s a young doctor working in Hong Kong’s department of maternal and child health, I learned some lessons that would last me a lifetime. Trained by the British civil service, I absorbed the importance of discipline and a methodical approach to every task. But I always ran behind schedule in my appointments with patients because I spent time trying to find the root causes of illnesses that came as much from social circumstances as from microbes. I could cure a child with a severe respiratory illness, but when that child went home to a damp and moldy house, I knew I would see her again with the same illness.
In 1994, when I became the director of Hong Kong’s department of health, I learned the lesson that it is wise to do whatever it takes to get government support on your side. My years of responsibility in that position cemented my belief that an integrated primary health care approach that puts people at the center is the cornerstone for an effective health system. That work also taught me to put my faith in people but to put my trust in the evidence.
In January 2007, when I began my decade of work as the World Health Organization’s director-general, I took these lessons with me. I knew I would need to get the governments of 194 countries on my side, or at least get them together enough so we could agree on a shared global health agenda.
Breaking with tradition, I engaged (usually with passion and sometimes with tears) in the debates among WHO governing bodies, especially when views were polarized and I could propose a path toward compromise. To my delight, this “butting in” was welcomed and gave rise to the so-called spirit of Geneva — a willingness to soften views and rigid positions in the interest of reaching consensus. Throughout my time in office, even highly contentious technical issues were eventually unanimously agreed upon, with never a need to vote.
Contentious issues were legion. Proposals that aimed to increase access to affordable medicines were nearly always sidetracked by people-versus-profits issues, with barely veiled suspicions that trade rules were rigged to favor rich and powerful nations. Equally difficult issues arose when public health interests crossed purposes with the interests of powerful economic operators, like the tobacco, alcohol, food, and beverage industries. Economic power readily translates into political power. Those industries fought nearly every move we made, from recommendations to reduce daily sugar intake and tax sugary beverages to warnings that alcohol front groups must not write national alcohol policies to our advice on how to stop the marketing of unhealthy foods and beverages to children.
The dirtiest fights came when the tobacco industry used trade agreements to sue sovereign governments for introducing laws, notably those mandating that cigarettes be sold in plain packages, aimed at protecting their populations from a deadly product. The tobacco industry had long regarded the WHO as its biggest enemy, and I worked hard to improve that reputation.
I took office calling for a return to the principles and approaches of primary health care, which had been the WHO brand since the Declaration of Alma-Ata was signed in 1978. But the health-for-all movement was overshadowed by the onset of HIV and the resurgence of malaria and tuberculosis, especially in the latter’s drug-resistant forms. Senior advisers warned me not to put too much emphasis on health systems at a time when investments in commodities for containing these three epidemics were soaring and governments wanted quick and measurable results. Strengthening health systems takes time and is notoriously difficult to measure. But I stuck to my guns.
The 2008 financial crisis coincided with a growing crisis in health care, characterized by increasing demand, rising costs, and greater emphasis on hospital-based curative care. I viewed a return to primary health care as a powerful corrective strategy. By that time, chronic diseases had overtaken infectious diseases as the leading killers worldwide. Primary health care, with its emphasis on prevention, was the only viable option for protecting health systems and budgets from the ruinous demands of long-term, if not lifelong, care.
I was vindicated in 2010 when the WHO published its World Health Report, “Health systems financing, the path to universal coverage.” The timing must have been good, since universal health coverage struck a chord as the right thing to do, especially in a world destabilized by increasingly vast inequalities in income levels, opportunities, and health outcomes. I was overwhelmed by the report’s reception, the movement it launched, and the place it secured for universal health coverage in the 2030 Agenda for Sustainable Development. As I argued at the time, universal health coverage is the ultimate expression of fairness and one of the most powerful social equalizers among all policy options.
My most profound regret is the WHO’s slow response to the Ebola outbreak in West Africa. As I frankly stated during my 2015 address to the World Health Assembly, “I do not ever again want to see this organization faced with a situation that it is not prepared, staffed, funded, or administratively set up to manage.” Fortunately, that resolve led to the establishment of a new health emergencies program. WHO engagement in the Ebola outbreak also allowed us to give the world its first — and highly effective — Ebola vaccine.
Recent G7 summits and a growing body of research see strong, mutually reinforcing compatibility between the goals of universal health coverage and those of global health security. Resilient and inclusive health systems are now regarded as the first line of defense against threats from emerging and reemerging diseases. Countries with well-functioning health systems are more likely to detect an outbreak early, when the likelihood of rapid containment is best. Moreover, the commitment to fairness and protection against financial ruin, embodied in universal health coverage, can inspire the public confidence and trust that underpin compliance with recommended control measures.
Going forward, I would like to see the WHO do more to address financing issues, both for its own budget and the health budgets of low- and middle-income countries. Member states keep asking the WHO to do more with the same budget, while resisting proposals to “sunset” some areas of work that fit the mandates of other UN agencies. Such a full-menu approach impairs strategic leadership.
Overall, the tendency in international public health is to move away from official development assistance towards greater reliance on domestic resources. I worry about this. In large parts of the developing world, especially in Africa, small-holder farmers in the informal sector remain the backbone of the economy, severely limiting domestic resources derived from taxes. Much of this agriculture depends on rain and is highly vulnerable to extreme weather events, which are becoming more common as the climate changes. The WHO needs to keep the world focused on responding to the growing number of crises caused by the triple blows of famine, armed conflict, and outbreaks of opportunistic diseases like cholera.
Strong leadership at the WHO is needed to keep pushing back against severe health threats that have their root causes in non-health sectors. These include chronic diseases and climate change, as well as the rise of antimicrobial resistance, for which agricultural practices play a major role.
Recent changes in the global poverty map are also important going forward: 73 percent of the world’s poor now live in middle-income countries. What happens to them when these countries lose their eligibility for financial support from the Global Fund and Gavi, the Vaccine Alliance, remain an unanswered question.
I have been greatly encouraged by the commitment to universal health coverage of Tedros Adhanom Ghebreyesus, my successor as director-general. At a time when policies in so many sectors are increasing social inequalities, I am pleased to see health lead the world toward greater fairness and security in ways that matter to each and every person on this planet.
Margaret Chan, M.D., steps down as director-general of the World Health Organization on July 1, 2017.