Director-General

Regional Committee for Africa, fifty-fifth session

Maputo, Mozambique
22 August 2005

Your Excellencies, "Bom dia"

Armando Guebuza, President of the Republic of Mozambique, Mr Chairman, Honourable Ministers, Madame Commissioner for Social Affairs of the African Union, Members of the diplomatic corps, Dr Sambo, colleagues,

What a dignified and warm welcome you have given us all. Thank you.

Africa is the centre of attention in current global discussions about the future of our world. It brings together some of our deepest concerns as well as some of our greatest hopes. People's lives depend on you, the decision-makers. This meeting, with all its ceremony, may seem far from the raw truth of poverty and disease faced by millions in Africa. It is not. The poor and the sick must be in our minds in all our discussions this week.

WHO has allocated Africa nearly 30% of all our combined income for the next biennium. This is the largest proportion of the Organization's budget. Using these resources effectively to achieve the required results will mean streamlining. It also means strong management, transparency and accountability.

Mozambique today sets a fine example. There is a saying "Smooth seas do not make skilful sailors". The Government of Mozambique has shown its navigation abilities. It moved from 16 destructive years of war, to peace in 1992. It has achieved national reconstruction with good governance, increased transparency and cooperation. Bilateral donor support has followed. The health of the country has benefited and good progress is being made towards several of the Millennium Development targets. Rapid declines in infant mortality and under-five deaths, especially among rural children, combined with increasing measles immunization coverage and a remarkable decrease in maternal mortality between 1997 and 2003, give us a picture of greatly increased survival for mothers and children. However, there is still much to be achieved in control of malaria. And HIV prevalence continues to climb.

Such navigation skills will be needed across the continent in the years ahead. Our common vision for the next decade recognizes that health is influenced by a wide range of non-medical factors like poverty and ignorance. Social, environmental, economic, and political issues, such as intellectual property rights and trade agreements play a part in health outcomes. Their consequences are clear in the accumulating burden of chronic disease and the continuing death toll from infectious diseases like HIV/AIDS, tuberculosis and malaria.

We in this room are responsible for making sure that people stop dying from these diseases. However, the question of how to apportion responsibility for reducing or stopping their causes is a complex one. Your discussion later on the draft general programme of work will make an important contribution to this.

Two years ago I talked to this Regional Committee about getting 3 million people onto antiretroviral treatment by the end of 2005 as a first step towards universal access. Many people thought that "3 by 5" was too ambitious. Good. We should set aggressive targets. But it was a lot to achieve in the timeframe, and it is evident that reaching 3 million people will take a little longer than originally anticipated.

You have achieved much in a short space of time. Close to 1.5 million people will be on antiretroviral treatment by the end of 2005 (and most of them will be in sub-Saharan Africa). Based on this progress, universal access is now recognized worldwide as a moral and social imperative, and as a practical necessity. The commitment made by Member States to increase access to treatment has become a movement which cannot be turned back. The momentum you have created inevitably led to the G8 recently setting an even more ambitious target. This was to get "as close as possible to universal access to treatment for all those who need it by 2010". You have helped to make this possible. Access for everyone to the health care they need is now recognized as being not only absolutely necessary for people who live with HIV, but entirely feasible.

Overall, antiretroviral drug prices are falling as more products become available and the market expands. WHO already prequalifies 63 antiretroviral drugs, including 29 generic formulations. The recent confidentiality agreement between WHO and the US Food and Drug Administration will further support the prequalification programme, accelerating the availability of lower-priced generic antiretroviral medication.

By making treatment more widely available, more people are now motivated to come forward for testing. In one district in Uganda, introduction of ART led to a 27-fold increase in demand for HIV testing and counselling. This is a vital step. In Africa, less than 5% of people living with HIV/AIDS are aware of their status. The availability of testing and counselling must be expanded. Treatment and prevention go hand in hand, each supporting the other's ability to save lives.

However, demand is greater than people or systems can manage to supply. At least 4 million people in sub-Saharan Africa alone need this therapy. There is an urgent need to train health workers and address the implementation bottlenecks.

