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Executive Board 107th session, Geneva, 15-22 January 2001: summary records

December 31, 2001 World Health Organization

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EB 107/200 l/REC/2

WORLD HEALTH ORGANIZATION

EXECUTIVE BOARD 107TH SESSION GENEVA, 15-22 JANUARY 2001

SUMMARY RECORDS

GENEVA 2001

EB 107/200 1/REC/2

WORLD HEALTH ORGANIZATION

EXECUTIVE BOARD 107TH SESSION GENE VA, 15-22 JANUARY 2001

SUMMARY RECORDS

GENEVA 2001

ABBREVIATIONS

Abbreviations used in WHO documentation include the following: - Administrative Committee on Coordination ACHR - Advisory Committee on Health Research ASEAN - Association of South-East Asian Nations CIOMS - Council for International Organizations of Medical Sciences ECA - Economic Commission for Africa ECE - Economic Commission for Europe ECLAC - Economic Commission for Latin America and the Caribbean ESCAP - Economic and Social Commission for Asia and the Pacific ESCWA - Economic and Social Commission for Western Asia FAO - Food and Agriculture Organization of the United Nations IAEA - International Atomic Energy Agency IARC - International Agency for Research on Cancer ICAO - International Civil Aviation Organization IFAD - International Fund for Agricultural Development ILO - International Labour Organization (Office) IMF - International Monetary Fund IMO - International Maritime Organization ITU - International Telecommunication Union ACC OAU OECD - Organization of African Unity - Organisation for Economic Co-operation and Development PAHO - Pan American Health Organization UNAIDS - Joint United Nations Programme on HIV/AIDS UNCTAD- United Nations Conference on Trade and Development UNDCP - United Nations International Drug Control Programme UNDP - United Nations Development Programme - United Nations Environment UNEP Programme UNESCO - United Nations Educational, Scientific and Cultural Organization UNFPA - United Nations Population Fund UNHCR - Office of the United Nations High Commissioner for Refugees UNICEF - United Nations Children's Fund UNIDO - United Nations Industrial Development Organization UNRWA - United Nations Relief and Works Agency for Palestine Refugees in the Near East US AID - United States Agency for International Development WFP - World Food Programme - World Intellectual Property WIPO Organization WMO - World Meteorological Organization WTO - World Trade Organization

The designations employed and the presentation of the material in this volume do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation "country or area" appears in the headings of tables, it covers countries, territories, cities or areas. - 11 -

PREFACE

The 107th session of the Executive Board was held at WHO headquarters, Geneva, from 15 to 22 January 2001. The proceedings are issued in two volumes. The present volume contains the summary records of the Board's discussions, list of participants and officers elected, and details regarding membership of committees and working groups. The resolutions and decisions and relevant annexes are issued in document EB107/2001/REC/1.

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CONTENTS

Page Preface .. .. .. .. .. .. ... . .. .. . .. .. .. .. .. . ... ... .. .. .. .. .. .. .. . .. . ... . .. .. .. .. .. . .. ... .. .. .. ... .. .. .. .. .... .. ... . ... .. .. . ... ... .. .. .. .. .. .. ... ... ... .. . Agenda............................................................................................................................................. List of documents . .. .. .. . .. .. .. .. ... ... . ... .. .. .. .. .. ... . .. .. .. .. .. .. . .. ... .. .. .. .. .. ... .. .. .... .. .. ... .. .. .. .. .. ... .. .. .. .. .. .. .. .. ... .... .. List of members and other participants .......................................................................................... . Committees and working groups..................................................................................................... n1 IX

x1n

SUMMARY RECORDS First meeting I. 2. Opening of the session and adoption of the agenda ............................................................. . Tribute to Professor Jean-Luc Mamdaba ............................................................................. . List of documents ................................................................................................................. . Report by the Director-General ............................................................................................ . Comments and questions ........................................................................................... . 17 17 17 18 21

3. 4.

Second meeting Technical and health matters Global strategy for infant and young child feeding .................................................... Health promotion .. .. ... . ... .. . .. ... . .. .. .. .. .. .. .. . ... .. .. .. .. ... .. ... ... .. ... .. .. ... .. .. .. .. ... .. .. .. .. .. ... ... . .... .. .

30 37

Third meeting I. 2. Expression of solidarity with the Salvadoran people ........................................................... . Technical and health matters (continued) Communicable diseases ............................................................................................. . • Global health security: epidemic alert and response .............................................. . • Control of schistosomiasis and soil-transmitted helminth infections ..................... . 42 42 42 50

-V-

Page

Fourth meeting Technical and health matters (continued) Health systems performance assessment..................................................................... • The world health report 2000 ........ .... .. .......... .... .................... .................................. • The world health report 2001 .. .................... ............................ .............. ............ ......

53 53 53

Fifth meeting Proposed programme budget for the financial period 2002-2003 General programme of work, 2002-2005 .................................................................... Overview ................................................................................. .. ..................................

63 65

Sixth meeting 1. 2. Procedure for technical briefings .......................................................................................... . Proposed programme budget for the financial period 2002-2003 (continued) Part 11. Strategic orientations 2002-2003 by areas of work ...................................... . Communicable diseases ................................................................................... . Noncommunicable diseases and mental health ................................................ . Family-and community health .......................................................................... . Sustainable development and healthy environments ...................................... .. Health technology and pharmaceuticals ........................................................... . Evidence and information for policy ................................................................ . External relations and governing bodies .......................................................... . General management. ....................................................................................... . 77 77 77 80 81 83 84 87 87 87

Seventh meeting Proposed programme budget for the financial period 2002-2003 (continued) Part 11. Strategic orientations 2002-2003 by areas of work (continued) General management (continued) .. .. .. .. .. .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. .. ...... .. .. .. .. .. .. ... Director-General, Regional Directors and independent functions.................... Country programmes......................................................................................... Aspects of financial management................................................................................ Approaches to cost increases and exchange rates............................................. Miscellaneous income....................................................................................... Allocation and utilization of extra budgetary resources during the biennium 1998-1999 by programme, region and country........................... Efficiency savings, 2000-2001, and management reviews...............................

89 89 90 91 91 91 92 93

Eighth meeting 1. Proposed programme budget for the financial period 2002-2003 (continued) Aspects of financial management (continued) Framework for programme evaluation ............................................................ . Technical and health matters (continued) Strengthening health services delivery: human resources .......................................... . Strengthening nursing and midwifery .............................................................. .

97 97

Page

Ninth meeting 1.

Technical and health matters (continued) Strengthening health services delivery (continued) Partnerships with nongovernmental health care providers ...................... ......... Procedure for technical briefings..........................................................................................

107 122

Tenth meetings 1. Financial matters................................................................................................................... Assessed contributions................................................................................................ Status of collection, including Members in arrears in the payment of their contributions to an extent that would justify invoking Article 7 of the Constitution ..... .............. ...................... ......... ....... ............................................. Special arrangements for settlement of arrears................................................. Casual income............................................................................................................. Real Estate Fund ... ........................................ ........................... .................... .... ........... Financial Rules............................................................................................................ Staffing matters Human resources Annual report.................................................................................................... Policy development.......................................................................................... Technical and health matters (continued) Health systems performance assessment (continued) .................... ........ ....... ............. . 123 123

123 124 126 126 127

129 131 13 5

Eleventh meeting 1. 2. 3. Tribute to the memory of Dr Charles Merieux.................... .................................................. Organization ofwork ............................................................................................................ Staffing matters (continued) Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service .................... .......................... Human resources (continued) Report ofthe International Civil Service Commission..................................... Confirmation of amendments to the Staff Rules ................. ................... .......... Collaboration within the United Nations system and with other intergovernmental organizations ...... .... .......................... .... ....... ...................... ....... ....... .... .. .. .... .. ... .. ..... ..... ..... .... Technical and health matters (continued) Communicable diseases (continued) • Control of schistosomiasis and soil-transmitted helminth infections (continued)... • Global health security: epidemic alert and response (continued)............................ Other management matters.................................................................................................... Reports of the Joint Inspection Unit........................................................................... Guidelines on working with the private sector to achieve health outcomes............... 142 142

143 148 148 149

150 151 155 155 155

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Page Twelfth meeting 1. Other management matters (continued) Guidelines on working with the private sector to achieve health outcomes (continued) ..... ......................... ................ ..... ... ....... ......... .... ................. ... ...... ............ .. Reports of the Executive Board Committees Nongovemmental organizations....................................................................... Awards.............................................................................................................. Other: Report of the Audit Committee of the Executive Board........................ Technical and health matters (continued) Reporting of information on the health of populations .. ............................................ . Other management matters (resumed) Governing body matters ........ ................... ........... ........................................................ Date and place ofthe 108th session ofthe Executive Board...................................... Matters for information Report on meetings of expert committees and study groups (including report on appointments to expert advisory panels and committees)........................................... Roll Back Malaria ................... ................. .. .. ........ ................... .... .............................. .. Making pregnancy safer.............................................................................................. Mental health 2001...................................................................................................... Eradication ~f poliomyelitis........................................................................................ HIV/AIDS ................................................................................................................... Framework convention for tobacco control .. .................................... .................. ........ Injection safety............................................................................................................ Technical and health matters (resumed) Global strategy for infant and young child feeding (continued)................................. Closure of the session............................................................................................................

157 163 163 164 166 169 171

2. 3.

173 173 175 175 177 177 177 180 181 185

5. 6.

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AGENDA 1

1. 2.

Opening of the session and adoption of the agenda Report by the Director-General o

Comments and questions

Technical and health matters 3.1 3.2 3.3 Global strategy for infant and young child feeding (decision WHA53(10)) Health promotion Communicable diseases o

Global health security: epidemic alert and response Control of schistosomiasis and soil-transmitted helminth infections

3 .4

Strengthening health services delivery o

Human resources2 Partnerships with nongovemmental health care providers

3.5 3.6

Reporting of information on the health ofpopulations Health systems performance assessment o

The world health report 2000 The world health report 2001

Proposed programme budget for the financial period 2002-2003

1 2

As adopted by the Board at its first meeting (15 January 2001). Including Strengthening nursing and midwifery (resolution WHA49.1).

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EXECUTIVE BOARD, 107TH SESSION

Financial matters 5.1 Assessed contributions o

Status of collection, including Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 of the Constitution Special arrangements for settlement of arrears

5.2 5.3 5.4 6.

Casual income Real Estate Fund Financial Rules

Staffing matters 6.1 Human resources o

Annual report Policy development Report of the International Civil Service Commission Confirmation of amendments to the Staff Rules

6.2

Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service

7. 8.

Collaboration within the United Nations system and with other intergovernmental organizations Other management matters 8.1 Reports of the Executive Board committees o

Nongovernmental organizations Awards Other

8.2 8.3 8.4

Reports of the Joint Inspection Unit Guidelines on working with the private sector to achieve health outcomes Governing body matters o

Method of work of the Health Assembly Future sessions -X-

AGENDA

Matters for information 9.1 Report on meetings of expert committees and study groups (including report on appointments to expert advisory panels and committees) Roll Back Malaria Making pregnancy safer Mental health 200 1 Eradication of poliomyelitis HIV/AIDS Framework convention on tobacco control Injection safety

9.2 9.3 9.4 9.5 9.6 9.7 9.8 10.

Closure of the session

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LIST OF DOCUMENTS

EB107/1 Rev.3 EB107/2

Agenda 1 Statement by the Director-General to the Executive Board at its 107th session Global strategy for infant and young child feeding Health promotion Global health security- epidemic alert and response Strengthening health services delivery: strengthening nursing and midwifery Partnerships with nongovemmental organizations Measuring and reporting on the health of populations Health systems performance assessment Status of collection of assessed contributions including Members in arrears to an extent which would justify invoking Article 7 of the Constitution Casual income Real Estate Fund2 Financial Rules3 Human resources: annual report, 2000 Human resources: policy development: confirmation of amendments to the Staff Rules4 Report of the International Civil Service Commission5

EB107/3 EB107/4 EB 107/5 and Corr.I EB107/6 EB107/7 EB107/8 EB107/9 EB107/10

EB107/11 EB107/12 EB107/13 EB107/14 EB107115 and Add.l

EB107/16 and Add.l

1 2

See page ix. See document EBl07/2001/REC/I, Annex I. See document EBI07/2001/REC/I, Annex 2. See document EB 107/2001/REC/1, Annex 3. See document EBl07/2001/REC/l, Annex 4.

