Regional Committee for the Americas, Washington DC, United States of America
Address by Anders Nordström, Acting-Director-General
Indeed, Monday 22 May was a very dramatic sad day for all of us, with the World Health Assembly opening with the announcement from the Spanish Minister that the Director-General was dead. This was even more dramatic for me personally, knowing what Dr Lee had asked me to do in this kind of event – a situation that you never think will happen – but still I had to do it. I would like to thank Member States and also colleagues across the world in the WHO regional and country offices for what you have done. I would not have been able to take on this task without the very strong support from the team in Geneva and across the world.
The Acting Director-General continues in Spanish.
Mr President, Honourable Ministers, and Colleagues. Good morning. It is a great pleasure to be with you today and to share a few global perspectives that I believe are also of regional relevance to all of us. Mirta, thank you for a very interesting analysis and presentation.
The Acting Director-General continues in English.
This is now my sixth regional committee. I have greatly enjoyed the opportunity to share some views with colleagues across the world as well as to experience what kind of Organization we are. We are quite a diverse Organization but across the world there is a very, very strong commitment for health, for WHO and for its core functions.
Last year when I came to this Committee, I unfortunately spent most of my time in bed ill but I understand you had a very good discussion on the General Programme of Work. Unfortunately I was not able to be part of that, but the year before that I was here for the discussion on the Proposed Programme Budget. Your discussion and input on the programme budget, the directions in which we move forward in the Organization and also the discussion around the General Programme of Work have highly influenced our work on the Medium-Term Strategic Plan and the Proposed Programme Budget you will discuss later in the session.
I would like, first, to share with you three perspectives, which relate to the remarks made by the President. We experience good collaboration and hear many positive reports, but are we making a difference on the ground? Are we making sure that more people have access to drugs? Are we addressing the major health issues? So, three perspectives: First, if we really want to have an impact on health, where do we need to move? Second, we have now a more engaged but also a more complex health architecture. If we would like to capitalize on the benefits and engagements from so many partners, where does the health architecture need to move?. Third, where is WHO moving (over and above the election of the Director-General, which I will not be discussing)?
In answer to the first question, I think that today we have a very good knowledge about what is needed, especially in this Region. We know that we need to scale-up basic health services and to have an impact on reducing poverty; to address the bottlenecks within health systems, in particular regarding human resources; and to address the underlying determinants of health. We also know that we must have a more balanced approach in addressing communicable and noncommunicable diseases. But what are the implications of this knowledge, knowledge we have had now for some time? The realities have become much more complex but sometimes we are trying to manage these complex realities with old solutions. While we do not need to reinvent the wheel, we need to make the wheel move in slightly different ways. We cannot manage what is happening in the environment, what is happening in terms of air pollution, in the same way as we tackle immunization programmes. There are no simple solutions and we need to find efficient ways of dealing with the complexity. This has implications for all of us in terms of the functionality of our ministries and of WHO as an Organization.
The second perspective concerns improvement in how we manage and capitalize on the growing interest from a number of partners. At the global level we have new instruments, new partners, the GAVI Alliance, the Global Fund to fight AIDS, Tuberculosis and Malaria, etc., and at the local level in countries we also have growing interest from different stakeholders. For example, there was a very clear message this morning on the engagement of Brazil, Cuba, and Venezuela in south-south cooperation. This again means that we have a more complex reality, with more partners at all levels. It is not as easy as it was 40 to 50 years ago, when there were just a few agencies and programmes within the United Nations system. Sometimes we perceive this engagement from new partners as being a problem. We need to turn that perspective around and see the engagement from the private sector, the public sector, the multilateral system, bilateral systems and neighbouring countries as a positive development. But again, as with the health agenda, this means a more complex reality to manage at the global level.
WHO has a role to play here in terms of providing leadership and coordination, ensuring that we have a good direction but also that in countries, governments, have the main responsibility to maximize the benefit from this engagement. So, the principles agreed in Paris a couple of years ago in terms of ownership, harmonization, alignment, simplification and focusing on results must now be translated into practice in countries. On the positive side, there is strong agreement among partners that this is what needs to happen.
