Regional Committee for Europe, Copenhagen, Denmark
Address by Anders Nordström, Acting-Director-General
It is a great pleasure for me to join this, my fourth regional committee session. It has been a pleasure seeing the strong commitment, relevance and engagement in the core functions of WHO. I will return to these six core functions later. We hear a much stronger call today for leadership and coordination both from WHO generally, and in specific areas.
Yesterday I spoke about the need to increase the profile of research. WHO itself does not conduct research, but we play an important role in information gathering and influencing the research agenda. We need to ensure that we continue the critical function of norms and standards.
We also need to provide policy options especially those relating to increasing the efficiency of health systems.
The fifth core function, of providing technical support to build sustainable national capacity, is very important if we are to be able to translate the agenda for initiatives like "Making pregnancy safer" into practice in the national context.
The sixth core function concerns monitoring and surveillance. It is essential that WHO is able to deliver data information with quality and integrity.
I missed the Regional Director’s report yesterday on progress in the Region. However I have read it and appreciated its clarity and strong focus on countries.
I would like to highlight three specific topics. The first is the prevention and control of noncommunicable diseases. We need a balanced approach. We need to continue to focus on tackling communicable diseases, finishing the work on polio, but we also need to address the underlying causes of noncommunicable and chronic diseases. The European Strategy will be very important here. The specific emphasis here on obesity is also going to be interesting for the rest of the world.
The discussion yesterday about health security will feed into next year’s world health report with its theme of health and security – which is also going to be the theme for World Health Day.
The third issue that I would like to highlight is health financing. The progress made and lessons learnt from this Region can also be shared globally.
These topics clearly indicate how we need to work together throughout the Organization, in Geneva, the regional offices and country offices, as well as in the Member States and the Secretariat.
Your discussions on the future role of the Regional Office will support this alignment and complementarity, making sure that the global framework is translated into the regional or country context.
Yesterday we discussed the Medium-Term Strategic Plan for 2008 to 2013 and the Proposed Programme Budget for 2008 to 2009. I very much appreciate the discussion and your comments. We will revise the document after the regional committees and then it will be submitted to the Executive Board. I strongly encourage you to attend the session of the Board, if you normally do not. It will be crucial. The revised document will be ready at that time.
The increase in the budget is a direct reflection of increased expectations and demands from Member States. It will target core areas of need, namely: achieving the Millennium Development Goals for maternal and child health; increasing the focus on noncommunicable diseases; making health development sustainable through greater attention to the determinants of health; implementing the International Health Regulations, and strengthening health systems.
To finance these plans, the Proposed Programme Budget for 2008-2009 has been costed at US$4.2 billion. This is very ambitious and a major challenge to all of us, as we discussed yesterday. Again - as was presented and discussed - the proposed financing of the programme budget is through: an 8.6% increase in assessed contributions from the Member States amounting to $1 billion; the introduction of negotiated core voluntary contributions amounting to $600 million; and the remainder through specific voluntary contributions.
Even with this increase, the share of the assessed contributions will continue to decline (23%). This is unfortunate. We hope however that the introduction of negotiated core voluntary contributions will achieve better alignment and reduce the transaction costs.
The total proposed increase for the European Region is about 36% against the current biennium. This represents an absolute increase of $72 million for a total of $273 million.
There are five main areas of focus coming from the General Programme of Work, the proposed Programme Budget and the Medium Term Strategic Plan.
The first is increasing universal coverage, scaling up basic health services to people with an equitable perspective.
The second is the health security dimension, which is becoming more prominent with the implementation of the International Health Regulations. Today WHO has a different and much stronger role in security and humanitarian issues as the Health Cluster lead. I am shortly going to see Jan Egelund in Geneva to discuss how we can further improve the ways that WHO and OCHA work together.