3 4

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EXECUTIVE BOARD, 107TH SESSION

EB107117 EB 107118 and Add .I

Confirmation of amendments to the Staff Rules 1 Collaboration within the United Nations systems and with intergovernmental organizations other

EB107/19

Collaboration with nongovernmental organizations: report of the Standing Committee on nongovernmental organizations2 Guidelines on working with the private sector to achieve health outcomes Governing body matters: method of work of the Health Assembly Provisional agenda for the Fifty-fourth World Health Assembly Injection safety Report on meetings of expert committees and study groups ~eport on expert advisory panel and committees and their membership Roll Back Malaria Making pregnancy safer Mental health 2001 Eradication of poliomyelitis HIV/AIDS Framework convention on tobacco control Communicable diseases: control of schistosomiasis and soil-transmitted helminth infections Reports of the Joint Inspection Unit Special arrangements for settlement of arrears General programme of work, 2002-2005 Governing body matters: report by the Chairman of the Executive Board

EB107/20 EB107/21 EB107/22 EB107/23 EB 107/24 and Add.1

EB107/25 EB 107/26 and Corr.l EB107/27 EB107/28 EB107/29 EB107/30 EB107/31

EB107/32 EB107/33 EB107/34 EB107/35 Rev.l

1 2

See document EBI07/2001/REC/1, Annex 5. See document EB107/2001/REC/1, Annex 6.

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LIST OF DOCUMENTS

Information documents EB I 07/INF .DOC ./I EB I 07/INF .DOC ./2 EB I 07/INF .DOC./3 EB107/1NF.DOC./4 EBI07/INF.DOC./5 EB107/INF.DOC./6 and Corr.l EB 107/INF .DOC./7 Approaches to cost increases and exchange rates Efficiency savings 2000-2001 and management reviews Framework for programme evaluation Use of extrabudgetary allocations Miscellaneous income Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service Global health security - epidemic alert and response: Revision of the International Health Regulations Proposed programme budget for 2002-2003 Proposed programme budget for 2002-2003

EB I 07/INF .DOC ./8 EB I 07/INF .DOC .19

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LIST OF MEMBERS AND OTHER PARTICIPANTS

MEMBERS, ALTERNATES AND ADVISERS CHILE

Dr. J. JIMENEZ DE LA JARA, Profesor Auxiliar, Facultad de Medicina, Departamento de Salud Publica, Santiago (Chairman) Alternate Sr. F. ERNST, Primer Secretario, Misi6n Permanente, Ginebra

BANGLADESH

Professor S.M. ALl, Director, National Institute of Ophthalmology, Sher-e-Bangla-Nagar, Dhaka (Rapporteur) Alternate Mr M.S. Rahman, Counsellor, Permanent Mission, Geneva

BELGIUM

Dr G. TRIERS, Directeur, Institut scientifique de la Sante publique- Louis Pasteur, Bruxelles (Vice-Chairman) Alternates M. J.-M. NOIRFALISSE, Ambassadeur, Representant permanent, Geneve Mme G. ZIKMUNDOV A, Attachee, Mission permanente, Geneve M. A. BERWAERTS, Directeur general, Ministere federal des Affaires sociales, de la Sante publique et de l'Environnement, Service des Relations intemationales, Bruxelles M. J. DAMS, Representant du Ministre de la Communaute flamande, Adjoint au Directeur de I' Administration des So ins de Sante, Bruxelles. M. P. NAYER, Delegue, Communaute fran<;aise Wallonie-Bruxelles, Geneve Mme P. MEGAL, Conseiller adjoint, Ministere federal des Affaires sociales, de la Sante publique et de l'Environnement, Service des Relations intemationales, Bruxelles Mme V. SIEBRAND, Conseiller adjoint, Ministere federal des Affaires sociales, de la Sante publique et de l'Environnement, Service des Relations intemationales, Bruxelles

BRAZIL

Professor J. YUNES, Professor, Public Health Faculty, University of Sao Paulo, Sao Paulo Alternates Mr A. DE AGUIAR PATRIOTA, Minister Counsellor, Permanent Mission, Geneva Mr F.S. DUQUE ESTRADA MEYER, Minister Counsellor, Permanent Mission, Geneva Ms D. COSTA COITINHO, Coordinator of the Technical Area of Food and Nutrition, Secretariat of Health Policies, Bras ilia - 1-

EXECUTIVE BOARD, 107TH SESSION

Mr J. BERMUDEZ, Coordinator of the Pharmaceutical School Assistance Body, National School of Public Health FIOCRUZ, Rio de Janeiro Mr C. SALM, Assistant to the Minister of Health, Brasilia Ms C. LAND MAN SZWARCWALD, National School of Public Health FIOCRUZ, Rio de Janeiro Mr J. GON<;ALVES VALENTE, National School of Public Health FIOCRUZ, Rio de Janeiro Ms C. TRAVASSOS, National School of Public Health FIOCRUZ, Rio de Janeiro Ms M. REA, Health Secretariat of Sao Paulo, Sao Paulo Mr J. BARBOSA, Director, National Epidemiologic Centre, National Health Foundation, Bras ilia Mr J.M. NOGUEIRA VIANA, First Secretary, Head, International Affairs Division, Ministry of Health, Brasilia Mr F. COSTI SANTAROSA, Second Secretary, Permanent Mission, Geneva Dr P.R. TEIXEIRA, Coordinator of STD/AIDS, Health Policies Secretariat, Ministry of Health, Bras ilia Mr G.J. CANNON, Consultant in Food and Nutrition Technical Area, Health Policies Secretariat, Ministry of Health, Bras ilia

CAPEVERDE Dr J.B. FERREIRA MEDINA, Ministre de la Sante et de la Promotion sociale, Ministere de la Sante et de la Promotion, Praia

CENTRAL AFRICAN REPUBLIC Dr G. N'GAINDIRO, Secretaire general, Ministere de la Defense, Bangui

CHAD Dr M. E. MBAIONG, Directeur general adjoint, Ministere de la Sante publique, N'Djamena (Vice-Chairman)

CHINA Mr LIU Peilong, Director-General, Department of International Cooperation, Ministry of Health, Beijing (Vice-Chairman) Alternates Dr QI Qingdong, Director, Division of Multilateral Relations, Department of International Cooperation, Ministry of Health, Beijing Mr HOU Zhenyi, Counsellor, Permanent Mission, Geneva Advisers Ms LIU Guangyuan, Assistant Consultant, Division of Multilateral Relations, Department of International Cooperation, Ministry of Health, Beijing Ms LI Hui, Associate Researcher, Capital Pediatrics Institute, Beijing

MEMBERS AND OTHER PARTICIPANTS

COMOROS Dr A. MSA MLIV A, Directeur general de la Sante, Ministerere de la Sante publique et de la Population, Moroni

CONGO Dr D. BODZONGO, Directeur general de la Sante, Ministere de la Sante, de la Solidarite et de 1' Action humanitaire, Brazzaville Alternates M. R.J. MENGA, Ambassadeur, Representant permanent, Geneve M.P.H. KENGOUYA, Conseiller administratif etjuridique du Ministre de la Sante, de la Solidarite et de l' Action humanitaire, Brazzaville Mme D. BIKOUTA, Premier Conseiller, Mission permanente, Geneve

COTE D'IVOIRE Professeur J.A. NAMA-DIARRA, Directeur de l'Institut national de la Sante publique, Abidjan (alternate to Professor R. ABOUO N'DORI), Alternates M. C. BEKE DASSYS, Ambassadeur, Representant permanent, Geneve M. J.K. WEYA, Premier Conseiller, Mission permanente, Geneve Dr K. COULIBALY, Abidjan

DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA Dr KIM Won Ho, Policy Adviser, Ministry of Health, Pyongyang Alternates Mr CHOE 11, Counsellor, Ministry of Foreign Affairs, Pyongyang Mr JANG Chun Sik, Counsellor, Permanent Mission, Geneva

EQUATORIAL GUINEA Dr S. ABIA NSENG, Director General de Salud Publica y Planificaci6n, Malabo

FRANCE Professeur J.-F. GIRARD, Conseiller d'Etat, Paris Alternates Professeur L. ABENHAIM, Director general de la Sante, Ministere de l'Emploi et de la Solidarite, Paris M. P. PETIT, Ambassadeur, representant permanent, Geneve Mme F. VARET, Chef de la Division du Developpement sanitaire et social, Direction generale de la Cooperation internationale et du Developpement, Paris Dr M. JEANFRAN<;OIS, Delegation aux Affaires europeennes et internationales, Ministere de 1'Emploi et de la Solidarite, Paris

EXECUTIVE BOARD 107TH SESSION

Dr R. LEFAIT-ROBIN, Delegation aux Affaires europeennes et internationales, Ministere de I'Emploi et de la Solidarite, Paris Mme M.-C. COENT, Delegation aux Affaires europeennes et internationales, Ministere de l'Emploi et de la Solidarite, Paris Mme J. HARARI-ANTOURVILLE, Direction generale de la Sante, Ministere de I'Emploi et de la Solidarite, Paris M. F. SAINT-PAUL, Representant permanent adjoint, Mission permanente, Geneve M. J.-C. TALLARD-FLEURY, Direction des Nations Unies, Ministere des Affaires etrangeres, Paris M. H. GARRIGUE, Conseiller militaire adjoint charge des Questions biologiques, Mission permanente, Geneve Mme M. BOCCOZ, Conseiller, Mission permanente, Geneve

GUATEMALA Or R. CABRERA MARQUEZ, Viceministro de Salud Publica y Asistencia Social, Ciudad de Guatemala Alternates Sr. A. ARENALES FORNO, Embajador, Representante Permanente, Ginebra Sr. I. ESPINOZA FARF AN, Ministro Consejero, Misi6n Permanente, Ginebra Srta. S. HOCHSTETTER SKINNER-KLEE, Segundo Secretario, Misi6n Permanente, Ginebra

INDIA Mr J. A. CHOWDHURY, Secretary, Health and Family Welfare, New Delhi Alternates Ms S. KUNADI, Ambassador, Permanent Representative, Geneva Dr S.P. AGGARWAL, Director-General of Health Services, New Delhi MrS. SABHARWAL, Deputy Permanent Representative, Geneva Mr K. TUHIN, First Secretary, Permanent Mission, Geneva

IRAN (ISLAMIC REPUBLIC OF) Dr B. SADRIZADEH, Senior Adviser, Ministry of Health and Medical Education, Teheran

ITALY Dr M. DI GENNARO, Secretaire generale, Conseil superieur de la Sante, Rome Alternates Dr G. MAJORI, Directeur, Laboratoire de Parasitologie, Institut superieur de Sante, Rome Or F. CICOGNA, Conseiller, Service des Relations internationales, Ministere de la Sante, Rome Dr E. MISSONI, Conseiller en Sante, Directorat general pour la Cooperation au Developpement, Ministere des Affaires etrangeres Dr N. QUINTA VALLE, Conseiller, Mission permanente, Geneve

MEMBERS AND OTHER PARTICIPANTS

JAPAN

Or H. SHINOZAKI, Director-General, Health Service Bureau, Ministry of Health, Labour and Welfare, Tokyo Alternates Mr 0. TASAKA, Director, International Cooperation Office, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo Mr M. WATANABE, Counsellor, Permanent Mission, Geneva Or H. ENDO, Director, International Cooperation Office, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo Mr A. BEPPU, Counsellor, Permanent Mission, Geneva Advisers Or M. SAKOI, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo Mr A. YOKOMAKU, First Secretary, Permanent Mission, Geneva Dr I. TSUNOI, Deputy Director, International Affairs Office, International Affairs, Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo MrS. HEMMI, Deputy Director, Division of Health for the Elderly, Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare, Tokyo Dr G. UCHIDA, Technical Officer, Management Guidance Division, Department ofNational Hospitals, Health Service Bureau, Ministry of Health, Labour and Welfare, Tokyo

JORDAN

Dr S. AL KHARABSEH, Director-General, Primary Health Care, Ministry of Health, Amman (alternate to Dr T.S. Suheimat) Alternate Dr M. KASSEM, Head, International Health, Ministry of Health, Amman

LAO PEOPLE'S DEMOCRATIC REPUBLIC

Dr Ponmek DALALOY, Ministre de la Sante publique, Vientiane

LEBANON

Dr K. KARAM, Minister of Tourism, Beirut

LITHUANIA

Or V.J. GRABAUSKAS, Rector ofKaunas Medical University, Kaunas

QATAR

Dr K. A. AL-JABER, Director, Department of Preventive Medicine, Ministry ofPublic Health, Doha