Turning to the final perspective concerning the direction of WHO, I can say that we are moving in a way that will enable us to respond to this more complex understanding and positioning of health. Sometimes I and my team are being challenged to set clear priorities. We will set priorities but we will not say that we will work on malaria but not tuberculosis or that we will focus on communicable diseases but not on noncommunicable diseases or the broader determinants of health. It would be impossible to ask us to set those kinds of priorities.
However, the way we address malaria will be very different from the way in which we address the broader determinants of health. How do we ensure that we are gaining maximum benefit from introducing an enhanced gender perspective in terms of our health planning? Input from WHO will again be very different. The way forward is for WHO to honour its core functions in a more systematic way.
WHO can do this through the Eleventh General Programme of Work, entitled “Engaging for health”, which has enabled us to capture the complexity of the health agenda in seven dimensions. These core functions, adopted by the Health Assembly, incorporate an understanding of the need to scale up basic health services but also to tackle broader issues such as strengthening of health systems, addressing the determinants of health and harnessing new knowledge and technologies. WHO will not be able to do everything in this complex architecture, so that we need to be clear about where there is complementarity and where WHO can add value.
An important next step for WHO is the Draft Medium-Term Strategic Plan 2008–2013, which you will discuss in detail tomorrow. This gives a six-year perspective in terms of where we should move as Member States and Secretariat, and will, we hope, provide inspiration to other partners on the key health priorities.
The Plan has five main areas. The first is support for countries in moving towards equity by ensuring universal coverage with effective public health interventions, reducing gaps in access and in health outcomes for people. The second dimension concerns the strengthening of health security at the global and local levels. The remaining areas relate to influencing the determinants of health, strengthening health systems, and strengthening WHO’s role in terms of providing leadership and coordination.
Within these five broad areas, we are now suggesting 16 strategic objectives, strengthening the focus on the expected results of our work while keeping in mind our core functions so that we set the right sort of priorities. I would welcome a critical review of what we have placed on the table. Are we focusing on the right results? Are we loyal to our core functions? Are these reasonable costs to enable us to achieve the results? Do these expected results respond to your needs and to your expectations of WHO?
There are increased expectations and demands on us as an Organization. We have therefore invested a considerable amount over the last years few years in management reforms, in order to provide even better value for the money that you provide through assessed or voluntary contributions. We need to manage these resources in a way that delivers maximum results for the money we are receiving. The result-based management is in focus here, and I would say that WHO is currently taking a lead in this within the United Nations system. But we have also addressed various matters relating to the more practical management of resource-mobilization, and management of financial and human resources. WHO is a knowledge-based organization, a technical, normative organization, so that the majority of our spending is actually on staff, and should be on staff. So the agenda in terms of how we can increase competence, the way we attract, manage and retain staff is critical for our work.
The Proposed Programme Budget 2008-2009, which you will discuss tomorrow, has been costed at an all-time high, US$ 4.2 billion. This is very ambitious but it is a clear reflection of expectations in terms of managing this complex health agenda. There are clear messages from you in resolutions from Health Assemblies and the Regional Committees, for WHO to scale up efforts in relation to noncommunicable diseases and to the determinants of health, where we have not perhaps paid so much attention in the past. But there are also very clear messages that WHO needs to scale up responses to ensure the maximum benefit from other resources that are coming to countries, two very concrete examples of these being from the GAVI Alliance and the Global Fund. Technical support from WHO has been critical in providing successful leverage of the other resources.
What does this increase in the budget mean for this Region? This refers only to the WHO contribution, not that of PAHO. It is important, however, to have both perspectives, and you will see that in the final document. The WHO part is increasing by 42%, or $ 84 million, giving a total budget for this Region of $ 282 million. The financing of the work of WHO has been discussed over a number of years, by the Regional Committees, the Executive Board and the Health Assembly.
