The global health landscape is changing. The burden of health needs is shifting. Falling fertility rates, longer life expectancy, migration and urbanisation are all contributing to changes in health needs.

At the same time, the financial crisis is putting publicly financed healthcare under pressure, and external financial support is wavering. Official development assistance is down. Donors have less appetite for giving.

After the MDGs and a decade of investment in health, there has been a shift towards sustainable development, where, as Richard Horton, Editor of the Lancet, has noted, health “is no longer the dominant idea underpinning the way we see human progress”. So we have to ask whether the world’s health is still a global priority in and of itself?

MSF has a very specific perspective on this issue. We provide medical, humanitarian assistance. We work at the extreme end of healthcare provision. We work where people do not have – or have extremely limited – access to healthcare.

Like everyone here, I imagine, our vision for the future of healthcare is one of equity, where everybody has access to the medical attention that they need. But we recognise that despite the progress of the past decade we are a long, long way from achieving it.

The MDGs have had an impact. More than eight million people with HIV are alive today thanks to antiretroviral treatment. Deaths from malaria have declined by one-third in Africa. New financing mechanisms like the Global Fund and PEPFAR have been central to these achievements. But last year the Global Fund had to cut ongoing grants and stop accepting new applications because it was short of funding.

The GF effectively had to hit the pause button because the donors’ pledges did not match the resources it needed.

Just as we should be pushing scale-up, we are facing the prospect of having to scale down.

In some places, there does not seem to be anywhere to scale down to. There are populations that remain stubbornly excluded from healthcare.

MSF’s medical action assists a person’s survival when that person is in crisis. It is not designed to be long-term. But in some places, unacceptable levels of excess mortality and suffering linked to the burden of disease are not short-term crises but long-term issues. Long-term issues that are not getting an adequate response. MSF works in some of these places, providing humanitarian assistance in the long term.

Let me give you an example. The Central African Republic’s healthcare system is based on cost recovery. Patients have to pay for the cost of their care out of their own pockets.

The system doesn’t work. Not for the patients. Not for the health system.

In fact, in a country like the Central African Republic, where the state is weak, the people are poor, and the burden of disease is high, cost recovery amounts to the abandoning of primary healthcare for most of the people. The lesson from the Bamako Initiative, which promoted cost recovery, is that if people don’t have money, introducing more services will not increase access to healthcare if those services have to be paid for.

User fees block access to healthcare. Nonetheless, in many countries, user fees persist.

Today, the Central African Republic is in a state of chronic medical emergency. Malaria – which is, for the most part, both preventable and treatable, at no great cost – is the main cause of death among hospital inpatients. The prevalence, incidence and mortality from tuberculosis are all estimated to have doubled between 1990 and 2009. Life expectancy is just 48 years.

The health problems in the Central African Republic are extreme. The people need a health system that works, not that preys on them as a source of revenue.

MSF has been working in the Central African Republic for 16 years. We know we will be there for another 10 years, even though we don’t really want to be.

What is the solution?

First, the government. Between 2001 and 2009 government health spending in the Central African Republic actually declined. The government of the CAR has an overwhelming to-do list, but health should be high on that list. The government should shoulder its responsibilities and meet the pledge made at Abuja to spend 15% of its budget on health. Meeting this commitment will not cover the health needs of the country. But it will show that the government is taking the population’s health needs seriously.

Second, external funding. Government commitment will help to apply pressure to foreign donors, whose investments in the country’s health are declining.

Investing in health has an impact far beyond the wellbeing of the individual. A high malaria burden affects GDP. HIV treatment saves lives, prevents new infections, curbs TB, and stops households from being pushed into poverty. As Michael Sidibe, UNAIDS executive director, says, “Pay now, or pay forever.” Waiting costs more in human lives and is not smart economically.

Third, we need to reach out to the community, and to patients themselves. Not to demand cash, but to encourage them to take part in the management of their healthcare. Community patient groups, and community health workers have been successful innovations elsewhere that have cut costs and improved access.

Where does the private sector fit in?

The innovations in global health financing over the past year have been strongly influenced by the for-profit and non-profit private sector or involved its participation. The private sector brings new ideas, and can implement change rapidly. It is largely that private sector that produces the drugs and materials we need.

The lower-income countries that have successfully achieved universal healthcare have all done so with a significant contribution from the private sector. Wealthier patients pay for private services, which complement the public system.

But there is still public sector involvement. Because when it comes to the people with least access to health services, governments must step up. Public funding is necessary to guarantee a basic level of care to everyone, including access to essential medicines and therapies, whatever their means.

Profit-driven entities stumble when they get to those who cannot pay. They need help from the government – the private sector can still implement, but public money is required to create a market, and public oversight is necessary.

In countries where business is booming, the market and the private sector may be driving economic growth, but they are not reliably driving improvements in the health indicators of the poor.

Take MDR-TB as an example. In terms of absolute numbers, four of the five countries with the highest burden of MDR-TB are BRICS countries. These countries have the resources to combat this disease, but we are not seeing them invest in a TB response.

Governments must meet their responsibilities. There is no getting around it.

If you look at the Human Development Index, you will find Niger somewhere close to the bottom. In 1990, Niger had the world’s highest rate of undernutrition and child mortality. Today, more children receive treatment for malnutrition in Niger than anywhere else in the world. In 20 years, child mortality fell by 40 per cent.

Of course, Niger has not been able to do this alone. Millions of dollars of external funding for medicines, diagnostics, drugs and ready-to-use food have been crucial to this progress. But Niger has shown what can be done when a government is determined and shows leadership. Their approach has not been confined to treating the severely malnourished. It has included free maternal care and free healthcare for under fives, nutritional surveillance, vaccination, vitamin A supplements, new models of care, and preventive action.

Let me sum up. The poorest people often bear the highest burden of disease and experience the most complex health needs. They should not have to depend on humanitarian assistance for healthcare.

The MDGs have almost run their course. They have taught us what can be achieved if we all focus. They have also shown us how much is left to do. We need not just the money but the political vision and will from all parties – industry, government, donors, civil society - to keep financing and investing in health so that it reaches the most extreme levels of need, and so that healthcare can be truly universal.