Keynote Address at the Ministerial Meeting on Universal Health Coverage: the Post-2015 Challenge
在全民健康覆盖问题部长级会议上的主旨发言：2015年后的挑战
Dr Margaret Chan, Director-General of the World Health Organization
世界卫生组织总干事 陈冯富珍博士
Singapore, 10 February 2015
新加坡，2015年2月10日
Your Excellency, Prime Minister Lee Hsien Loong, Minister Gan, honourable ministers, distinguished experts, colleagues in public health, ladies and gentlemen,
李显龙总理阁下、颜部长阁下、尊贵的各位部长、尊敬的各位专家、公共卫生界的各位同事、女士们、先生们，
It is a great honour to address a ministerial meeting on universal health coverage in Singapore, a city-state with an inclusive health system known for its affordable excellence. Last year, Bloomberg’s second annual ranking of countries with the most efficient health care placed Singapore at the top.
我深表荣幸能在新加坡的这次全民健康覆盖问题部长级会议上发言，这个城市国家以其出色且负担得起的包容性卫生系统而闻名。去年，在彭博社关于卫生保健最具成效的国家的第二次排名中，新加坡名列榜首。
WHO also places Singapore at the top for key health indicators, especially maternal and infant mortality, two of the most sensitive indicators of a well-functioning health system. Through foresighted and visionary planning, Singapore achieved first-rate health care, with outstanding health outcomes, at a cost lower than in any other high-income country in the world.
世卫组织也将新加坡排在关键卫生指标的前列，尤其是在孕产妇和婴儿死亡率方面，这两个指标是运转良好的卫生系统的最敏感指标。新加坡通过其高瞻远瞩的规划，实现了一流的卫生保健，卫生成果斐然可观，而费用则低于世界上任何其它高收入国家。
This achievement was firmly anchored in a value system that places a premium on fairness and inclusiveness as a route to social cohesion, stability, and harmony.
此一成就是坚实地奠定在这样一种价值体系上，即把公正和包容性视为社会凝聚、稳定与和谐之源。
Research guided individual strategies, but so did the wishes of the public, with opinion polls undertaken and conversations started to ensure that changes in the health system won public support and approval.
研究工作引导具体战略，但公众的意愿也起到引导作用，民意调查和对话确保了卫生系统的变革赢得公众的支持和赞同。
As we have just heard, Singapore’s version of universal health coverage balances the advantages of competitiveness and other market forces with the need for state intervention to steer these forces in the right direction. It balances freedom to choose providers, services, and facilities with an obligatory health savings account, the MediSave plan, with its emphasis on individual responsibility.
正如我们刚刚听到的，新加坡的全民健康覆盖模式，平衡了竞争和其它市场力量与需要国家干预来引导这些力量保持正确方向二者之间的好处。它对选择供应商、服务和设施的自由与强制性健康储蓄账户，即医疗储蓄计划作了平衡，后者强调了个人的责任。
There is no free lunch. The plan works to protect against the over-consumption of care. To help inform responsible decisions, the Ministry of Health publishes hospital bills for common illnesses on its website.
世上没有免费的午餐。该计划有效地防止了医疗的过度消费。为帮助形成负责任的决定，卫生部在其网站上公布了一般疾病的医院账单。
Another innovation, MediShield Life, embodies the principle of collective responsibility through risk pooling. This is the safety net. It protects households from falling into financial ruin when medical bills are especially high. Studies conducted by WHO show that catastrophic medical bills force 100 to 150 million people below the poverty line every year. While many governments are working hard to lift people out of poverty, these efforts can be offset when the health system and its financing actually contribute to poverty.
另一项创新，即终身健康保险，通过风险共担，体现了集体责任的原则。这是一个安全网络。它保护家庭在医疗花费太高的情况下免于倾家荡产。世卫组织的研究表明，每年有1亿到1.5亿人因灾难性的医疗费用跌至贫困线以下。许多政府正在大力帮助民众脱贫，如果卫生系统及其收费实际上是在加剧贫困，则这些努力都将落空。
As Singapore’s Minister of Health observed earlier this year, the scheme tells people that they “need not face life’s uncertainties alone, especially those who meet unexpected shocks in their life journeys.”
