Regional Directors, senior managers, heads of WHO country offices, colleagues, ladies and gentlemen,
Shortly after taking office, I set out to improve the way WHO uses the strategic value of its decentralized structure. I was asked specifically by Member States to make this structure perform better. It makes sense to do so. We all know that health problems, and the capacity to address them, vary considerably from region to region. Each country has its own unique set of threats to health. Health is affected by cultural beliefs, such as those that influence the status of women or stigmatize people with certain diseases. Health is influenced by political systems and the quality of governance. Health systems are themselves highly context-specific, shaped by history, and by the social, cultural, and political environment.
These observations lead us to an obvious conclusion: this Organization’s decentralized structure is an asset. It follows a time-honoured principle: delegation of responsibility to the level of greatest operational efficiency.
Since taking office, I have worked to engage Regional Directors more directly in the formulation of international health policies and in decisions about the day-to-day functioning of this Organization.
This is the fourth meeting of its kind, but we want to view this event as somewhat different than in the past. Through this meeting, we are extending participation in the policy dialogue to country offices. In addition, one of the objectives of this meeting is to find ways to make your participation more routine, so that WHO experience within countries operates as formal guidance when policy decisions are made.
As I have said, what gets measured gets done. And what gets done at the country level is the best measure of our performance.
This meeting is a policy dialogue engaging all three levels of the Organization. Nonetheless, I want to address my comments most specifically to the heads of country offices.
You are the representatives of the Director-General and the Regional Directors. You and your staff are the people on the frontline. You know the country and its culture. You see the health problems. You follow the national news. You are the closest to the Ministry of Health. You know the politics.
You are our health intelligence within countries, and you are also the public face and voice of WHO. You are the link between those frequently used phrases, “at the country level” or “in the field”, and the reality on the ground. You, your staff, your facilities, your connections are the operational base for the international response to emergencies. Much depends on your competence and operational efficiency.
Ladies and gentlemen,
Much depends on all of us. I believe we have arrived, in less than a decade, at a uniquely exciting, and yet a uniquely challenging point in the history of public health. Health has become an attractive area of engagement for a multitude of different agencies and actors.
In just the past seven years, more than 100 partnerships, focused on individual diseases, have formed. External funding for health in developing countries increased from $7 billion in 2000 to $10.7 billion in 2003, and is still climbing. The number of innovative funding mechanisms continues to grow, as does the size of resources they command.
Health has never before received such attention or enjoyed such wealth. But attention means close scrutiny, and resources come with an expectation of results.
We are at the midpoint in the countdown to 2015, the year given so much significance by the Millennium Declaration and its Goals. These Goals represent the most ambitious commitment ever made by the international community. They attack the causes of poverty at their roots, and they acknowledge that these causes interact. In short, they acknowledge the importance of multisectoral collaboration.
The Goals champion health as a key driver of economic progress. In so doing, they elevate the status of health. Health is no longer merely a consumer of resources. It is also a producer of economic gains.
Despite these welcome trends, we have to face the reality. Of all the Goals, those directly related to health are the least likely to be met. These are the Goals that aim to reduce high levels of premature death from diseases and health conditions that disproportionately affect the poor. These are the Goals that can make the greatest life-and-death difference for millions of people. These are the Goals that have powerful tools – drugs, vaccines and other interventions – to support their attainment.
Something is wrong.
Public health has political commitment, effective tools, good strategies for implementation, and resources from new sources. Finally, with so much working in our favour, we can see what is holding us back. It is this. The power of interventions is not matched by the power of health systems to deliver them to those in greatest need, on an adequate scale, in time.
All around the world, governments have failed for decades to invest adequately in basic health systems. It has taken a strong international commitment, like the Goals, to make the consequences of this failure painfully apparent.
The health-related Goals have at least two major policy implications. First, if we want better health to work as a poverty-reduction strategy, we must reach the poor. Second, if we want health to reduce poverty, we cannot allow the costs of health care to drive impoverished households even deeper into poverty. We are failing on both counts.
Ladies and gentlemen,
For all of these reasons, I want to speak to you at the policy level, using the WHO agenda as a framework. This agenda offers a simplified way of looking at some very complex challenges. It has six items.
The first two concern fundamental needs: for health development and for health security. The second two items are strategic: strengthening health systems and making the best use of evidence through research and information management. The remaining two items are operational: managing partnerships to get the best results in countries, and improving the performance of WHO, also to get the best results in countries.