The third dimension in the future concerns the determinants of health. We will see that increasing further. We look forward to 2008 and the report from the Commission on Social Determinants of Health. I had a meeting with the chairman, Mike Marmot, a month ago, to discuss how to make WHO's work reflect the knowledge of what really makes a difference in health.
The fourth area of focus is on health systems and the fifth on strengthening WHO’s leadership both at the global and regional levels, to support the work of governments in countries.
There has been a very thorough consultation throughout the Organization, reflecting what has been decided in resolutions, what has come from country strategies, and what has come from specific strategies on immunization, tuberculosis, etc. The process has been to gather this together to see what is the direction forward.
Let me then turn to five very specific areas.
First to noncommunicable diseases. Your strategy, “Gaining health”, describes very clearly how to plan to be able to tackle some of the major causes of chronic noncommunicable diseases. The Ministerial Conference in Istanbul on obesity will be very important and provide significant input on what we need to do in terms of chronic noncommunicable diseases. The Global Strategy on Diet, Physical Activity and Health is important; we need to translate it into practice now, seeing what we can do as Member States, what we can do as the Secretariat, which partners we need to engage with if we want to make a difference. The epidemic of obesity is growing very rapidly. There are a number of changes that need to be made in government policies, in private business practices and also by the consumer. WHO has an important role to play here.
We need to go beyond the obvious to look into the underlying causes of ill-health. What are the determinants that relate to women’s education, the empowerment of women, to the environment? What is happening in terms of air pollution? There are a number of underlying determinants of health that we need to tackle. This does not need to cost much. Policy decisions in other sectors than the health sector can have a large impact on health. It is a matter of finding the right modality for us to influence ministers, for example, so that road-building decisions also reflect public health interests and can save mothers that are dying in childbirth because of lack of access to healthcare services.
I was part of the Swedish Government when there was a Swedish parliamentary commission looking into the broad public health issues and the actions to be taken by the different sectors. How is that now translated into action? Do we then see an impact on health? That is the big challenge. It is easy to say; it is much more difficult to do.
This is something on which WHO needs to work on with you, to gain experience and to find the right modalities. This is an important health systems issue.
Countries of the European Region continue to take the global lead in research and action on health equity and on social determinants of health. The upcoming meeting on these issues in London in November will be important to explore them further.
A specific dimension of this is tobacco and the implementation of the WHO Framework Convention on Tobacco Control. So far, 136 countries and the EC have become Parties to the Convention. However, 14 Member States from this Region have not yet ratified, accepted approved or acceded to the Convention. I urge you to do so as soon as possible. WHO is very keen to work with all countries, both those which are Parties and those that are not.
Tobacco use is a critical risk factor if we want to have an impact on health. It is a very easy one to change. Just stop smoking. Easy to say. Difficult to do.
We have seen some important progress in terms of child health worldwide, including in this Region. More needs to be done. WHO is playing an active role in the Partnership for Maternal, Newborn and Child Health.
Immunization is a crucial part of our work and one of our most successful tools.
We have learnt of the engagement in this field by her Royal Highness the Crown Princess of Denmark, and that is very much welcomed. However, even though we have been working on immunization since Almaty, we still have two to three million children who are not immunized, who we are not reaching.
In St. Petersburg when I addressed the G8 leaders, I compared a generic cola bottle with a polio vaccine to make a point about access. One product is able to reach out in every single village. The other does not. So what is wrong? We can save lives for a fraction of the cost of a soft drink. We need to rethink how we reach out to be just as efficient. We need to think in terms of our health systems, our logistical systems, and to learn from those who are more efficient than we are to be able to reach out with the global public good of immunization.
This Region has made enormous progress, yet still much more needs to be done. We appreciate the partnership with the GAVI Alliance. Out of the 11 countries that are eligible for GAVI support, all have now successfully introduced Hepatitis B vaccine. Overall, this represents a financial commitment of some US$ 12 million.
