WHO Director-General addresses global meeting of heads of WHO country offices
Dr Margaret Chan
Director-General of the World Health Organization
Regional Directors, senior managers, heads of WHO country offices, colleagues, ladies and gentlemen,
Let me extend a very warm welcome to all of you as we begin this eighth global meeting of heads of WHO offices in countries, territories, and areas.
Much has changed since I spoke to this group two years ago. Your role within countries has become more visible as the practical, operational arm of WHO. Expectations for your performance are higher. Scrutiny is more intense. Your jobs have gotten harder.
In September, the UN General Assembly approved the new agenda for sustainable development. The agenda is unprecedented in its scope and highly ambitious in its vision, which seeks to transform the way the world works.
The emphasis has shifted from aggregate global and regional achievements to measurable results within countries. This is in line with the explicit commitment to equity, which aims to see the benefits of economic progress more evenly and fairly distributed. In the new agenda, the poor and vulnerable come first, not last.
More is expected from leadership in the governments and ministries of health you serve. More is expected from the smart investment of domestic resources and from the tax systems that generate much of this money.
More is expected from WHO as the only agency with the mandate to cover all targets under the new health goal. But we can’t to everything. We have to focus on our comparative advantage and unique contribution.
The outbreak of Ebola virus disease in West Africa brought more attention, including critical attention, to WHO than any other event since the start of this century. Our performance was put under a harsh spotlight, right down to our regional structure and the staff in country offices. Some of the criticism was justified. Much was not.
The May World Health Assembly approved the proposed programme budget for 2016–2017, representing an 8% increase over previous programme budgets. I am fully aware that budget approval comes with high expectations. Member States are clear. The dividend of investing more in WHO must be improved health outcomes in countries.
These are the three main items on your agenda: the transition to the SDGs, reform of the WHO response to outbreaks and humanitarian emergencies, and organizational accountability for results.
Ladies and gentlemen,
Fifteen years ago, human misery was thought to have a discrete set of principal causes, like poverty, hunger, poor water and sanitation, several infectious diseases, and the lack of essential care during pregnancy, childbirth, and childhood.
The MDGs galvanized international support around a limited number of time-bound, measurable, and easy-to-communicate goals that had great emotional appeal for politicians and the public. In health, the results surpassed the wildest dreams of many. Simply stated, investment in health development paid off in many millions of lives saved.
The MDG era left a legacy of innovative funding mechanisms and new technologies, like new vaccines, medicines, and point-of-care diagnostics for multiple diseases. Pursuit of the health MDGs also created a culture of measurement and accountability, reflected in accountability frameworks and mechanisms for the independent monitoring of results.
The world changed dramatically over the course of the MDG era. The SDGs will try to shape a very different world. The factors that now govern the well-being of the human condition, and the planet that sustains it, are no longer so discrete. The number of goals has grown from 8 to 17. The number of targets increased eight-fold, from 21 to 169.
The SDGs have been praised for their very broad and inclusive approach to development. In the view of many, the range of issues being addressed more accurately reflects the factors that a government must address when designing policies and making strategic choices.
But the SDGs have also been criticized as utopian, impracticable, unaffordable, and far too numerous. They are indeed ambitious. In fact, the declaration that precedes presentation of the goals and targets describes the agenda as “supremely” ambitious.
But the declaration is also frank in admitting the immense challenges now facing the world. It includes a catalogue of woes: global health threats, more frequent and intense natural disasters, spiralling conflict, violent extremism, terrorism, related humanitarian crises, and the forced displacement of millions. Climate change is singled out as one of the greatest challenges of our time.
This mix of idealistic optimism tempered by frank reality is perhaps best expressed in a single sentence: “We can be the first generation to succeed in ending poverty, just as we may be the last to have a chance of saving the planet.”
Some complain that health has lost political ground. After all, three of the eight MDGs were directly related to health. In the new agenda, health is only one of 17 goals. But that goal, with its 13 targets, covers nearly all of the Organization’s main areas of work.
Health benefits greatly from the agenda’s broad and integrated approach that addresses multiple economic, environmental, and social determinants of health. The relationships between the health targets and many others are dynamic and the benefits are reciprocal. As stated, the goals and their targets are “integrated and indivisible”.
This integrated approach with its cross-cutting elements breaks new ground for health. At last, it gives us a framework for policy coherence and integrated action across multiple sectors. Ministries of health will need your support in securing the engagement of other sectors, including powerful ministries of finance, trade, and development.
Several health targets reflect the need to pursue the unfinished MDG agenda. Building on success since the start of the century, the targets are much more ambitious, such as ending preventable deaths of newborns and young children, and ending the epidemics of AIDS, tuberculosis, malaria, and the neglected tropical diseases. However, the targets are realistic in the sense that progress can be measured with a great deal of precision.
Other targets derive from recent WHA resolutions and related action plans, including for NCDs, substance abuse, deaths and injuries from road traffic crashes, and exposure to hazardous chemicals and pollution.
