WHO Director-General discusses programme for Organization's reform
Dr Margaret Chan
Director-General of the World Health Organization
Mr Chairman, excellencies, honourable ministers, distinguished delegates, Ms Jakab, ladies and gentlemen,
Let me take the opportunity once again to begin by thanking the Government of the Republic of Azerbaijan for acting as such a gracious and accommodating host for this session.
I officially visited this country in 2008. I was personally very impressed, and still am, by the warmth of its people, the richness of its cultural heritage, and the strong commitment of its government to health development, and can see the great progress this country has made in the past five years.
As the country’s Prime Minister told me during that visit and others, the responsibility for creating a healthy society extends well beyond the actions of the health sector.
A government that spreads a country’s wealth among its people is the best possible. Your investment in health care is impressive, but don’t forget the importance of primary health care and noncommunicable diseases. This government follows an inter-ministerial approach to health development, with leadership in different sectors complementing the overall drive for better health.
Ladies and gentlemen,
Why is the Regional Committee session so important? Despite the diversity of items being considered during this session, I believe I can make three general observations about your agenda and supporting documents.
First, your agenda is ambitious and courageous. I might even say daring, especially at a time when many countries in this region face severe financial constraints.
With work towards the Health 2020 policy, you are aiming at nothing less than a rejuvenation of the public health agenda in the European Region.
You are aiming to rejuvenate the capacity of this Regional Office to support ministries of health as they tackle some extremely complex challenges, or to use your vocabulary, some very “wicked” problems.
You are also preparing to cope with some heavy new problems heading our way as the climate changes, the globalization of unhealthy lifestyles spreads with a stunning sweep and speed, populations age, health costs soar, and the economic downturn deepens.
Many problems currently facing this region represent collateral damage to health caused by policies made in other sectors, or in the international systems that govern the way our highly interconnected and interdependent world works.
As we all know, these systems, whether for trade or global finance, create benefits, but the fair distribution of these benefits is almost never an explicit policy goal.
This brings me to my second observation. In line with the traditional values of this Region, you are deeply concerned about fairness and equity. But you are also deeply determined to tackle the root causes, the real reasons for today’s vast and growing gaps in health outcomes, in access to care, and in opportunities to lead a better life.
Your determination to influence the social determinants of health is readily apparent throughout the agenda, but especially so in the action plans for HIV/AIDS and for combating drug-resistant forms of tuberculosis.
You plan to reach the migrants, the homeless, people marginalized by stigma and discrimination, and people with difficult lifestyles, such as alcoholics and injecting drug users.
In a complementary move, ways of improving health capacities and services, including through primary health care, are put forward as the route to greater fairness in access to care and greater efficiency in service delivery.
This must be the greatest challenge of them all: maximizing measurable and equitable health gains at a time when budgets for health, nationally and internationally, are stagnant or shrinking.
And this is my final general observation. It can be done. Your documents show how to do this with a limited number of smart, evidence-based interventions with a proven impact.
If we want to maintain the momentum for better health that marked the start of this century, health programmes must show a thirst for efficiency and an intolerance of waste. Your documents, and especially your action plans, do this admirably.
Equally important, the interim report on implementation of the Tallinn Charter tells us that ambitious commitments can indeed be operationalized, even in the current climate of financial constraints.
I agree. The Tallinn Declaration on Health Systems for Health and Wealth was a landmark achievement for health policy in the European Region and a flagship product of this Regional Office.
It was immediately put to a severe test. It was issued in 2008, right at the time when the world abruptly shifted from an outlook of prosperity to belt-tightening austerity.
As noted, several countries turned the financial crisis into a political opportunity to shift priorities and achieve efficiency gains that reduced the adverse effects on the poor and vulnerable. At a time when public spending is critically scrutinized, efforts to sustain health system performance also produced evidence about the efficiency of that performance, demonstrating the accountable use of funds.
Let me single out this Region’s Pharmaceutical Pricing and Reimbursement Information Network as a smart and powerful way to save money in one of the biggest area of health expenditure.
As famously stated in the Tallinn Charter, “Today, it is unacceptable that people become poor as a result of ill health.”