Let me now turn to an area which is of great interest and importance to me, to WHO and also very specifically to this Region - the area of sexual and reproductive health. Much more needs to be done here, especially the underlying problems relating to maternal mortality. We have seen some progress globally in terms of child health. The infant mortality rate and the under-5 mortality rate have gone down during the last 10, 20 and 30 years. Maternal mortality has not really seen any change. Many countries in this Region have also made good progress but much more needs to be done.
WHO’s governing bodies have approved a series of strategies that will be important for us to be able to take this agenda forward. We have the strategy on sexually transmitted infections; we have the strategy on reproductive health; we have the strategy on family health; we also now have the new strategy on HIV/AIDS. All of these now need to be translated into practice on the ground. We must try to focus even more on young people.
The European strategy for child and adolescent health that was adopted last year will be an important framework in the Region.
I have tried, during my months in this Office, to make this a personal commitment. One of the first meetings I had was with Thoraya Obaid, the Executive Director of UNFPA. We held a very good review of what each agency is doing. This has been going on for some years and we trying to increase the focus on countries and complementarity on the ground. We sent a joint letter to emphasize that we do have different roads and different mandates. We are now implementing certain decisions by our governing bodies. Working together is crucial for concrete actions in countries.
I recently attended the XVI International AIDS Conference in Toronto. The theme of that Conference was “Time to deliver”. One of the key outcomes of that Conference was “Stop talking; do it”. Despite some people's concerns about big conferences I would say that this was not a conference, this was not about producing a declaration, this was about working. I am not ashamed that we had 100 people there. We needed to be back on the stage to be able to do our work. We gained a lot also from listening to others, so that we can take the work forward. I am very happy with the new five-year strategy for WHO, making sure that we are an effective partner and cosponsor to the UNAIDS broader UN programme.
During the last years, thanks to Dr Lee Jong-wook, we have put treatment back on the agenda through the 3 by 5 initiative. Nobody believed it was feasible when he announced this initiative but he proved that change was possible. We did not reach the three million on treatment but, at the AIDS Conference in Toronto, we had reached 1.65 million, with the figures for Africa having increased by 10 times from 100 000 to 1 million on treatment in Africa alone. We have not seen anything like this for any disease before - achieved in roughly two years. That was enormous progress. We should recognize what the Director-General did there.
We need now to move forward on HIV/AIDS in a balanced approach, making sure that we work on behavioural aspects, that we work on new opportunities when it comes to prevention and that we continue to work on treatment.
At the Conference I introduced the "3 Ms" : the three key areas for action of Money, Medicines and a Motivated workforce.
We have seen an increase in terms of financial resources. Yet more is needed. The total measures for this biennium are expected to be in the region of $8 to 10 billion.
There have also been major improvements in terms of access to drugs. Prices have come down and new products are available. I recently attended a conference with the Secretary-General and some of the CEOs from the largest pharmaceutical companies in the world on the Secretary-General’s Accelerating Access Initiative. There has been a major improvement both in terms of drug prices and in terms of new formulas for children, primarily targeting developing countries. Still, much more has to be done in terms of getting prices down on paediatric formulas for second-line treatments. But it is still a very different situation compared to five to six years ago, when the Secretary-General initiated that discussion.
Yet neither of these two will bring more than short-term benefits if the longer-term development issues of an effective health system and the health workforce crisis are not dealt with. Everybody recognizes that this is the main bottleneck.
At the Toronto Conference WHO launched the "Treat, train, retain" initiative to protect and support health workers living with HIV. This joins wider global efforts to sustain and build through the Health Workforce Alliance.
HIV/AIDS work and the epidemic have opened our eyes, both technically and politically to the need to address issues on motivation, incentives, salaries and structure of the health sectors, both private and public. People today are driving taxis instead of delivering health services. We need to understand the structural issues of public sector health reform -something which is not WHO's role, but that of the governments, the role of the ministry of finance.
