Harare,
21 April 1999

"Making a Difference for Africa"

When I addressed the meeting of the Regional Committee of Africa here in Harare eight months ago, I said that Africa is a key priority for WHO.

Through this week's visit to three African countries, I am reconfirming that commitment. I appreciate this opportunity to share with you how I believe the World Health Organization, with your support, can make a significant contribution to meeting the crucial challenges to health and development in the African region.

This morning I arrived from Mozambique, a country which is rebuilding itself after many years of war and instability. It is fighting a formidable AIDS epidemic and struggling with different types of diseases. It is doing so with woefully inadequate resources.

However, what I saw was impressive and uplifting. From the highest levels of government to the local health centre, I sensed a commitment to improving health that was heartening and inspiring. I saw a willingness to break down traditional barriers to progress. I saw a determination to succeed.

For the last decades the social sector in Africa has had to do more with less resources. Africa has seen more money leaving the continent to pay for goods and service debt than it has received in aid and for the sale of its products. The average African household consumes far less today than it did 25 years ago.

A story of remarkable African achievement is all too often ignored against the reporting of daunting health challenges. Africa has built a remarkable surveillance system against disease. Africa has paved the way in controlling complex diseases such as onchocerciasis or river blindness. Africa has given glowing examples of how regional cooperation and donor resilience can lead to drastically improved health conditions.

Before the AIDS epidemic so tragically began to erode the health gains made through decades of hard work, infant mortality had been significantly reduced in many countries. Against powerful odds, Africa has demonstrated that the tides of ill-health can be turned.

I have come to Africa to pay tribute to the tremendous efforts that are being made by health workers under difficult conditions. Without the dedicated work of these brave people, the health situation in many African countries would have been far worse. Many countries outside Africa can learn valuable lessons from innovative health policies and practices drawing on broad networks of community involvement.

My message to those I meet this week is one of support and of service. I offer WHO as a genuine partner to African governments in their work to improve health levels for their people. During this visit I am exploring with the leaders of Mozambique, Zimbabwe and Ivory Coast how WHO's expertise can be brought to bear on the challenges facing Africa.

We are reforming WHO – pulling together what this Organization, working as One WHO - can provide of support from all levels. Based on the countries' own identification of needs and priorities, we are ready to do what we can to lend our support.

There are major opportunities to pursue.

Let us start with our understanding of how improved health can foster human and economic development. The perspectives are changing. There is mounting evidence of the critical role wise health investments can make to lift populations out of poverty.

A recent study from Harvard University calls for a reassessment of the role played by public health in the promotion of growth. It suggests that two-thirds of the weight of Africa's growth shortfall over the last decades can be attributed to conditions linked to geography, demography and public health. Their conclusion is that policy makers need to go beyond macro-economic policies and market-liberalization and deepen their understanding of the linkages between the physical environment and social outcomes.

I firmly believe that the role of health in development has been under-estimated. One of WHO's priorities is to provide the evidence base to prove these links and to put forward health strategies which can contribute to lasting change. If underpinned by solid facts, the health-growth equation will call the attention of decision-makers in a different manner. Presidents, Prime Ministers and Finance Ministers will be reminded that they are truly health ministers themselves.

We must opt for effective health policies which drastically reduce the burden of disease and build more cost-effective, equitable health systems.

• We know that weak health sectors are unable to carry out the work needed to reduce maternal mortality or the impact of AIDS, malaria or tuberculosis – not to mention facing the growing burden from non-communicable diseases. But we also know the minimum requirements for an effective health system, beginning with the essential role played by primary health care.
• We know the effectiveness of broad-based programmes which work across the boundaries of single diseases, and which focus on prevention and early treatment. The Integrated Management of Childhood Illness is one example of such programmes. 22 countries in Africa now apply these guidelines jointly developed by WHO and UNICEF.
• We know that immunization works. It is one of the best and cheapest tools we have to prevent disease. A large number of countries in Africa have become experts in strengthening their immunization services and carrying out mass immunization campaigns, the latest key effort being the struggle to kick polio out of Africa by the end of 2000. I have a vision that research and development in vaccines soon will turn the tide of diseases such as AIDS and malaria. And when that day comes the advances must reach all – not only the fortunate few.
• We know that we will continue to see amazing advances in technology and research that may bring improvements in health in the 21^st century. But we also know that whereas 90 per cent of the disease burden is in the developing countries, these countries have only got access to 10 per cent of the resources going to health. Countries in Africa struggle hard to access essential drugs. We need public voices – and you can count WHO as one - to speak out for the rights to health of all those who fall outside the cold logic of the market economy.
• We know more about the changes in the burden of disease in the years to come, and we can prepare for these changes. Tobacco is one such change. Deaths caused by tobacco are likely to nearly triple from four million deaths annually world-wide today to 10 million deaths thirty years from now. Most of the increase will take place in developing countries.
  
