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Opening remarks: Gro Harlem Brundtland

Høsbjør, Norway 8-11 April 2001
Dr Gro Harlem Brundtland
World Health Organization

Opening Remarks

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Introductory remarks: Adrian Otten
Closing remarks: Gro Harlem Brundtland
Closing remarks: Adrian Otten

State Secretary,
Ladies and Gentlemen,

Let me add my own warm welcome to you all, and extend my thanks to the Government of Norway for hosting this important meeting.

Exactly one year ago — in the first week of April 2000 — I addressed the Parliamentary Commission on the Investigation of Medicines in Brasilia on the subject of access to essential drugs and vaccines. My focus then — as it remains today — is how we can ensure that vital medicines are accessible to all the people that need them — regardless of their income, regardless of the health conditions they are suffering from, regardless of the country they live in. Reliable access to medicines on the basis of need rather than on the ability to pay. That is the goal. That — I believe — is what brings us all together here.

Just twelve months on: and a great deal has happened. With the rapid unfolding of events, almost on a day by day basis, one could be forgiven for believing that the situation has been transformed. Perhaps in some ways it has.

Greatly increased access to treatment for people living with AIDS, TB and malaria in low income countries is now on the agenda in a way that many would not have thought possible a year ago.

Real reductions in the price of drugs for treating people living with AIDS are now beginning to happen.

And perhaps most important of all: access to pharmaceuticals is no longer an issue for health professionals and government officials alone. It is headline news. A much wider constituency is now engaged — with all the complexity that this brings in terms of new possibilities and public expectations.

These are significant changes. We should give credit to those who have helped to bring them about.

In the last twelve months, we have witnessed an unprecedented effort, driven by committed people in governments, non-governmental organizations, activist groups, UN agencies, bilaterals, different branches of the pharmaceutical industry, and the media. Together we have begun to tackle the obstacles that are preventing essential drugs from reaching the millions who need them. Popular outrage, political will, market forces and the best of science: a powerful coalition. There are things we can rightfully celebrate.

But let us pause. The excitement of the campaign and the growing attention of the international media must not divert us from basic realities. For too many of the world’s poor people those with an income of one or two dollars a day nothing very much has changed at all. The onset of serious illness in the family too often leads inexorably to death, disability and impoverishment.

In over 30 countries public spending on medicines is less than two dollars per capita per year. I recently heard the Minister of Health from Malawi, describing how changes in the value of the local currency had reduced planned government spending on drugs this year from $1.25 to just 75 cents per head.

Inevitably, in such circumstances, the cost of care falls to the individual and the family. Few poor people have access to health insurance. They have to pay for drugs when they get sick. Out-of-pocket payments — a large proportion of which go on medicines — constitute up to 90% of total health spending in some poor countries. No matter what the time of year, no matter what the state of family finances, the situation for many is stark: no cash, no cure.

Access to care is not just about access to drugs. It is about access to effective health systems. Safe and reliable care requires trained staff who receive their salaries on time and who stay in post. It requires supplies, buildings, information systems, supervisors. All this and more is needed for the safe diagnosis and treatment of childhood pneumonia – let alone more complex problems like the management of multi-drug resistant TB or HIV. We will hear in this meeting about huge differences in access to health services that exist between and within countries.

A substantial increase in development assistance can make a difference. The OECD estimates that total Official Development Assistance for health – for all purposes, for all countries, from all sources, loans and grants — is currently about $3.5 billion a year. We now suspect that this estimate might be a little low. But just to treat one million people with AIDS in Africa, with the prices now on offer, would require that the $3.5 billion be increased, almost immediately, by one third.

This then is the background against which we must frame our discussions and measure our progress. Drug prices are critically important. New financing even more so. But we must never forget that some of the most basic problems of development are not going to be amenable to quick-fix solutions.

Ladies and Gentlemen,

Let me turn now to meeting itself. We have a unique opportunity over the next three days. WHO’s collaboration with WTO has helped to bring together an extraordinarily exciting and knowledgeable group of people, representing some of the most important actors concerned with access to essential drugs in the world today. We all come to the meeting with different perspectives. The ethical and financial stakes are very high. So are the issues we are dealing with emotive and complex. There are different and deeply held opinions as to the way forward.

Let us be clear about the purpose of the meeting. Achieving greater clarity about strategies that will make the prices paid for key pharmaceuticals more closely in line with the economic circumstances of the purchasing countries. This is our task.