正如新加坡卫生部长今年早些时候所言，该项计划告诉民众，他们“尤其是那些在生命旅途中遭遇意外变故的人，不会独自面对生活中的不稳定性。”
Of course, not all of these innovations can be applied elsewhere. UHC is intrinsically country-owned. To work well, it must be home grown in line with each country’s culture, domestic political institutions, the legacy of the existing health system, and the expectations of citizens.
当然，所有这些创新，并非在任何地方都适用。全民健康覆盖本质上是国家所有。要想行之有效，它必须根据每个国家的文化、国内政治体制、现行卫生系统的遗产和公民的期望因地制宜。
In achieving UHC, Singapore had some distinct advantages. The huge challenge of extending health services to reach remote and impoverished rural areas was non-existent. Singapore has only one rural area, a small island and tourist attraction.
在实现全民健康覆盖方面，新加坡有一些独特的优势。不存在需要将卫生服务扩展到边远和贫穷农村地区的挑战。新加坡只有一处农村，是一个小岛和旅游胜地。
A tradition of cross-ministry collaboration makes it easier to address the upstream causes of ill health through environmental improvements and the use of fiscal and regulatory measures to encourage healthy lifestyles.
跨部门合作的传统使之可以通过环境改善和采取财政和监管措施来鼓励健康的生活方式，从而解决健康不良的上游原因。
Singapore has also enjoyed political stability and a high level of public trust in government for decades. That helped as well.
几十年来，新加坡还保持了政治稳定，政府的公信力极高。这也是很有帮助的。
With these advantages, UHC in Singapore has gone beyond providing and financing fair and inclusive health care. UHC in Singapore has worked as a strategy for building an inclusive, caring, and progressive society. These are assets for any country in the world.
出于这些优势，全民健康覆盖在新加坡不仅仅是提供公平和包容性的卫生保健，并为之筹资。新加坡的全民健康覆盖成为建设一个包容、关爱和进步社会的战略。这些对世界上任何国家都是一笔财富。
Ladies and gentlemen,
女士们，先生们，
Our world is in turmoil from multiple causes. The signs are there for anyone to see: fluctuating currencies, unstable economies, prolonged conflicts, ethnic clashes, and inexplicable acts of violence. Organized acts of terrorism are the newest omnipresent and unpredictable threat.
我们的世界因多种原因而变乱不定。这方面的迹象有目共睹：货币波动、经济动荡、旷日持久的冲突、种族纠纷、不可思议的暴力行为。有组织的恐怖主义活动则是一种最新威胁，它无处不在，难以预料。
The climate is changing, antibiotics are failing, and health care costs are soaring. Inequalities, in income levels, opportunities, and access to social services, both within and between countries, have reached the highest levels seen in nearly a century.
气候变化，抗生素失灵，卫生保健费用扶摇直上。国家之内和国家之间在收入水平、机会和获取社会服务方面的不平等，已经达到了近百年来曾未见过的最严重程度。
Countries are losing their middle classes, the backbone of democracy. Last month’s Oxfam report on wealth distribution contains a startling statistic: just 80 rich and powerful people own more of the world’s total wealth than 3.5 billion people at the other end of the scale.
各国正在失去其作为民主制中坚的中产阶级。上个月乐施会关于财富分配问题的报告载有令人震惊的统计数字：仅仅80个有财有势者，其在世界总财富中所占份额，就超过了底层的35亿人。
Many economists take optimism from the fact that several of the world’s fastest growing economies are in Africa, often fuelled by foreign extractive industries. But if you look at income distribution within these countries, what we are really seeing is more and more rich countries full of poor people.
许多经济学家感到乐观的是，世界上有若干增长最迅速的经济体在非洲，它们背后往往是外国采掘工业在推波助澜。但注意一下这些国家的国内收入分配，我们不难看到，在这些越来越富裕的国家中，到处都是穷人。
An African medical blogger contrasted growths in GDP with weaknesses in health systems laid bare by the Ebola outbreak. He asked the following question. What good does it do to cover the ceiling of your house with golden paint when the walls and foundation have cracks?