  WHO has launched the Tobacco-Free Initiative, to galvanize global support for evidence-based tobacco control policies and actions; to build new partnerships, to heighten awareness and to mobilize resources; and to accelerate the implementation of national, regional and global strategies against smoking.

• Finally, we know more about the benefits of co-operation. We know that the sum of a partnership is much larger than the piecemeal effort of individual participants. When people with different backgrounds come together with a shared purpose, creativity is released and expertise is used in new and constructive ways.

Together we possess all this knowledge. To make proper use of it, WHO works to become more strategic in our work with countries – more focused in helping to obtain better and more equitable health outcomes - more effective in supporting health sector development - and more innovative in creating influential partnerships.

During this visit I have chosen to focus on three major issues where I believe we can make a real difference in the years to come. I am talking about Malaria, AIDS and Maternal Health.

Malaria takes a daunting human toll and represents a roadblock to development. When I took office I heard Africa's call for action. Africa carries 80 per cent of the malaria burden. African governments were committing resources and commitment and our Regional Office responded. I therefore pledged the full support of the whole of WHO to this cause.

Roll Back Malaria has the ambition to cut by half the number of deaths from malaria within a decade through better access of all people in malaria-affected areas to a range of effective interventions. The project will be owned by African nations, driven by their needs, adapted to their circumstances.

Six principles guide Roll Back Malaria: early detection of disease, rapid treatment, multi-pronged interventions, well coordinated strategies, determined research and the building of a dynamic social movement against malaria.

Roll Back Malaria is a global partnership, drawn from malaria-affected countries, organizations of the United Nations, bilateral development agencies, development banks, nongovernmental organizations and the private sector. WHO's role is to provide strategic direction, coordination and technical support to the global partnership, and to work as a single body at all levels for implementing Roll Back Malaria.

If we succeed – and we will – this approach will reach beyond malaria. This is a new way of working for WHO, for governments and for our other partners. As we proceed this approach will benefit our work in other areas such as HIV/AIDS and tuberculosis.

Let me then move to AIDS. The HIV/AIDS epidemic represents an unprecedented crisis for the continent. More than 20 million Africans are infected with HIV today. Over two million died of AIDS in 1998, including nearly half a million children.

Four million new HIV infections occurred in Africa last year. In the most severely affected countries, a quarter of the adult population is infected. Hard-won gains in life expectancy and child survival are being wiped out. If left unchecked, the AIDS situation in Africa will continue to worsen. The numbers of dead, dying and orphans will continue to grow exponentially and development will be set back.

Over the last months WHO has restructured its own work on AIDS. WHO is both the lead UN agency in health and one of the seven co-sponsors of UNAIDS. We are developing a joint plan of action where we will focus our efforts where we have our comparative strengths - reaching out to countries with a particular focus on supporting the health sector to cope with the challenge.

Together with the other co-sponsors of UNAIDS we are backing the Partnership Programme for Intensified Action against HIV/AIDS in Africa.

The goal of this Partnership is to urgently mobilize nations and civil societies to address more effectively the evolving HIV/AIDS epidemic. There is no magic solution to this daunting challenge. Our vision has to be that we will see an effective, safe and affordable HIV vaccine. But even when that day comes we will need to pursue dedicated policies of prevention and care as mainstays of our response to the epidemic.

If we – the UN organizations, governments, NGO communities, and donors – act now, together, and effectively divide the tasks according to our comparative advantages – then by the year 2005 we may see in Africa:

• that several millions of HIV infections will have been averted
• that incidence in 15-24 year olds can be reduced by 25 per cent in the 25 most affected countries
• that a large proportion of HIV-positive pregnant women can have access to a voluntary testing/counselling/treatment/replacement feeding programme
• that at least half of all HIV-positive persons can have access to drugs for common infections that follow HIV, such as TB and pneumonia.

The third area of emphasis is maternal health.

Every few minutes an African woman dies unnecessarily from causes related to pregnancy and childbirth. The lifetime risk of suffering a maternal death is as high as 1 in 16 in some African countries compared to 1 in 4000 in developed countries. On this continent, each year around 2 million infants are stillborn or die during the first few days of life. Millions more are crippled by birth trauma and asphyxia during delivery, or suffer lifelong consequences.

This is the largest disparity we can find in any health care indicator between industrialized and developing countries. These deaths are allowed to occur despite the fact that we have the knowledge, technologies and interventions to reduce them.