EXECUTIVE BOARD, 107TH SESSION

RUSSIAN FEDERATION Dr N. N. FETISOV, Director, International Relations Department, Ministry of Health, Moscow (alternate to Professor Y. L. Shevtchenko) Alternate Mr R. A. KOLODKIN, Deputy Permanent Representative, Geneva Advisers Dr S.M. FURGAL, Deputy Director, International Relations Department, Ministry of Health, Moscow Mr O.A. NOVIKOV, Counsellor, Department oflnternational Organizations, Ministry of Foreign Affairs, Moscow Dr V .K. RIAZANTSEV, Chief of the Division, International Relations Department, Ministry of Health, Moscow Professor A.V. KARAULOV, Head of the Chair, Sechenov Medical Academy, Moscow Mr R.J. ALYAUTDINOV, Counsellor, Permanent Mission, Geneva Mr P.G. CHERNIKOV, Counsellor, Permanent Mission, Geneva Dr A.V. PAVLOV, Counsellor, Permanent Mission, Geneva Mr V.P. KOVALENKO, Counsellor, Permanent Mission, Geneva Mr V.V. TSOTSOV, Third Secretary, Permanent Mission, Geneva Dr R.V. GRISHCHENKO, Attache, Permanent Mission, Geneva

SWEDEN Ms K. WIGZELL, Director-General, National Board of Health and Welfare, Stockholm Alternates Mr J. MOLANDER, Ambassador, Permanent Representative, Geneva Ms A.-C. FILIPSSON, Director, Special Expert, Ministry of Health and Social Affairs, Stockholm Dr A. MOLIN, Senior Programme Officer, Swedish International Development Authority MrS. ZAVISIC, Head of Division, Ministry ofHealth and Social Affairs, Stockholm Mr I. SUNDQUIST, Counsellor, Permanent Mission, Geneva Ms P. STAVAS, First Secretary, Permanent Mission, Geneva Ms B. SCHMIDT, Administrative Director, National Board of Health and Welfare, Stockholm

SWITZERLAND Professeur T. ZELTNER, Directeur, Office federal de la Sante publique, Berne Alternates Dr R. DURLER, Chef, par interim, Section des Affaires internationales, Office federal de la Sante publique, Departement federal de l'Interieur, Berne Dr M. BERGER, Conseiller Special (Sante), Mission permanente, Geneve M. R. VONOVIER, Premier Secretaire, Mission permanente, Geneve

TRINIDAD AND TOBAGO Dr R. EDWARDS, Chief Medical Officer, Port-of-Spain (alternate to Dr H. Rafeeq) Alternates Ms M.-A. RICHARDS, Deputy Permanent Representative and Charge d'Affaires a.i., Geneva Ms L. BOODHOO, First Secretary, Permanent Mission, Geneva

MEMBERS AND OTHER PARTICIPANTS

UNITED STATES OF AMERICA Dr T. NOVOTNY, Deputy Assistant Secretary for International and Refugee Health, Department of Health and Human Services, Rockville, Maryland Alternates Ms A. BLACKWOOD, Director for Health Programmes, Bureau oflnternational Organization Affairs, Department of State, Washington, D.C. Mr E. SONDIK, Director, National Centre for Health Statistics, Centres for Disease Control and Prevention, Department of Health and Human Services, Hyattsville, Maryland Ms M.L. V ALDEZ, Associate Director for Multilateral Affairs, Office of International and Refugee Health, Office of Public Health and Science, Department of Health and Human Services, Washington, D.C. Mrs L.A. VOGEL, International Health Attache, Permanent Mission, Geneva Advisers Mr D.E. HOHMAN, Director, Office oflnternational Affairs, Office of the Secretary, Department of Health and Human Services, Rockville, Maryland Mrs K. JOHNSON, Political Officer (Budget), Permanent Mission, Geneva Dr G. MEYER, Director, Centre for Quality, Measurement and Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland Ms P. STEPHENSON, Senior Adviser in Mother and Child Health and Nutrition, Bureau of Global Programmes, Agency for International Development, Washington, D.C.

VANUATU Mrs M. Abel, Director of Public Health, Ministry of Health, Port Vila (Rapporteur)

VENEZUELA Dra. A. ABREU CATALA, Directora General de Cooperaci6n Tecnica y Relaciones Internacionales, Ministerio de Salud y Desarrollo Social, Caracas (alternate to Dr G. Rodriguez Ochoa) Alternates Dra. N. LOPEZ, Directora General de Epidemiologia y Amilisis Estrategico, Ministerio de Salud y Desarrollo Social, Caracas Sr. R. SALAS CASTILLO, Segundo Secretario, Misi6n Permanente, Ginebra

YEMEN Dr A. 0. AL-SALLAMI, Under-Secretary for Pharmaceuticals, Ministry of Public Health, Sana'a

GOVERNMENT REPRESENTATIVES ATTENDING BY VIRTUE OF RULE 3 OF THE RULES OF PROCEDURE

Agenda item 2: Report by the Director-General Mr H. Selim-Labib, First Secretary, Permanent Mission, Geneva Egypt

EXECUTIVE BOARD, 107TH SESSION

Mr H. Waxman, First Secretary, Permanent Mission, Geneva

Israel

Agenda item 3.6: Health systems performance assessment Ms J. Bennett, Assistant Secretary, Department of Health and Aged Care, Canberra Dr. F. Antezana, Ministerior de Salud y Previsi6n Social, La Paz Dr J. Frenk Mora, Secretario de Salud, Ciudad de Mexico Mr S.G. Nene, Ambassador, Permanent Representative, Geneva Dr T. Stamps, Minister of Health and Child Welfare, Harare

Australia Bolivia Mexico South Africa Zimbabwe

Agenda item 4: Proposed programme budget for the financial period 2002-2003 Mr H. Selim-Labib, First Secretary, Permanent Mission, Geneva Dr T. Stamps, Minister of Health and Child Welfare, Harare Egypt Zimbabwe

Agenda item 8.4: Governing body matters Mr S.A.O. Hussain, Counsellor, Permanent Mission, Geneva Mr D.K. Johns, Counsellor (Health Affairs), Permanent Mission, Geneva Mr D. Ristic, Minister Counsellor, Permanent Mission, Geneva Iraq South Africa Yugoslavia

REPRESENTATIVES OF THE UNITED NATIONS AND RELATED ORGANIZATIONS United Nations MrS. KHMELNITSKI, External Relations and Inter-Agency Affairs Officer, Geneva Ms M. TEBOURBI, Human Rights Officer, Office of the High Commissioner for Human Rights

United Nations Development Programme Mr E. Bonev, Senior Adviser, UNDP Office in Geneva United Nations Environment Programme Mr J.B. WILLIS, Director, UNEP Chemicals, International Environment House, Geneva Mr S. MILAD, UNEP Chemicals, International Environment House, Geneva

United Nations Children's Fund Dr A. EL ABASSI, Senior Project Officer

United Nations Population Fund United Nations Conference on Trade and Development Mr R. URANGA, Senior Economic Affairs Officer, Division for Services Infrastructure for Development and Trade Efficiency Mr A.L. MACDONALD, Director, UNFPA Office, Geneva Mr E. PALSTRA, Senior External Relations Officer, UNFPA Office, Geneva Dr A.M. PETITGIRARD, Consultant, UNFPA Emergency Relief Operations, Geneva

MEMBERS AND OTHER PARTICIPANTS

Ms E. ORZECHOWSKA, Consultant, UNFPA Office, Geneva MrS. KOLEV, Consultant, UNFPA Office, Geneva

World Food Programme Dr M. MOKBEL, WFP Liaison Officer to WHO, Geneva

United Nations Relief and Works Agency for Palestine Refugees in the Near East Dr F. MOUSSA, Director of Health

UNAIDS Dr P. PlOT, Executive Director Ms K. CRAVERO, Deputy Executive Director Ms J. CLEVES, Chief, Office of the Executive Director

Mr M. BARTOS, Policy Analyst and Speech Writer, Office of the Executive Director Dr A.-M. COLL-SECK, Director, Department of Policy, Strategy and Research Mr J. SHERRY, Director, Programme Development and Coordination Group Mr 0. ELO, Director, Department of Country Planning and Programme Development Mr E. HAARMAN, Manager, Finance and Administration Ms J. GIRARD, Manager Human Resources Mrs R. CHAHIL-GRAF, Manager, Governance and United Nations System Ms M.-0. EMOND, External Relations Officer Ms L. NIEMINEN-SOLA, External Relations Officer

SPECIALIZED AGENCIES International Labour Organization Ms G. ULLRICH, Sectoral Activities Department Dr S. NIU, In Focus Programme on Safe Work

World Bank Mr J.C. LOVELACE, Director, Health Nutrition and Population

Food and Agriculture Organization of the United Nations Mr T.N. MASUKU, Director, FAO Liaison Office with the United Nations, Geneva Ms N. BRANDSTRUP, Liaison Officer, FAO Liaison Office with the United Nations, Geneva

United Nations Industrial Development Organization Ms E. MERZ, Liaison Office, UNIDO Office at Geneva

International Atomic Energy Agency Ms J. KNESI, IAEA Liaison Office, Geneva

United Nations Educational, Scientific and Cultural Organization Mme A. CASSAM, Directrice du Bureau de Liaison de L'UNESCO, Geneve

REPRESENTATIVES OF OTHER INTERGOVERNMENTAL ORGANIZATIONS League of Arab States M. S. ALF ARARGI, Ambassadeur, Observateur permanent, Geneve M. M.L. MOUAKI, Conseiller, Delegation permanente, Geneve Dr 0. EL HAJJE, Delegation permanente, Geneve

EXECUTIVE BOARD, 107TH SESSION

Organization of African Unity Mrs S.A. KALINDE, Permanent Observer, Geneva Mr V. WEGE-NZOMWITA, Deputy Permanent Observer, Geneva

M. G. THINUS, Direction generate de la Sante et de la Protection du Consommateur, Commission europeenne, Bruxelles M. C. DUFOUR, Attache, Delegation permanente de la Commission europeenne

European Commission M. F. SAUER, Directeur, Direction generate de la Sante et de la Protection du Consommateur, Commission europeenne, Bruxelles M. B. MERKEL, Direction generate de la Sante et de la Protection du Consommateur, Commission europeenne, Bruxelles

Health Ministers' Council for Gulf Cooperation Council States Dr H. GADALLAH

Commonwealth Secretariat Ms J. PARRIS, Acting Head, Health Department

REPRESENTATIVES OF NONGOVERNMENTAL ORGANIZATIONS IN OFFICIAL RELATIONS WITH WHO CMC- Churches' Action for Health DrM.KURIAN Mrs R. BONNER Mrs B. VON DER WElD

Inter-Parliamentary Union Council for International Organizations of Medical Sciences Dr J.E. IDANPAAN-HEIKKILA Mr S.S. FLUSS Dr J. GALLAGHER Mr S. TCHELNOKOV

International Alliance of Women Ms G. HAUPTER MrsM.PAL

Council on Health Research for Development MrY.NUYENS

International Association for Maternal and Neonatal Health Mrs G.M. SANTSCHI

FDI World Dental Federation DrJ. MONNOT

Industry Council for Development DrD.JONAS

International Association of Agricultural Medicine and Rural Health Dr A.V. PATIL Dr A. WOJTYLA

Inter-African Committee on Traditional Practices affecting the Health of Women and Children Mrs B. RAS-WORK Mrs M. GREUTER

International Association of Lions Clubs (Lions Club International) MrG.E. CANTAFIO

MEMBERS AND OTHER PARTICIPANTS

International Clearinghouse for Birth Defects Monitoring Systems DrE. ROBERT

International Federation of Medical Students Associations MrS. SAPKOTA Ms J.T.M. TROON MrO. SAKA MrY.GOEDBLOED

International College of Surgeons Professor P.B. HAHNLOSER

International Confederation of Midwives Ms P. TEN HOOPE-BENDER MsR.BRAUEN MsJ.BONNET

International Federation of Pharmaceutical Manufacturers Associations Dr H.E. BALE, Jr Dr E. NOEHRENBERG DrD. WEBBER Dr 0. MORIN CARPENTIER MsS.DOUCET

International Consultation on U rological Diseases Professor S. KHOURY

International Federation of Surgical Colleges Professor S.W. GUNN Professor M. MASELLIS Dr K.-0. SUNDNES

International Council of Nurses Dr J .A. OULTON Dr T. GHEBREHIWET Mrs L. CARRIER-WALKER

