Forty-eighth session, Harare, Zimbabwe

Mr President
Ministers
Dr Samba
Colleagues
Ladies and Gentlemen,

Attending the meeting of the Regional Committee for Africa represents a special moment for me. This is the first meeting of a Regional Committee that I attend as Director-General.

And this is a special moment because Africa is a key priority for WHO. Nobody could really disagree: at the dawn of a new century we need to resurrect international solidarity with Africa. The century that gave African countries independence failed, despite progress on many fronts, to put Africa firmly on a path of hope and prosperity.

It is a privilege for me to address you today and to have the opportunity to listen and learn from your discussions. I will use this occasion to raise a few issues which I believe are important to Africa. Towards the end I will share with you the process of change that I have initiated with my colleagues in the WHO Secretariat - a process which aims at doing better work - not least for Africa and its countries.

Nowhere is the need and potential greater than in Africa. I have pledged as my ambition to make a difference.

Look around: Never have so many in this world had such great opportunities. Never has our knowledge been greater. Never has there been such a steady stream of new discoveries and breakthroughs in the field of health as today - when the price of just a few fighterplanes can buy vast inroads into the burden of disease.

Yet people in the developing world carry over 90 per cent of the disease burden, and have access to only 10 per cent of the resources used for health. This is unacceptable. This has to change. With the fading of the Cold War came high hopes for a peace dividend for human development. But many countries seemed to let go of Africa.

You have placed important themes for African health on your agenda. Let me address some of the key challenges as I see them:

First, there is the single biggest threat to health - and that is the threat from poverty.

Ill-health leads to poverty and poverty breeds ill-health.

We in the field of health need to take a broad perspective. Health is a critical asset for the individual. But it is more; it is the very core of human development. The deep roots of global health challenges are still linked to poverty and underdevelopment.

We need a new and vigorous effort to drive home the message that providing even the most basic access to health services is an investment in the social and economic development of society. Investing in health can play a critical role in breaking the vicious circle binding together poverty and ill-health.

I believe we can succeed in this effort. We are getting the evidence that illustrates the fundamental links between health and development.

We need not remind Health Ministers - you already know. But we need to go beyond and tell the Presidents, the Prime Ministers and the Finance Ministers that they are really Health Ministers themselves. Investing in health gives tangible results. Breaking the poverty circle. A better workforce. More receptive pupils and students, able to harness the ultimate resource of the 21st century - not least in Africa: the human resource and knowledge base. Less social costs. Less mental stress. More human progress.

Second - we cannot avoid raising it - the deadly conflicts that continue to haunt the continent.

We will never be able to come anywhere close to health for all when there is war and armed conflict. Africa continues to have its tragic share. Your Regional Office had to move due to armed conflict. Hopefully it will soon be able to return.

But new conflicts flare up, often destroying decades of development and painfully won achievements. Since 1980 conflicts have caused 4 million excess deaths in Africa. That alone has inflicted an estimated average cost to the African Region of 13 billion dollars a year. It is a staggering amount, especially if we measure what we could have provided in terms of vaccines and primary health care for that sum of money.

Conflicts lead to destruction of physical infrastructure. They lead to social disruption, leaving women and children especially vulnerable. Uprooting of communities. Mass population displacement. They lead to transfer of spending from social needs to military needs. In sum - destitution and ill-health.

What can WHO do? You made your voice heard two years ago when the Regional Committee stressed that peace was an absolute need for sustainable health and human development. WHO has to bring that message to the international community.

And WHO has to aid the victims of conflict - support proper health services for refugees, emergency care, rehabilitation for those wounded and disabled.

We can make a difference. A few years ago many thought that the spread of landmines could not be halted. But we took one giant step towards that goal last year with the signing of the anti personnel landmines convention. It may soon enter into force and we should cheer as the 40^th state ratifying the convention makes it part of international law.

We need to add our efforts to the prevention of conflict. Today conflicts are more often within states than between states. We need a continuous focus on the deeper roots of conflict: poverty, population growth, environmental degradation and lack of economic opportunity.

These are the sources of conflict which we should deal with before they escalate and the costs become enormous. Reading the Human Development Report or the World Health Report can tell more about the need for preventive action than counting the weapons on every potential battlefield. We must keep the survival issues on the international agenda.

