Washington DC
18 April 2001

Fourth Meeting of the Global Roll Back Malaria Partnership

Ministers,

Mr Wolfensohn,

Ms Bellamy,

Colleagues,

I am very pleased to be with you here today. The challenge of Rolling Back Malaria has been dear to me since I started to prepare for my role as WHO's Director-General.

I start by reflecting on the changing context within which we are all working. There is increasing recognition by key decision makers - whether in government, in the private sector or in civil society - that healthy communities and societies are vital for the future development of nations and of our planet. Simply put, investing in health used to be seen as a luxury, to follow investing in energy, in transport or in defence. Now the health of a society is seen as one of the first pre-requisites for the development of its people.

Taken together, the facts tell us that differences in people's life expectancy and well-being are one of the most vivid signs of the divisions in our world. They are also one of the main causes of this divide.

When we talk about economic development of the poorest countries, improvements in health stand out as a key pre-requisite to progress.

When we talk about global trade, we cannot ignore the issues of access to life-saving medicines and technology at affordable prices.

When we talk about human security in our modern world, the global spread of diseases such as malaria, tuberculosis and HIV/AIDS form an important threat.

When we talk about the frontiers of technology and science, advances with potential impacts on health are dominating the picture.

When we talk about the environment that nurtures us, we worry about the consequences for our health of unsafe food and lifestyles, of pollution and of global warming.

This growing recognition that the health of societies and communities is important leads to a broader interest in global health issues.

I believe there are two reasons for this: The first is the growing realization of our common vulnerability to disease in a globalized world.

The second reason for increasing interest in health is the growing body of evidence linking ill health and the slow progress of economic development.

We know that communicable diseases - particularly HIV/AIDS, TB and malaria - are themselves major causes of poverty. The success or failure of our collective response to these threats is critical. It holds the key to the economic and physical security - not just of individuals and communities - but of nations and continents.

Last year I set up the WHO Commission on Macroeconomics and Health, chaired by Jeff Sachs. This will provide solid evidence for future action, based on sound economic analysis. The Commission has already assembled some powerful data. Quite simply, the devastating effect of ill health on the economic prospects of the world's poor communities has been under-estimated. Massively so.

Africa's GDP would be far greater than it is now if malaria had been tackled through political resolve 30 years ago, when effective control measures first became available.

There is no way the poorest countries will be able to achieve sustained economic development until we manage to stop the devastation caused by HIV/AIDS, malaria, TB and other conditions that cause poverty.

For these countries, health is the first and most important investment. Of course, it does not mean we should hold off investment in industries, infrastructure or education until these countries are less affected by ill health. It means that without new investments in health, many of the other efforts are unlikely to be effective or sustainable.

The key to driving back illnesses that cause poverty is straightforward: spend more, and spend it well. WHO estimates that no country can offer an effective basic healthcare to its population without spending at least $ 60 per person per year on health. Yet, most countries that suffer from widespread malaria, HIV/AIDS and other infectious diseases have less than $ 15 per person per year to spend on health. I recently heard the Minister of Health from Malawi, describing how changes in the value of the local currency have reduced planned government spending on drugs this year from $ 1.25 to just 75 cents per head.

How much more is needed?

In order to reach agreed targets for malaria, TB and HIV/AIDS, additional annual investments of $ 5-10 billion per year for at least fifteen years are called for. If that sounds a lot, it equals 0.04% of the combined GDP of the industrialized nations - the same nations which have pledged to spend 0.7% of their GDP on development assistance, but in recent years have reduced it to an average of less than 0.2%.

I am confident that finance will become available, though under quite tight conditions. That is why I have encouraged WHO staff, and colleagues within other UN agencies, to think ahead. Last year we asked ourselves "how would our work change if we were to catalyse a massive effort to improve health". After a period of intense and focused work, in all parts of the organization, we are now ready to respond to the challenges of scaling up; plan an unprecedented new push for health.

We will face some great challenges.

