Regional Committee for the Western Pacific, Auckland, New Zealand
Address by Anders Nordström, Acting-Director-General
I believe that there is a traditional Maori saying "Wiho ma te tangata e mihi", meaning "Let someone else acknowledge your virtues". It is my pleasure today to acknowledge the virtues of this Region, and of this country, and to thank you for the warm welcome we received this morning. I would like to share with you some global perspectives on the challenges we face together.
I am extremely encouraged to see your concrete plans in this Region, including: the joint Asia-Pacific Strategy for Emerging Diseases; and the Regional Strategies on the prevention and control of TB; addressing human resources in health; and reducing alcohol-related harm.
I am also very pleased to see your strong emphasis on tackling the noncommunicable disease epidemic and on translating health research into policy and practice. These are all issues that affect not just the countries of this Region. They affect us all, globally. Your regional health agenda is very much at the cutting edge of the global agenda.
Last year you gave us your very valuable insights and input to the draft Eleventh General Programme of Work. This May, the World Health Assembly approved it. Thank you for all that you have contributed to its strategic direction, particularly Australia, for having chaired the extraordinary session of the Programme, Budget and Administration Committee. The document clearly sets out the gaps and the challenges, the seven priority areas for action, and the six core functions of WHO. The title, Engaging for health, describes what we have to do now. Together, we have to implement the shared vision of the global health agenda.
Shortly we will discuss the Medium-term Strategic Plan 2008¬-2013, the Proposed Programme Budget 2008¬-2009, and the next steps under the General Programme of Work. Like the General Programme of Work, they draw on countries' practical experiences, challenges and needs. The Medium-term Strategic Plan is a new instrument for WHO. It takes a six-year perspective on directions, priorities and objectives.
The MTSP suggests that WHO should focus its work in five main areas:
- support for countries in moving to universal coverage with effective public health interventions;
- strengthening global and local health security;
- generating and sustaining action across sectors to modify the behavioural, social, economic and environmental determinants of health;
- increasing institutional capacities to deliver core public health functions through strengthening of health systems; and
- strengthening WHO leadership, at both the global and regional levels, to support the work of governments in countries (this is a message that has emerged clearly at the other regional committee meetings).
To finance these plans, the Proposed Programme Budget for 2008-2009 has been costed at US$ 4.2 billion. This is ambitious, and the highest budget so far requested. The increase in the budget is a direct reflection of increased expectations and demands from Member States. We have seen an increasing demand for health care across the world, from national governments, which did most of the spending, and from development partners.
The budget 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 (in these two areas we are proposing an increase of around 100% - not much in terms of dollars, but a clear message in terms of priorities);
- implementing the International Health Regulations, where more resources are needed for surveillance and rapid response;
- and strengthening of health systems.
For the Western Pacific Region, this amounts to a total increase of about 50% against the current biennium. This represents an absolute increase of $118 million, or a total of $351 million. The share of the total budget for the Western Pacific Region, excluding Polio and Emergencies, has significantly increased, from 7.7% to 8.6%.
The proposed financing of the programme budget is through: an 8.6% increase in assessed contributions from the Member States, amounting to $1 billion; negotiated core voluntary contributions; and the remainder through specific voluntary contributions.
Even with this increase, the share of the assessed contributions will continue to decline to 23%. This is unfortunate, and Member States have expressed concern at the situation over the last three years.
However, the negotiated core voluntary contributions have successfully increased the flexibility of income, providing a better alignment of resources with the programme budget, and lower transaction costs for the Organization. We hope to double the amount from $300 million to $600 million in the next biennium. At present, we have some 4600 agreements on contributions, and the Organization has to make 1500 reports to donors. Accountability is important, but the present arrangements cost a lot of time and money that could be spent in other ways.
I would like to make a few specific comments on selected issues:
Regarding the MDGs and child health, a meeting on this is taking place today in New York, with the participation of the Norwegian Prime Minister and the Secretary General of the United Nations, among others.
Progress towards the health MDGS is still slow. Infant mortality rates measure child survival and reflect the social, economic and environmental conditions in which children and their families live. The rates are declining in most countries, but are actually increasing in others. To reach the Millennium Development Goal for child health, the key is to reach every newborn and child, in every district, with a set of priority interventions.
Good progress is being made in the implementation of the joint WHO/UNICEF Child Survival Strategy, adopted at the Regional Committee last year. There is a strong emphasis on child health in this Region. One example is Cambodia (where I worked in a district hospital some 17 years ago), where the child survival policy has been shaped by understanding the quality of care at first-level health facilities. Case management of sick children in the country improved remarkably after the Integrated Management of Childhood Illnesses was implemented. Health worker training changed the extent to which malaria cases were handled appropriately, from 20% of cases being managed properly, to 60%.
