rog ress in inc rea sing life expec ta nc y a t

birth in recent years, enormous health problems are still with us. Absolute

mortality levels in developing countries remain unacceptably high and global

health conditions worldwide are not improving. Actually, the Millennium

Deve lopme nt G oa ls on Hea lth – c om bat a ga inst HIV/ AIDS, Ma laria , Tuberculosis

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and other diseases – prevention efforts are proving successful in some places,

but deaths and new infections continue to increase. Let me expand a little on

HIV-AIDS and Tub erculosis.

In respec t o f HIV-AIDS, overa ll ra tes of infec tion a re still growing and the numberof people living with HIV has continued to rise, from 36.2 million in 2003 to 38.6

million in 2005. There were 4.1 million ne w infe c tions in 2005. The number of AIDS-

related deaths also increased that year to 2.8 million, despite greater access to

antiretrovira l trea tme nt a nd imp roved ca re in som e reg ions.

Now , reg a rd ing tuberculosis d id you know tha t it kills 1.7 million p eo p le a yea r?

Did you ever realise that 5,000 people die of tuberculosis every day? Did you

know that the number of new cases of tuberculosis is growing by about 1% peryea r, with fa stest inc rea ses in Sub-Saha ran Africa ? Did yo u know tha t

Tub erculosis is the b igg est killer o f p eop le living with HIV/ AIDS?

Your feelings are probably of stupefaction. I must confess that I too, when

confronted for first time with these monstrous figures, understood the extent to

which this dramatic reality is poorly understood in our days and the extent to

which the widespread belief that tuberculosis is the sickness of 19th century

romantics or the sickness of the 20th

century poor or the sickness solely of theunderdeve lop ed c ountries of the 21st c entury is false a nd p rec onc eived .

Tub erculosis a sickness of the past? No ! Tub ercu losis a sickness of o thers? No !

Tubercu losis is an evil of o thers, an individua l prob lem ? No! Nothing c ould be

further from the truth.

Firstly, tuberculosis continues to be a serious public-health problem at global

leve l in our da ys.

Sec ond ly, this pandem ic , fa r from being und er co ntrol, is expa nd ing and the

forecasts are dramatic, for they suggest 35 million deaths during the coming 20

yea rs if nothing is done .

Third ly, there are two c ontinents tha t will not b e a ble to com p ly with the g lob a l

objective of cutting tuberculosis and its associated mortality by half by 2015 –

these regions a re Afric a a nd , believe me, Europ e.

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Fourthly, of the wo rld ’ s twenty-two high-burde n TB countries, nine a re loc a ted in

Africa, and the list also includes large countries and emerging economies such

as Ch ina , Ind onesia, Ind ia, Russia a nd Brazil.

Fifthly, and last b ut no t lea st, we a re not ta lking about a sickness for which the reis no treatment, but rather one that can be prevented and cured, and

c hea ply. Did you know me d ic ines tha t c ure TB cost a bout tw elve d olla rs per

c ase of illness ?

How can we therefore decline our responsibility in the combat against this

scourge? How can we refuse to take part in this fight? How can we leave

de ath unlea shed if, tog ether, we ca n mo unt a sieg e a ga inst it and de feat it?

Now w hat is my p oint? App arently TB c ould b e tho ught of a s a not to o d iffic ult

glob a l health p rob lem as it is an a ffordab le, p reventab le, c urable d isea se. But,

in reality, it is a quite complex one. Why? Mainly because of all the problems

related to poverty, malnutrition and sanitation, shared by all developing

countries. But also because of the lack of infrastructures. By infrastructures I

mean the physical, institutional and human components of the health-care

system. Bec ause of infrastruc ture g aps in ma ny c ountries millions of peo p le d ie

everyday.

Third po int: Strategies that c ould be tter ensure a sustainable hea lth po licy

regarding its human com po nent

I oug ht to em phasise tha t the c risis in huma n resources for hea lth ca re is one o f

the g rea test cha lleng es for TB c ont rol and for the Millenn ium Develop ment

Go a ls in general.

There is c urrently a severe sho rta ge of physicia ns, nurses and hea lth-ca re

workers in many places around the world, particularly in low-income, high-

disease burden countries. Just to give you a more precise idea, let me say that

the shortage is about 4.3 million health care workers of all sorts. But in Africa this

p rob lem is muc h mo re a c ute in that, while they ha ve a bout 25% percent o f the

global disease burden, only 1.3% of the world’s health-care workers actually

wo rk there. These figures show quite c learly how the g loba l burden a nd

resources a re unequa lly distribute d , with huge d ispa rities. We a lso find the same

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inequalities within the countries themselves between urban and rural areas,

since existing resources tend to be c lustered in urban a rea s.

Now, in my view, to address the human resource crisis, three aspects at least

have to b e c onside red .