We will need to be disciplined in how we define our task. We must begin with a few central diseases and conditions: malaria, TB, HIV/AIDS, childhood diseases and conditions that cause maternal and infant deaths. Gradually - but still quickly, as health systems are strengthened and capacity increases, we need to widen the task towards other health priorities, such as the growing burden of noncommunicable diseases and mental illness, and the high level of injuries.

We must ensure equity. It is the poorest who suffer most from disease, yet, they are the hardest to reach. The middle classes in the cities, with their political clout, have always managed to skew health priorities towards their needs. We must ensure that health interventions are aimed at the poorest - whether they live in the slums of the cities or the rural outback.

We need to focus on diseases - yet, we cannot succeed unless we build up health systems. When we increase the funding tenfold or more, it will change the whole dynamic, which has pitched those working in disease-specific or so-called "vertical" programmes against those concerned with "sector-wide approaches". These are not competitive agendas. We must do both. And we must make sure that both local authorities and international donors agree on the priorities.

In short, we must focus on outcomes - not on structures, philosophies or ideologies. If we can show measurable reduction in disease within a reasonable period of time, we continue. If not, the funding stops. This is a new and - for many - tough approach to public health. But like any investor, governments and the private foundations and companies which will invest in this new push for health must be able to see a return on their investment.

We cannot expect there to be a single entity in control, directing others with military precision. We cannot expect another smallpox eradication campaign. Instead, the work will be taken forward by a variety of groups - government, private, or voluntary; faith based or secular; international and local; campaigning on behalf of others, or doing something themselves. This is where Roll Back Malaria sets the example - bound by common values and a well-understood concept, with partners knowing what has to be done and how to do it. RBM is characterised by rapid, flexible and decentralised decision making in ways that hold different groups together so that they can make the best use of investments to ensure effective action. They have shown an ability to do this even in countries with underdeveloped public sectors and weak health systems.

Colleagues,

Roll Back Malaria was launched in October 1998 by WHO, UNICEF, UNDP, and the World Bank in response to calls from heads of state and government. A broad range of partners has joined the movement. I know that many who wanted to be with us here today could not be invited for space reasons. It is a sign that the global partnership is healthy.

The movement has agreed the goal of halving the global malaria burden by the year 2010. It can be achieved, though much hard work will be needed. We do not speak only of reducing deaths and episodes of illness. Rolling back malaria is also about reducing the economic burden to countries.

We are all working in new ways to Roll Back Malaria, but what we do is firmly based on we have learned from past experience. Countries have taken on the hard work of doing analysis so that evidence-based solutions could be defined. They have changed their ways of working, to include non-traditional partners, such as non-governmental organizations and for-profit companies who can play a pivotal role in expanding countries' capacity to improve the delivery of goods and services.

We are now in a position to sketch out our future work, and this is one of the main objectives of the meeting.

The Country Partnerships formed to roll back malaria are the backbone of the movement. Governments are working with a wide range of partners to develop evidence-based strategic plans and plans of action. They respond to country needs and potential.

Eleven out of forty country partnerships in Africa are now implementing the plans that have been jointly elaborated. These plans, developed around a national consensus by all RBM stakeholders, reflect an agreement on how best to scale up the national and local response to malaria.

Partners at country level all pledged investments into these plans, thus sharing and endorsing the technical and institutional features of national strategies. There are budgetary gaps and global partners are invited to help ensure that those plans do not fail. Countries seek support through bilateral development assistance, though were there a multilateral facility for supporting Roll Back Malaria action, the resources would certainly be well used. This potential to support a country-developed effort is totally different from earlier top-down disease control blueprints.

The move towards a multilateral facility means that global partners pool their technical capacity and resources. They can help to scale up the response through backing for existing country strategies.

This is how Roll Back Malaria is an element of the new approach to international health that is starting to emerge. Not project-based aid, but a large scale international response to the expressed needs of countries and their people. It is built up from work with affected communities, with local organizations, with researchers and with campaigners.

