Opening remarks at the Fifth Global Meeting of Heads of WHO Country Offices

Dr Margaret Chan
Director-General of the World Health Organization

Opening remarks at the Fifth Global Meeting of Heads of WHO Country Offices
Geneva, Switzerland


Regional Directors, senior managers, heads of WHO country offices, colleagues, ladies and gentlemen,

It gives me great pleasure to welcome you to Geneva. The most important measure of WHO’s overall performance is the impact our work has on the lives of people in the countries where you serve. Results at the country level matter most.

International norms, standards, strategies, statistics, meetings, reports, and calls to action are very important parts of our work. But a health agency driven by results-based management must ultimately deliver better health outcomes, and be held accountable if it fails.

Results in countries are the best measure of the relevance of our work and the effectiveness of our methods. If our work, at all three levels, is relevant, the problems you see on a daily basis in countries will be visible in workplans here in Geneva. If our methods of work, at all three levels, are coherent, consistent, and coordinated, ministries of health can reap the dual benefits of WHO’s direct presence in countries, directly linked to a vast resource of international experience and expertise.

Likewise, the international community benefits when staff in country offices help coordinate a quick response to emergencies or help make development aid do the greatest long-term good, in line with national priorities and capacities. This is the ideal way things should work.

Increasingly, an ability to improve health within countries is also a measure of our ability to adapt to new challenges in a rapidly changing world. And this is where the ideal clashes loudly with the reality.

Let me repeat a question I have raised before. Is WHO fit-for-purpose given the unique health challenges of the 21st century? Are we lean, nimble, flexible and fast? The answer is no. Or maybe I should say: not yet.

Does WHO need to get its house in order, on all three floors? The answer is yes, and urgently so.

Both of these questions are a good deal more relevant than they were when I addressed this group two years ago. The need for reform is a good deal more urgent than it was two years ago.

Since then, our closely interdependent world has demonstrated its ability to produce one surprising global crisis after another. Last year, we experienced, in short order, a fuel crisis, a food crisis, and the most severe financial crisis and economic downturn seen since the Great Depression began in 1929.

Scientists also delivered compelling evidence that the impact of climate change has been significantly underestimated. This past June, WHO declared the start of the first influenza pandemic in four decades.

As the economists tell us, the financial crisis has been so dramatic because it occurred at a time of radically increased interdependence among nations. All of these crises are highly contagious, rapidly moving from one country to others, and from one sector to many others. Though all of these crises have a global sweep, the consequences are not evenly felt. Developing countries have the greatest vulnerability and the least resilience. They are hit the hardest and take the longest to recover.

Health is affected by all of these crises, but also by other powerful international trends that shape health threats everywhere, like demographic ageing, rapid urbanization, the globalization of unhealthy lifestyles, and a corresponding rise in chronic noncommunicable diseases. The job of protecting health has become much broader, and the job in WHO country offices has become much harder.

These events come at a time when the world is in the midst of the most ambitious drive in history to reduce poverty and reduce the great gaps in health outcomes. The Millennium Development Goals give the world its best chance ever to introduce greater fairness and balance into the very fabric of societies, also for health. Precisely because of these global crises, the price of failure to meet the Goals keeps getting higher.

Already, nearly one billion people are living on the margins of survival. It does not take much – a financial crisis, a changing climate, a loss of food or job security, or an influenza pandemic – to push them over the brink.

At times of crisis, health in developing countries is best supported by robust and inclusive health systems that aim for universal coverage. Last year’s report of the Commission on Social Determinants of Health concluded that health systems organized to achieve universal coverage do the most to improve health outcomes. The Commission endorsed primary health care as a model for a system that deliberately aims for equity, but also acts on the underlying social, economic, and political causes of ill health.

As we think about WHO’s roles and responsibilities in countries, let me remind you that a health system is a social institution. Properly managed and financed, a health system contributes to social cohesion and stability. These are assets for any country, and for many ministries other than health.

Ladies and gentlemen,

What does all of this mean for the work of WHO, what is expected from us, and how our performance is assessed?

At a time of multiple crises on multiple fronts, the world is watching the performance of WHO, looking for a measurable impact, questioning whether investments in our work bring an equivalent payback in health outcomes in countries. Like consumers during an economic recession, donors are looking for the best buys and cutting out the luxuries.

The performance of WHO is also being compared. There are more initiatives, programmes, funding mechanisms, NGOs, and donors engaged in health work than in any other area of development. The field is crowded. The competition is stiff. Not everyone performs well. And not everyone is welcome in the recipient country.

Heads of country offices know what this means in terms of the demands on national capacities. In addressing the problems, countries have support from instruments like the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. They have operational platforms, like the Harmonization for Health in Africa framework and the International Health Partnership. With this support, countries need to move out of the helpless victim mentality and take charge.