Let us be very clear about this issue. Women who suffer and die as a result of pregnancy-related complications are not dying because of disease. Pregnancy is a normal part of human development and should be a time of joy and happiness. Around the world, all women suffer and die from the same complications – bleeding, infection, hypertension, obstructed labour and complications of abortion.

WHO and our partners in the UN system, the World Bank, governments, donors and NGOs are prepared to intensify their work to change this situation. Maternal mortality is an indicator not only of women's health but also of access, integrity and effectiveness of the health sector. Our common aim is to reduce pregnancy-related mortality and morbidity by 50 per cent of 1990 levels by 2005.

Three factors are vital to succeed:

One: Every pregnancy should be wanted.

Two: All pregnant women must have access to skilled care. And

Three: All pregnant women must be able to reach a functioning health care facility when complications arise.

These interventions are feasible, measurable and cost-effective, even in settings where resources are limited.

I reiterate the strong commitment of WHO to the global effort to reduce maternal mortality. Last year on World Health Day, WHO's message was "Pregnancy is special – let's make it safe".

Today, a year later, as we take stock five years after the Population Summit in Cairo, I pledge renewed commitment to MAKE PREGNANCY SAFER.

We will be seeking to forge new partnerships, globally, regionally and at country level. We will seek to involve other sectors, particularly those with responsibility for finance and planning. We will remind development banks and aid agencies of their responsibilities in this key area of public health. At country level we will propose new partnerships, forging alliances between health care providers and women's groups, between those responsible for the provision of health care and those receiving it.

Running through these three areas of focus is the need to strengthen and reform the health systems of African countries. Weak health systems are at the roots of the underdevelopment of the health sector.

At WHO we are starting to promote the need for "a new universalism" - a new way of addressing universal coverage. Universal access to quality care remains the bedrock principle. Governments take more responsibility for securing access to care. Only the public sector can guarantee this basic universal right. Governments should provide strategic leadership and set priorities. There are indeed limits to the care governments can finance, and these limits each country has to define for itself.

WHO will assist governments by providing evidence of what works and what doesn't, and how solutions best can be adapted to specific country settings. Improving health is cost-effective. But it is not free. An offensive to improve health needs investment. In most cases national governments will need to increase their investments in health and to be more effective in the use of scarce resources. If done in the right way, the returns will be high.

African countries have the right to expect support. It is indeed disturbing that development assistance is in severe decline. Rich countries have committed 0.7 per cent of their GDP to official development assistance. A very few countries stick to their obligations – but the world average is getting close to 0.2 per cent. There is the unresolved issue of crippling debt which eats up resources. There are countries in Africa where the debt servicing exceeds the size of the budgets of health, education, police and judicial systems combined.

This must change, not as an act of charity by the rich countries of the world, but as an act of enlightened self interest. In a globalized world, there is no such thing as a localized health problem.

Globally, we need to pledge our support to the Copenhagen Summit's 20/20 initiative. The aim is simple – to persuade donors to invest a minimum of 20% of their development aid in basic health, education and social services in exchange for similar commitments in the national budgets by recipient governments.

When I spoke here last August, I said it was necessary to raise the issue of the deadly conflicts that continue to haunt the continent. Since then, the conflicting parties in Angola have again descended into a full-scale armed conflict, Eritrea and Ethiopia are clinched in a futile and wasteful war, and many countries in Africa experience internal conflict with violence and displacement of populations.

Yet, one small but significant break-through took place last month, when all the warring parties in the Democratic Republic of Congo agreed to respect a period of tranquillity to carry out an extensive polio vaccination campaign later this year. If this campaign succeeds, it would mean an important step towards our goal of eradicating polio by the end of next year. Health can indeed be a bridge to peace.

Let me end with a message to WHO staff. This Regional Office is in itself an example of having to do their work and lead their family and personal lives under difficult circumstances. Staff at AFRO and many WHO colleagues assigned to countries in the Region have experienced the disruption of strife and conflict. This Regional Office has gone through its own tumultuous two years, with dangers, evacuation, displacement and rebuilding.

This morning, I thanked the authorities here in Zimbabwe for the great hospitality that this country has shown in welcoming us and providing us with a place to work. I would like thank all of you in the Regional Office – and through you, our colleagues working throughout the Region for the commitment which has made it possible to continue our work in Africa almost uninterrupted.

I greatly appreciate the effort of each and every one of you which has made this possible, and I pay a special tribute to Dr Samba, the Regional Director, for his tireless efforts and dedicated contribution to health in Africa.

Looking ahead the challenge facing us is formidable. The issues we need to address call for bold and innovative initiatives. Never before in human history have we had so much knowledge. This is what gives me cause for hope. We need to make this knowledge applicable and available to all.

We will do together what it takes to make a difference.

Thank you.