We will undertake a global effort to find new cures for malaria, as drug resistance increases. During the working group session, the Medicines for Malaria Venture will be able to talk about their exciting plans to develop a new anti-malarial every 5 years.

The TDR programme participates in the Roll Back Malaria movement through working with the pharmaceutical industry to find ways of making combination drugs more accessible. The discussions last week in Norway should help us move forward on principles for increasing availability of patented medicines - including combination therapies - in low-income settings.

Combination therapy is not only useful for treating individual patients. It also slows the development of drug resistance. Its gametocidal action will also impact on malaria transmission. These additional public health benefits can be classed as public good externalities. Reducing the transmission and infection through effective drugs and insecticide treated materials has an impact on everyone. We cannot expect individual families to assume the total burden of paying for that public good. Indeed, if we were to leave the choice of an anti-malarial drug policy to market forces alone, which would strongly favour individual short term results in contrast to longer public health benefits, it is unlikely that the new combination anti-malarial therapies would ever be applied on a wide scale. The large scale introduction of combination therapies is clearly an area where innovative public-private partnerships will be key.

We have also seen development in efforts to prevent people being bitten by malaria-carrying mosquitoes. Five years ago, it was difficult to find a mosquito net in Africa for less than $ 10. Appropriate insecticides were hard to find. Insecticide treated nets for half that price are now available in many countries. The private sector has responded to the call of promoting these materials and has invested private capital into factories in many countries, Tanzania and Nigeria being two particular examples.

Last year in Abuja, the Heads of State committed their governments to reducing or waiving taxes and tariffs on net material and insecticides used in public health. To date, the number of countries who made good their Abuja commitment is small. Don't misunderstand me, the abolishing of taxes and tariffs on nets is not the only measure to ensure the wider utilisation of insecticide treated materials. But the action that has been taken clearly indicates governments' commitment to bold actions to prevent malaria.

The effort to Roll Back Malaria is also an initiative for strengthening health systems. Effective action to roll back malaria involves improving people's ability to access effective health care systems. This also means enabling more people to manage their health in the home. However, it is also our responsibility to make sure that shopkeepers and other private informal practitioners have the skills to identify severe disease for urgent referral to the formal health services.

We cannot forget the millions of people around the world living in countries severely affected by conflict. These people are often amongst the most vulnerable to malaria. Country partnerships in some of the worst affected situations have identified their capacity and needs and are already beginning to scale up ground level action.

Some RBM's country partnerships have significant participation of the private sector. Their motivation varies from country to country. Enlightened engagement by multinational corporations has resulted in plans going beyond the short term self interest of keeping a workforce healthy by addressing health needs of communities. Two recent examples from Eastern Europe and Africa exemplify this approach. Action taken by these countries clearly indicates their governments commitment to bold actions to prevent malaria, and I hope that other countries will follow their example in the near future

ExxonMobil has recently announced its commitment to country level partnerships in Angola, Cameroon, Chad, Equatorial Guinea and Nigeria. They are working with the government and with non-governmental partners to build and maintain new health care facilities in under served areas, to better treat not only malaria but also a range of other diseases.

Eni has continued its strong support to RBM in Azerbaijan and expanded its health investments now into areas in Africa.

I sense that the scale of this engagement and operation could still be significantly increased.

Colleagues,

It is right that we have taken the time to take stock, to define strategies and principles, to establish partnerships. But it is now time for more action, to deliver on our promises.

The global partnership needs resources to support country action, to back its advocacy and communication work, to promote the development of health systems to roll back malaria, to foster effective research and to measure outcomes.

I hope that at this meeting Global RBM partners will consider ways to commit the resources and support for effective and speedy implementation of the agreed national strategies. Local partnerships are key and must take the lead but they cannot do it alone: they need vital finance and infrastructure.

Partners also need the resources and support necessary to develop new tools and to make those that exist accessible to those who need them.

Thank you.