一个非洲医学博客拿国内生产总值的增长与埃博拉疫情显露的卫生系统的薄弱作出比较。他提出了如下问题：如果墙壁和地基都在坍塌，则在屋顶上描金敷彩，又有什么意义？
Decades of experience tell us that this world will not become a fair place for health all by itself. Health systems will not automatically gravitate towards greater equity or naturally evolve towards universal coverage.
几十年的经验教训告诉我们，这个世界单凭自身，不会成为一个有利健康的公平场所。卫生系统不会自动倾向于更大程度的公平，或自然而然地演化出全民覆盖。
Economic decisions within a country will not automatically protect the poor or promote their health. Globalization will not self-regulate in ways that ensure fair distribution of benefits. International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines.
国家内的经济决策不会自动去保护穷人或增加他们的财富。全球化不会自我调节，确保利益的公平分配。国际贸易协定本身，不会保障粮食安全、就业安全，卫生安全，或获取可负担的医药。
All of these outcomes require deliberate policy decisions.
所有这些成果都要求作出深思熟虑的政策决定。
Universal health coverage is one of the most powerful social equalizers among all policy options. It is the ultimate expression of fairness. If public health has something that can help our troubled, out-of-balance world, it is this: growing evidence that well-functioning and inclusive health systems contribute to social cohesion, equity, and stability. They hold societies together and help reduce social tensions.
全民健康覆盖是所有政策选项中最有力的一个社会平衡器。它是公正的终极表达。公共卫生如果能对我们这个扰攘不断的、失衡的世界有所帮助，那就在于：越来越多的证据显示，运转良好的包容性卫生系统将促进社会的凝聚、公平和稳定。它们将社会聚拢在一起，帮助缓和了社会紧张局势。
At a time when policies in so many sectors are actually increasing social inequalities, I would be delighted to see health lead the world towards greater fairness in ways that matter to each and every person on the planet.
在如此之多部门的政策实际上正在加剧社会的不平等之时，我很高兴能看到，卫生以对地球上每个人都很重要的方式，引领世界走向更大的公平。
Ladies and gentlemen,
女士们，先生们，
As the world enters the post-2015 era, it faces health challenges that are far more complex than they were at the start of this century.
世界正在进入2015年后时代，它所面临的卫生挑战的复杂性，要远远超出本世纪初。
The sharp distinctions between health problems in wealthy and developing countries are dissolving. Everywhere, health is being shaped by the same universal pressures: the globalized marketing of unhealthy products, population ageing, and rapid urbanization.
富国与发展中国家在卫生困扰上的明显差异正在消失。所有地方的卫生工作都受到同样的普遍压力：不健康产品的全球化推销、人口老龄化和迅速的城市化。
Our very definition of what constitutes socioeconomic progress is being challenged.
我们关于社会经济进步为何的定义本身正在受到挑战。
Beginning in the 19th century, improvements in hygiene and living conditions were followed by vast improvements in health status and life-expectancy. These environmental improvements aided the control of infectious diseases, totally vanquishing many major killers from modern societies.
从十九世纪开始，伴随卫生和生活条件的改善，是健康状况和预期寿命的巨大改善。这些环境改善帮助控制了传染病，在现代社会彻底消灭了许多主要的致命疾病。
Today, the tables are turned. Instead of diseases vanishing as living conditions improve, socioeconomic progress is actually creating the conditions that favour the rise of noncommunicable diseases. Economic growth, modernization, and urbanization have opened wide the entry point for the spread of unhealthy lifestyles.
如今，形势急转直下。疾病没有随生活条件的改善而消失，社会经济进步实际上正在造成有利于非传染性疾病出现的条件。经济增长、现代化和城市化为不健康生活方式的蔓延敞开了大门。
The ancient burden of deaths from infectious diseases has been joined by a newer burden of even more deaths from NCDs. Rapid unplanned urbanization has added a third burden: deaths from road traffic crashes and the mental disorders, substance abuse, and violence that thrive in impoverished urban settings.