This need is reflected in your agenda, with its emphasis on national health strategies and plans. But we still have some big questions to address. In this overcrowded, competitive, messy, sometimes unhealthy landscape of public health, who is the boss?

Who is accountable for successes and failures? Who shows the way forward and, equally important, sets the pace? Is it the country, the donors, the global health initiatives, the foundations that provide the greatest slice of funds, or the Member States of WHO?

Being constitutionally mandated to act as the directing and coordinating authority on international health work is no longer a security blanket for WHO. It is no longer a guarantee that WHO will indeed direct and coordinate. In this day and age, a leadership role is not mandated. It is earned.

The complexity of roles and responsibilities, leadership and accountability is enormous, and grows bigger with every global crisis. Results within countries are the most important measure of WHO’s overall performance. Yet countries are no longer fully in control of what happens in their borders. Health in nearly every country is profoundly shaped by global forces, by transnational threats, by policies made in other sectors, and by the international systems that govern financial markets, economies, trade, commerce, and foreign affairs.

Health is often on the receiving end of bad or short-sighted policies made in other sectors or international systems. Health has little if any say about how these systems function or how policies are set. In a proactive response, health is best promoted and protected through a whole-of government approach, in which health concerns are addressed in all government policies. Yet ministers of health usually have far less clout, money, and persuasive power than ministers of trade, finance, or foreign affairs.

In response to the transnational nature of many threats to health, member states clearly see value in international treaties, like the Framework Convention on Tobacco Control, and legal instruments, like the revised International Health Regulations. Under the unique conditions of this 21st century, countries are increasingly willing to give up a piece of their national sovereignty in exchange for collective security against shared threats.

But implementation of the International Health Regulations depends on core capacities within countries, and the Framework Convention on Tobacco Control works only when countries have sufficient regulatory and enforcement capacity. Even if we start at the international level, we come right back to implementation capacities within countries and the need to strengthen health systems.

Countries, partners, global health initiatives, and funding agencies increasingly recognize that weak health systems are an absolute impediment. No matter how good the interventions or how much money is there to buy them, weak health systems ultimately block or stall further progress. But the push is still on to produce quick and readily visible results.

Last week, I travelled to Spain with colleagues from the Regions to receive a prize awarded to WHO by the Prince of Asturias Foundation. All of the WHO achievements cited by the jury concern the control of infectious diseases, like smallpox, polio, outbreaks, epidemics, pandemics. Efforts to strengthen health systems will never win an international prize. They will never get a headline or even much attention, they are so basic, behind-the-scenes, and hard to measure.

This brings me to three overarching problems confronting health development within countries.

First, in the overcrowded and competitive landscape of public health, lines of accountability have become lost or blurred. To whom are global health initiatives, funding agencies, donors, and NGOs accountable? To the governments of the countries they serve, or to the agencies that provide the funds? Who takes the blame when things go wrong? Who is responsible when health workers leave the countries that invested in their training?

These questions are important, also for the countries you serve. A government’s authority and accountability to its citizens are diminished when it loses control over the health agenda. A government gains legitimacy and credibility in the eyes of its citizens when it protects their health.

Second, the drive to reach international commitments, like the Millennium Development Goals, has unleashed great momentum, determination, and innovation. But time-limited goals also mean impatience. Resources come with an expectation of results.

With the exception of maternal mortality, the health-related Goals are largely an infectious disease agenda. Arguably, delivering vaccines, or antiretroviral drugs, or anti-TB medicines, or bednets is easier to do and measure than changing human sexual behaviours, dietary habits, and the social status of women.

The strengthening of health systems, which have been neglected for decades, takes time and progress is much more difficult to measure. There is a risk that absolutely vital work in this area will be missed when donors look for achievements and assess the return on their investments.

Finally, the pressure to reach international goals has fragmented the health agenda. Single diseases are managed by multiple initiatives, sometimes using different strategies and drugs. Overlapping diseases are managed by separate initiatives. Opportunities for operational efficiency are missed.

Instead of strengthening health systems, one option has been to circumvent this weakness by introducing parallel systems for delivering a limited range of interventions at a time when the greatest need in many countries is for comprehensive primary health care.

Faced with fragmentation, we need to remember the big-picture values. Prevention is the heart of public health. Equity is the soul.

Ladies and gentlemen,

Let us look again at some of these problems in the light of your jobs and the items on your agenda.

Two years ago, we agreed on 16 key action points as a way to improve WHO’s performance in countries. I promised that I and the regional directors would do everything possible, within our mandates and resource constraints, to meet these requests. I believe we have done reasonably well.

Action has been taken on almost all of these points, and you have received a copy of the report. Progress has been slower in some areas, including staff rotation and mobility, performance assessment, and resource mobilization at the country level.