Most child deaths could be prevented through better nutrition in combination with immunization, clean drinking-water, good hygiene, and better access to basic medicines.
Nutrition issues are also now gaining increasing attention globally. The launch by WHO of the new international growth standards for children under five was very well appreciated. Last year's Meeting of Experts on Childhood Obesity in Kobe, Japan, was very important.
In countries like China, Malaysia and the Republic of Korea, undernutrition is declining annually. However malnutrition has increased in Mongolia.
District hospitals are essential to help the most severely ill children, and more still needs to be done to improve these facilities in the Region.
Immunization is a crucial part of our work and one of our most successful tools. Millions of children and millions of pregnant women in any given recent year are at risk for life-threatening illnesses simply because they have not been vaccinated.
The GAVI Alliance is an important partner and continues to increase access to vaccines and to improve immunization safety.
Overall routine EPI performance is strong in the Region, but there are significant differences at district level, ranging from 100% coverage to only 40%, which means that more work needs to be done.
Regarding polio, the high population immunity levels have been maintained. Your preparedness plans are vital to react quickly to possible re-infection. The fragility of polio-free status was well demonstrated this year in Singapore, when a Nigerian child who had travelled there was diagnosed with polio.
The success of the global polio eradication effort now depends on political will and strong commitments to close the funding gap.
There are four remaining areas of indigenous polio worldwide. In the recent session of the WHO Regional Committee for South-East Asia, held in Bangladesh, I spoke about interrupting the final chains of polio transmission in Afghanistan, India, and Pakistan. In the session of the Regional Committee for Africa, I similarly spoke about the situation in Nigeria. For 2006, we urgently need $50 million by October. For 2007-2008, a $390 million funding gap remains.
Much more remains to be done in addressing the underlying problems in mothers' and women's health. We are far behind the goals set for 2015, and progress is much too slow.
I have personally made maternal and reproductive health a priority during my few months in this office. In June I met with Thoraya Obaid, the Executive Director of UNFPA. We sent a joint letter encouraging collaboration between WHO and UNFPA, and, with senior colleagues, we reviewed how to better coordinate action on sexual and reproductive health. Globally, momentum is increasing to address this aspect of health.
WHO's governing bodies have approved a series of strategies and measures aimed at tackling sexually transmitted infections and improving reproductive health, especially among young people. I am very pleased to see the attention this Regional Committee is paying to the health of young people. Their well-being is our responsibility.
We must look carefully at the vulnerabilities of adolescents. They face a range of choices relating to behaviours that could put them at risk: consumption of alcohol, tobacco products, certain foods and soft drinks that are high in salt, saturated fats or sugar. Another risk is leisure time that, in some places, is predominantly spent on-screen, rather than in physical exercise. These young people are also a responsibility of the private sector, whose products they consume and whose marketing practices support levels of consumption and behavioural choices. Globally, we are working with industry and other partners to explore how best to honour our responsibilities to our young. I am very pleased to see how seriously you are taking this, and the focus on young people as a vulnerable group in your draft Regional Strategy on the Reduction of Alcohol-related Harm.
I am also very pleased to see the action taken in this Region with the development of a Regional Strategy on Adolescent Sexual and Reproductive Health. For example, in Viet Nam, the "SAVY" initiative is an excellent one. This extensive Survey and Assessment of Vietnamese Youth will provide vital information that can form the basis of specific plans to protect the health of this growing population, such as the Asian Development Bank’s project on HIV prevention among young people.
Regarding HIV, globally there is strong momentum now towards achieving universal access to HIV prevention, treatment, care and support. This was boosted at the UN General Assembly, and commitments were made at the XVI International AIDS Conference in Toronto, Canada. Together we now need to define achievable goals and targets in each country, in prevention as well as in treatment. Clear political and financial commitments were made at the conference. Its theme was “time to deliver”.
My message at that conference was not “3 by 5” but “three M’s”: money, medicines and a motivated work force. Progress has been made on money and medicine, but the key message was the need for motivated health workers. It was encouraging to see activists call for more nurses and doctors; the lack there is a key bottleneck to delivery. The declaration of the G8 Summit this year made a commitment to scaling up basic health services, including access to treatment, care and prevention.
There is progress. For example in Cambodia, 75% of those in need are on antiretrovirals - excellent progress. However, the treatment gap in the Region overall is still immense. In 2005, 190 000 people were in need of treatment, and of those, 50 000 are now on ARVs. The gap is therefore still far too big - 140 000 people still do not have access to treatment.