But it is a battle against time. Life expectancy is decreasing in sub-Saharan Africa. For example, in Botswana, it is currently 36.4 years. Yet it is forecast to get even worse - falling to 34.4 years of life by 2010. In Swaziland it will even reach 30.6 years over the next five years. These are unfolding catastrophies. We must reverse this trend by turning back the tide of deaths from HIV/AIDS.

Universal access is also a key to tuberculosis control. Following the declaration of a global emergency in 1993, there has been a rapid scale up of DOTS across the world, and the incidence of TB is either declining or stable in most of the world. Only in Africa is the rate still increasing rapidly, resulting in a net global increase in incidence of about 1% a year. We have a cure for TB. The main obstacles to implementing these treatments and stopping needless deaths are the same; the health systems are not yet strong enough, and there are not enough trained health workers.

Over the years of the polio eradication effort, we have together made progress towards almost universal vaccine coverage in polio-endemic countries. However, the reintroduction of the virus to several previously polio-free countries has also demonstrated how easily we can lose the fragile advantages we have gained for health.

Only when immunization has reached every single child will the transmission of poliovirus be stopped. The African Union responded to the outbreaks last year with synchronized polio campaigns in 24 countries that reached about 100 million children. This is the largest ever internationally coordinated operation to have been carried out in peacetime. As a result, this year, West and Central Africa have reported the lowest level of polio cases in recent years.

We need to increase the polio immunization campaigns in the Horn of Africa and in Nigeria, where too many children are still being missed. Immunization and full coverage with surveillance are a pressing need for all countries. The health workers being deployed to achieve this make a vital contribution to the whole health infrastructure, particularly for protection against the childhood diseases.

"Make every mother and child count" was the theme of this year's World Health Day. Here too, financial barriers to access need to be reduced and an effective workforce built.

To make this more real, let's look at the experience of one 17-year-old pregnant girl from Ethiopia. Her name is Hiwot. She and her daughter Elizabeth are included in the six-country photo essay linked to the launch of the World Health Report this year. She was then still a schoolgirl, living with her mother and sister. When she knew she was pregnant, Hiwot walked 30 minutes to attend the nearest antenatal clinic. She's lucky to be able to do this. Only one in four Ethiopian women are able to make even one such visit. Elizabeth was born safely, with the assistance of Doctor Asfau, and weighed 3.3 kg. Fortunately there were no complications as the hospital had no special help, and only limited facilities. There was no running water, only a bucket. In Hiwot's country, only 9.7% of births are assisted by a skilled attendant and 1 in 14 women dies in pregnancy or childbirth. Baby Elizabeth has grown well, being breastfed, and made it safely past her seventh day of life. But 38 out of every 1000 babies die in their first week. She has made a start on the immunizations she needs to protect her. One in six Ethiopian children dies before their fifth birthday from preventable diseases such as pneumonia, diarrhoea and malaria.

These are the figures that we have to change. But they are not just figures. They are people's lives. All the Elizabeths and Hiwots of this world must have the best possible chance of health - equally.

For malaria, the Abuja Declaration set 2005 as the year in which coverage rates should reach 60% for the main curative and preventive interventions. Few countries will reach that target this year. The supply crisis for artemisinin-based treatments is one of the reasons for the delay. Large-scale cultivation in East Africa of Artemisia annua could provide a reliable and adequate supply. We are also looking at ways to make long-lasting insecticide-treated nets available to 80% of young children and pregnant women before 2010. Globally, local manufacture of these products, and of essential medicines such as antiretrovirals and antimalarials, move countries further towards self-reliance and increased national capacity. Domestic production brings strengthened regulatory systems and reduced dependence on external financing.

Despite the progress being made in access and coverage, significant challenges to health systems still remain. Behind every area of vulnerability in health systems nationally and globally is the lack of health care workers. Without enough skilled workers, health care systems cannot function properly. Vital programmes cannot be carried out. Daily directly-observed treatment for TB just can't be done if the only health worker is 25 kilometres away. The annual review of the Stop TB programme found that 10 of the 22 high-burden countries reported major deficiencies in staffing at central level and another 7 were struggling for staff at peripheral level. A study by the Global Alliance on Vaccines and Immunization (2003) found that management and human resources represent a major constraint in 40 Vaccine-Fund-eligible countries and in 18 was the primary barrier to scaling-up immunization. Reviews of the implementation of the Integrated Management of Childhood Illness noted human resource barriers as critical health system constraints. A major investment is needed to expand and retain the health workforce in Africa as a whole by the recommended 1 million workers by 2010.