A motivated health workforce requires more than training. That has been our solution for many years. We need to go beyond training. We have to address the underlying issues. Health workers are being driven away by low salaries and poor working conditions. Some are forced away to other jobs, either nationally or elsewhere in the world.This year's World Health Day and World Health Report had the theme "Working together for health" to highlight this. The Report proposes immediate country-based actions within a 10-year plan.
The work on HIV/AIDS, and the recognition of the threat to human health from emerging infectious diseases has catalysed action in many areas not previously viewed as a priority in public health.
So let me now turn to the implementation of the International Health Regulations, and to avian influenza. Those of you here who were involved in the careful negotiations to revise the International Health Regulations know how highly this instrument is regarded by Member States.
This is not only about controlling avian influenza, of course; it is not only about narrow disease control, it is also about building systems in countries that are robust enough to be able to monitor, and to be able to respond. It is also about transparency, communication across the world and taking more of a global approach to how we can manage key health challenges.
In terms of avian flu and the risks of a human influenza pandemic, there is still a threat.
Today, more than 50 countries in central and southern Asia, Europe, Africa and the Middle East have reported outbreaks in birds. Human cases have now been reported in 10 countries, including 2 from this Region. As at 8 September there had been 244 confirmed cases and 143 deaths.
Information and communication are key here, to have a good understanding of how you can protect yourself and what you need to do. For example, it is safe to eat cooked chicken. But it is not safe to handle dead birds in certain ways, and that message needs to get across. I am encouraged to see that we now have preparedness plans in more or less all countries, and I hope that these will be broad enough also to be able to build up wider health systems and surveillance systems. It is important that they are tested so that they can become operational.
Manufacturer capacity in terms of antiviral drugs has improved considerably. New licenses have been granted and production capacity is increasing in some of the developing countries. We also see some progress in terms of a vaccine. The capacity issue is more difficult, but there is movement. We are now focusing on capacity-building in developing countries. Some recent clinical trials are showing promising results.
Let's look briefly at a couple of other areas of importance to our health work.
First I would like to say a few words about tuberculosis. This Region has one of the highest rates of multidrug-resistant TB. We have learnt a lot from how you have been able to tackle this here. It is still a severe threat to human health and to public health, especially in the countries where there is a high rate of HIV/AIDS. The ministerial conference to be held next year will be important and I encourage everybody to participate in this. It is an important issue for all countries, not only developing countries and HIV/AIDS-affected countries, but for all countries in this Region.
In terms of malaria, there are still some key challenges in this Region. At the same time, we have seen some important and impressive progress. I congratulate all the malaria-endemic countries in the Region that have achieved a decrease in malaria relative to 2000.
In polio eradication, only four countries in the world remain polio-endemic; Nigeria, Afghanistan, India, and Pakistan. Our work to reach all those children continues, urgently. Until polio has gone, children everywhere will continue to be at risk.
The success of the global polio eradication effort now depends on political will, and strong commitments to close the funding gap. I particularly congratulate the Russian Federation's leadership in making a new commitment of $10 million to support polio eradication. It is essential that other G8 countries now follow suit. For 2006, we urgently need $50 million by October to ensure activities through the rest of the year can proceed. For 2007-2008, we face a $390 million funding gap.
And this brings me to the last of the core areas identified in the proposed Programme Budget: the need to continue strengthening health systems. Without functioning and efficient health systems we will not be able to scale up basic health services nor achieve the MDGs.
I think health reform and health systems generally need to be de-mystified. Simply: we need to achieve four things.
First, we need to improve the organization and the management and delivery of health services. That has to do with primary health care, with ensuring that we have hospitals, with getting efficient delivery of health services, including both the private and the public sectors, and with making sure that we achieve public health through that approach. We need to encourage different stakeholders’ and providers’ involvement in that.