Third, let me turn my attention to half the world's population - women. You, Health Ministers, should do the same. It is time to say; Africa's women are the continent's greatest unused resource.

When you educate a woman you educate a family. Investing in women give high returns, both economically and socially. Not only do women nurture the next generation. They also provide the bulk of health care available to the sick, the infirm and the needy.

The health problems that women face are partly linked to their social status and roles. Women generally live longer than men, but they do not necessarily live healthier lives. But women's reproductive health is a concern for women and for men. We need safe motherhood - but also responsible fatherhood.

In many societies girls are subject to discrimination even from conception. Where the status of women is low, their health, education and emotional needs take second place to those of men. Girls eat last and eat least, are overworked and under-educated and sometimes can prove their worth only by bearing many children from early age.

We encounter neglect, abuse and victimisation. Infanticide, genital mutilation, malnutrition and anaemia, all affect girls and women the most. Early bearing of children, abortion, sexually transmitted diseases, HIV/AIDS add to the total burden.

Safe motherhood means safe families. Healthy women mean healthy populations. We need to drive this message home.

Fourth - let us look at Africa's children.

In some African countries 20 per cent of children still die before reaching the age of five. Seven in ten deaths in childhood in Africa are due to malaria, acute respiratory infections, diarrhoea, measles and malnutrition.

We have to reverse this trend. WHO is giving it high priority - working with the countries in Africa - with the Regional Office and all the dedicated people working here. Take the Integrated Management of Childhood Illness. Nineteen countries in Africa are applying this approach, helping them to deal more effectively with reducing the numbers of casualties among children.

Vaccination remains one of the most cost-effective interventions available. Technological advances are opening new avenues that we could not dream of a few years ago. We may head towards effective vaccines against HIV. We may be able to prevent malaria. Not for tomorrow but in a future within our grasp - a future that also has to be within Africa's grasp.

But the challenge is a complex one. We are doing away with diseases, such as smallpox. We may be able to eradicate polio. But we may also fail - at the last stretch if funding fails - and if countries - also here in Africa - do not take it seriously. I have pleaded strongly for a renewed effort to finance the extra mile of the polio marathon. Key partners such as Rotary International are ready to make an extra effort. And I plead strongly to you to keep the focus until polio enters the annals of past burdens.

In many African countries access to drugs and scientific innovations is still highly inequitable. The public sector may lack critical drugs, while private pharmacies have them in large quantities but affordable only to a few. Some countries spend as much as 20-40 per cent of the health care budgets on importing drugs.

Industry must push for new drugs and new vaccines. We must push for funding and a distribution system that can make the advances available and affordable to all - especially to those in greatest need.

Many of you will remember the heated debate on the Revised Drug Strategy at the World Health Assembly. The Executive Board will continue to discuss this issue and I have given immediate attention to it.

We are looking for the right balance. National strategies must ensure equity of access, rational use, and quality for existing drugs. At the same time, to meet pressing public health needs we need new drugs and vaccines. This is true for emerging diseases, but also true because of the serious threat from growing resistance to drugs for common killers such as malaria, tuberculosis, bacterial meningitis, and pneumonia.

To develop new drugs we need innovative research and industry, with appropriate incentives for innovation. I see all of this as an integral part of public health in a broad perspective.

WHO has an overriding responsibility to see to it that essential drugs are developed and that they are made available to those in need. New international trade agreements present new opportunities, challenges, and also uncertainties. We need to analyze and monitor to see how these agreements can support public health.

We need to do that - and you - the Governments need to do it. Before trade issues reach the international negotiation table, public health needs must be fully considered at the national negotiation table. Governments must be consistent and send the same message about their policy in different international bodies. We cannot slice the world into pieces - one for health, one for trade and one for the environment.

WHO will speak out. WHO will be more active and vocal in its dialogue with the World Trade Organization (WTO). Our Action Programme on Essential Drugs will continue to work with countries to find the best means of improving the availability and affordability of medicines. This means working even more closely with Ministries of Health. But it also means working with the private sector and civil society - professional organizations, NGOs, and industry.