Progress in meeting the Charter’s commitments maintains the truth and conviction of that statement today. This is extremely encouraging in a world beset by one global crisis after another.
Ladies and gentlemen,
I agree with the upbeat sentiment in many of your documents: countries can radically change the health situation by seizing the right opportunities for action. With evidence-based interventions and smart policy choices, it is perfectly feasible to maintain the momentum for better health.
Multisectoral collaboration, especially for the prevention and control of chronic noncommunicable diseases, is one such opportunity. In fact, many of you alluded to whole-of-government approaches, which are essential for many of those “wicked” problems you aim to address.
For example, as your action plan on alcohol makes clear, reducing the harmful use of alcohol depends on the concerted action of national authorities, traffic police, licensing officers, the criminal justice system, and safety authorities, in addition to health officials.
It further depends on support from civil society organizations, especially as such groups can exert pressure for stricter controls and compliance with measures to counter drink–driving.
But, as you have also noted, health ministries often do not have sufficient authority within the government hierarchy to initiate changes outside their own portfolios. As the Health 2020 policy takes shape, it is clear that ministries of health need more political clout.
Ironically, health ministers may be in an unprecedented position to gain this political clout because of two especially troubling trends. These are trends that command the attention of the international community and require action at the highest level of government.
The first touches the top political priorities of international stability and security. This is not health security, or human security, or epidemiological security. This is security against the threats of social unrest and state failure
This is security against the start of conflicts that may require international intervention and always require massive humanitarian assistance. These days, this assistance can be especially difficult and dangerous to deliver.
Like the 2008 financial crisis, this year’s Arab awakening took much of the world by surprise. With the advantage of hindsight, many experts and analysts view the events that started in Tunisia and Egypt as predictable.
They cite long-standing inequalities, in income levels, in opportunities, especially for youth, and in access to social services as the root cause of the struggle for change. They refer to the so-called “rising tide of expectations” that has historically fuelled protests and revolutions.
They refer to countries where the economy is steadily growing while each year more and more people fall below the poverty line. They refer to countries that have lost their middle classes.
And they conclude that greater equity must be the new political and economic imperative if we indeed strive for a stable and secure world.
Public health, which is so well-positioned to improve equity, would welcome such a change in top-level thinking.
The second trend, which you will be addressing, comes with the rise of chronic noncommunicable diseases (NCDs). Next week’s high-level meeting during the United Nations General Assembly must be a wake-up call, not for public health, but for heads of state and heads of government.
These are the diseases that break the bank. A recent World Economic Forum and Harvard study estimates that, over the next 20 years, NCDs will cost the global economy more than US$ 30 trillion, representing 48% of global gross domestic product (GDP) in 2010. Left unchecked, these costly diseases have the power to devour the benefits of economic gains, sending millions of people below the poverty line.
The health and medical professions can plead for lifestyle changes and tough tobacco regulations, treat patients and issue medical bills, but the health and medical professions cannot reengineer social environments to make healthy behaviours and choices the easy ones.
When a problem, like obesity, is so widespread throughout a population, the cause is not a failure of individual will power but a failure of political will at the highest level.
Your action plan for the prevention and control of NCDs deserves special mention. With 86% of deaths in this Region caused by this broad group of diseases, I can understand why the plan is so tough and targeted.
It has teeth, especially in its call to use fiscal policies and marketing control to full effect to influence the demand for tobacco, alcohol, and foods high in saturated fats, trans fats and sugar.
As noted, salt in processed foods is a major reason why daily salt intake in most countries exceeds the WHO recommendation. I fully agree: salt reduction is one of the most cost-effective and affordable public health interventions.
The approach taken in the action plan is similar to what WHO aims to do with its model lists of essential medicines. That is, rationalize the use of scarce resources in ways that bring the greatest benefits to the largest number of people. I look forward to the adoption and implementation of the action plan, and this Region will show the way.
Ladies and gentlemen,
As I said, you are rejuvenating the public health agenda for the European Region. WHO is also undergoing a rejuvenation process in its ongoing programme of reform.
Global health needs have changed considerably since WHO was established more than 60 years ago, and have evolved with exceptional speed during the first decade of this century. WHO continues to play a leading role in global health but needs to evolve in pace with these changes.
