Washington D.C.,
27 October 1999

WHO/USAID Collaboration for Health in the Millennium

Since I was elected Director-General of the World Health Organization and throughout my time in office, I have greatly valued the support of the United States, and particularly the agency that you lead, Mr Administrator. This continued interest and support is now translating into this exceptional meeting, to exchange views on the global health agenda. When I met with Deputy Administrator Babbitt in London last May she suggested that we arranged this meeting. I wholeheartedly supported it and it is a great pleasure for me to be here today with my colleagues to look at ways to broaden and deepen the longstanding partnership between WHO and USAID and to improve the well-being of people and nations around the world.

Global health today is marked by a growing gap between what could be achieved and what we actually achieve at the dawn of a new millennium. The 20th century has brought about dramatic improvements in health, but the unfinished agenda is there before us: more than a billion human beings have been left behind in the health revolution. The burden of disease and disability on the poor remains unbearable in many parts of the world both in terms of suffering and the economic strains it leads to. In particular, the tragedy of the HIV epidemic continues to take a heavy toll and increases young adult mortality in sub-Saharan Africa.

In his speech to the General Assembly of the United Nations last month, President Clinton himself talked about the importance of reducing poverty as a prerequisite for the success of globalization, and he placed health at the core of his agenda to reduce poverty. In this agenda, USAID will have to play a central role. We already do a lot together and I am convinced we can do even more.

At the brink of a new century, we are facing a massive transition in global health.

Today, respiratory diseases, diarrhoea and perinatal conditions remain the main contributors to the overall global burden of disease and to mortality among children, against a backdrop of chronic malnutrition. But at the same time, and in the same countries of the developing world, we face the mounting burden of heart diseases, cancer, diabetes, accidents and mental health conditions, against a backdrop of ageing and new risk factors of which tobacco use is the most prominent. The epidemic of tobacco use will make it the single largest cause of disability and premature death in the coming twenty years.

Our ability to influence the development of the future burden of disease will have great impact on the future of industrialized countries. If we are successful in reducing the burden of infectious diseases, we are assisting in creating healthier populations who will better contribute to their countries’ development. We will also reduce the risk of these infectious diseases spreading to countries which so far have avoided them. That such a risk is real not only you – but also the people of New York – are well aware. If we are able to reduce some of the future burden of accidents, of mental problems, of smoking-related disease, we will also create societies that have freed more resources for positive development. This, as Mr Clinton so eloquently illustrated, will strengthen the ability to perform in a open market world economy and improving economic growth.

During our exchanges today we will address several of these issues, and I would like to place them into the context of the global health agenda and WHO's strategic approach to it. I wish to share with you the broad strategic directions for our work.

First and foremost, we must clearly focus on reducing the burden of excess mortality and morbidity suffered by the poor.

This means renewing our attention and commitment to controlling diseases such as malaria and tuberculosis, which disproportionately affect the poor. This means reinvigorating our efforts against HIV/AIDS. These diseases are both human tragedies and major impediments to economic growth.

Women suffer extreme poverty much more than men. 70% of the 1.3 billion people living on less than a dollar a day are women. We need a gender perspective to understand the ways that gender as well as biological sex differences place women at risk for poor health and disease throughout the life cycle. We need to take the reproductive health agenda forward and look at population issues within the agenda set forth in Cairo nearly six years ago. Making pregnancy safer is a priority: a woman in some parts of Africa faces a one in ten risk of death because she may not receive appropriate care during pregnancy. This risk in Europe and North America is only one in four thousand.

We also have to address the looming burden of malnutrition and micronutrient deficiency. A healthier world tomorrow demands that all children gain access to primary care, clean water, adequate nutrition and immunization.

Clearly, we need to revitalize and extend the coverage of immunization, one of the most powerful and cost effective technologies available. I have committed WHO to renewed leadership in the area of immunization: together with UNICEF, the World Bank, the Rockefeller Foundation, Gates Foundation and private industry, we are launching the Global Alliance for Vaccines and Immunization. The first meeting of the board of GAVI will take place tomorrow, and I have accepted to become the chair of this new global alliance for the next two years.

I am extremely pleased by the initiative made by Mr Clinton in his speech to the General Assembly to convene experts and political leaders to find ways to boost research for new vaccines to combat killer infectious diseases for the poor. WHO will put its resources and its expertise at their disposal and will be delighted to discuss any effort to coordinate and complement existing work in this area.

On all these aspects of our agenda, USAID and WHO have been working closely together for many years, Mr Administrator, and we appreciate your continuing support.