Firstly, it requires imp lem enta tion of human resources develop ment stra teg ies in

the public hea lth sec tor, e.g. mo re a ttrac tive c a ree r and sa la ry struc tures and

better training as well as the establishment of partnerships with communities

and all health-care providers, in order to use and engage all available human

resources. Allow me to em phasise c lea rly tha t in my o wn persona l view eq ua l

ac c ess to he a lth for all is a ma tter of huma n rights and only dem oc ra c ies offer

rights. By this I me an tha t the re have to b e na tiona l hea lth infrastruc tures so tha twe c an make sure tha t p oo r pe op le ha ve rights. Therefore a n overall Huma n

Resources Strategy in the he a lth sec tor ha s to b e d esigned b y governme nts

tha t a re responsible fo r it. This is to say tha t the priva te and corpo ra te sec tor,

NGOs, charities, associations and foundations have indeed an important part

to play in the health field, but their action has to take place under public

po lic ies de fined and c o-ordinated by go vernments.

Sec ond ly, it req uires stronger internationa l ac tion in hea lth educ a tion andtraining. Health education remains a critical point because it is the basis of

everything, a way of empowering people in preventing health problems.

Educ a tion in hea lth is, in a wa y, as important a s trea ting d isea se… With rega rd

to tra ining, nee d less to say there must b e bette r co-ordination of international

ac tions and initiatives to a void o verlaps and ga ps and to e nsure tha t they mee t

real needs of the people. In this respect, I do think that national health

authorities and national health policy makers have a most important role to

p lay in ensuring the long -term susta inab ility of efforts and results.

Third ly, it req uires a broad multila te ra l fram ew ork for migrat ions and for c ross-

border movement of people, preventing the brain drain from poor to rich

countries. It is well known that this problem is particularly acute in essential

social services such as education and health. While domestic policies to

increase the incentives and opportunities for skilled labour to remain at home

are an important part of the solution, it has also been suggested that the

industrialised countries should co-ordinate their hiring policies with developing

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countries facing these skill shortages in essential services. Measures to stimulate

a p roc ess of “ skills c irculation” (suc h as training , ta x incentives to stimulate the

return of skilled migrants to their home countries etc.) could be considered

bec ause they w ould bene fit b oth industrialised and deve lop ing countries. The

former co uld still co ntinue to hire skilled labour from deve loping c ountries. The

la tter co uld a lso b ene fit from this c irc ula tion w ithout b eing d ep rived of the very

category of workers that they need most and without suffering the loss of their

investment in tra ining . The a dop tion of a kind of Code of Good Practice in

health-care worker migration could be a useful tool to prevent a permanent

brain drain from poor to rich countries and to stimulate the return of skilled

migrants to their ow n c ountries. The Europ ea n Union c ou ld p lay a ma jor role in

this respec t.

Fourth point: The Europea n Union – its main responsibilities in de signing and

imp lementing a European Glob al Hea lth Stra tegy

Let me start with a few examples of the internationalisation and increasing

interdepend enc e of hea lth risks: SARS and Avian Influenza outb rea ks, and the

c ontinuing spread of multidrug-resista nt t ub erculosis (MDR-TB) a nd extensivelyd rug-resista nt tub ercu losis (XDR-TB) in Afric a , Ea ste rn Europ e a nd Ce ntral Asia.

But apart from health risks related to infectious diseases, there are also health

risks of a non-infectious nature such as the global spread of obesity and all the

threa ts to hea lth arising from our lifestyle.

My p oint is tha t g loba l hea lth issues req uire a new form o f go vernanc e. The b est

internal policies will not be enough to meet the many challenges and threats

from globalisation for our societies and way of life. One central issue is indeed

to ensure tha t c ollec tive a c tion a t internationa l leve l as we ll as a t na tiona l leve l

is well co-ordinated.

To c om e b ac k to the e xamp le o f tube rc ulosis: the wo rld ’ s hot zone of

multidrug-resistant tuberculosis lies on the periphery of the European Union.

Could one think that Europ e c an afford not to have a c om mo n Strate gy to

fight a ga inst this c risis ? Could one think tha t Europ e c an avoid including hea lth

issues in its Neighb ourhood polic y ?

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All these examples clearly show that we must mobilise political and social

ac tion within Europ e, take the glob a l hea lth ag end a fo rwa rd a nd transla te

Europ ea n values into a c tion on hea lth as a g lob a l public go od . A Europ ea n

approach to global health must be based on the assumption that health is a

human right and that it is a central dimension of human security, prosperity,

solida rity and susta inab le deve lopme nt. The key me ssa ge is tha t the Europ ea n

Union should play a more proactive role in global health, together with

foundations, the corporate sector, health-professional groups, NGOs and other

Europ ea n orga nisa tions.

In my opinion, Europe should include health issues and global health in all

policies: trade policy, security and foreign affairs. Global health is not only

about disease, it also means assuming responsibility for health determinants in

new wa ys. It is impo rtant to reca ll tha t glob a l hea lth is ab ove a ll abo ut pe op le –

about privileged European peoples, but also about the many citizens of the

world still living on less than a dollar a day, having to cope with disease and

extrem e p ove rty.

