WHO Director-General discusses reforms in country offices

Dr Margaret Chan
Director-General of the World Health Organization

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

7 November 2011

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

Let me extend my very warm welcome to all of you as we begin this sixth global meeting of heads of WHO country offices.

You have an exciting and extremely timely agenda, focused on practical problems of burning importance. This is an agenda clearly designed to share experiences and best practices. It is designed to produce results, and I can assure you, Member States and development partners are hungry for results, especially at the country level.

As we all know, the lean years are upon us as the economic downturn deepens, money gets tighter and tighter, and our interdependent world is beset by one global crisis after another.

But I think we can all agree that the first decade of the 21st century was extremely good for public health. You will be discussing the MDGs, which stimulated so much commitment, cash, and action, and created impressive innovations, including new financing instruments and new partnerships to develop medical products for diseases of the poor.

We have much good news. The number of under-five deaths dipped below 10 million for the first time in almost six decades and kept on dropping, with the figure now standing at 7.6 million deaths.

This is still way too many, as more than two-thirds of these deaths are entirely preventable through inexpensive and highly effective tools. But we have to admit: this is progress, welcome and measurable progress.

The tuberculosis epidemic, once a global health emergency, has peaked. Nearly seven million people in the developing world are now seeing their lives prolonged by antiretroviral therapy for HIV/AIDS.

For decades, the malaria situation was described as stable as it could hardly get any worse. But now we are seeing stunning progress, with many countries, especially African countries, reporting significant reductions in malaria cases and deaths.

The malaria map is shrinking. Since 2007, four countries have been certified by WHO as malaria-free.

Hopes are high and, I believe, fully justified because the single most important ingredient for success is present. This is commitment and political will at the highest level of government, as represented in the African Leaders Malaria Alliance, or ALMA. I know you will be addressing the importance of political commitment during this meeting.

We welcome this progress for better health. At the same time, we have to admit that the first decade of this century evolved in turmoil. In our world of radically increased interdependence, the fuel, food, and financial crises were all global in their impact and profoundly unfair, damaging countries that had nothing to do with the causes.

The same is happening with climate change. The countries being hit first and hardest are the countries that contributed least to greenhouse gas emissions.

All of these global crises are still very much with us.

We have seen this turmoil deeply concentrated during the current year, with record-breaking natural disasters, crises, sky-high food prices, and public uprisings, especially in the Eastern Mediterranean Region. The result is a deepening of human misery with direct effects on the health of millions of people.

As I like to remind every audience: never forget the people. Also remember the people, in thousands of cities around the world, who are right now protesting against corporate greed and the misery this brought to their personal lives, with no thought about equity or solidarity, the values that drive the best in public health.

All of these dramatic events mean that the job of WHO is getting harder at a time when expectations for WHO performance keep getting bigger.


The timing of this meeting is excellent, ideal in fact, as it follows the Special Session of the Executive Board devoted to WHO reform, which finished its work late on Thursday of last week.

We will be briefing you on the objectives, spirit, and striking outcome of the special session tomorrow.

With a healthy dose of pride, let me highlight just a few points from the EB session that directly concern your work and your agenda for this meeting.

I was especially proud to hear, repeatedly, praise for WHO’s unique and vital role as the only truly representative, consensus-led, democratically governed agency with a global health mandate. Without question, the world needs a global health guardian like WHO, a custodian of values, a protector and defender of health, including the right to health.

As I also heard, WHO has an enviable and unique brand name that stands for world-class scientific and technical excellence. Our staying power, and that means at country level, is equally famous. The developing world is littered with the debris of short-lived projects, but not from this Organization, not from our WHO.

As Board members debated reforms for a healthy future, health needs and priorities at country level took centre stage.

Priority setting must be bottom-up, driven by grassroots needs in developing and least-developed countries. These needs are backstopped by expertise from all levels of the Organization and by our traditional work in developing norms and standards and providing direct technical support to countries.

As the EB confirmed, the work done by WHO within countries is the most important measure of the performance of the entire Organization.

During the special session, it was quickly apparent that expectations for country offices have risen to unprecedented heights. This means a more precise and ambitious definition of your responsibilities. EB members readily agreed that more authority should be delegated to country offices.

Country offices should be strengthened, but this means much more that just adding staff. In some instances, fewer staff are needed, but they need to be more senior. Many suggested the types of skills needed: technical and epidemiological, of course, but also managerial, communications, negotiating, and diplomatic skills. Above all, skills available in country offices should closely match the specific health problems and needs of countries.

Board members also saw great wisdom in grouping countries facing related problems together when seeking expedient solutions, as this facilitates context-specific exchanges of experiences and best practises. You are already doing this during this meeting.

Here is how the EB sees your job in a reformed WHO. In a truly networked WHO, you channel, from whatever appropriate source or level of the Organization, the expertise needed to help countries develop their national health policies, strategies, and plans. These are, of course, part of the WHO country cooperation strategies, and you have last year’s excellent guide to assist you in this work.

You negotiate with all development partners and civil society organizations implementing programmes within the country. You persuade them to work in harmony, reading from the same script, which is explicitly spelt out by the country and owned by the country.

As you will soon be discussing, burdens on your offices are especially great during outbreaks, natural disasters, humanitarian crises, and civil strife, when threats to health intensify and the heat is on for emergency action.

The strengthening of institutional capacities, especially health systems, is viewed as a top priority. Development partners need to understand that capacity building is the route to self-reliance, something deeply desired by developing countries. They want capacity, not charity. The objective of good development aid is to put aid out of business by building this self-reliance. Self-reliance is also self-respect in a situation where citizens can hold their politicians accountable for safeguarding public health.