Our second strategic objective is to assist countries to counter threats to health resulting from economic crises, an unhealthy environment or risky behaviour.

The single largest and most preventable of these threats is increased tobacco consumption, driven by a part of industry which massively focuses its marketing efforts on women, youth and children in developing countries. We are building a strong coalition against the increase in tobacco use and working right now with our partners to prepare an international Framework Convention on Tobacco Control. I am pleased to say that while we are sitting here, the first meeting of the technical working groups are assembled in Geneva to discuss the foundations for the Framework Convention.

We have to address the risks created by environmental hazards and unsafe food. We have to understand and face the environmental and economic conditions that contribute to the evolution of dangerous antimicrobial resistance and recognize the possibility of outbreaks rendered more serious by the increase in international travel, trade, and some elements of climate change. We will address many of these issues together today, Mr Administrator, in particular during our discussions on global surveillance and adolescent health.

Finally, we must also address the growing burden of mental illness, so often driven by rapid changes in society and the global economy, using better knowledge, evidence, and tools. I have made mental health a priority for WHO. A lot needs to be done to address the suffering of so many people who all too often are forgotten in rich and poor countries alike.

Our third strategic focus is to develop more effective and equitable health systems.

In many countries health systems are ill equipped to cope with the present demands, let alone those they will face in the future. It is of little use to define priorities and identify key interventions if the health systems cannot deliver them or fail to reach the poor.

Health sector development has now become a strategic direction for all the work we do in WHO. When we help Roll Back Malaria, we wish to see a strengthened health system as a result, a system that can more effectively, efficiently, and sustainably combat tuberculosis and HIV/AIDS, deliver immunization, make pregnancies safer, decrease mortality and morbidity.

We need to help governments strike the right balance in the financing of health sectors, without placing an even greater financial burden on the poor. We need to emphasise financing strategies which rely on solidarity and avoid exclusion.

The issue of strengthening health systems underpins the agenda of our discussions today, and rightly so. It is only if we analyse systemic issues that we will understand why, for instance, immunization coverage has stagnated in too many countries and how it can be boosted in the coming years.

We recognize the critical role played by governments when it comes to setting health policy directions, creating an appropriate regulatory environment, securing financing for basic health services, and providing a framework for the growing private sector of health care delivery. Systems have to be efficient, equitable and fair.

Besides its impact on poverty and inequality, improving health systems will have a direct impact on the overall economy as health expenditures make up a considerable part of the economy, especially in middle-income and high-income countries. This factor should not be underestimated when we assess the benefits of health systems reform.

The World Health Report that we are preparing for the year 2000 will provide a complete analysis of health systems and help governments measure health system performance, both nationally and internationally.

The fourth focus is to build new partnerships to firmly place health at the centre of development. Mr. Administrator, let me expand a little on this. We know that health plays a key role in fostering human and economic development, and we share the same values and the same goals of halving the number of people living in absolute poverty by 2015. I believe this goal is attainable, provided we find new ways of working together, and change some of our resource allocation mechanisms.

When, in May, at the invitation of Clare Short, WHO convened the London meeting on developing health and reducing poverty, we were able to better understand each other's positions on the critical role of health in development. After London, both WHO and the donor countries that attended have been working to making a stronger case for health as their approach in reducing poverty through their assistance. We are seeking ways to achieve results through better spending on health in addition to more spending in many countries. We are looking at how selected governments, which have the foundations for success in place, can be assisted in formulating a health component of Poverty Reduction Strategy Papers. And we are looking at ways to improve the sharing of experiences between countries.

The London meeting opened a useful dialogue about new forms of partnerships between national governments, bilateral and multilateral agencies, and today we take this process one step further. I want to repeat here that I believe WHO must be the driving force for putting health at the centre of the development agenda. Better health provides a route to lead people out of poverty, and investment in health is an investment in economic development.

Through our Country Representatives, WHO has accumulated a great body of knowledge on the specific needs, policies and limitations of the health systems in our Member States. In short, we know a lot about what countries need, what they have the capacity to absorb in terms of assistance and change, and what the “best buys” are when it comes to health interventions. We are in the process of sharpening this knowledge and focusing it according to our new corporate strategies. There is still some way to go. We all have to adapt our skills and knowledge in a rapidly changing world. We are developing explicit country strategies for a number of developing countries. This makes WHO a central partner for bilateral agencies in the planning of their country strategies on health. We are delighted to share our knowledge with donor agencies, such as USAID to achieve the most effective use of donor money in achieving maximum improvements in health.

Mr Administrator, what then is the role of WHO in preventing and reducing poverty?