Second, we need clear information and evidence, to be able to take the right sort of decisions. We need to strengthen the evidence base of health systems to support policy-making and implementation. This means good information and surveillance systems and investing in national capacity for research. I think we have seen some progress here. I am very happy that the health matrix partnership will improve how we can work with countries in terms of getting more quality data and information.
Third we need fair sustainable financing. This means looking at policy options for how to finance health services, exploring different financing alternatives, and reviewing the most effective allocation of resources. There are a lot of experiences in this Region that can also be shared with others.
The fourth component is the people, the staff, the human resources. This is the key area, both where we spend most money, and also where we can make rapid progress if we are prepared to deal with the underlying issues.
I would also like to say a few words about development assistance for health, and the aid effectiveness agenda. Some of you in this room are key partners in terms of development assistance. You provide substantial amounts which are very welcome. We see a very clear increase in investing in health in terms of overseas development assistance. This is vital, but one should see it in perspective. The world today spends $3600 billion on health worldwide, $340 billion in developing countries. About $10 billion of that is development assistance.. Sometimes we believe that development assistance will solve everything. It will not. The majority of the resources, if we want to scale up basic health services, are already coming from domestic resources. That will continue to be the future. Development assistance is important, both in terms of showing political will and political support. The G8 in St Petersburg was extremely important – and again, many thanks to the Russian Government for their firm positioning of health issues on that agenda. The G8 outcome document was the most elaborated thus far and a strong commitment to sustain scaling up and to invest in health.
A number of European partners have announced timetables to achieve this increase. ‘Scaling up’ thus remains an achievable goal. And one that we are firmly committed to achieving.
WHO is not the lead in terms of development assistance or aid effectiveness but it is critical that we work with countries on some of these issues. The first and most important thing is to ensure that there is country ownership: that there are national plans, national budgets, national policy frameworks, that are truly owned and that are technically sound in terms of priorities. We are engaging in many countries to support and to respond to their needs and expectations.
We need to empower those plans and those governments, respecting what has been developed and what are the national priorities. That needs to be at the forefront if we want to be effective. And we must work on the health systems issues which are crucial if we are to be effective in development assistance. The bottlenecks are related to the systems. I think we can do more to work with countries on that.
Partners providing Development Assistance can also do more. Discussion, however tentative about the next four or five years, will help all those involved to begin to get a better alignment between financial resources and priorities. There has been some good progress in this. The European Union and the European Commission are doing some very interesting work on MDG contracting, to achieve long-term financial support, both in this Region and elsewhere.
The way money is spent must focus on building sustainable national capacity. I therefore believe that we have to look closely and critically at the way that technical assistance is provided and discuss this openly.
The Paris Principles on Aid Effectiveness provide us with a guide for what needs to be done. Working together we can make them a reality on the ground, moving from principles to practice.
In concluding: our goal is to make WHO more responsive to the needs of countries. Our goal is a WHO that works effectively as part of the UN system.
We are engaging fully in the current debate on how the UN system should better coordinate its work in countries. We are engaging in the system to see how we can be become a more efficient partner, especially in the resident coordinator system. One of my staff members is currently in New York to discuss with UNDP what we can do in practical terms.
We have had a number of discussions with the UN High-level Panel on System-wide Coherence, and we are very much looking forward to the outcome of that report. The financing of the specialized agencies and the nature of the work of the specialized agencies are issues that we have brought to that Panel. We are now putting this together.
The Executive Board agenda in January includes an item called “WHO and UN reforms”. There will be a paper that sets out the broad directions on this, to support discussion with the governing bodies based on the report that was reviewed by the World Health Assembly last year.
Finally, I would like to thank Marc Danzon and his team, and the Member States, for the support you have given to me and the team since the shock of Dr Lee's death in May. I think we have been able to move on and make progress. The Organization had a shock but was not paralysed. This is quite a robust organization. This is very much thanks to your continued efforts during the World Health Assembly, thanks to a strong team, and thanks to the support I have been given during these months from Marc and from other colleagues. Thank you very much.