I have invited industry at large - including the pharmaceutical industry - to sit down with us to map out the challenges and get a clearer view of what we can achieve together and where our views differ. I believe there is a lot to be gained. Local and international, generic and innovative pharmaceutical companies should know that working with WHO means developing new markets - sustainable markets - and contributing to improved public health.

Fifth, let me touch on three pressing issues that in one way or another are closely interlinked: the HIV/AIDS pandemic, Roll Back Malaria and health sector reform.

You know the challenge facing us from HIV/AIDS and the terrifying magnitude of the numbers.

HIV/AIDS will claim a greater share of mortality in the years ahead, partly reversing the gains in child survival that have been achieved with such difficulty, also reversing other social and economic hard-won gains. HIV is now the problem of adolescents, with half of new infections being in young people. What we are witnessing is in fact a gradual threat to the economic, social and consequently even the political structures of sub-Saharan Africa.

We must face this challenge. You - the Governments must considerably enhance the response to HIV/AIDS. In no country in Africa is the epidemic under control. Yet the knowledge, the technology and the strategies exist to curb the spread of the virus and to mitigate its impact.

WHO has just taken over as chair of the cosponsors of UNAIDS. We will lend our full support to the efforts of UNAIDS and give increased attention to the way WHO addresses the HIV epidemic in all parts of its work - across programmes - as an integral part of our work and our policy advice.

Let me focus on one difficult issue - mother to child transmission of HIV by breastfeeding. Yes there is evidence that this happens and we must address it. But let us reflect carefully before we draw broad conclusions. Mothers need correct and cautious advice.

It is of overriding importance to avoid scaring women from breastfeeding. We still need to remain vigilantly on guard against aggressive marketing of breast-milk substitutes that generally undermine breastfeeding. Decades of work could be lost and the children will be the losers. Nothing can change the basic fact that breastfeeding remains the most powerful prevention against both malnutrition and infectious diseases.

Then there is another intolerable situation on the continent. In 1995, according to UNAIDS, one in every four blood transfusions given in sub-Saharan Africa had not been screened for HIV.

The technology to make blood safer, not only for HIV but also for other blood-borne infectious agents, is commercially available. I appeal to Governments in Africa to pursue their efforts towards increasing blood safety. WHO will make a special effort to extend its support to national initiatives, which will strive towards this aim and reduce the world disparity of access to safe blood.

There are great inequities in access to treatment - such as the highly effective anti-retroviral therapies - or HEART as it is often called. WHO has a strong commitment to exploring ways and means to enhance quality care in the developing world. These therapies are already present in the developing world, but only available to the few who can afford them, not to the many who cannot. The question is no longer if these expensive, complex-to-use drugs should be there, but rather how. We cannot conclude, from existing poor quality information, that these drugs cannot find their place in poor health economies.

The obligation of Governments and of international organizations supporting them is to demonstrate whether, in what ways and to what extent Africa can benefit of the product of scientific discovery in the development of new HIV/AIDS drugs.

Then there is the other main killer - malaria.

I have pledged to the World Health Assembly that WHO will take the lead in Rolling Back Malaria.

Every day 3000 children die from malaria. Every year there are 500 million cases among children and adults. Many of those who are infected, but do not die, suffer permanent losses. The economic consequences are striking making malaria not only a killer, but also an enemy of economic growth.

It was not only this magnitude of the problem that convinced me after my visit to several African countries last fall, it was also the African response to the threat. To me it was clear: WHO must hear Africa's call.

Some say: Why malaria? - it is too daunting a task. It has been tried before but major success has eluded our grasp. My answer is this: WHO would be out of touch with realities if it did not respond.

We are aware of the complexities. Roll Back Malaria will not offer a quick fix. This is a generational effort. We cannot opt for eradication, but we can substantially reduce morbidity and mortality. We can strengthen health systems to deal with malaria and thus enable those systems to address the challenge from other communicable diseases. What we learn in terms of strengthening health systems and bringing relief to the vulnerable will benefit our struggle against the HIV epidemic and a future Roll Back Tuberculosis.

Africa will spearhead our efforts in Roll Back Malaria. Roll Back Malaria will work as a broad global partnership, building a coalition with partners such as the Member States, the World Bank, UNDP and other UN agencies, the private sector, the research community and civil society.