International Hospital Federation MrB.GRUSON MrsP.DEVOS

International Council of Women Mrs P. HERZOG

International Cystic Fibrosis (Mucoviscidosis) Association Mr H.J. WEGGEN Professor J. DODGE Mrs L. HEIDET

International Lactation Consultant Association Ms M. LEHMANN-BURI Ms J. THOMANN LEMANN

International Epidemiological Association Dr R. SARACCI

International Organization of Consumers Unions (Consumers International) MsA.ALLAIN Ms B. BATIONO Ms B. FIENIENG DrA. GUPTA Dr K. COULIBALY Ms A. LINNECAR Ms E. PETITAT-COTE Ms P. RUNDALL Professor A. SEGALL HELENO CORREA Ms M. MORSINK MsM.EWEN MrJ.LOVE MsL. HAYES

International Federation of Gynecology and Obstetrics DrS.NAZEER

International Federation of Hydrotherapy and Climatotherapy Professor U. SOLIMENE ProfessorS. SERRANO

EXECUTIVE BOARD, 107TH SESSION

MsE. 'tHOEN Mr B. V AN DER HEIDE Ms N. DENTICO MrB.MISRA

International Union ofPharmacology Professor F. SJOQVIST

La Leche League International International Pharmaceutical Federation Mr P. KIELGAST MrT.HOEK MsD.GAL Ms L. McCLURE Ms G. LAVIOLLE Mr V. JIRASKOVA

Medicus Mundi Internationalis (International Organization for Cooperation in Health Care) DrT. PULS DrE. WIDMER

International Society for Preventive Oncology Professor H.E. NIEBURGS Professor L. SANTI

Organisation pour la Prevention de la Cecite Professor Y. POULIQUEN

International Society of Doctors for the Environment Dr G. SILBERSCHMIDT

Save the Children Fund (UK) Ms J. GOODWIN Ms E. STEVENS

International Special Dietary Foods Industries Dr A. BRONNER Mr A. MICARDI Mr M. DE SKOWRONSKI MrK.DEJONG MrJ. KEITH Mr N. CHRISTIANSEN Ms H. MOUCHLY WEISS Mr L.C. DELGADO Ms C. DROTZ-JONASSON Ms H. ENGQVIST Mr D. SPIEGEL Mr LUONG V AN MY THIEN Ms S.JACOBS Ms N. CHEPYZHOV A Ms K. BOLOGNESE

Soroptimist International Mrs I. TORSSONEN Mrs I.S. NORDBACK

The Network: Community Partnerships for Health through Innovative Education, Service, and Research DrP. KEKKI

World Association of Girl Guides and Girl Scouts Miss L. SCHURCH Miss S. SCHAFFSTEIN

International Union against Cancer Dr S. KVINNSLAND Ms I. MORTARA International Union against Tuberculosis and Lung Disease Mr A. OLUW AFEMI Mr R. NAV ARRO Mr J. SHARMAN

World Federation for Medical Education DrH. KARLE

World Federation for Mental Health DrS.FLACHE

MEMBERS AND OTHER PARTICIPANTS

World Federation of Occupational Therapists MrsA.DIDAY Ms P. SCHARPF

World Hypertension League Dr T. STRASSER

World Federation of Public Health Associations DrT.ABELIN MsJ.GUNBY

World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians Dr I. HELLEMANN

World Self-Medication Industry Dr J.A. REINSTEIN

World Federation of United Nations Associations Dr L. CIAFFEI MrM. WEYDERT Dr M. VIOLAKI PARASKEV A Dr J.W. STEINBART

World Vision International OrE. RAM MsK. MULVEY Mr S. MOODLIAR

World Heart Federation MsJ. VOUTE

COMMITTEES AND WORKING GROUPS

Programme Development Committee

Dr J.B. Ferreira Medina (Cape Verde), Dr M.E. Mbaiong (Chad, member ex officio), Mr J.A. Chowdhury (India), Dr Ponmek Dalaloy (Lao People's Democratic Republic), Dr K.A. Al-Jaber (Qatar), Ms K. Wigzell (Sweden), Dr T. Novotny (United States of America) Seventh meeting, 11-12 January 2001: Mr J.A. Chowdhury (India, Chairman), Dr M.E. Mbaiong (Chad, member ex officio), Dr Ponmek Dalaloy (Lao People's Democratic Republic), Dr K.A. Al-Jaber (Qatar), Ms K. Wigzell (Sweden), Dr T. Novotny (United States of America)

Administration, Budget and Finance Committee

Dr G. Thiers (Belgium, member ex officio), Dr A. Msa Mliva (Comoros), Dr Kim Won Ho (Democratic People's Republic of Korea), Dr R. Cabrera Marquez (Guatemala), Dr H. Shinozaki (Japan), Dr K. Karam (Lebanon), Professor T. Zeltner (Switzerland) Fourteenth meeting, 10-11 January 2001: Professor T. Zeltner (Switzerland, Chairman), Dr G. Thiers (Belgium, member ex officio), Dr Kim Won Ho (Democratic People's Republic of Korea), Dr R. Cabrera Marquez (Guatemala), Dr H. Endo (Japan, alternate to Dr H. Shinozaki)

Audit Committee

Mr Luo Meifu (China, alternate to Mr Liu Peilong), Dr J. Jimenez de la Jara (Chile, member ex officio), Mr P.H. Kengouya (Congo, alternate to Dr D. Bodzongo), Mr G.R. Patwardhan (India, alternate to Mr J.A. Chowdhury), Mr V. Vislykh (Russian Federation, alternate to Professor Y.L. Shevtchenko), Mr J. Payne (United States of America, alternate to Dr T. Novotny), DrN.N. Al-Aji (Yemen, alternate to Dr A.O. Al-Sallami) Third meeting, 10 January 2001: Mr J. Payne (United States of America, Chairman, alternate to Dr T. Novotny), Mr Luo Meifu (China, alternate to Mr Liu Peilong), Dr J. Jimenez de la Jara (Chile, member ex officio), Mr P.H. Kengouya (Congo, alternate to Dr D. Bodzongo), Mr G.R. Patwardhan (India, alternate to Mr J.A. Chowdhury), Mr V. Vislykh (Russian Federation, alternate to Professor Y.L. Shevtchenko), Dr N.N. Al-Aji (Yemen, alternate to Dr A.O. Al-Sallami)

Standing Committee on Nongovernmental Organizations

Professor S.M. Ali (Bangladesh), Dr G. N'gaindiro (Central African Republic), Dr B. Sadrizadeh (Islamic Republic oflran), Dr M. Di Gennaro (Italy), Dr A. Abreu Catala (Venezuela, alternate to Dr G. Rodriguez Ochoa) - 15-

EXECUTIVE BOARD, 107TH SESSION

Meeting of 16 January 2001: Dr N'gai"ndiro (Central African Republic, Chairman), Professor S.M. Ali (Bangladesh), Dr B. Sadrizadeh (Islamic Republic of Iran), Dr M. Di Gennaro (Italy), Dr A. Abreu Catahi (Venezuela, alternate to Dr G. Rodriguez Ochoa).

Leon Bernard Foundation Committee

The Chairman and Vice-Chairmen of the Executive Board, and Professor J.-F. Girard (France)

Meeting of 17 January 2001: Dr J. Jimenez de la Jara (Chile, Chairman), Dr G. Thiers (Belgium), Dr M.E. Mbaiong (Chad), Professor J.-F. Girard (France)

Sasakawa Health Prize Selection Panel

The Chairman ofthe Executive Board, a representative ofthe founder, and Mrs M. Abel (Vanuatu)

Meeting of 19 January 2901: Dr J. Jimenez de la Jara (Chile, Chairman), Professor K. Kiikuni (representative ofthe founder), Mrs M. Abel (Vanuatu)

Ihsan Dogramaci Family Health Foundation Selection Panel

The Chairman and one Vice-Chairman of the Executive Board, ex officio, a representative each of the International Pediatric Association and the Turkish and International Children's Centre, Ankara, and the President ofBilkent University or his or her appointee

Meeting of 17 January 2001: Dr J. Jimenez de la Jara (Chile, Chairman), Dr G. Thiers (Belgium), Professor I. Dogramaci (President ofBilkent University), Dr P.L. Erdogan (representative of International Children's Centre)

United Arab Emirates Health Foundation Selection Panel

The Chairman of the Executive Board and a representative of the founder, members ex officio, and Dr K.A. Al-Jaber (Qatar)

Meeting of 18 January 2001: Dr J. Jimenez de la Jara (Chile, Chairman), Dr K.A. Al-Jaber (Qatar), MrN.S. Al-Aboodi (representative ofthe founder)

SUMMARY RECORDS

FIRST MEETING Monday, 15 January 2001, at 9:35 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

OPENING OF THE SESSION AND ADOPTION OF THE AGENDA: Item 1 of the Provisional Agenda (Document EB10711 Rev.2)

The CHAIRMAN declared open the 107th session of the Executive Board and welcomed all participants. Referring to the provisional agenda, he said that the title of the second item to be discussed under agenda item 3.4 had been amended to "Partnerships with non governmental health care providers", to reflect the subject matter more accurately. The allocation and utilization of extrabudgetary resources during the biennium 1998-1999 by programme, region and country had been included under agenda item 4 (document EB107/INF.DOC./4). In the absence of any objections he took it that those changes were acceptable. The agenda, as amended, was adopted. 1

TRIBUTE TO PROFESSOR JEAN-LUC MAMDABA

The CHAIRMAN paid tribute to the work of Professor Jean-Luc Mamdaba, the Board member designated by the Central African Republic, who had died in October 2000. The Board observed one minute's silence. Dr N'GAi'NDIRO (Central African Republic) thanked the Board for the esteem it had shown towards Professor Mamdaba, whose work he would strive to continue.

PROGRAMME OF WORK

The CHAIRMAN, announcing the dates and times of meetings, said that the opening and closing times for meetings would be strictly observed.

See page ix.

- 17-

EXECUTIVE BOARD, 107TH SESSION

REPORT BY THE DIRECTOR-GENERAL: Item 2 of the Agenda (Document EB107/2)

The DIRECTOR-GENERAL recalled a recent visit to the Russian Federation, which had brought home to her the immense difficulties of developing strategic options for controlling multidrug-resistant tuberculosis in a large country and, in particular, in vulnerable groups such as prison populations. Tuberculosis and drug resistance were of course global problems, which affected the poorest and weakest and impoverished those it afflicted. The search for means to reduce people's vulnerability to illness went far beyond the reach of any health ministry. An effective response called for resources, an informed society and a functioning health system in its widest sense. The challenge posed by tuberculosis reflected the approach spelt out in the WHO corporate strategy, which the Board had endorsed at its 103rd session. Already the Organization was making progress in its central task of contributing to the reduction of poverty through improving health. She had visited many countries and experienced many new situations, as well as some old ones, on behalf of the Organization. They had only served to strengthen her belief in the principles underlying WHO's work. During the previous year the world had woken up to the fact that good health was the basis for human development and prosperity. Health had been a central theme at the United Nations General Assembly Special Session on Social Development in June 2000, and at the Millennium Summit in September 2000. The importance of health within political processes had again been evident at the start of work on the framework convention for tobacco control in Geneva in October 2000. It had also been reflected in the new and wide-ranging framework for cooperation between WHO and the European Commission, which had come into effect in mid-December 2000. However, there remained a massive gap between the resources needed to help poor communities tackle different causes of illness and the funding and human capacity currently available to them. It would take an additional US$ 1000 million a year to reach targets for rolling back malaria in Africa; more than US$ 500 million a year to treat tuberculosis in countries with a high burden of the disease; and about US$ 3000 million to tackle HIV/AIDS through improved prevention, treatment and support facilities in Africa alone. Good health could only be achieved through sustained and adequate investment. A dramatic increase in resources for health was required, particularly in poor countries, and those who did not respond had to be challenged and asked not to ignore the evidence. The resource gap could be partially filled through greater financial efforts by the countries themselves, despite the constraints facing them, but a significant and sustained increase in development assistance - including debt relief funding was also needed to promote better health outcomes among poorer people. In order to stimulate new investment, there had to be evidence about the extent of need and what could be achieved if activities were properly implemented. Standardized systems for surveillance of global, regional and country disease burdens were an essential tool. Data on the incidence, prevalence and distribution of communicable diseases (including HIV/AIDS, malaria and tuberculosis), violence and injury, child health, maternal health and noncommunicable illnesses were available from WHO, which, wherever possible, were analysed by sex, age and social group. The findings of WHO's Commission on Macroeconomics and Health would assist in making the economic case for investing in health by indicating the range of effective interventions that were currently available. It would highlight the cost of investing too little in health, or of making the wrong investment choices. Health systems reflected the constellation of actions designed to improve people's health outcomes. Following discussions in the Board, and in other settings, a consensus had been emerging on the desirable goals and functions of national health systems and those had formed the basis of a group of indicators developed by WHO for measuring health system performance. In order to make quantitative performance assessments for the world's health systems, WHO had developed, using methods that drew on public health and econometrics, values for those indicators, based on available data from each Member State. Where data had been unavailable, values had been estimated using standard mathematical techniques, and uncertainty had been expressed in terms of confidence intervals. The results had appeared as indices in the Statistical annex to The world health report 2000. The attempt to develop instruments for analysis and policy dialogue had aroused considerable interest