除过传染病致死这一古已有之的负担，新增了非传染性疾病造成甚至更多死亡的负担。迅速和无计划的城市化加重了第三个负担：道路交通事故和精神疾病、物质滥用以及城市贫穷环境中迅速滋生的暴力行为造成的死亡。
The rise of NCDs adds considerably to the costs of health care. The costs of cancer care, for example, are becoming unaffordable for even the wealthiest countries in the world. In 2012, the US Food and Drug Administration approved 12 drugs for various cancer indications. Of these 12, 11 were priced above $100,000 per patient per year. How many countries can afford this cost?
非传染性疾病的加剧导致卫生保健成本大增。例如，甚至对世界上最富有的国家而言，癌症护理的费用也正在令人不堪重负。2012年，美国食品和药物管理局为各种癌症适应症批准了12种药物。在这12种药物中，有11种 的价格超过每个病人每年10万美元。有多少国家能够负担得起这笔费用？
Prevention is by far the better option, but this, too, is more problematic than for infectious diseases, many of which can be prevented by vaccines or cured by medicines, all delivered by the health sector.
迄今为止，预防是更好的选择，但相对于预防传染病，它也问题多多，许多传染病是疫苗接种可以预防或药物可以治愈的，而且它们均由卫生部门提供。
The root causes of NCDs reside in non-health sectors. They escape the direct purview of health. When health policies cross purposes with the economic interests of sectors like trade or finance, economic interests will trample health concerns nearly every time.
非传染性疾病的根源在于非卫生部门。它们不在卫生部门的直接权限范围之内。当卫生政策与贸易或金融等部门的经济利益不一致时，几乎每次都是经济利益践踏健康方面的考虑。
Implementation of the WHO Framework Convention on Tobacco Control is a notable exception. It provides one of the best examples of cross-ministry collaboration, driven by overwhelming evidence of the health and economic costs of tobacco use.
执行《世卫组织烟草控制框架公约》是一个明显的例外。它提供了跨部门合作的最佳范例之一，关于烟草适用的健康成本和经济成本的压倒性证据激励了这一合作。
It tells us that the health sector, working in tandem with others, can generate huge benefits. It can even tackle a powerful, devious, and dangerous industry on multiple fronts, including through fiscal and regulatory measures.
它告诉我们，卫生部门与其它部门携手努力，可以产生巨大效益。它甚至可以在多条战线，包括通过财政和监管措施，对付一个有权有势、阴险狡猾和危险的行业。
As yet another challenge in the post-2015 era, health and medical professionals in every region of the world are losing their first-line antimicrobials as drug resistance develops. In several cases, second-line medicines are failing as well. For some cases of multi-drug resistant tuberculosis and gonorrhoea, even last-resort antibiotics fail.
2015年后时代的另一个挑战是，随着耐药性的发展，世界每一地区的卫生和医疗专业人员正在失去他们的一线抗菌素。在若干情况下，二线药品也失灵了。在一些耐多药结核病和淋病案例中，甚至作为最后手段的抗生素也失灵了。
With few replacement products in the pipeline, the world is moving towards a post-antibiotic era in which common infectious diseases will once again kill. A post-antibiotic era is a game-changer on a par with climate change. But antimicrobial resistance will kill us before climate change.
由于正在开发的替代产品很少，世界正在走向后抗生素时代。在这个时代中，普通的传染病将再次戕害生命。同气候变化一样，后抗生素时代也将改变游戏规则。但抗菌素耐药性将先于气候变化，将我们致于死地。
Ladies and gentlemen,
女士们，先生们，
I began with the strategies used by Singapore to achieve and sustain universal coverage. Let me conclude with the strategies used in a very different country: Bangladesh.