Moreover, global health is about solidarity and global citizenship and for this

reason Europe must explain to its citizens the importance of playing an active

pa rt in globa l health and globa l governanc e for hea lth. Europ e c annot be an

island in interdependent world; it must help shape a world where others have

access to health and health care as part of their human rights and human

d ignity. As the m ain pa rtner of the d eve lop ing w orld, Europ e c ould d o m ore to

improve health systems worldwide, to strengthen programmes to reduce the

burden of disease, to promote education for health for all, to mobilise sufficient

susta inable resources and to e nc ourage go od go vernanc e on hea lth.

But global health is also about opportunities. For example, global

pha rma ce utic al and informa tion te c hnolog y co mp anies ba sed in Europ e

could contribute to delivering great improvements to the lives of millions, if only

their creativity could be applied to the problems of the poor. We have the

pote ntia l to a dd ress ma ny prob lem s with resources tha t a re minor if c om pared

with spend ing o n a rmaments or p rod uc ts ha rmful to hea lth. This is another field

where Europ e c ould play a muc h mo re p roa c tive role.

In short, Europ e c ould and should d o mo re, bette r and faster for glob a l health.

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Conclusion

Let me finish with confidence: this speech was nurtured in Asia, from where I

ha ve just returned . It is why I ha ve chosen to foc us this add ress on a g lob a l issue

ra the r tha n on typ ica lly Europ ea n q uestions.

Viewed from a global perspective, or at least from the viewpoint of the

deve lop ing w orld , the Europ ea n Union a pp ea rs to b e a kind of p a rad ise w here

security is assured for its citizens and solidarity offered to all other peoples

wo rldwide. Sec urity indeed a t d ifferent levels, but p a rticula rly at soc ial ones.

Solida rity bec ause o f its very ge nerous c ontribution to help build susta inab le

de velop ment a ll around the w orld.

One common remark that I often hear in those Asian countries I have visited is

“ We d on’ t ha ve soc ial we lfa re systems here like those in your Europ ea n

countries. If we fall ill, we have to pay or put up with it; if we don’t have

c hild ren, nob od y will c are for and loo k a fter us in our old ag e a s we don’ t have

pensions unless we a re c ivil servants” .

But, as you know, our social protection systems are under threat in the global

wo rld and ma jor refo rms a re und er wa y. Tha t is why refo rming the Europ ea n

social model is a key issue, even if not the only one, because, as Giddens

rec a lls, “ the EU exists to b ring ec ono mic bene fits to its me mb ers tha t o therwise

they would not have”.

One of the m a in prob lems of the Europ ea n Union is tha t it is not p erforming we ll

eno ugh ec ono mica lly. It ha s muc h lowe r grow th levels than the US, not to

me ntion less deve loped countries suc h a s Ind ia a nd China . This me ans tha t

Europe simply must gear up for change. But, at least in my view, along with

ec onom ic reform w e m ust p reserve a nd inde ed de ep en our co nce rn for soc ial

justice.

In my view, the future of the European Union depends greatly on widespread

refo rms of its soc ial mo del. The e vidence shows two things:

Firstly, countries that have been able to reform have done well in the global

marketplace and have sustained high levels of social justice (e.g., the

Scand inavian c ountries).

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Sec ond ly, co untries tha t do no t have e ffec tive we lfa re systems – includ ing

China and India, the rising powers – will have to build them if they want to

c rea te integra ted , inc lusive soc ieties.

We often hear the question “Can Europe afford its social model?”, but I dobelieve that we should put it the other way round: “Can Europe afford not to

have its social model?” In my view, the European Union will emerge as a major

politica l ac tor at wo rld leve l if it ma nage s to c om b ine succ essfully internal and

external strength. Internally, reforming the European social model is one of the

main challenges to address. Externally, the European Union has to promote

wa ys of improving globa l governanc e.

The Europ ea n Union c an sha re its unique expe rienc e o f structured c oo peration ,its values and principles when it comes to promoting and strengthening the

global multilateral approach in terms of both greater efficiency and

democratic legitimacy. For my part, I continue to believe that the European

Union represents a priceless opportunity for peace, stability, prosperity,

sustainable development, democracy, justice and respect for human rights in

Europ e a nd the wo rld . But opportunities ha ve to b e turned into realities. Tha t is

why we nee d m ore a nd b etter Europ e.

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List of EU Diplomacy Papers

1/ 2006

H.E. Ka rel De Guc ht , Belgia n Ministe r for Foreign Af fa irs, Shifting EU Foreign Polic y

into Highe r Gear

2/ 2006

Günter Burgha rd t, The Europ ean Union's Transa tlant ic Relat ionship

1/ 2007 Jorge Samp a io, Glob a l Answe rs to Glob a l Prob lem s: Hea lth as a Glob a l Pub lic

Good

edp_1_2007.sampaio

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