We recognize that poverty is multi-dimensional by nature and has several causes, including poor health, and several cures, including health status improvement. We see WHO's contribution to poverty reduction as the design and implementation of health policies, strategies and interventions, specifically designed to improve the health status of the poor.

WHO has to build and strengthen knowledge about the links between poverty and health, the mechanisms by which better health can reduce poverty, and those by which reduced poverty can improve health status.

This is one of the major elements of the work plan of our clusters on sustainable development and evidence and information for policy.

I am also establishing the Commission on Macroeconomics and Health. Under the chairmanship of Professor Jeffrey Sachs, this Commission will provide new and better evidence on the links between investments in health and economic growth and human development. The first meeting of the Commission will take place in Geneva in December.

We must also support Member States to incorporate effective health strategies into poverty reduction policies and practice through technical cooperation and advice.

In all these areas, we need to work with like-minded partners committed to poverty reduction. Together, we must analyse our current practices and not hesitate to modify policies and resource allocation of international development agencies and national governments towards "pro-poor" health policies, both within and outside the health sector.

Already, WHO has been asked to provide health input into the OECD Development Assistance Guidelines on effective poverty reduction programmes, and also into the European Union's new policies for human development.

We are also working with the IMF and the World Bank on how health funds can be best allocated and spent in countries receiving debt relief to ensure maximum impact on the poor.

But we must not fool ourselves, the poor are not only in poor countries. They are a very heterogeneous group, and each Member State of WHO has to be concerned with the widening inequalities in health and economic status between the rich and the poor, across countries, but also within their own country. Equity is a core value for WHO.

How then is WHO reforming its own internal approaches to face these health challenges?

We have organized a major structural change at Headquarters. We now have fewer directors, with clearer responsibilities, organized in clusters that reflect priorities of the Organization, and are headed by Executive Directors with real mandates and accountability. We have moved away from the fragmented Organization that sometimes appeared discordant to its partners, into a "one WHO", with one strategic budget, integrating all resources into one single document.

We have shifted resources towards our strategically important areas and made them more visible. Two cabinet projects have been set up - Roll Back Malaria and the Tobacco Free Initiative. New initiatives have also been developed in HIV/AIDS, tuberculosis, and blindness prevention. Of course, WHO is fully committed to accelerated efforts towards finishing polio eradication, and we are, as I mentioned earlier, starting the Global Alliance on Vaccines and Immunization with our partners.

We have placed large emphasis on partnerships - reaching out has became one of the key policies of WHO. We have strengthened our links with the IMF, the World Bank, the World Trade Organization, and our UN partners in UNICEF, UNFPA and UNDP. WHO has joined the UN Development Group for stronger field coordination. We have stepped up our partnership with bilateral cooperation agencies like USAID, which we consider partners, not just donors. We have organized roundtables with private sector industry and have undertaken several initiatives in partnership with corporations and foundations. We are working closely with scientific organizations and nongovernmental organizations.

We have also changed and simplified internal processes to increase WHO's performance level and accountability. New reporting mechanisms, fully linked with the budget, will provide our partners with a better view of how we work and what we achieve. We are developing an evaluation mechanism, which will involve both internal and external evaluators, and we are targetting our work plans towards specific and measurable outcomes.

The Cluster structure reflects our field of responsibilities and how we group them together, but it does not in itself say anything about our priorities and the direction for our work. To define these priorities and set the directions we are developing a "corporate strategy" encompassing the four strategic directions I referred to. This will more clearly articulate WHO's role in world health and give guidance to activities and resource allocation, while providing the conceptual and managerial glue to animate WHO's decentralized parts to be "one WHO." We will more clearly define WHO's comparative advantage, both globally and in countries, to define the functions we perform and how we work with others.

We still have some way to go to face some of our remaining challenges, such as integrating reconciling regional priorities with corporate strategic directions, linking this process with cooperation strategies in countries, and measuring corporate performance.

The changes that have taken place – and still are continuing – will make WHO an even better tool for its Member States. We also feel that our changes represent the best spirit of UN reform – a reform that genuinely improves our agency, breaks down barriers to effective action and reduces turf battles. The UN system must be an effective player on the international scene together with national governments and the private sector. We are striving to make WHO such a good player.

We are pleased that the US Government and USAID consider health-related programs to be such important areas of foreign assistance, central to USAID's mission to promote development and poverty reduction. Let us move into the future as partners. We can make a tremendous difference. I look forward to furthering and expanding this collaboration with USAID to make a lasting difference together in the lives of millions around the world.

Thank you.