SUMMARY RECORDS: FIRST MEETING

and some criticism. Despite the controversy, it appeared that information on the performance of national health systems had helped health ministers to demonstrate how resources were being used and enabled them to raise awareness of their needs, to explain the main policy issues facing health systems and to seek support from finance ministries and funding from other sources. In order to assist WHO to help countries in regularly assessing health system performance, while taking account of the useful insights being offered by all Member States, she would establish a technical consultation process that brought together personnel and perspectives from Member States in different WHO regions. She would also ensure that WHO consulted each Member State on the best data to be used for assessing health system performance, and that it provided advance information on the indicator values obtained using those data. She expected that WHO would compile a report on the performance of Member States' health systems every two years, the next round to be completed in May 2002 for publication, after consultation with Member States, in October 2002. She would ensure that Member States received the report before it was released to the general public. She would also establish a small advisory group to help monitor WHO's support for the assessment of health system performance. Member States and WHO should adopt a constructive, transparent, credible and fair approach to assessing health system performance, which would ultimately encourage all Member States to become involved. Evidence was the foundation of all WHO's work for people's health. WHO supported countries in scaling up effective responses to health priorities and in improving outcomes by bringing together researchers to address gaps in the evidence base; establishing effective technical networks linking country teams, the regions and headquarters; building on the new political momentum created; linking up with partners capable of contributing to an effective response; and measuring progress. As a cosponsor of UN AIDS, WHO was scaling up support for effective health systems action to prevent HIV infection, reduce vulnerability and ensure appropriate and compassionate care and support for infected people, including access to antiretroviral medication. Through the newly formed department of HIVI AIDS in the cluster of Family and community health, WHO was helping societies to address the pandemic by offering governments the tools and information they needed in the health field to strengthen their policies and actions. The HIV/AIDS epidemic continued to spread, however, and the international response remained inadequate. WHO was also scaling up action to improve maternal and child health. Its country teams, regional offices and headquarters were working in close cooperation with other organizations of the United Nations system and development banks, so as to help them support best practice at country level through their policies and programmes. Immunization had also been scaled up. Poliomyelitis eradication was progressing well; transmission was well down in India, the disease had been eliminated from the Western Pacific Region and immunization coverage was improving dramatically in Africa. Surveillance systems were coming into operation, enabling small outbreaks, such as those in Hispaniola and Cape Verde in 2000, to be detected more rapidly. The hope was that transmission would cease by the end of 2002, with certification of eradication by 2005. WHO was helping to rebuild general immunization services, incorporating them into health systems, and the Global Alliance for Vaccines and Immunization (GAVI) was moving forward. Funds were coming in, and cooperation between governments, agencies and the private sector was excellent. During the past year, the Alliance had received and processed proposals from 3 8 countries, of which 21 had been approved, representing commitments amounting to about US$ 310 million over five years. GAVI worked with countries in strengthening their health systems: investments in 2001 would increase immunization coverage by nearly 30%, thereby saving half a million lives. WHO expected even more of GA VI in 2002. Roll Back Malaria efforts were also expanding. The strategy was straightforward, cost-effective and widely supported. Effective prevention and treatment were available and prices for essential commodities had fallen. Health systems were intensifying their efforts to take on the malaria challenge and WHO and its partners would monitor progress, which, however, depended on further resources. WHO also responded to complex emergencies by helping to set standards, coordinate service providers and monitor progress, as well as by mobilizing additional resources. For instance, there had

EXECUTIVE BOARD, 107TH SESSION

been a prompt and effective response to a call from the Ugandan Government in September 2000 to help contain a major outbreak ofEbola virus infection. Referring to mental ill-health, which undermined well-being and caused particular difficulties for the world's poor, she said that The world health report 2001 would review current knowledge about the effectiveness of prevention and the policies needed to ensure the eradication of stigma and discrimination. WHO's advocacy efforts in that area would be focused on World Health Day in April 200 l, the aim being to raise awareness and to ensure that mental health was accorded the same priority and respect as physical health. The scaling up of responses called for effective health systems, with effective stewardship by national governments to ensure best use of public sector resources and partnerships with private, voluntary and community organizations. WHO was therefore increasing its response to requests from countries for support in enhancing their health system performance and was working closely with national governments and development agencies, reviewing experiences and sharing best practice. Countries also expected WHO to help them identify and respond to risks to health, and promote healthy lifestyles. "Risks to health" was to be the theme of The world health report 2002. WHO activities included help in establishing voluntary codes of practice, international health regulations and framework conventions. WHO strove hard to assess scientific issues in areas such as infant nutrition, food safety and environmental health. For example, as concern had recently grown over depleted uranium munitions used in Iraq and in the Balkans, individual countries and NATO were looking to the United Nations for guidance in determining the real risks to the health of the populations concerned. WHO was working with IARC and UNEP with a view to undertaking further investigations. At the same time, WHO was working with those directly involved. It was proposing study protocols that could be used by the appropriate civilian and military authorities in analysing the relative risk of leukaemia and other effects on health associated with different exposure patterns. In view of the fact that some 1.5 million children still died every year because they were inappropriately fed, WHO continued to support Member States in their efforts to improve infant feeding practices. Two remarkably successful examples had been the Baby-friendly Hospital Initiative and the International Code of Marketing of Breast-milk Substitutes. The year before, she had initiated the development of a new global strategy for infant nutrition, intended as a framework for action by all concerned, progress on which would be discussed by the Executive Board at the current session at which a draft resolution was being presented. WHO currently recommended that the optimal duration of exclusive breastfeeding should be between four and six months. Data compiled during a recent comprehensive review would be discussed at an expert consultation to be held in Geneva in March 2001 to determine whether any change in that recommendation was warranted. She pledged her unequivocal support for tobacco-free lifestyles, stressing that the preparation of a framework convention on tobacco control constituted the first attempt by WHO to develop an international treaty to improve public health. It had required the establishment of a new internal mechanism, the Intergovernmental Negotiating Body, which represented the first Member State-driven process run separately from the Health Assembly proceedings. That body was due to meet again in April-May 2001 and would provide an opportunity for all views to be heard - an approach that might be used more often in tackling complex policy questions. At the same time, WHO had published the text of an independent study on the attempts by tobacco companies to influence its work, which had led inter alia to the establishment of policies for WHO on conflict of interest. Through its work with other international partners and the private sector, WHO had stressed the need for globalization in working for the poor, in particular by improving access to essential drugs and other pharmaceuticals. Patents for essential drugs should be managed in ways that benefited both the patent holders and the public, by encouraging equitable pricing for medicines covered by patents and the production of generic products for those not so covered. WHO was seeking new relationships to that end. WHO would also play a major role in a series of international and regional meetings during 2001, in particular at the United Nations General Assembly special sessions on HIVI AIDS and on children, and at the United Nations Third Least Developed Country Conference.

SUMMARY RECORDS: FIRST MEETING

WHO was making progress in learning how to work as an effective and unified network that responded to the particular needs of each country and people. Its country teams were crucial, and support to them had been rendered more effective by new and cheaper telephone and video systems. In order to obtain maximum benefit from precious human resources and scarce finances, high priority was being given to improving WHO's information technology. In addition, efforts were continuing to ensure that its partnership arrangements were as dynamic and productive as possible. After thanking the Government of Switzerland for hosting the very successful Executive Board retreat held in November 2000, she turned to the Proposed programme budget for 2002-2003, which constituted the major agenda item for the current session and had been prepared along new lines. The corporate strategy was at the heart of the budget and was pursued within it through focused programming around 35 areas of work, which set out international goals, expected results, and indicators of achievement. Particular care was being taken to ensure synergy between areas of work as they interacted with countries. Subsequent to a two-year pilot programme, a strategic approach for cooperation with countries had been established jointly by WHO and national authorities, which included the Global Programme Management Group to monitor progress. She pointed out that, despite increased demands and costs, the regular budget remained static; she consequently expressed her gratitude to those who were contributing to a growth in voluntary contributions. Voluntary income was expected to increase by 15% in the next biennium. Extrabudgetary funds supported WHO's values and did not undermine its governance structures or established procedures. However, many activities could only be financed out of the regular budget, and she had therefore been encouraged by the latest statistics, which showed that the proportion of assessed contributions received during 2000 was 87%, the highest annual rate for 15 years, although a sizeable amount of arrears still had to be paid off. The Executive Board would be reviewing the outcome of the Organization's work so far to develop and improve its human resources policies. She thanked all those who had been involved in the process, and paid tribute to the extraordinary commitment, productivity and energy of the staff, despite the real inconvenience and, in certain cases, extreme personal danger they had suffered. She concluded by assuring the Executive Board that WHO would continue to respond to a changing environment and increased expectations, setting standards and doing everything possible to ensure sound results. The Organization would be judged on its results and could not afford to fail. Comments and questions

Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil), recalling that WHO's work in assessing national health system performance had given rise to some controversy, welcomed the Director-General's comments, which provided new perspectives on future developments in that area. Brazil would be proposing a draft resolution on the subject and, in order to save time and to allow for a fuller discussion, he proposed the establishment of a drafting group to analyse the draft resolution and report back to the Executive Board. He also requested a technical briefing in order to settle doubts in relation to the methodology used in the assessment exercise. Such a briefing could form the start of the technical consultation process called for by the Director-General. Professor ALl (Bangladesh) commended the timely publication of The world health report 2000. He endorsed the measures announced by the Director-General for addressing criticism of that report, emphasizing the importance of recognizing different approaches to the assessment of health systems. Ms WIGZELL (Sweden) speaking on behalf of the Member States of the European Union, commended WHO on its efforts to ensure that health became a priority on the political agenda. Health was being discussed in important new fora, such as the Group of Eight, and attracting new financial contributors. The challenge for WHO was to pursue and guide such initiatives in a manner that would support the sustainable health development of countries most in need, on their own terms. She was

EXECUTIVE BOARD, I 07TH SESSION

confident that the Director-General would make the most of the current opportunities. A key objective was the agreement on and the full implementation of the proposed 2002-2003 programme budget, which would advance WHO's core functions through new initiatives. WHO should also continue to invest in change through the development of new skills, systems and processes within the Organization, with the aim of adopting the right priorities, planning implementation, delivering action and evaluating the results. She welcomed the information provided on the WHO report assessing the performance of health systems and on the proposed consultation process. She supported the principle of such a report, which was in full accordance with the responsibilities of the Director-General as head of WHO. The world health report 2000 and the ensuing discussions would provide important inputs, and she therefore looked forward to an inclusive and transparent consultation process leading to consensus. A new feature of the international scene was that partnerships for action had become important means of reaching common objectives. Sustainable health development and the alleviation of poverty were priorities for cooperation between WHO and the European Commission, cooperation which had been the subject of an exchange of letters in December 2000. It was her sincere hope that the resulting agreement would give rise to practical cooperation for health development both in Europe and in developing countries. In view of the fact that smoking was the biggest single avoidable cause of death worldwide, the European Community and its Member States reaffirmed their support for the work on a framework convention on tobacco control. They would continue to participate in the negotiations in a positive and constructive manner. She added that the European Union had decided to go forward with accelerated action targeted at major communicable diseases within the context of poverty reduction. A plan of action was being developed and would be presented to the European Council in the spring. Such accelerated action would complement and supplement existing broad-based sectoral work. Finally, she reaffirmed that the development of effective and sustainable health systems must underpin all action to be taken as part of new initiatives and partnerships for the reduction of poverty-related diseases. Dr AL-JABER (Qatar) drew attention to those regions of the world in which the human right to health was being violated. The continued existence of malnutrition and ill-health was the reason why WHO prepared an annual report on the health of populations throughout the world. The health situation of the Palestinian people was discussed regularly by the Health Assembly, but not by the Executive Board. He therefore called on the Director-General to publish an annual report on the health situation of the Palestinian people, as requested in earlier resolutions, and to submit the report to the Fifty-fourth World Health Assembly. WHO had done much to improve the health situation of children in Iraq and he hoped that it would be able to do the same for children in Palestine where, if the current deplorable situation continued, there would soon be a generation of disabled children. He hoped that in future world health reports could contain details of health situations at national level. Dr NOVOTNY (United States of America) welcomed the Director-General's suggestions concerning the preparation, review and publication of world health reports. The flexibility shown would help all concerned to provide input for those reports and to gain a better understanding of how they could be used to improve health systems in all countries, including his own. He looked forward to the commencement of the technical review process and supported Mr Nogueira Viana's proposal that a drafting group be established. He also welcomed the proposed technical paper on HIVIAIDS, which would provide an opportunity for considering the issue of drug access, particularly in the context of the revised WHO drug policy. He had noted the emphasis placed by the Director-General on infant and child health as a broad mandate cutting across all WHO's priority areas, as well as the planned scientific review of infant and child nutrition. Mr CHOWDHURY (India) noted the higher profile of WHO action in various parts of the world. He also welcomed efforts to improve international funding for the public health sector