We invite partners to grasp this opportunity and support our efforts to roll back the biggest child killer in so many African countries. Just after the World Health Assembly, the G7 in their meeting in Birmingham declared their readiness to lend their support. It is now time to move ahead.

We will work systematically with the Regional Office and the WHO Representatives. More than 70 qualified people applied for the position as Project Manager and I hope to make the appointment in a few days. Step by step, during the coming weeks and months, the project will start its work.

As a common denominator to all the challenges I have raised - and we all know that there are many more - we have to ask: how can we build sustainable health systems that can stand the test of changing times and economic constraints? How can we ensure access to basic health services in situations where the base of public finance collapses?

Africa's tragedy is that as we still face major threats from infectious diseases, we are experiencing the silent epidemic from non-communicable diseases, mental health and ageing. Coping with both at the same time is exceedingly difficult and will require a major rethinking of how to succeed in policies of prevention, how we train our health workers and how we finance our services.

Take tobacco. If unchecked - disease from tobacco consumption may end up as the single most important burden of disease in a couple of decades, even in Africa.

Each country must choose its own path - given its pattern of disease, its institutions, its resources and the needs of its people. I believe there are two parallel tracks to pursue:

First, we need to work across sectors. Many determinants of better health lie outside the health system all together. In better education. Cleaner environment. Sustained reductions in poverty. Each health sector - each health ministry - and on the global scene WHO - must serve as an active and informed advocate of health-friendly policies.

Second, we must look towards health sector reform.

The performance of market forces has enormously increased productivity in many sectors of the world economy. Markets have failed to achieve similar success in health. In general terms the private sector may be good at allocating resources cost-effectively. But the private sector - private industry - will never become the key provider of primary health stations or the guarantor of securing health services to the poor. Neither will it assure universal access.

A key responsibility for Governments should be to secure access to care. Only the public sector can guarantee basic universal rights. It is a useful reminder in this year of the 50^th Anniversary of the Declaration of Human Rights.

Many Governments - not least in Africa - have great constraints on their public finances and have overextended their capacity to provide services. We need to start a discussion on norms and standards of a "new universialism" - a new way of addressing universal coverage. This will be a major issue on the agenda of each country. Accordingly it has to be on the table of WHO and we are organising part of our work to deal with it effectively.

Universal access to quality services is a bedrock principle. Governments should provide strategic leadership - through setting priorities - acknowledging that there are limits to the care Governments can finance, limits that each country must decide for itself. But setting priorities and defining limits requires knowledge of what efforts will make the best impact, reach the most people, and achieve the most effective results. WHO should be there to advise you in this process.

Then we need to reach out. Provision of government financed services must come from the most efficient source. That may mean providers from the private sector. Or from NGOs. Governments should seek to engage capacity wherever it may be in meeting its responsibility of universal care.

As a final point, I would like to share with you some key elements of the reform process that I have initiated in WHO.

On 21 July I took office and appointed a new senior management team at headquarters level. We are five members from the South and five from the North. Six women and four men. All WHO's Regions are represented. It is a strong global team.

Together with the Regional Directors, the WHO Representatives and more than 3500 staff we are embarking on a process of change along the lines I presented to the World Health Assembly in May. These are the main guidelines:

First - we must secure a better unity of purpose of what we do. We cannot do all - and we should be very good at what we decide to do.

We need to be able to say that WHO is one. Not two - meaning the one financed by the regular budget and the one financed by the voluntary contributions. Not seven - meaning Geneva and the six Regions. And not more than fifty - meaning all the different programmes of the Organization.

WHO must be setting its priorities as one, raising additional resources as one, speaking out as one. Let us not forget: WHO is a small organization if we measure it against its mandate - and against the scores of unmet needs. WHO is not a deliverer of health services. National and regional authorities are. NGOs, private providers and communities are. You are. It is through our combined efforts that we can make a difference.

At Headquarters we have grouped the programmes into nine clusters - each sending a clear message of what business we are in. In the coming months, under the supervision of the Executive Directors, each cluster will streamline its activities in order to optimize what we can do together - across the organization and in partnership with others.