Our work on HIV is closely linked to that on TB. I congratulate you for having reached the global 2005 TB control targets as a Region. This shows strong political commitment. However, what we face in this Region, as in other parts of the world, is widespread multidrug-resistant tuberculosis (MDR-TB), as reported recently in the press, which is a great challenge. The Regional Strategy to Stop Tuberculosis outlines what we need to do in terms of the multidrug-resistance threat. This is important. And it is serious. We need to gather all available resources to tackle the situation.
I have spoken already about the importance of health workers. Let me say a few more words about that. I think we all recognize that we will never be able to succeed in terms of scaling up if we do not have the necessary people in hospitals and health centres. This was the theme of this year’s World Health Day and World Health Report: “Working Together for Health”. That report proposed immediate country-based action and a 10-year plan. What we have to do is begin to talk about and address the underlying issues. The issue is not only training. If we are going to solve the problems caused by the lack of health workers, or sometimes the wrong kind of health workers, we also need to look into the underlying causes. Why are health workers being driven away? To do something else? To move to another country? Much of this has to do with salary structures and incentives and we need to start discussing how to motivate health workers and keep them in the right place. Again, going back to both the G8 in St Petersburg, Russia, and also to Toronto, I made this same point. In Toronto, we launched the "Treat, Train, Retain" initiative, which focuses specifically on health workers living with HIV-AIDS. We need to keep them in the health sector by providing treatment and training, and also the right incentives to enable them to stay. I am very much looking forward to the discussion of the draft Regional Strategy on Human Resources for Health, and I am very happy to see the strong emphasis in that Strategy on building sustainable national capacity.
Turning now to where this Region is really making headway, noncommunicable diseases. As I already mentioned, the Medium-term Strategic Plan in the proposed Programme Budget is suggesting a substantial increase, not only in terms of focus, but also in terms of financial resources allocated to noncommunicable diseases. In this Region specifically, those diseases account for nearly 80% of deaths. We anticipate an increase, over the next 20 years, of 20%. We see diabetes increasing possibly by over 50% over the years to come, a major challenge to all of us. Not only diabetes, but also other noncommunicable diseases, can be prevented. The Global Strategy on Diet, Physical Activity and Health that was adopted two years ago is a key entry point to this.
Another key entry point where this Region has been able to provide some very important leadership is in terms of tobacco control. This Region is the first where all eligible Member States have become full Parties to the WHO Framework Convention on Tobacco Control. This instrument is one of the most important in terms of the control of risk factors leading to chronic diseases.
I would like to thank New Zealand for its leadership in addressing the issues specific to indigenous peoples, both in the development of the Framework Convention but also now in terms of its implementation, an important priority. Implementation is not a simple matter. It will require a lot of determination, just like giving up smoking. It is easy to say; it is much more difficult to do. We have some 400 million adult smokers in this Region, 40% of the smokers in the world. China alone has 300 million adult smokers and is also the number one tobacco grower, manufacturer and consumer. We have some important work to do together to address this situation.
We also need to address the underlying determinants of health. The more we are able to influence the factors that influence health, the greater chance we have to improve people's health and well-being. The action required to tackle most of these determinants goes beyond the control of the ministers of health in this room. We need to reach out to our colleagues in other sectors, in other parts of government, and also outside the public sector. The challenge in terms of the determinants of health is not so much knowing what to do and the importance of the determinants, because we have that knowledge. The important challenge is how to translate that knowledge into practice and action.
Specific thanks are due to the Commission on Social Determinants of Health (CSDH) Knowledge Network on urban settings, based in the WHO Kobe Centre in Japan. They have taken important steps forward. The recognition of the threat to human health from emerging infectious diseases has also catalysed some important actions in other areas not previously seen as part of public health. The global HIV/AIDS epidemic has opened our eyes to what needs to be done. We have realized that money and medicine are not enough. The political attention given to HIV/AIDS has now made us realize that we also need to address bottlenecks in health systems.
Let me say a few words now about the International Health Regulations and about avian influenza. I think all of you who participated in the careful negotiations of the International Health Regulations recognize how highly this instrument is appreciated and valued by Member States. It is much more that just an instrument to address avian influenza. It is about building capacity in countries to be able to survey and to be able to respond. The voluntary compliance that was agreed at the World Health Assembly will be important in enabling us to move quicker than originally anticipated. This is especially important now because of the threat from avian influenza – a threat that is still very much present. We must remain vigilant, and prepared.