In addition, you mobilize resources to support health development within the country. The Board saw no conflict between resource mobilization at country level and the proposed new policy of unified resource mobilization in a networked Organization.

Board members praised WHO’s reputation as a specialized technical agency. The work of WHO is relevant in every country, benefits every country. In the developing world, the work of WHO fundamentally contributes to socioeconomic development. Without health, development is impossible.

The high expectations I have just described are the culmination of a recent process that first became public in the January Executive Board when reforms were first being discussed on a formal basis.

Kenya, speaking on behalf of the African Union, set out five priority areas for improving the efficiency and effectiveness of WHO. One priority was to strengthen WHO country work, also through the country offices.

As stated, a good country office can be instrumental in raising more domestic resources for health through negotiations with ministries of health, ministries of finance, the private sector, civil society organizations, and the media. In Kenya, this kind of WHO engagement increased the health budget by US$ 400 million within a single year.

This is what you can achieve. This is the kind of country engagement that makes all of us proud to work for WHO.

Now, I hope I have put you in a reasonably good mood, despite the long distances many of you have travelled from vastly different climates and time zones.

Unfortunately, and in all honesty, I must drop a little rain on this parade of praises.

Board members mentioned inspections that have revealed serious mismanagement in some country offices, including financial mismanagement.

We know this problem. We have taken steps to reduce this problem. We must make this problem disappear entirely.

This is part of reform for a healthy future, and it is imperative. Increased delegation of authority goes together with a demand for increased transparency and accountability. Every single dollar made available for health must be invested exactly as intended, with no exceptions.


Now, let me make some comments about items on your agenda.

You will be discussing health emergencies.

Member States fully recognize the unique advantage that country offices bring during outbreaks. Your epidemiologists are on the spot to investigate rumours or facts and put the regional and head office on alert, or in a position to reassure the rest of the world. When needed and with the country’s agreement, we can get international teams, under the GOARN umbrella, into the country and at work within 24 hours. No other health agency in the world can perform this function so well. This is the result of investment in our human and systems capacities over the years to fulfil our obligations and responsibilities under the IHR.

I know you frequently speak to the media because I see the quotes. I see your faces on TV or in the print media. Many of you are highly effective in quelling rumours and setting the record straight, calming panic, and assuring citizens that their government is doing the right thing, with full WHO support when needed.

Such public statements, backed by the authority of WHO, can make a world of difference. Public panic always vastly increases the social disruption and costs of an outbreak, especially when tourism and trade are affected.

Frankly, WHO does less well in managing humanitarian crises, but we are rapidly improving. I am sure some of these improvements will become apparent as you debate this agenda item. The value-added role of WHO is two-fold. WHO helps disaster-prone or fragile countries strengthen preparedness, and WHO has great staying power. When the media spotlight turns off and other agencies go home, WHO stays there to strengthen preparedness for the future.

Take the example of the Horn of Africa right now. Ethiopia is a haven of food security in the midst of very severe hunger and starvation elsewhere. This is widely attributed to good preparedness, facilitated by WHO engagement.

Chronic noncommunicable diseases are on your agenda. These diseases, and especially their population-wide prevention, are now a top WHO priority. They are now part of your job, especially as you help ministries of health negotiate with other sectors. All the main root causes of these diseases lie outside the purview of ministries of health. Multisectoral actions are imperative.

NCDs are now the biggest killers, and they are everywhere, fuelled as they are by universal trends, like rapid urbanization and the globalization of unhealthy lifestyles. Diseases like heart disease, diabetes, and cancer know no north-south, tropical-temperate, or rich-poor divide.

Growing rates of obesity are the tell-tale signal that the root causes of these diseases are not being addressed. The world certainly needs to feed its population of seven billion people, but it does not need to feed them junk food.

These are the diseases that break the bank. In some developing countries, treatment for diabetes alone consumes 15% of the entire national health budget.

These are chronic conditions and they require chronic, if not life-long treatments. Some of these treatments are prohibitively expensive for developing countries, especially now as the number of patients is growing exponentially.

The costs of these diseases can easily devour the benefits of modernization and economic growth, effectively putting a brake on development. This must be recognized, and it must be recognized at the highest level of government, as noted during the September high-level meeting on these diseases during the United Nations General Assembly.

NCDs deliver a two-punch blow to development. They cause billions of dollars in losses of national income, and they push millions of people below the poverty line, each and every year. They are able to do so because far too many countries still rely on user fees and have no viable safety nets for protecting households from catastrophic health expenditures


At a time of deepening financial austerity, the tremendous momentum for better health that marked the start of this century can indeed be maintained. We know this.

We are seeing this, with malaria for example, and with the many billions of dollars committed to the UN Strategy for Women’s and Children’s Health, which you will be discussing.

For momentum to continue to build, health programmes, and health systems, must develop a thirst for efficiency and an intolerance of waste.

This was a key concept underlying the development of last year’s World Health Report, which gave countries a menu of options for moving immediately towards universal coverage, in any resource setting.

From the wealth of guidance in that report, let me single out one clear way to reduce waste. A policy that encourages the use of good quality generic medicines can save around 60% of the costs of medicines in many countries.

And let me give just one example of ways to increase revenue while protecting health. A review of 22 low-income countries shows that, by raising tobacco taxes by 50%, these countries could together generate new funds for health amounting to more than US$ 1.4 billion each year.


You have a serious and worthy agenda and a unique opportunity in the next few days to share experiences and ideas.

I look forward to hearing your views, especially on how WHO can promote multisectoral action for health and development. I also seek your views on how to maintain a leading role in global health that enables other stakeholders to play to their core competencies.

I wish you a most productive meeting. We are here to listen.

Thank you.