SUMMARY RECORDS: FIRST MEETING

worldwide. He remained concerned, however, at the composition and sources of the funding available to WHO. The regular budget was a limited and fixed sum for which contributions had not been paid in full, thereby causing operational difficulties. Moreover, although the proposed regular budget for 2002-2003 accounted for only 37% of the total resources available to WHO, only the regular budget portion of those resources was subject to the full scrutiny of WHO bodies. Extrabudgetary resources, although directed towards WHO targets and priority areas, were frequently subject to bilateral negotiation between donors and recipients, which sometimes gave WHO only limited leverage in channelling such funding to certain parts of the world. He added that it would normally be expected that the 35 priority work areas enumerated in the proposed programme budget would be given high priority in relation to both the regular budget and extrabudgetary resources. However, in certain major work areas, such as communicable disease prevention, eradication and control, sustainable development, health and environment, health technology and pharmaceuticals, the proposed level of extrabudgetary funding was very much higher than the regular budget. There was therefore a risk that the projects approved for extrabudgetary funding might not be exactly what the Executive Board or the Health Assembly would have determined. The same was true for certain flagship projects in such areas as malaria, tuberculosis and HIVI AIDS, where the regular budget accounted for less than 10% of the proposed funding. Funding for global public health should not be used as a weapon or an instrument of leverage in international relations. He therefore urged WHO to endeavour to obtain financing from sources such as United Nations organizations, international funding institutions and charities, based on broad criteria. All targets for which such resources were used should be fully examined by the various WHO bodies. Dr DI GENNARO (Italy) shared the concern expressed about the significant lack of resources for fighting major diseases, that were undermining the health and development of whole populations. In that regard, she was ready to welcome the new partnerships developed by WHO with other organizations and institutions, provided that WHO retained its position as the lead agency in the field of health. She also expressed support for the new approach to health system performance assessment envisaged by the Director-General, in particular the planned improvement in the involvement of Member States. The report constituted an innovative and courageous initiative, as confirmed by the reactions that it had provoked. There was widespread public expectation that WHO should become involved in investigations related to the possible health effects of the use of depleted uranium in munitions. She therefore looked forward to the results of the work being conducted by WHO in that area, which should make it possible to reach conclusions based on scientific evidence. Dr SADRIZADEH (Islamic Republic of Iran) congratulated the Director-General on her comprehensive report. The fight against communicable diseases should be taken seriously and should be waged in cooperation with all sectors of society and all concerned international organizations. In addition to tuberculosis and HIVI AIDS, many other serious communicable diseases were prevalent in prisons and other institutions, as well as among vulnerable population groups. Progress in the battle against those diseases depended on global commitment, interagency and intersectoral cooperation, and the active involvement of communities. WHO should assist countries in the timely detection of major communicable diseases and in their prevention and control. Education and communication campaigns were needed as well as a free flow of information both within and between countries, and new technologies should be made more affordable and accessible. The capacities of countries for epidemiological surveillance needed to be strengthened, in order to permit better diagnosis and more timely identification of epidemics. The problem of the constraints imposed by the cuts in WHO's regular budget should be overcome by prioritization and by increased efficiency.

EXECUTIVE BOARD, 107TH SESSION

Dr Ponmek DALALOY (Lao People's Democratic Republic) congratulated the DirectorGeneral on the considerable efforts made by WHO to improve world health through a broader and more efficient partnership with efforts being made to reduce poverty. Within the space of only one year a wide range of activities had brought significant progress in the fight against diseases such as poliomyelitis and malaria and improvements in maternal and child health, especially in poor countries. Despite the difficulties, the report was optimistic in tone and highlighted numerous successes. Of course, many problems remained, and greater efforts were called for with regard to tuberculosis, HIVI AIDS, tobacco control and strengthening health systems. The report offered clear, pragmatic and realistic approaches based on good sense and on a determination to resolve problems through cooperation, in line with the corporate strategy. Dr SHINOZAKI (Japan) commented that, at the recent conference on the control of infectious diseases in Okinawa, the Group of Eight had expressed its strong commitment to the control of HIVI AIDS, tuberculosis and malaria in cooperation with WHO, developing countries, nongovernmental organizations and the private sector. In the light of the increasing importance attached to communicable disease control by all partners, he hoped that WHO would play an active role in the development of global strategies. However, he had noted with concern the continual introduction of new structures and governing mechanisms within WHO as well as regular leadership changes in the various areas of work, which might have contributed to difficulties in achieving progress in the area of communicable disease control. Sustainable and measurable progress should be a priority for WHO and for all concerned. Dr KARAM (Lebanon), commending the Director-General on her comprehensive report, said that her depth of involvement with health issues provided a solid foundation for the health strategies being pursued by countries and regions. There were no infallible solutions or perfect health systems, but with WHO's support, all countries should strive to improve their performance and attain better health indices. Dr FETISOV (Russian Federation) expressed his appreciation for the efforts being made to improve the Organization's prestige, overcome financial constraints and strengthen links between WHO and Member States. He also approved the measures taken by headquarters and the regional offices to ensure better results. He fully endorsed the view that state intervention in the health sector and a combination of public and private resources was the way to achieve the greatest possible effectiveness at the lowest possible cost. The impact on health of negative factors such as economic depression, the fall in living standards, the destruction of the vertical pattern of health care and financial constraints could have been even worse if his country's Ministry of Health had not taken urgent measures to reform the system. In line with the Ottawa Charter for Health Promotion, it had adopted the approach that the situation could only be improved through interdepartmental and interagency collaboration and through the cooperation of the public, and the basic orientation of its health plan for the period up to 2005 was very much in line with WHO's strategy. The Director-General had touched on the problem of drugresistant tuberculosis in Russian prisons. Efforts were being made to improve that situation through the federal tuberculosis control programme and through the setting up of interdepartmental working groups in which WHO was participating. But further efforts and increased financing were required, and he hoped he could count on support from WHO and other international agencies and nongovernmental organizations. He supported WHO's plan to set up a high-level scientific group to study the problem of the effects of depleted uranium on health. He urged that work in that area be expedited, and hoped that a Russian expert would be selected to participate in the group's work. In conclusion, he regretted that the statement of the Director-General and certain other documents had not been made available until the last minute, a delay that had made the Executive Board's work more difficult.

SUMMARY RECORDS: FIRST MEETING

Mr LIU Peilong (China) congratulated the Director-General on the work accomplished in the past year with respect to strategic orientation and work objectives, and on the substantial progress achieved in many areas. He was pleased to note that health was now being given increased prominence on the agenda of the United Nations. His Government had made tuberculosis control a priority, and was cooperating in that effort with WHO, other international organizations, and other countries. The eradication of poliomyelitis in the Western Pacific Region marked yet another success achieved through cooperation between members of the international community and reflected the indispensable role played by WHO, although efforts should not be relaxed as long as poliomyelitis still existed on the planet. However, the pandemic of HNIAIDS had still not been contained and he welcomed WHO's reorganization of the HIVI AIDS area of its work. He recalled that at its 105th session the year before, the Executive Board had discussed a reduction in the cost of AIDS drugs: he asked what the outcome of that discussion had been. Or MBAIONG (Chad) commended the Director-General's pledge to place health at the heart of the fight against poverty and welcomed the emphasis accorded to the African Region in regard to projects to combat diseases of poverty, such as tuberculosis, HIVI AIDS, malaria and malnutrition. He pointed out that the Group of Eight and the Group of 77 offered opportunities that WHO could use to help implement its strategies for the period 2002-2005 for the benefit of marginalized populations. Or N'GAi'NDIRO (Central African Republic) also applauded the progress made over the previous two years in placing health at the centre of human development. Although the problem of tuberculosis in Russian prisons had been highlighted, it should not be forgotten that tuberculosis was above all a disease of poverty and as such was of great concern to Africa, where drug resistance was a serious problem. WHO should devote more resources to combating tuberculosis in the developing countries, particularly in the African Region, taking into account the association between tuberculosis and HIVIAIDS. In view of the havoc caused by HIVIAIDS in African countries and the lack of resources available there to fight the disease, research into a vaccine against the different strains of the virus, supported by WHO, would be of great benefit to the region. Recalling that most world-scale epidemics reported were located in Africa, he emphasized the need for WHO to support epidemiological surveillance and the setting up of emergency drug stocks at health district level. Countries would then be able to react immediately to the outbreak of an epidemic without waiting for action by the international community, which was often delayed. The African Region should also set about strengthening its health systems in view of their importance to the implementation of other activities, and in that connection he supported WHO's framework for the evaluation of health systems performance. In view of the lack of resources in the Region, the regional offices and country offices should mobilize resources to provide support to countries in evaluating their performance. Professor NAMA DIARRA (Cote d'Ivoire) was pleased to note that as a result of WHO's efforts health was becoming a central theme at international conferences. A Franco-African summit would shortly be addressing the subject of the health challenges confronting Africa as a result of globalization. She believed that such challenges could only be met by strengthening action at regional level, by increasing financial, human and technical resources and by taking bolder and more innovative approaches, for instance mobilizing extrabudgetary resources for such priority areas as nutrition and communicable disease surveillance and control. Professor GIRARD (France) expressed support for the Director-General's efforts to bring health out of its isolation and to put it at the centre of the political arena. Her statement had touched on the problem of communicable diseases, which in France had high priority, and on the problem of drug resistance, particularly resistance to antibiotics, which would undoubtedly become more acute over the coming decade. Although the debate on The world health report 2000 had already begun, and progress

EXECUTIVE BOARD, 107TH SESSION

had been made, it was important that it should continue in the Executive Board, where policy issues needed to be discussed and solved before technical and methodological issues were addressed. Despite increased efforts, the AIDS control campaign was going badly, and the only positive aspect of the situation was that WHO had at last resumed its place at the forefront of AIDS control activities, following its regrettable departure in 1997-1998. The problem of the health effects of depleted uranium had been recognized since 1986, and should have been addressed by WHO before it was taken up by the press and public. Other subjects of concern were the increasing importance of extrabudgetary contributions, the follow-up of decisions and resolutions, and essential drugs, on which some questions remained outstanding from the discussions two years earlier. Other issues, such as the rights and dignity of the patient, were becoming increasingly important, and by discussing them WHO could help to overcome the cultural differences which often lay at the root of such problems. Dr GRABAUSKAS (Lithuania) endorsed the statements by Ms Wigzell, Dr Di Gennaro and Professor Girard in support of the Director-General's call for sustainable health development. Data provided by his country's health information system clearly indicated that even a small and relatively homogeneous country such as Lithuania faced a risk of increasing social inequalities unless the necessary action was taken in the health sphere. He therefore welcomed the focus on health risk assessment in The world health report 2002. He supported the main thrust of WHO's activities for the coming years, in particular actions that would focus on health risks and inequities in health. Dr THIERS (Belgium) endorsed the view expressed by Dr Di Gennaro in respect of paragraph 45 of the Director-General's statement (document EB107/2). WHO, as the uncontested international authority on health, had a duty, on occasions when the media was spreading panic that was not necessarily justified, to identify the risks. He recalled that in the early days of the mad cow disease crisis WHO had rapidly convened a group of experts whose assessment of the situation had greatly assisted all countries, and that at the time of Belgium's dioxin crisis two years previously it had also provided timely support. While it was not up to WHO to solve the problem of health effects of depleted uranium, it should continue to fulfil its role, which was to provide expertise and to facilitate risk assessment. With regard to information technology, his country attached great importance to rapid and direct Internet access to WHO, but had recently found it both difficult and time-consuming to identify the officers responsible for dealing with particular issues. WHO's web site should make such information quickly and easily available. Dr ABREU CATALA (Venezuela) expressed her country's great concern for the consequences of the earthquake in El Salvador. Venezuela, which had suffered a similar tragedy in 1991, was aware of the importance of international support. With regard to the Director-General's statement, while health had again become central to the political debate on human development, it was equally true that the health sector and ministries of heath at country level had a crucial role to play in that debate. It was therefore important that international organizations, including WHO, should help Member States to give the public a better understanding ofhealth issues and the role of health systems through the dissemination of information. With regard to communicable diseases, Venezuela's position continued to be that the proposed measures to tackle HIVI AIDS should be accompanied by research into a specific vaccine with strong support from international organizations. Venezuela had increased funding for antiretroviral treatment by 400% in 2000, and planned another considerable increase for the current year. Action should also be taken as a matter of priority to combat chronic diseases such as cancer, hypertension and diabetes, in the area of prevention as well as in that of diagnosis and treatment. Such action should include sufficient technological and financial support to ensure equity of access to drugs and treatment.