Let us look at each of these items in more detail.
Health development has been the bread-and-butter work of this Organization since its inception. Some of this work has received a sharper focus with the Millennium Development Goals. This focus is most welcome. Our strong programmes in this area include those for HIV/AIDS, tuberculosis, and malaria, for child health, immunization, making pregnancy safer, and improving gender equality.
But health development has a broader meaning at WHO. We must also address the rise of chronic diseases. These diseases now impose their greatest burden on low- and middle-income countries. Many chronic diseases require lifelong care, vastly increasing the burden on health systems. These diseases also increase costs – for households, health systems, and government budgets.
In many developing countries, the speed of modernization has outpaced the ability of governments to provide the necessary supporting infrastructures. This is true in urban shantytowns, and this is true on the roads. Developing countries, already saddled with the double burden of infectious and chronic diseases, do not need a third burden of injuries, disabilities and deaths from violence, accidents, suicide, and traffic crashes.
Under health development, we also include the neglected tropical diseases. These diseases affect the poorest of the poor in huge numbers. The sheer scale of those affected – more than one billion people – makes control of these diseases a significant poverty-reduction strategy. Fortunately, progress on many fronts is making it possible, for the first time in history, to set goals for eliminating many of these ancient diseases of poverty.
Health security is concerned, in part, with acute shocks to the health of populations. These may come during outbreaks of emerging or epidemic-prone diseases, following natural disasters, or in conflict situations.
Natural disasters and conflicts are localized events. But conditions in the 21st century – our high mobility and the interconnected nature of our businesses and economies – have made emerging and epidemic-prone diseases a much greater international threat. Any country with an international airport is at risk. Again, we have strong programmes for health action in crises, and for implementation of the revised International Health Regulations. We will need these programmes all the more as the health consequences of climate change are increasingly felt.
A second dimension of health security concerns assurance that households and communities have access to the fundamental prerequisites for health. This means adequate and safe food, water, sanitation, and shelter, and access to essential health care. It also means that health care must be appropriate and affordable. As you will know, these are needs addressed in the primary health care approach. Once again, we see the importance of multisectoral collaboration.
At the strategic level, the strengthening of health systems is perhaps our most critical and urgent task, both for governments and the international community. Fortunately, we are seeing some encouraging trends at the international level.
This past September, several heads of state launched a new International Health Partnership in response to stalled progress in reaching the health-related Millennium Development Goals. It acknowledges the explicit need to invest in health systems. To make aid more effective, it introduces a framework of mutual accountability that recognizes the need for health initiatives to be country-owned and country-led.
In another welcome trend, both the GAVI Alliance and the Global Fund have recognized the need to improve health systems. In short: interventions and money are not enough. If we intend to meet our international commitments, we must have better delivery systems.
As you know, I have called for a return to primary health care as an approach to strengthening health systems. Fortunately, a number of initiatives, both regional and international, are under way to pave the way forward. I am glad to see that the strengthening of health systems will be discussed during this meeting. As health systems are so context-specific, ways to strengthen them must be worked out at the country level.
Evidence is also strategic. Evidence is the foundation for setting priorities, crafting policies, and measuring results. Evidence can have great persuasive power at the policy level. As one example, the strategy for the Integrated Management of Childhood Illness has had a strong evaluation component since 2000. Evidence from this evaluation has helped overcome one of the greatest barriers in public health: moving from pilot projects to national scale.
Evidence can also bring attention to neglected health problems. As one recent example, WHO worked closely with The Lancet to generate evidence and formulate a call for action to increase coverage of mental health services in low- and middle-income countries. The data, published in September, generated broad media coverage. This is an important step towards correcting a bleak situation: mental health services are being starved of both human and financial resources.
But we are not yet realizing the full strategic power of evidence within countries, where basic health data and statistics are usually weak or poorly used. The Health Metrics Network, hosted by WHO, was established to address the lack of reliable health information in developing countries. Most recently, this Network has drawn attention to the consequences of inadequate systems for civil registration – that is, counting births and deaths and recording the cause of death. For example, WHO receives reliable cause-of-death statistics from only 31 of its Member States.
Without these fundamental health data, we are working in the dark. We may also be shooting in the dark. Without these data, we have no reliable way of knowing whether interventions are working, and whether development aid is producing the desired health outcomes.