We are not here to make decisions. Nor are we here to prepare a grand plan — as I have seen in the press.

For WHO, however, the results of this meeting will be an important input to be considered by our Member States when they debate the follow-up of the Revised Drug Strategy at the forthcoming World Health Assembly.

I find it helpful to think about moving from positions to principles. If we are to move forward on the issue of differential pricing in a way that ensures more equitable access, there are many questions that need to be addressed. We need principles that can act as a lode stone or a compass as we, and many others, deal with the details and the practical problems that lie ahead.

Let me give you an example. If I were to put myself in the position of a Minister of Health or Minister of Finance, I would attach considerable importance to predictability and sustainability. Is the price I am paying for drugs now going to change dramatically next year? How long — as they say — does the current offer last? Predictability and sustainability of demand is just as important to the producers of medicines. We can use these principles as a yardstick against which to assess the effectiveness of different approaches to improving access.

Another principle is to recognise that if we are to achieve the goal of more equitable access to good quality health care, all the different groups represented here today have a role to play. It is easy for diversity to appear as an obstacle to progress. The challenge, indeed our main challenge at this meeting, is to turn diversity into creativity.

We must remember the capacities that each of the different actors brings to the table: the major investments and risks born by the research-based pharmaceutical industry in developing new products; the convening power and country experience of the UN, underpinned by the mandate provided by its Member States and Governing Bodies; the resources available from development banks and other donor agencies; the role of the generics industry in promoting commercial competition for drugs no longer protected by patents; and the critical role of governments in low income countries. We need WTO as an effective and fair forum for negotiating trade rules and resolving disputes. We need groups and individuals that provoke us into thinking differently — groups that force us to confront problems and solutions from radically new perspectives. And of course we need those NGOs and other bodies that demonstrate effective ways of improving access through their work on the ground in low income countries.

Productive working relationships do not necessarily mean we will agree on everything. Nor do we become, or adopt the agenda of, those with whom we collaborate. In WHO, just to give an example, we meet regularly with NGOs, with staff of the WTO, with the CEOs of several research-based companies, and with generic manufacturers. We often get the impression that each of these groups thinks that we favour one or more of the others. This suggests to me that we probably have our position about right.

As we move from positions to principles, let us also try and get away from some of the unhelpful dichotomies and repetitive arguments that have characterised the debate about access to drugs. Reducing prices versus investment in health systems, for instance. Both are important. They are complementary, not competitive agendas to be used in defending rigid positions. If we are going to fix the pipes, we have to put water in them to see if they work.

But in our search for principles, there are also some fundamentals. Drugs are not a commodity like any other. Access to health care is a human right and many of the actors I have mentioned have an obligation to see that this right is progressively realised. Access to essential drugs is part of this obligation. Not just for one set of health conditions, but for all.

We need new technologies. We do not yet have a cure for AIDS and our present tools for HIV/AIDS, TB, malaria and for many other conditions leave much to be desired. Continuing innovation which requires both incentives to invest in the diseases that drive poverty and protection provided by international agreements on intellectual property is essential.

We have some fundamental positions on the way health systems function. Particularly about the way they respond to peoples needs, about fairness, responsiveness and solidarity in the way they are financed — and about the key role of government in overall stewardship. Health care provision is not just the business of the public sector, in all our deliberations we must factor in the important role of the private sector, NGOs and civil society groups. The task of governments is to set the frameworks, to make the hard choices, and to ensure delivery of required services.

Our job in WHO and in the other UN agencies is to do what we can to help governments make wise choices, based on the best information and evidence available. This includes monitoring the impact of international agreements on trade of services and intellectual property on health.

As I talk to Ministers and Heads of State about the health crises they are confronting, I realise that recent developments have in some ways made their task harder. Reducing the prices of previously unaffordable medicines has fuelled public expectations. A significant and sustained increase in external financial assistance has to be part of the answer. But external aid cannot and should not remove the responsibility of governments to set priorities.

Ladies and Gentlemen,

This is a long awaited meeting. I am sure that its outcome will be scrutinised carefully in the weeks and months to come.

Achieving greater clarity about approaches to ensuring more equitable access to drugs is an important part of a larger picture. That picture is one in which people, particularly poor people, are not excluded from care by virtue of their poverty. It is one in which poor people can expect to be treated with respect and receive quality treatment whenever and wherever they fall ill. And it is a picture that for a large part of the world’s population remains distant and hazy. We can make an important contribution to bringing it into sharper focus.

I look forward to joining you in the debate.

Thank you.