To date, more than 50 countries in central and southern Asia, Europe, Africa and the Middle East have reported outbreaks in birds. We have human cases in 10 countries and, as at 14 September, there had been 246 confirmed cases and 144 deaths. All Member States need to develop, strengthen and maintain core surveillance and response capacities. The greatest risk to human health from the virus does not come from the big commercial poultry farms, but from the small backyard flocks. In these informal settings, people's knowledge of how to protect themselves from infection is less, and their vulnerability is therefore greater.
Again, as we have learnt in terms of public health, information and communication are essential strategies and priorities. One aspect of this is the need for Member States to establish their own procedures for complying with the International Health Regulations and to communicate the designation of national focal points. It is also extremely important to have close and effective working relationships between the health and agriculture sectors.
Almost all countries in this Region now have pandemic preparedness plans. These now need to become operational and to be tested to ensure they will work in a real situation.
We see some promising progress in manufacturing capacity for antiviral drugs. Licensing has now also been granted to produce these drugs in several developing countries. Much attention is being given to vaccines and we have seen some progress. Next month we will be pleased to launch an initiative to support the expansion of vaccine manufacturing capacity focusing on some of the developing countries.
The capacity issue brings me to the last core area as 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 or achieve the MDGs. So what do we need?
There are four components.
First, we need to have good policy options. We need to address how best to organize ourselves, how to improve management, and how best to deliver health services. This means working out how to engage the public and private sectors in the most effective way, how to engage different stakeholders, how to involve communities, and how to improve management.
The second thing we need to do is strengthen the evidence base of health systems to support policy-making and implementation. This means having good information systems and investing in national capacity for research. The ministerial round table later on this week will be an important occasion to discuss not only progress but how to link health research, planning, policies and practices.
For the third component, we need fair, adequate and 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.
The fourth element, without which we shall fail, is a stronger health workforce. We need proper human resource planning that takes into account specific country needs.
A few words now about money and systems, development assistance and aid effectiveness. This Region and this room hold some of the key governments and partners involved in and responsible for development assistance in health, and also some of the key recipients. I would like to thank you for your political and financial commitment. This is important even if still, on balance, development assistance is quite small. In terms of scaling up basic health services in some countries it is still very important. We need to continue to increase and sustain it, but we also need to make it more effective.
Strong government commitments have been confirmed at the G8 meeting this year and also in other settings. What can we do therefore to make sure that countries can access the additional support that is needed to improve health outcomes? In WHO, we are doing three things. First, we are trying to work with key health partners to enable countries to prepare better and more robust policy frameworks, plans and budgets. Second, we are trying to work with both partners and countries to ensure that countries are empowered to coordinate and manage partner assistance. Third, we are trying to pay more attention to the bottlenecks in health systems.
What can the partners providing development assistance do? First, be more long-term in terms of their financing. More long-term, predictable financing, with disbursements against substantive rather than political criteria, would make a huge difference to countries. A second, important part of development assistance relates to technical support, which needs to better reflect country needs rather than partner-specific needs or timetables. A lot of development assistance resources today are spent on human resources but do not always focus on building sustainable national capacity.
I believe that we need to have a broader discussion and debate around technical support in order to ensure that it will build sustainable national capacity truly owned by countries. We have talked about the efficient flow of financial resources being insufficient in terms of technical support. The Paris Principles on Aid Effectiveness provide us with a guide in terms of what needs to be done. Now we need to move from the principles to the practice.
In concluding, our goal is to make WHO more responsive to the needs of countries. Our goal is also to make WHO work effectively as part of the United Nations system. We are fully engaged in the current debate on how the United Nations could better coordinate its work, specifically in countries. I personally think we need changes in the resident coordinator system and the way WHO works within that structure.
We have had a substantive dialogue with the Secretary-General's High-Level Panel on United Nations System-wide Coherence over the last three months. Its report is expected to be available in two weeks’ time. This has led to a very engaged discussion within the WHO Secretariat on what United Nations reforms mean to WHO and we have this item on the agenda for the Executive Board in January. I believe that we now need to look more widely throughout the Organization at how we can further improve our work.
I am proud that WHO is perceived as working effectively within the United Nations system. It was a pleasure to have the Secretary General visit WHO Headquarters in June. When he came into the building, I think he felt the high level of appreciation from WHO staff and Member States for the support he has given for the control of poliomyelitis, tobacco, malaria and HIV/AIDS. I feel certain that, with your continued active engagement and direction in the process, this Region will be able to tackle the many challenges we have in front of us.