SUMMARY RECORDS: FIRST MEETING

Dr AL KHARABSEH (Jordan) expressed appreciation for the consultative arrangements that had been set up to identify the best methods of assessing health systems performance. In that connection, Member States should provide the requisite data to WHO in a timely fashion, and not consider it as confidential. It was particularly important that there should be a margin for manoeuvre in order to enable the Organization to take the necessary action without first having to obtain the agreement of individual countries. The Director-General's efforts to raise extrabudgetary resources were highly commendable. Such resources should be used to benefit countries with special problems, such as Iraq, which was still subject to a strict embargo. He expressed support for the request by Dr Al-Jaber for a report on the health status of the populations of the occupied Arab territories, including Palestine, for the next Health Assembly. Dr KIM Won Ho (Democratic People's Republic of Korea) welcomed the statement of the Director-General, which highlighted the contribution made by the Organization to health promotion. He agreed with earlier speakers that there should be adequate consultation on health systems performance assessment before The world health report was published. Mr SELIM-LABIB (Egypt), speaking at the invitation of the CHAIRMAN, 1 thanked the Director-General for her full report, which made clear the need to adapt health systems to enable them to combat poverty and to promote progress and social development. He appreciated the cooperation between WHO and his country's Ministry of Health in projects being executed in Egypt, and in services being provided by the Regional Office in Cairo. He noted that the items on the Executive Board's agenda were closely linked to health programmes targeted at the most needy and at the problems of developing countries, emphasizing the link between health and socioeconomic development. His Government welcomed in particular the Organization's work to improve maternal and child health. If the programmes executed jointly by WHO and the Egyptian Government proved successful, they could be applied to other countries in the region. The Organization continued to suffer from a lack of financial resources. Since the question of extrabudgetary resources presented an obstacle to the implementation of programmes, there was evidently a need to look at the way they were spent, as well as at the distribution of regular budget funds. His Government wished to reiterate the need for WHO to support health programmes and to assess health systems on the basis of indicators that were accepted by countries at a similar level of development and which were compatible with their existing potential. He drew attention to the problem of the health situation of the Palestinian people in the territories occupied by Israel, resulting from the occupation itself and from the embargo placed on those territories. Thousands of children, as well as adults, were at risk of death or injury from acts of violence, and the present situation was in flagrant violation of the Fourth Geneva Convention relative to the Protection of Civilian Persons in Time of War. He appreciated the efforts of the Organization to assist the Palestinian people, but urged it to intensify its action through emergency intervention programmes as well as through ongoing projects, to meet the most urgent needs of the people in the occupied territories. Mr WAXMAN (Israel), speaking at the invitation of the CHAIRMAN/ said that it was regrettable that the Executive Board, an impartial professional body, was being used as the setting for a political debate. The Health Assembly was the proper forum for discussing the health problems of the Palestinian people. The current violence in the region had been initiated by the Palestinian Authority which, instead of taking the tough but necessary decision to respond positively to the peace proposal made by the Prime Minister of Israel at Camp David, had chosen the path of violence against Israeli soldiers and citizens in the hope of gaining greater advantages. There had been continuing

By virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

EXECUTIVE BOARD, 107TH SESSION

incitement to acts of violence on the part of the Palestinian media, contributing to the increase in casualties on all sides. Israel had offered to cooperate with the Palestinian Authority in all health matters, including the supply of medicines, but had been rebuffed. It had made every effort to enable Palestinians to receive medical assistance, partly through contributions from countries with which it did not have diplomatic relations. Palestinian citizens were in fact being treated in Israeli hospitals, with the cooperation of the two national societies, the Magen David Adorn and the Palestinian Red Crescent. As the Director-General had said, WHO was a forum for facts, not ideologies. If those who had spoken so eloquently on the health of Palestinians had shown the same eagerness to respond to the Organization's recent appeal for assistance to them, real results could have been achieved. The DIRECTOR-GENERAL thanked members of the Executive Board for their support. She welcomed their comments, which indicated that the Organization was following the correct course. The request for a technical briefing on the The world health report would be met in the course of the Board's session. The question raised by Dr Al-Jaber and Dr AI Kharabseh, concerning the health situation of the Arab population in the occupied territories and assistance to them, would be considered in detail by the Health Assembly, which would receive a full report on the Organization's efforts in that area. As for Dr Novotny's request for further information on what the Organization was doing to scale up its work on HIV/AIDS, the Board would be receiving a paper on the subject next day which would throw light on the background to its work and the constraints on it, and would also help to answer the question raised by Mr Liu Peilong concerning increased access to and affordability of AIDS drugs. The relationship between the regular budget and extrabudgetary funds had been mentioned by more than one speaker. She agreed that of the current expenditure of US$ 2200 million, the proportion accounted for by the regular budget, 37%, did not seem high. It was, however, a question of compromise and of seeking to limit the negative factors in the situation. The Organization's flagship programmes illustrated its success, not only in scaling up its own efforts, but also in mobilizing additional funds from donors and the World Bank, and even from private foundations. The fact that less than I 0% of the US$ 100 million spent on the Roll Back Malaria programme came from the regular budget in itself testified to the Organization's ability to mobilize increased resources when necessary. Most of the money went to regions and individual countries able to use it flexibly; it was not retained at headquarters. As progress was made on the strategic budget, the ability to distribute funds strategically would also improve. However, until the regular budget was increased, there could be no solution to the problem of the present distribution of funds. She agreed with Dr N' ga"indiro that tuberculosis had assumed epidemic proportions. Linked to poverty, that major communicable disease required a bigger global response. The problem of resistance to antibiotics lay in the lack of effective programmes and treatments, and the Organization was emphasizing the need for a broader and wiser use of microbials and for combating other communicable diseases besides tuberculosis. WHO had been engaged with the assessment of risk from depleted uranium for some time in the context of its use in Iraq and the Balkans, and was collaborating with UNEP on the issue. It was endeavouring to ensure that assessment was based on a proper epidemiology, which was still difficult because of the lack of concrete data on exposure levels. Evidence about the incidence of cancer caused by depleted uranium was now becoming easier to obtain because more precise information was being provided by NATO. The revised drug strategy would be an important topic at the Health Assembly. WHO had an important role to play in helping civil society and governments to assess risks and to increase knowledge and advocacy where drug applications were concerned. As for the Organization's web site, the general policy was that information should be available from the cluster responsible for each individual area of work, but that individuals or even small teams should not necessarily be identified as dealing with matters which were the responsibility of the Organization as a whole. However, she agreed that there was a need to improve the procedure of finding answers to questions through the web site.

SUMMARY RECORDS: FIRST MEETING

The CHAIRMAN noted that there had been a proposal to set up a working group to draft a resolution on The world health report 2000. He invited members of the Executive Board to volunteer to participate in the group. Professor GIRARD (France) said the Executive Board should have an opportunity for full discussion before the group began its drafting work. The CHAIRMAN suggested that the topic should be discussed in the afternoon meeting on Tuesday, 16 January. It was so agreed.

(For continuation of the discussion of The world health report, see the summary record of the fourth meeting.)

The meeting rose at 12:55.

SECOND MEETING

Monday, 15 January 2001, at 14:30 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda

Global strategy for infant and young child feeding (decision WHA53(10)): Item 3.1 of the Agenda: (Document EB107/3) The CHAIRMAN, introducing the report on the global strategy for infant and young child feeding (document EB107/3), said that several ideas had also been put forward by the DirectorGeneral in her report (document EB107/2) for analysis and consideration. The key elements of the global strategy were strategic and programmatic; those aspects had been the focus of the March 2000 technical consultation among experts, at which meeting UNICEF had made an important contribution. The strategy document also covered the related and important aspects of mother-to-child transmission of HN through breastfeeding, exclusive breastfeeding, complementary feeding and maternity protection in the workplace. Ms COSTA COITINHO (alternate to Professor Yunes, Brazil) drew attention to Annex 2 of the report under discussion, which contained the draft resolution submitted by her delegation during the Fifty-third World Health Assembly, and amendments thereto, as a basis for discussion by the drafting group open to all Member States which was to meet during the current session of the Board, pursuant to decision WHA53(1 0). In addition, another version of the draft resolution incorporating relevant comments and suggestions made by Member States during the Fifty-third World Health Assembly had been circulated to facilitate the work of the drafting group. While she welcomed the progress made on the development of a global strategy, she emphasized that further guidance from Member States was still needed. Examples of achievements that might be drawn on included the Baby-friendly Hospital Initiative and the International Code of Marketing of Breast-milk Substitutes, which in Brazil had proved particularly useful in improving breastfeeding and timely complementary feeding practices. Infant and child nutrition was, however, a complex subject, and that should be borne in mind by Member States participating in the drafting group. She understood that WHO had already received some preliminary results from the systematic review of published scientific literature on the optimal duration of exclusive breastfeeding, and requested that those results should be made available to the drafting group for information. Professor ALl (Bangladesh) said that the Organization's handicap was its lack of resources as compared to other bodies, such as the World Bank, which were now playing a greater role in health matters. The Organization's main asset, however, was results, and its decisions must therefore be results-based. That too should be borne in mind by the drafting group. Dr SADRIZADEH (Islamic Republic of Iran) said that most recent studies provided evidence against the use of complementary feeding for babies between the age of four and six months, for various reasons, including no especial growth advantage, the displacement of breastmilk, a net loss of nutrients and higher morbidity rates. With the exception of children born to HIV-infected mothers, in which case informed choice of breast-milk substitutes was a possibility, UNICEF and WHO had -30-

SUMMARY RECORDS: SECOND MEETING

recommended that children should be exclusively breastfed for around six months. Iran was one of 58 developing countries that had adopted a national policy of promoting the optimal duration of breastfeeding in an effort to resolve the serious problem of infant malnutrition. Ms WIGZELL (Sweden), speaking on behalf of the European Union, reaffirmed the fundamental importance of appropriate feeding practices for infants and young children and the European Union's commitment to continued support for measures to protect and promote breastfeeding. Commending the report, she expressed support for the two principles underpinning the strategy: a basis of science and evidence and the participation of all relevant parties. It was essential that work on the global strategy should be completed in accordance with the timetable laid down in Annex 1 of the report. The draft resolution set forth in Annex 2 supported the process. Before issuing any further recommendations on the duration of exclusive breastfeeding and the age for the introduction of complementary food, the Board should await the results of the review of scientific studies on optimal breastfeeding practices and of the related expert consultation. It was important for Member States that WHO, UNICEF and FAO should reach joint conclusions on the matter without delay, taking into account work under way within the Codex Alimentarius Commission relating to the draft Codex standard for cereal-based complementary foods. It would have been useful if the report had provided information on recent work by UNICEF on infant feeding. Linked to concerns about the substantial risk of mother-to-child transmission of HIV was the fear of a reduction in breastfeeding among mothers whose HIV status was unknown or among others who were unable to offer their children a safe alternative to breastfeeding. Basic scientific research and operational research in settings of high endemicity of HIV infection were required. Particularly interesting, warranting further research, were the findings of one study that suggested that exclusive breastfeeding in the first three months of life might carry a lower risk of HIV transmission to the infant than mixed feeding. The European Union supported the view that the joint UNICEFIUNAIDS/WHO guidelines issued in 1998 1 still provided the best advice on that matter. The draft resolution should be based on them. Or NOVOTNY (United States of America), recalling the remarks of Professor Ali and Ms Wigzell, said that the challenges of infant and child nutrition must be considered in the context of solid scientific evidence and a changing health environment. Raising global awareness and building commitment to alleviate malnutrition, strengthening food and nutrition surveillance systems, and ensuring the adequate nutrition of infants born to HIV -positive mothers were crucial responsibilities for Member States. Although the document and the relevant draft resolution had served to stimulate debate, the focus should not merely be on exclusive breastfeeding guidelines but instead on the full range of critical nutritional needs for infants and children. More effective strategies were required to tackle malnutrition, including the identification and assessment of specific micronutrient deficiencies and a better understanding of relevant culture-specific practices and community standards. Member States must also continue to support the development of a global strategy on infant and young child feeding based on the principles of science and evidence, transparency, and participation by all interested parties. Any draft resolution agreed upon during the current session should reinforce and support that process rather than pre-empt it. He acknowledged PAHO's leadership in convening a technical consultation on the recommended length of exclusive breastfeeding in August 2000, at which experts from countries in the Region of the Americas had, inter alia, encouraged WHO to consider carefully the scope and framing of the global strategy. Meanwhile discussions held at national level in the United States had endeavoured to focus on scientific aspects with a view to addressing crucial nutritional matters and defining key elements for the global strategy. Malnutrition should be recognized as a major public 1

UNICEF, UNAIDS, WHO. HIV and Infant Feeding:Guidelines for decision-makers. A guide for health care managers and supervisors. A review of HIV transmission through breastfeeding. Geneva, WHO, 1998 (documents WHO/FRH/NUT/CHD/98.1-3).