We are all concerned at establishing effective financing in order for WHO to be able to carry out its functions, functions that require a degree of independence to ensure that it can provide information and set norms and standards with integrity. We are therefore proposing an increase of 8.6% in the assessed contributions, which will amount to $ 1 billion. This is still very small, however, and the proportion of the total budget represented by assessed contributions will continue to decline, to 23%. We are also proposing to introduce “negotiated core voluntary contributions”. Discussions with partners providing voluntary contributions have shown a positive response to the use of the programme budget direction and the expected results as a framework for the allocation of voluntary contributions in a way that aligns better with the Organization’s needs.
We are also hoping to expand the level of flexible resources, that is, resources that are not earmarked. The United Kingdom has been taking a lead here, but other partners are following suit. Having said that, there are generally very few conditions attached to extrabudgetary resources, since there is a high level of respect for our priorities and the integrity of our work. However, there are major transaction costs: in the last biennium we had 4600 agreements and are expected to deliver 1500 reports back to our donors. That is a waste of resources.
Let me turn to the five specific areas of the draft Medium-Term Strategic Plan and Proposed Programme Budget: strengthening health systems, attaining the United Nations Millennium Development Goals for maternal and child health; paying attention to the determinants of health; implementing the International Health Regulations (2005), and increasing the focus on noncommunicable diseases. We all recognize that strengthening of health systems is crucial to everything we do. If we are to scale up basic health services, we need to tackle the bottlenecks and, as clearly stated in the discussions here, questions related to equity – the gaps in access to health care and health outcomes. It is time also to demystify the strengthening of health systems. We have been talking in vague terms about health reforms for many years, but what does it mean in practice? It means determining how we can improve the organization, management and delivery of health services, how we can work with both the private and public sectors, and it means assessing the role of government in ensuring equity and quality of care. I was very happy to hear Dr. Roses addressing intersectoral approaches at the local level in her remarks. I remember one of the visits I made to Nicaragua some 10 or 12 years ago to see how the integrated local health system (SILAIS)was working.
Information, the second aspect of health system strengthening, provides the evidence we need to enable us to take the right decisions. We also need also to invest more in research. The achievements of the Ministerial Summit on Health Research held in Mexico in November 2004 are being taken forward internally in WHO, and we are very much looking forward to the follow-up meeting in Bamako in a couple of years' time.
The third aspect is financing: we need effective ways of raising and managing financial resources. Here there are no norms and standards, but WHO can play a crucial role in discussing with countries the different policy options for financing health systems and allocating resources.
One of the most difficult questions across the world is the current shortage of human resources for health agenda. Even when money is available to ensure supplies, the lack of a motivated workforce prevents drugs from reaching patients. We need to start talking about the realities; we will not solve the health workforce crisis by training alone. There are more fundamental questions for societies and governments: can we pay people adequate salaries? What should be the size of the public sector? What are the policies in place today? How are we moving from a public-sector approach to a public-private mix? How can we gain a better understanding of why people choose to drive taxis rather than deliver health services?
We also need a global perspective on the migration of human resources for health. These are difficult questions that neither WHO nor Ministries of Health can solve; we need discussions with Ministries of Finance at the most senior level possible to see what can be done. As I mentioned in my opening remarks to you yesterday, this was one of my key messages when I spoke at the G8 meeting in St. Petersburg, Russian Federation, in July 2006, and at the XVI International AIDS conference in Toronto, Canada, in August 2006. I am very pleased that The world health report 2006 focused on this subject and provides an agenda for action over the next ten years as well as indicating what can be done immediately. Your round table discussions on human resources later in the week will add to the debate. There are also some very encouraging practical examples from this Region, not only what I saw in Nicaragua, but also in Brazil (continuum of care for women and children), Bolivia and Mexico (health insurance programmes), and Ecuador (free maternity programmes). The health workforce is particularly important in relation to programmes for mothers and children. If we are going to attain the Millennium Development Goals we need to reach every child in every district with a certain set of interventions. We know that we are making good progress at the country level, but there are still major gaps in particular areas or districts of individual countries.
Neonatal care and health care for indigenous peoples are other areas of concern in this Region and where we don’t see enough progress, as the Director’s report shows. I understand that in Guatemala, infant mortality in indigenous communities can be as much as 60% higher than in other parts of the country. This is not simply a question of access to services. There are underlying factors – mothers underweight or dying and a number of other determinants – that also influence the outcome for these populations. There are 45 million indigenous people in the Americas and your five-year strategy for improving the health of those people is of extreme importance. As for people with disabilities, it is a question of human rights and avoidance of discrimination.
