The world health report

Global health improvement and WHO: shaping the future

A world torn by gross health inequalities is in serious trouble. The global health community can do much to reduce suffering and death among vulnerable groups. WHO is changing its way of working, alongside member states and financial and technical partners, to reach key national health goals and strengthen equity. The most urgent objectives include the health-related Millennium Development Goals, the 3 by 5 target in HIV/AIDS treatment (to provide 3 million people in developing regions with access to antiretroviral treatment by the end of 2005), and addressing the growing epidemics of non-communicable diseases. The key to achieving these objectives is strengthening of health systems guided by the values of Health For All.

New approaches at WHO

To meet these challenges and accelerate progress on global health equity, WHO is fundamentally changing its way of working. This change builds on past innovations and accumulated knowledge, such as the experience gained through the polio eradication campaign and WHO's coordination of the SARS battle. Now our approach to HIV/AIDS embodies the paradigm shift. The idea is to synergise swift responses to health emergencies with long-term strengthening of health infrastructure. On Sept 22, 2003, I declared lack of access to effective HIV/AIDS treatment a worldwide health emergency. This declaration is a commitment to extraordinary action. It is linked to a practical objective, the 3 by 5 HIV/AIDS treatment target. This goal was originally proposed by scientists working at UNAIDS and other agencies.13 The global community is uniting around this objective and driving toward its fulfilment, on the way to the final goal of universal access to antiretroviral drugs for all who need them. During the SARS outbreak, WHO personnel and our national and international partners worked in crisis mode to assess the epidemiology of the disease and arrest its spread. Scaling up antiretroviral treatment demands the same intensity of response.

As we take urgent action to bridge the treatment gap, we continue to emphasise a comprehensive approach to HIV/AIDS control, insisting on the fundamental importance of preventing new infections. We need a balance between prevention and treatment, for both to work optimally. In many countries, the balance has been skewed because antiretroviral treatment has simply been unavailable, especially for the poor. There is growing evidence that provision of antiretroviral therapy in resource-poor settings can actually facilitate and strengthen HIV-prevention in several ways: increasing demand for voluntary counselling and testing; reducing stigma and promoting greater openness on HIV/AIDS; and helping to keep families intact and economically stable, thus slowing the growth of at-risk populations such as orphans and sex workers.14,15 WHO will not cut back on its prevention efforts. Instead, we are seeking new and additional resources to facilitate treatment scale-up. Within days of the September emergency declaration, the first of a series of WHO country emergency missions was implemented (in Kenya) preparing a detailed countrylevel analysis and working with national and local partners on plans for HIV/AIDS treatment scale-up. On Dec 1, 2003, WHO's HIV/AIDS department, in collaboration with UNAIDS and other partners, unveiled a global strategy for reaching 3 by 5. The strategy covers 14 areas of work, grouped under five headings: international partnership and advocacy; direct support to countries; simplified and standardised instruments to identify patients, deliver antiretroviral therapy, and track progress; measures to ensure a reliable supply of effective medicines and diagnostics; and rapid identification and dissemination of new knowledge to improve programme quality. As the 3 by 5 plan unfolds, WHO will send emergency response teams to all high-burden countries that request them, to work with treatment implementers on identifying and overcoming barriers to national antiretroviral treatment objectives in line with 3 by 5. WHO is also launching an AIDS medicines and diagnostics service to expand patients' access to high-quality, low-cost drugs and commodities. This will be similar in some respects to the Global TB Drug Facility whose creation I oversaw when I directed WHO's tuberculosis programme. The service will help countries and implementers to navigate drug purchasing and financing while considering best prices and ensuring quality, thus helping to overcome one of the greatest barriers faced by countries in HIV/AIDS treatment scale-up.

To reach 3 by 5, sustained cooperation among many partners will be needed. Most fundamentally, countries must be ready to acknowledge the emergency and respond with exceptional measures. Demand from countries and communities must drive the process. We are encouraged by the degree of commitment WHO's 3 by 5 country support teams have found among national health officials and political leaders. As we strengthen our cooperation with countries, WHO, UNAIDS, and the Global Fund must also coordinate with other multilateral institutions, including the World Bank's Multi-country HIV/AIDS Program, with bilateral treatment initiatives, such as the US Presidential HIV/AIDS initiative, and with private foundations. Some employers have taken a bold lead in launching treatment programmes for their workers, opening new ground for public-private partnerships. Success depends on our ability to work together.

Rolling out 3 by 5 will raise difficult issues of equity, such as how communities will be prioritised, which patients to enrol first, and how to handle questions of confidentiality and stigma. We need to ensure that programmes maintain a focus on reaching the poor and other vulnerable groups. As antiretrovirals become more widely available, monitoring and responding to drug resistance will be a key responsibility. For more than a year after the 3 by 5 target was first widely publicised, at the July, 2002, International AIDS Conference in Barcelona, enrolment of patients into treatment was slow. To many, perhaps, the obstacles seemed too daunting and the risks too great. Now WHO and its partners are breaking the inertia and facing the risks. The alternative-to watch millions more human beings die when therapies exist to treat them-is simply unacceptable. With determined action by all partners, the 3 by 5 objective can be reached. If the 34 countries with the highest rates of HIV infection each provided antiretroviral treatment to 50% of those who need it by the end of 2005, 92% of the target would be attained.

The HIV/AIDS fight is vital in itself, and as a test for new work patterns at WHO and new forms of cooperation across the global health community. The sense of urgency, clear goal-setting, intensified cooperation with countries, and do-what-it-takes mindset that characterise WHO's HIV/AIDS team are echoed in more and more parts of the organisation. The effects of this new approach will be felt in WHO's many other focus areas, including expanded action against a range of non-communicable diseases and cooperation with countries to achieve the health-related Millennium Development Goals. Not only for WHO, but for other health and development institutions and member states, 3 by 5 is a proving ground that will tell us whether we really have the stomach to tackle tough challenges. If we cannot reach 3 by 5, there is no reason to believe we will achieve the Millennium Development Goals. On the other hand, the innovative work strategies and resultsfocused partnerships we are building to move toward 3 by 5 can enable progress on other key objectives in line with Health For All.