Our aim is to structure our work throughout the Organization so that it has a maximum impact where it matters the most - at the country level. What we do in Geneva or in a Regional Office matters very little if it does not have an impact in the countries in terms of better WHO collaboration, more relevant input, better pooling of knowledge, better global advocacy for health and better resource mobilization.

Three weeks ago I met with the Regional Directors for a first common discussion of our common work. I intend to work closely with them all - seeing them as key advisors. We have started a major modernization of our information technology network enabling us to link the six corners of the world by the push of a button, by voice or by image in real time. There will be better communication and there will be money saved from doing away with unnecessary travel.

I also intend to establish more direct relations with the WHO country representatives. In a few months I will invite all the WHO Representatives to Geneva to learn from their experience and to introduce them to the new WHO and what it has to offer - in order to strengthen the bridges to the Member States - and in particular those in greatest need.

And I will invite the Executive Board to closer contact and more focused debates on the challenges facing us.

You know it from the numerous calls from the Governing Bodies; Member States want more relevant and tangible results from our efforts at a country level. Time has come for the Secretariat to make its response. We have initiated a fast track task force to make concrete recommendations on how we can turn the ambitions into reality.

We need a unifying mechanism that can see our country performances in connection. Today it happens that we are heavily involved in one country and only superficially involved in the neighboring country, that may struggle with similar problems.

Our relationship with countries is a two way challenge: You - the Member States must report back to us on the health status of your population. The success of WHO will ultimately depend on how Member States live up to the imperative of equity and social justice expressed in Health For All.

In short we need more unity of purpose. My vision is that WHO will be a place where you can come for the best knowledge and the most updated expertise and where we know sufficiently well your needs to tailor our efforts accordingly. We need a structure which is unified and at the same time draws on our unique diversity - with Regional Offices ready and able to make their efforts such as here in AFRO.

Secondly I have underlined the need for us to reach out.

The whole notion of a specialized agency in this inter-dependent world has little meaning if we fail to integrate our efforts with the other stakeholders. We should encourage many actors to get involved in health.

I wish to invite all those who have real contributions to make to join us. Our UN partners. The international financial institutions. The NGO community. The private sector. The people and communities themselves.

Thirdly - I have stressed the need to underpin our work with solid facts.

We must have the right figures - the right connections - and the best evidence - not only the moral conviction that health is essential. We have created a special cluster called Evidence and Information for Policy. This knowledge base is there for you to use. And to enrich. We will report important facts. And the fact is that healthy people help build healthy economies.

Fourthly - in addition to organizing our work in coherent clusters we are launching a new way of working.

You will see more of our work organized in projects that cut across clusters and regions and that frequently engage other partners. High visibility, intensive efforts, tangible targets. We have launched two such projects since 21 July - Roll Back Malaria - which I will return to - and Tobacco Free Initiative. More will come.

The bottom line is this - we need to make WHO more user-friendly - more evidence-based - for you who need it most, so that you can get more out of your health policies. This is a process of hope. We can do better. We will do better.

Mr President, Ministers, Colleagues, Ladies and Gentlemen.

I have raised several problems, problems you knew so well. It would be easy to be discouraged - for the problems are major ones. Yet, there are reasons for hope :

• The health sector has a track record of success in the past 40 years; it is our mandate, yours and mine, to carry that record forward;

• Science has given us many powerful tools. More tools are needed, but tools, we already have. The need is for commitment: political, financial and ethical. Commitment can roll back not only malaria but also many other scourges. This was not true 75 years ago; science has made it true today;

• We are learning more and more how critical better health is for economic development. Economic researchers will carry this message to Finance Ministers and Prime Ministers and the international financial institutions; and you and I should back up those facts. Then we might rightly hope to see health placed at the top of the development agenda, where it rightly belongs.

So I am hopeful. And Africa must be hopeful. At the World Health Assembly in May Member States decided - after long discussions - to change the regional allocation of our regular budget - providing increased resources to Africa and to Europe. Reaching consensus on such issues is always difficult. More resources to two Regions mean less to the other four. But the decision was made - in itself a sign of solidarity and true multilateralism in our Organization.

Mr President, Ministers: My pledge to you is to do everything in my power to make WHO a better instrument for you, an instrument to turn our hopes into realities.