There are some good developments in terms of child health. Your performance assessment report shows that 14 of 22 countries will see a reduction in undernutrition in children, and that 20 countries have reduced their child mortality.Your regional newborn health strategy will support this important progress in specific countries. The nutrition agenda is gaining increased attention across not only this Region but across the world. I was very excited to see the target set in Bolivia of “malnutrition zero”, an example of a strong political commitment and message.
Immunization is another crucial part of our work and this Region is one of the most successful in rolling out immunization programmes. In addition to eradication of poliomyelitis and elimination of measles, you have been at the forefront in introducing new vaccines, such as the rotavirus vaccine, in routine immunization. WHO’s partnership with the GAVI Alliance is essential and we very much appreciate how GAVI has been able to improve access to more and underutilized vaccines, and is now also investing more in health systems. In other areas, however, progress towards the Millennium Development Goals is not so successful and there is still a lot of work to do if we are to reduce overall extreme poverty and maternal mortality, and to improve access to sanitation.
Maternal health is a subject close to my heart, not only because I am married to a midwife, but also because this is an area where we have not seen enough progress and we remain far from the goals set for 2015. However, there is a growing momentum at the global level and we have had some important Health Assembly decisions recently, including adoption of the strategy on the prevention of sexually transmitted infections, with a strong focus on young people, the strategy on reproductive health, and the strategy on family health, all of which will enable us to take the work forward. During my few months in this office, I have tried to make this a priority. One of the first meetings I had in this role was with Thoraya Obaid, the Executive Director of UNFPA: we reviewed carefully what WHO and UNFPA are doing, especially in countries, and we issued a joint letter to our respective organizations to encourage all staff to ensure complementarity as we make progress on sexual and reproductive health. Again there are activities in this Region that will make an important contribution to work at the global level in respect of the focus on the health of young people and the impact on them of violence and will provide examples from which countries in other parts of the world can learn. The new regional strategies on HIV/AIDS and sexually transmitted infections are important, and it is encouraging to see the progress being made in countries such as Bolivia. In the area of HIV/AIDS, WHO has been able to contribute to the development of guidelines for antiretroviral drugs and to advocacy around HIV/AIDS, and to encourage a multidisciplinary approach, where there has been good progress.
Tuberculosis remains a major problem across the world despite a very strong Stop TB partnership. Again you have a very good regional plan. We need to make sure that we can implement it and provide sufficient financial resources to close the gap between rich and poor people, a major challenge in combating tuberculosis.
Similar inequities remain in relation to the burden of malaria and, unfortunately, while a number of countries have seen a decline in the incidence of the disease, others have been reporting increases. Again we have a regional plan, but we need commitment to implement it. I hope that our recent revision of the global strategy for malaria will be helpful in this Region. The strategy now focuses on combination therapy and provision of bednets; but it also reintroduces residual spraying with DDT or other agents, an important component. There are also other approaches as mentioned in your regional presentation here. The Rollback Malaria Partnership is crucial. We have been actively engaged in partnership activities and we will host the next Partnership Board meeting in Geneva in November 2006, just after the special one-day session of the World Health Assembly. The meeting should ensure that WHO programmes are delivering and that the Partnership is functioning well, with strong commitment from other multilaterals, such as the World Bank, and key governments, such as that of the United States of America.
Let me now turn to the broader determinants of health. Again, this Region has taken the lead in terms of recognizing the underlying factors. We have knowledge but how are we translating this knowledge? What is happening in our environment, for example? Visiting Lima a year ago after an absence of 15 years, I noticed that the level of air pollution had increased quite dramatically with an impact on people’s mental health, respiratory infections, etc. So, what can we do as ministers of health, health organizations, and health leaders to influence environmental and social determinants through other sectors? I am very pleased with the work of the Commission on Social Determinants of Health, and have had meetings with its Chairman, Mike Marmot, a month ago and again yesterday. You will be discussing the work of the Commission later today. I hope that we will be able to act on the Commission’s findings on translating knowledge into practice immediately and not wait until its report is published. We need a multisectoral approach at the local level if we are to have an impact on the determinants.