I thank you for participating in the evaluation of staff competencies, which was a revealing exercise. Some did well. Others did not. We know now that performance capacity is uneven, and needs to improve.

As I said, global crises and challenges make the job of improving health much broader, and they make the jobs of staff in country offices much harder. I am personally committed to a programme of staff recruitment and development that recognizes the need for an expanded range of competencies and skills.

The items on your agenda provide a good opportunity to think about our performance, and not just as an internal exercise among family. We need to do so with a keen awareness that many critical eyes are watching, and that the hands holding the purse strings are clutched a good deal tighter than two years ago. As part of UN reform, WHO is participating in several pilot projects, and these are also being watched very closely.

You will be looking at the response to public health and humanitarian emergencies. We have an opportunity to craft a new vision of public health emergency management. Under the pressure of an emergency, strengths and weaknesses of response capacity become readily apparent. They are all the more visible right now, when WHO at all levels is expected to lead the response to the influenza pandemic.

For once, the question of who is in charge is easier. For once, in an urgent operational setting, we must be lean, nimble, flexible, and fast. It is frankly deadly to let bureaucracy or territorial thinking get in the way. This is also true for WHO as the leader of the health cluster during humanitarian crises. Cluster leadership involves more than coordination. It requires arguments and evidence that persuade multiple actors to join forces in a common response strategy.

The International Health Regulations recognize one WHO only, and their implementation requires that all levels of the organization act in a consistent and coherent manner. As support, we have the Event Management System, which was designed to operate as a corporate platform for gathering and sharing data during a public health emergency.

Using this web-based system, staff in country offices, regional offices, and headquarters can trace the evolution of an emergency as it is reported, in real-time. Reporting formats in the system align with IHR requirements, further promoting coherence. The system was launched in June to support pandemic reporting and is already being used in all WHO regions as a tool for truly corporate communications during emergencies.

Under the item on strengthening WHO performance in countries, I welcome the emphasis given to national health strategies and plans. This is the right way forward. Strong national health plans are the best defence against many of the problems I have mentioned. If a country has a good grip on its own needs and priorities, it is easier to say yes or no to aid and shape the way aid is delivered.

This is the opportunity for WHO staff to operationalize those advantages that come from being linked to an international body of experience and expertise. This is where WHO technical guidelines, norms, standards, and statistics take on practical significance. This is where WHO can rightly influence health development, counter the chaos, and get partners working in line with national priorities and capacities.

I believe we have seen this happen with the turnaround in malaria control, where we are finally making progress. WHO defined a limited number of very clear and feasible technical strategies, and ministries of health and their multiple partners have united behind these strategies. Here we see a good marriage between work at the international level and measurable results in countries.

Countries face other problems where WHO can provide support. The logic for good aid is straightforward. Good aid builds the foundation, the capacity, and the infrastructure needed to move towards self-sufficiency. Good aid aims to eliminate the very need for aid. If aid does not explicitly aim for self-sufficiency, the need for aid will never end. Good country plans and strategies help ensure that aid is channelled in ways that strengthen national capacities, rather than circumvent them.

In supporting national health plans, WHO staff also need to enable ministries of health to negotiate with ministers in other sectors. As I mentioned earlier, health is more and more at the receiving end of bad or short-sighted policies made in other sectors. Consensus is growing for a whole-of-government approach to health, in which health concerns are addressed in the policies of all sectors.

Finally, you will be looking at the consequences of just one of these global crises: the financial crisis and economic downturn. Staff in country offices are best placed to know, first hand, what is actually happening and to sound the alarm.

From my attendance at the Regional Committees, we get a mixed picture. Some areas appear to have been relatively spared, while others are clearly suffering, with no end in sight. We can guess what might happen. Countries that could invest billions of dollars in bailouts and stimulus packages are likely to recover first, while misery elsewhere will continue. We count on you to help us assess the situation. And rest assured, this will not be the last global crisis that our imperfect world delivers.

Ladies and gentlemen,

Results in countries matter most. Health systems must be strengthened. Primary health care is the right way forward. Progress is some areas is stalled. Setbacks are looming. Corrective action is needed. Leadership must be earned. But who judges achievements and which criteria are used?

Donors are impatient. The competition is stiff. Responsibilities are blurred. The criteria for measuring performance favour short-term results. Countries need long-term support. Patience is required to build up capacities. Much aid is ineffective. The debate about donor spending rages on. Some say too much money is spent on AIDS and the pandemic, too little on reproductive health, chronic diseases, and others?

The answer lies in what countries want and need, as reflected in their national health strategies and plans. Good performance ultimately rests on delivering what countries and communities want and need.

This is the context in which WHO is expected to reform. I wish you a most productive meeting. I look forward to hearing your views and seeing how, with support from the Regional Directors, we can share our responsibilities with one objective: making the health of people better.