Priorities need to match urgent health needs which WHO is uniquely well-placed to address, and funding needs to align with these priorities. Budgetary discipline and changes in staffing and recruitment procedures are needed in WHO to improve efficiency, flexibility, and impact.
Stronger leadership from WHO can promote greater coherence in the actions of multiple health partners and better alignment of these actions with priorities and capacities in recipient countries.
For these reasons, I launched a consultative process in 2010 on the future of financing for WHO that will shortly culminate in a plan of reform for the Organization.
The proposed reforms are comprehensive, encompassing the technical and managerial work of WHO as well as the governance mechanisms that guide and direct this work.
The reforms are ambitious, with improved health outcomes in countries regarded as the most important measure of WHO’s overall performance.
Most importantly, reforms are driven by the needs and expectations of Member States and respond to their collective guidance.
I am fully aware of the challenges, but I remain highly committed, enthusiastic, and confident that working closely with Member States, staff and partners will result in a WHO that is more efficient, transparent and accountable, stronger on areas where WHO is badly needed and sharper on priorities where WHO is uniquely effective.
Above all, the result must be a WHO well-positioned to meet the current and future challenges for improving health in a complex world.
I thank this Regional Committee for bringing greater clarity to many of these “wicked” challenges, and also for devising workable solutions. Perhaps most important, these solutions reaffirm the value system that drives the work of WHO at all three levels of this Organization.
Ladies and gentlemen,
There is one last point I need to make.
In addressing this Regional Committee, I am fully aware that I am also addressing representatives of countries that have traditionally been the most generous financial supporters of WHO. I want to thank you for all the support you have given to the Organization.
Intense domestic pressure in many of your countries is reshaping development assistance with a firm emphasis on value for money and a growing demand to demonstrate that investment brings measurable results. The work of the Commission on Information and Accountability for Women’s and Children’s Health, facilitated by WHO, responded to that trend.
This trend brings two problems that WHO must overcome as we undergo reform.
First, we need to do a better job in communicating the nature of our work and the impact it has. Even our biggest supporters tell us this. If we want parliamentarians to fund the work of WHO, their constituents need a much better understanding of what we do and why it is important.
Clear articulation of WHO’s value-added contribution to health development is critically important with the rise of high-profile global health initiatives, like the Global Fund, GAVI, PEPFAR, several malaria initiatives and many others.
The second problem is closely related. The impact of much of our work is difficult to measure, or behind the scenes and out of the headlines, or even largely invisible until something terrible goes wrong, like a disease outbreak or when air pollution or water contamination or the level of additives in food exceeds our safety standards.
For example, WHO does not purchase or distribute antiretroviral medicines. But the AIDS community largely credits the technical work of WHO, especially our constant efforts to simplify and streamline treatment guidelines, as making it possible for nearly 7 million people in low-resource settings to see their lives revived and prolonged by these medicines.
Obviously, it is far easier to count the number of vaccines, bednets, and medicines distributed by single-disease initiatives than it is to measure the impact of WHO’s technical work. Now let me emphasize that WHO is not in competition with these initiatives. We work together as partners. But it is important for WHO to do a better job in communicating what we do.
I will conclude with a last example. In July, WHO urged countries to ban the use of inaccurate and unapproved commercial blood tests to diagnose active tuberculosis. WHO meticulously gathered and verified solid evidence that these tests are inconsistent, imprecise, and put patients’ lives at risk.
The tests are unreliable. False-positives mean that patients take toxic medicines for months, for no reason. False-negatives mean that people take no precautions to prevent infecting others.
More than a million of these inaccurate blood tests are carried out each year, often at great financial costs to patients, who may have to pay up to US$ 30 per test.
Certainly, it is the right thing for WHO to sound an evidence-based alarm and urge a ban on these tests, just as it is right for WHO to campaign against the continuing use of monotherapies for malaria, especially in the private sector. But how do we measure the impact of such work?
Ladies and gentlemen,
The world needs a global health guardian, a protector and defender of health, including the right to health.
Reform in WHO, in my view, starts from a position of strengths: the unique functions and assets of the Organization.
I am personally determined to see that the reform process strengthens these functions and assets. And I very much look forward today and tomorrow to hearing your views on this process.