Next year we will launch the world health report on the human resources crisis. Through your efforts the problems of migration have been brought to world attention. The two recently-adopted World Health Assembly resolutions on the international migration of health personnel were initially sponsored by African nations. These must now be implemented.

The adoption of the International Health Regulations 2005 by the Health Assembly this year was a historic step. Pandemic influenza was a dominant concern of the negotiations, and it is a danger that has continued to increase. Marburg fever in Angola, with its high fatality rate, appears to be controlled, but was a particularly harsh reminder of the hazards we face. It also demonstrated how coordinated, rapid and effective action could gain control of outbreaks faster.

At present the need for security measures against pandemic influenza outbreaks is felt largely in Asia and the Pacific. But no country can afford to ignore this risk. Such a pandemic can affect all countries equally in the space of a few days. Avian influenza is not formally on the agenda for this regional committee, but Africa's peoples are as vulnerable to infection as anywhere else. No effort must be spared to build the necessary mechanisms for disease detection, alert, response and information-sharing, both within countries and between them. Despite the many challenges for controlling infectious diseases, we cannot afford to ignore the rapidly growing burden of chronic diseases in Africa. Total deaths in Africa from noncommunicable diseases are projected to increase by 27% over the next 10 years. Most notably, diabetes mellitus mortality is projected to increase by 42% between now and 2015. Cardiovascular diseases are now the leading cause of death worldwide. By 2015, they will still be the leading cause of chronic disease mortality, accounting for 46% of all deaths from this cause in Africa. I welcome the Regional Committee's discussion of this important topic and urge you to take immediate preventive action. The global report on preventing chronic disease, coming out in October, will stress the importance of taking steps now, in all developing countries, to curb the rise of cancer, cardiovascular disease, chronic respiratory disease and diabetes, among others.

I thank those of you whose countries have become parties to the Framework Convention on Tobacco Control, and urge the rest of you to follow suit. It is an excellent example of how international cooperation can provide strong support for national efforts to tackle the root causes of many cancers and heart disease.

Slow progress in reducing poverty and ill-health is widely recognized as a grave danger to security and development. Yet, the delayed response in the international community to repeated government and United Nations appeals for aid to countries in the Sahel is in strong contrast to the Millennium commitments made. WHO is playing its part in a timely manner in Niger: there has been very good cooperation between the Ministry of Health, WHO and other humanitarian partners to get the relief efforts off the ground.

Again, let's look at a personal example. Aminatou Iyaye from Niger has a field of chickpeas in which nothing is growing. The locusts ate everything last year. People in her village eat once a day, if they are lucky. Their food is maize flour mixed with water and a little sugar. The water is untreated, and comes from an open well. There is a threat of cholera. Her daughter, Oumana, is in a precarious situation. She is four months old and severely malnourished, weighing less than 2kg - half of what Elizabeth from Ethiopia weighed at one week old. There are an estimated 32 000 severely malnourished children like Oumana in Niger. Experts have been working with Ministry of Health officials to avert the crises in nutrition and outbreaks of infectious disease, setting up emergency vaccination programmes and training volunteers to help with screening and referral of children. All of this is very positive. The people of Aminatou's village have renewed hope.

However, I am concerned that no attention was paid to the warning signals sent out by the Government of Niger and by our offices last year, until the situation reached crisis level. The Millennium Development Goals - and our own global agenda - will not be reached through crisis management, but by steady work on strengthening the fundamental systems and resources in countries.

There is great potential for progress. The main problems are known, recognized, and are being tackled. Moves towards debt relief and increased development assistance have begun to present a real possibility of recovery and new strength in Africa. Increased investment in health, combined with good governance, and stewardship of external and internal resources can yield the high returns that are so urgently needed. The decisions you will be making this week can accelerate these positive trends, and bring life-saving interventions to the many people who count on your support.

What you achieve here in this continent will have an effect on the rest of the world. I wish all of us every success in the important discussions of this week. Let us use them to combine our strengths and seize the opportunities now before us to bring new strength and health to the peoples of Africa.

Thank you.

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