我开头讲的是新加坡为实现和维持全民覆盖所采用的战略。让我以一个迥然不同的国家采用的战略作为结束：孟加拉国。
The Bangladeshi story shatters the long-held assumption that countries must first reduce poverty, then better health will follow almost automatically. Bangladesh decided to reverse the order by first freeing populations from the misery caused by ill health.
孟加拉国的故事驳斥了人们长期以来的假设，即国家必须首先减贫，则健康自然就会有所增进。孟加拉国决定颠倒这个次序，先让民众免遭健康不良带来的苦难。
Driven by a commitment to equity, the country aimed for universal coverage of its vast and very poor population with a package of high-impact interventions. To compensate for a severe shortage of doctors and nurses, the country trained and then closely supervised a brigade of community health workers, mostly women, who followed a doorstep-delivery approach.
在实现公平的承诺的推动下，该国的目标是利用一整套影响力巨大的干预措施，对其为数众多的非常贫穷的人口实现全民覆盖。为弥补医生护士的严重短缺，该国培训了一大批采取上门交付方式的社区保健人员，主要是女性，并对其进行密切监督。
The country also used its world-class research capacity to experiment with innovations. Formal and contractual arrangements were made with nongovernmental organizations that were best placed to win community trust and reach marginalized populations. Improvements in school enrolment, especially for girls, and in agriculture brought huge benefits for health.
该国还利用其世界水平的研究能力进行创新实验。与非政府组织作出正式的合同安排，这些组织最有可能赢得社区信任，抵达边缘人群。入学率的提高，特别是农村女孩入学率的提高，给健康带来巨大的好处。
The efforts of Bangladesh were driven by another reality. When government health services fail to reach poor areas, private providers and shops selling medicines will mushroom. Charges for services from these unregulated and largely unqualified health care providers work to deepen poverty, not reduce it. To prevent this from happening, the government built and ran nearly 12,000 strategically located community clinics
另一种现实也是驱动孟加拉国努力的因素。在贫困地区，当政府的卫生服务鞭长莫及时，私人供应商和出售药品的商店就会蜂拥而起。这些不受管控且基本上无资质的医疗保健提供者对服务的收费，加剧而不是减少了贫穷。为防止这种情况发生，政府建立并管理了近1.2万个位于战略位置的社区医务所。
Perhaps most important was the strong strategic bias towards women and girls. The approaches used explicitly recognized that empowered women will turn health into a nation-building strategy.
或许最重要的是对妇女和女孩的强大战略倾斜。所采用的方法明确承认，能力增强后的妇女将使健康成为一项国家建设战略。
Their needs, including for sexual and reproductive health services, came first. Their human rights were legally protected. That approach led to a stunning reversal in excessive mortality of girls compared with boys
她们的需要，包括对性健康和生殖健康服务的需要被摆在了首要位置。她们的人权得到了法律保护。伴随这一方针，女孩的死亡率大大高于男孩的现象得到了显著扭转。
As we have learned from ample evidence, investing in health is investing in economic growth, investing in the health and well-being of people. Every country needs healthy human capacity to sustain development. Without this capacity, it is hard to even begin to talk about sustainable development.
正如我们从充足的证据中所了解，投资于卫生，就是投资于经济增长，投资于人民的健康和福祉。每个国家要维持发展，都需要健康的人力资源。没有这一能力，甚至很难开始谈论可持续发展。
The Singapore experience and all of the other experiences we have heard about give us one compelling message. Any country that really wants to move towards universal health coverage can do so. There are no excuses.
新加坡的经验和我们听到的所有其它经验，都传递了一个令人信服的信息。任何国家，只要真正希望实现全民健康覆盖，都是可以做到的。不存在任何借口。
Health is likely one of the most precious commodities in life. But it is highly political and it requires investment. You need political leadership. You need commitment. And you need a conversation with the public, as has been done here in Singapore. I thank you for the opportunity to participate in this discussion.
健康可能是生命中最宝贵的商品之一。但它是高度政治性的，而且还要投入资金。需要政治领导。需要承诺。需要与公众对话，就像新加坡所做的那样。感谢大家使我有机会参加这次讨论。
Thank you.
谢谢大家。
来源：WHO
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