Additional targets address means of implementation, such as the WHO Framework Convention on Tobacco Control and early warning systems for the detection of national and global health risks.
Perhaps most important is the inclusion of universal health coverage. UHC is the health target that underpins all others and is key to their achievement. It provides a much needed platform for coherent integrated service delivery, especially as pursuit of the health-related MDGs encouraged fragmentation through vertical initiatives for single diseases.
UHC is one of the most powerful equalizers among all policy options. The declaration says it best: “To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind.”
The new agenda has many exciting features, but we do need to temper our enthusiasm. The political and financial contexts are less promising than they were 15 years ago. In much of the rich western world, economic insecurity, domestic cuts in public services, and growing inequality reduce political interest in international development and increase public hostility to foreign aid.
Only if governments in wealthy countries tackle inequality and insecurity at home will they have the political space to pursue the spirit of solidarity that underpins the new agenda.
Consensus is growing that the SDGs will not be primarily financed from aid budgets. Moving forward, countries are expected to make their tax systems more efficient and introduce measures to combat tax evasion and illicit tax flows. This marks a fundamental change in patterns of health financing, where the burden is placed on domestic budgets.
At the same time, we need to remember that, during the MDG era, which saw large increases in financing for health, the average low-income country still financed 75% of its total health expenditure from domestic resources.
I expect that in most of your countries, anything you can do to bring in resources and coordinate them with national health plans will be most welcome. At the same time, countries will need your support to improve efficiency and reduce waste in the way resources are used.
Ladies and gentlemen,
The Ebola outbreak is not yet over, but we are nearly there. As we moved into the final phase of tracking the last cases and breaking the last transmission chains, WHO deployed nearly 1000 staff to 68 field sites in the three countries.
As the pace of the response slows and the facts begin to come in, the picture of WHO leadership during the outbreak differs markedly from the narrative in most media reports over the past year.
The narrative has changed from blaming WHO as a convenient scapegoat to understanding that the capacity to respond to something so severe and sustained simply was not there, not within countries, not within the international community, and not within WHO.
The emphasis at the recent meeting of G7 health ministers was firmly placed on the need to build robust and resilient health systems as the best line of defence against future outbreaks.
The importance of having basic health services and infrastructures in place was also recently emphasized by Liberia’s President, Ellen Sirleaf Johnson. As she asked in an article in Foreign Policy, “How could clinics contain this disease when, in many cases, doctors and nurses lacked clean, reliable running water, functioning toilets, incinerators, and other equipment to ensure rigorous hygiene?”
During the outbreak WHO staff from headquarters and all regions dealing with both outbreaks and humanitarian crises worked together. This collaboration provides proof of concept for the single new emergency programme that I announced during the May Health Assembly.
Managerial responses were slow at the start. But we found a way to streamline administrative procedures and speed things up. The lessons we learned will feed into the design of the new programme’s expedited recruitment and deployment procedures, which will be separate from the rest of WHO.
No internationally agreed procedures were in place for coordinating the activities of the multiple response teams that eventually arrived. To reduce some of the chaos of uncoordinated and sometimes inappropriate aid, WHO made an inventory of the qualifications and skills of foreign medical teams and developed a register. Again, this work will feed into plans for establishing a global health emergency workforce.
Thanks to WHO leadership, the world is on the verge of having a safe and effective Ebola vaccine. Again, the impact of the vaccine depends on the strength of the health system. As a frontline doctor in Sierra Leone stated last month, “The gaps in our health care system that allowed Ebola to advance so quickly must be filled if this new vaccine is to realize its life-saving potential.”
WHO has pre-qualified four rapid point-of-care diagnostic tests. These tests can help restore the confidence of patients and staff alike in the safety of health facilities, especially for high-risk settings like maternity and surgical wards.
WHO is developing an R&D blueprint, with generic clinical trial protocols and arrangements for fast-track regulatory approval, to expedite the development of new medical products during the next emergency.
Like all other responders, we were slow at the start, but we made quick course corrections. These changes created conditions that made it possible for multiple responders, national and international, to work to their full advantage. In this way, WHO showed leadership.
This is an important point. Leadership means collaboration and coordination that is fully inclusive of partners. We want you to be good partners, not just with the government, but with its development partners as well.
Managing the global regime for controlling the international spread of disease is a central and historical responsibility of WHO. If we fall short in managing this responsibility, all of WHO, and all of its programmes suffer. You will be hearing more about these issues in the discussion of WHO’s emergency reform platform.
Ladies and gentlemen,
Organizational accountability is the third main item on your agenda. We have been given more money. More results, at country level, are expected in return.
In this session, we will be looking to you, through group work, for insight, experiences, and advice on opportunities and constraints as we seek to improve accountability for both results and resources. On the positive side, significant progress has been made on many “asks” from the 7th meeting. This is accountability!
As I have said, the spotlight is on your performance as never before. Knowing how to get things done in countries will likely be WHO’s greatest asset.
I wish you a most productive meeting.