This is part of our job: to be accountable. We cannot be fully accountable without research. And public health cannot move forward without innovation. These are additional challenges facing this Organization.
Ladies and gentlemen,
Let us turn to the remaining two items, as these have particular relevance to your daily work. Both aim to get the best results in countries.
At the operational level, the management of partnerships is a comparatively new challenge. And it is a big one. Increasingly, health development within countries is being pursued by multiple agencies, often with little coordination. Efforts overlap and may not align with country priorities and capacities.
In addition, national capacities in recipient countries may be strained by high transaction costs, multiple reporting requirements, and multiple distribution and delivery channels. Single-disease initiatives can draw staff away from the provision of essential care. I am aware of the added burden partnerships place on country offices and their staff.
Country offices are also on the frontline in that second operational area: the performance of WHO. WHO is constantly working to align its financial and administrative instruments with a rapidly changing environment. We have a results-based budget and the Eleventh General Programme of Work. We have guidance from the priorities and organization-wide strategic objectives set out in the Medium-term Strategic Plan.
You will be hearing about implementation of the Global Management System and its implications for your daily work. Some of you are directly engaged in pilot projects for UN reform, delivering as one. I know you will have a panel discussion on UN reform this afternoon, followed by group work on partnerships and UN reform. WHO is committed to UN reform, and we are fully engaged in each of the eight pilot projects.
I know that your responsibilities have changed dramatically within less than a decade. This is in line with some of the changes in the health landscape that I outlined earlier. Recent trends have brought specific obligations, such as those arising from the revised International Health Regulations. These trends also include the consequences of trade agreements, especially those influencing trade in health services and access to affordable medicines. I know you will be addressing this issue as well.
More funds are available. But someone must help countries put together convincing proposals. More partners are now working in health than in any other sector. But someone must help align their activities with country priorities and capacities. Otherwise, all this flurry of activity and flow of new funds may end up doing more harm than good.
Ladies and gentlemen,
Let us take a look at one more hard reality. What is the comparative advantage of WHO? What is our added value? Do we perform essential functions? Is our work relevant or redundant?
If an agency is the only one working in a particular field, it can claim leadership as a given. This is not the case with health. Health leadership must be earned.
As I have said, the field is crowded. Attention brings scrutiny and resources come with an expectation of results. Progress in meeting the health-related Millennium Development Goals has stalled. Where are the results?
We earn the right to lead by demonstrating results within countries. I know very well: we can design programmes and strategies, but WHO has neither the mandate nor the means to directly implement them within countries. There are exceptions, of course, such as the response to emergencies of international concern as mandated by the International Health Regulations.
Country offices exist to advise ministries of health, to translate international guidelines, norms and standards into country-relevant approaches. You are the bridge between what a country needs and what headquarters and regional offices have to offer. You are also the bridge between multiple implementing agencies and the wishes and priorities of the ministry of health. Traditionally, ministries of health are among those government departments with the lowest status. Country offices need to help ministries of health negotiate with other sectors. Evidence can increase this negotiating power, especially when evidence shows the economic consequences of failing to address health problems.
The rise of chronic diseases makes this negotiating power all the more critical. The causes of these diseases – inappropriate diet, lack of exercise, tobacco use, and excessive alcohol consumption – lie outside the direct responsibility of the health sector. Prevention depends absolutely on multisectoral action, with health given pride of place.
The need for coordination is equally absolute. If a country gets one set of recommendations from UNICEF, another from the World Bank, and yet another from WHO, confidence in the authority of international agencies is diminished. If a country gets conflicting recommendations from WHO headquarters and regional offices, confidence is demolished.
Leadership and authority are not guaranteed by our Constitution. We have to earn this role in a highly competitive and rapidly changing environment. We need to move down from lofty phrases about our technical excellence and concentrate on our performance, on the ground, in the countries we serve.
If WHO cannot deliver, a country can turn to many other providers and sources of advice. Again, are we relevant? Is the money being given us by Member States and donors bringing measurable results?
Let me make one final point. As I said, these are exciting but challenging times for public health. All the good will we are seeing – the good intentions, the new funding mechanisms, the multiple partnerships – actually operate under the real conditions in the countries where you serve.
We must aim for the best results in countries. You are the frontline troops. We eagerly seek your guidance.