We have not paid sufficient attention to the current epidemic of noncommunicable diseases. They represent some 78% of all deaths in this Region and they will continue to increase. The diabetes epidemic everywhere is shocking. At the Regional Committee for the Western Pacific, held in Auckland, New Zealand I learnt that diabetes rates are escalating. In this Region we will see an 80% increase in deaths related to diabetes over the next 10 years. This is very closely related to our eating habits, our diets and our lack of physical activity. The strategy on diet, physical activity and health that we adopted a couple of years ago will be a key approach to tackling noncommunicable diseases.
We have in place a very important instrument in the WHO Framework Convention on Tobacco Control. However, there is a challenge to all of us to translate this Convention into practice in countries, to establish national tobacco-control programmes, ensure smoke-free environments, and where appropriate to introduce tax on tobacco products, in order to reduce the number of people that are smoking. The Framework Convention shows that WHO can add value by getting Member States around the table and to agree on this kind of instrument.
Another recent major success has been the adoption of the International Health Regulations (2005). All of you who were involved in the negotiations to revise the Regulations have seen how everybody values this instrument. It is much more than an international agreement; it will enable us to ensure that we have the capacity in countries, and the right kind of behaviours in terms of transparency and sharing of information. It gives us an opportunity to prepare not only for the immediate threat of avian influenza but also broader public health threats. There is also the possibility of accelerating the implementation of the International Health Regulations (2005) through the voluntary compliance that was agreed in May 2006. We are prepared to move WHO but we need your support and your inputs to be able to do the necessary work.
We see no signs globally that the threat from avian influenza is diminishing. We are at a peak in terms of numbers of cases because of the season, but there are outbreaks in birds in more than 50 countries around the world. As at 25 September 2006, there have been 249 confirmed cases and 146 deaths in humans. Preparedness plans are now in place in most countries but in some cases, these are just plans – they have not been tested. We must make sure that they will work in practice so that they can be put into operation if necessary. We are pleased to see the considerable improvements in capacity to manufacture antiviral drugs and that production licenses have been granted to a number of developing countries. There is a need for more attention to vaccine development and manufacturing capacity. Next month we will launch an initiative to support the expansion of vaccine capacity in certain countries, and I would like here to acknowledge specifically the support we have received from the Government of the United States, including from President Bush himself. I know that Dr Lee very much appreciated this engagement. In this room, we also have some of the key partners for development assistance, which still plays an important role in improving health in some of the poorest countries. This has been a positive development over the last few years. The volume of assistance has increased, but it needs to be sustained, and its effectiveness improved. WHO needs to move slightly more into this to area to work with countries to ensure more effective use of financial resources, but also resources for capacity-building through technical support.
In conclusion, our goal is to make WHO more responsive to the needs of countries, and to ensure that the Organization is working as an effective member of the United Nations system. As I indicated in my remarks at the opening of the session, WHO is fully engaged, in the current debate on how coordination of the work of the system can be improved, especially at the country level. We strongly believe that there is a need for a change in the Resident Coordinator system. At the same time, we must ensure that WHO continues to have a presence and maintains the quality of its work.
WHO has had a substantial dialogue with the United Nations High-level Panel on System-wide Coherence and we look forward to the report and to discussions on how to take the work forward. There is also a debate within WHO on the implications of United Nations reforms for the Organization; there will be a paper on the subject for consideration by the Executive Board in January 2007 to determine Member States’ perceptions of WHO in the broader context of the United Nations system.
I am very proud that WHO is perceived as working effectively within the system and that we are at the forefront in many areas. As mentioned by Dr Roses, collaboration between countries and between the United Nations organizations in this Region is good and provides an example of best practice.
I thank you for this opportunity to be able to share a few perspectives from Geneva. I feel certain that your continued active engagement and your clear direction as Member States and as a governing body will yield success in this Region and contribute to WHO’s global success in improving the health of all people.