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health problem that affected physical, cogmtive, social, educational and economic development. Current strategies to reduce malnutrition among infants, young children and women of reproductive age should be expanded to include research and data collection so as to determine what combinations of functional outcomes were most predictive of positive health outcomes. Scientific evidence weighing up the comparative risks and benefits of breastfeeding, breast-milk substitutes and early weaning practices in HIV-infected mothers should be recognized. Additional scientific information was necessary to ensure the adequate nutrition of infants and mothers affected by the disease. Other global objectives, such as the target in the 1996 World Food Summit Plan of Action of halving the number of undernourished people by the year 2015, should also be taken into account. Continued cooperation between WHO and FAO with Member States in developing and implementing food and nutritional surveillance was required to assess and monitor infant and child nutritional status. In conclusion, he looked forward to participating in the drafting group in a discussion which was science-based but at the same time took account of national policies, with a view to defining the key elements in the global strategy. Dr BODZONGO (Congo) noted that breastfeeding for as long as possible was the rule in Africa. However, the issue had been complicated by the AIDS pandemic, wars, and the displacement of populations. It was all very well to set a figure of four months or six months, yet the question remained of how a malnourished mother, herself ill, could be expected exclusively to breastfeed her child. Admittedly the report spoke of adapting the strategy to local conditions, but Africa's particular situation warranted special consideration. Dr AL-JABER (Qatar) said that the Forty-seventh Regional Committee for the Eastern Mediterranean had requested the Regional Director for the Eastern Mediterranean to convey the following recommendations to the Executive Board, in order that they might be taken into account in the definition of the global strategy. Exclusive breastfeeding should be promoted from birth until the age of six months; thereafter adequate complementary food should be introduced and breastfeeding continued until the age of two years. Complementary foods for infants and young children should essentially be home-made, and, where locally produced, should be based on culturally acceptable food mixes based on dietary habits in the Region. Such foods should be produced using locally available ingredients, fortified whenever possible with essential micronutrients, should be able to be safely prepared and should be in line with the guidelines on complementary foods of the Codex Alimentarius. Dr ABREU CATALA (Venezuela), praising the report, singled out the success of the Babyfriendly Hospital Initiative in various countries. The Initiative had led to a redistribution of budgetary resources, an integrated approach to mental health and child development, and many other achievements. Dr DI GENNARO (Italy) said that it was crucial to reach a consensus on optimal breastfeeding practices. However, scientific evidence would become available only in March 2001. The strategy must build on past achievements such as the Baby-friendly Hospital Initiative, the International Code of Marketing of Breast-milk Substitutes, and the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. It was necessary to adopt a clear scientific position on counselling for HIV-positive mothers and guidance on their different options for infant feeding. Currently such guidance should conform to the UNICEF/UNAIDS/WHO 1998 guidelines for decision-makers. The choice lay with the mother, but she needed support. She would be a member of the drafting group and would seek a consensus on the issues. Dr KIM Won Ho (Democratic People's Republic of Korea) noted that malnutrition was one of the world's worst public health problems and that the situation in the South-East Asia Region was especially severe. The proposed strategy could serve to promote better health in infants and young

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children. He supported the proposals on protection from hazardous agents, increasing the duration of maternity leave and reinforcing entitlement to paid breastfeeding breaks. His country gave 150 days' paid maternity leave. The optimal duration of breastfeeding should take account of the special circumstances obtaining in each country. In the Democratic People's Republic of Korea, six months was the recommended period. Complementary feeding should be improved by using locally available, affordable food. The final document should also cover ways and means of implementing the strategy. Professor ZELTNER (Switzerland) fully endorsed the report and the position put forward by the European Union. However, ifthe drafting group were to start work during the session of the Board, it must bear in mind that technical information would not become available until March 2001. He therefore suggested reconvening the drafting group, possibly at the beginning of the Fifty-fourth Health Assembly, in order to amend the draft resolution in the light of that information. He concurred with previous speakers that sound scientific evidence was necessary in that area, as it was in the case of HIV-positive mothers. Women in modern urban society faced the dilemma of reconciling breastfeeding and their obligations in the workplace. Here again, evidence was required. A foundation had been set up in Switzerland that brought together the Government and other bodies to search for ways of improving the parental care of children, and Switzerland would be willing to share its experience in that regard. Mr LIU Peilong (China) commended the report, and endorsed the principle of basing the strategy on scientific evidence and encouraging participation by all parties. As a developing country with a large population, China was willing to participate in formulating the strategy and welcomed the proposed timetable. Since any recommendation on the optimal duration of breastfeeding must be based on scientific evidence, he supported the review of all the relevant literature. Dr SHINOZAKI (Japan), welcoming the report, said that Japan had been promoting the proper feeding of infants and young children, including breastfeeding, in line with previous Health Assembly resolutions. It must be understood, however, that the duration of breastfeeding varied hugely between mothers, and that social and cultural factors influenced that practice. He looked forward to receiving the results of the expert technical consultation in March 200 1. Dr FETISOV (Russian Federation) said that the report accurately reflected the current status of the global strategy for infant and young child feeding. In the Russian Federation, for various reasons, it was customary to breastfeed children up to the age of one year, and, in some cases, even up to two years. However, he considered that the optimal duration for exclusive breastfeeding was that recommended by the Regional Committee for Europe, namely up to the age of between four and six months in all cases. As for the problem of HIV transmission through breastfeeding, Russian experts held that, since it was impossible to assess the extent of the risk of infection in children under the age of three months, breast-milk substitutes should be recommended for the children of HIV -infected mothers from birth. Mrs ABEL (Vanuatu) said that Vanuatu had undertaken numerous activities to promote exclusive breastfeeding and "baby-friendly" hospitals. Such activities were expensive and timeconsuming and, in order to avoid confusion, she would prefer to see the current practice continue and to await the findings that would become available in March 2001, so that a resolution could be developed advocating measures that were cost-effective and appropriate to each country's situation. ProfessorNAMA DIARRA (Cote d'Ivoire) praised the quality and detail ofthe report. Nutrition was a fundamental right of the child. The time had come for the Health Assembly to adopt a resolution on the subject, taking into account the many scientific papers advocating exclusive breastfeeding for a period of six months, the conclusions of the XIIIth International Conference on AIDS (Durban, South Africa, 2000) and the results of South African studies on mother-to-child transmission of HIV, bearing

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in mind also the joint work of UNICEF!UNAIDS/WHO, the International Code of Marketing of Breast-milk Substitutes and ILO's revised Maternity Protection Convention. She looked forward to seeing the results of the global consultation begun in March 2000. She endorsed the draft resolution, with the proviso of seeing the revised text. Professor GIRARD (France) said that the importance of the topic of infant and young child feeding was indicated by the large number of speakers. Scientific evidence was being given greater prominence than usual, and he wondered whether that evidence would provide a solution to the problem of whether greater weight should be given to extending the period of breastfeeding or to increasing the number of infants benefiting from it. The low figure of 35% of infants breastfed worldwide referred to in paragraph 1 of the report concerned him more than the duration of exclusive breastfeeding. He urged that drafting the resolution should be done as expeditiously as possible in view of the urgent requests made at the Fifty-third World Health Assembly and at the current session of the Board. The most satisfying solution would be for a working group comprising all interested Member States to begin its deliberations on the first day of the Fifty-fourth World Health Assembly, by which time it would be in possession of the necessary data. He advised that the subject should be approached with great. humility and flexibility in view of the socioeconomic and cultural issues involved. Dr Ponmek DALALOY (Lao People's Democratic Republic) acknowledged the importance of the complex problem under discussion; where poverty prevailed, malnutrition was one of the prime causes of infant mortality, as it was in the mountainous and isolated parts of his country, despite the progress made to date. At present, the policy of breastfeeding for between four and six months was applied in his country in a responsible manner and in keeping with the actual situation. Between the ages of six months and two years, breastfeeding was complemented by other food. He was aware of the risk of transmission of HIV through breastfeeding, and wished to await the conclusions of the expert group before deciding on the optimal duration for which exclusive breastfeeding should continue. Dr KARAM (Lebanon) praised the report, adding that the ill effects of malnutrition on babies and the nutritional and hygienic benefits of breastfeeding could not be denied. Two issues needed to be addressed: the first was the number of children who it was hoped could eventually benefit from breastfeeding and the efforts required to promote it, and the second was the optimal duration of exclusive breastfeeding. Those issues could not be tackled without addressing both the working conditions of women and the status of maternity leave in different societies. Ms WIGZELL (Sweden) supported the approach described by Professor Girard, which was in line with that advocated by the European Union on awaiting the outcome of discussions on the duration of exclusive breastfeeding. Dr TURMEN (Executive Director) said that she had taken note of the comments made, which supported evidence-based policies and the development of global infant and young child strategies, and stressed the importance of research on issues of HIV and breastfeeding. However, since the Organization had embarked on a systematic scientific external review, which was to be peer reviewed by a group of scientists who were to meet in March 2001 and make recommendations to the DirectorGeneral, the request for the preliminary draft paper to be made public was premature. Moreover, the comments made in regard to the lack of benefits of early complementary feeding were justified. Further basic and operational research on the link between HIV and breastfeeding was also very important; new data were emerging every day, which was why WHO was studying infant feeding practices in areas where HIV was prevalent. The remarks made about shifting focus to more critical areas of infant and young child nutrition such as malnutrition and micronutrients, as well as about the need to consider economic and social differences, were also apposite. Many allusions had been made

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to mother-to-child transmission of HIV, a problem of which infant feeding practices was only one aspect. The view of WHO regarding breastfeeding by HIV -infected mothers was that the 1998 guidelines for decision-makers jointly issued by UNICEF, UNAIDS, and WHO remained valid. Ms BATIONO (Consumers International), speaking at the invitation of the CHAIRMAN, said that her organization, which was associated with International Baby Food Action (IBFAN), a coalition of over 150 citizens' groups that had worked to protect infant health in more than 90 countries over the past two decades, wished to continue working with WHO to ensure that all Health Assembly resolutions were upheld. The highest attainable standard of health for the majority of the world's infants was undoubtedly achieved through breastfeeding; she welcomed the report on the topic but drew attention to points not reflected in it. On the recommended duration of exclusive breastfeeding, resolution WHA47.5 advocated appropriate complementary feeding from the age of about six months, a position supported by research, which, however, was continually being ignored and undermined. The Director-General had called for science-based evidence: WHO's review of studies in developing countries had recommended a period of "about six months" and she therefore questioned the need for further delay in stating WHO policy clearly. The economic interests involved were evident, but financial gain ought not to influence health policy. If the review were completed by March 2001 she hoped that a resolution settling the marketing question would be adopted by the Health Assembly in May 2001, since that would greatly facilitate the adoption of a strong Codex standard on complementary foods, benefiting the majority of the world's infants and saving lives. IBF AN had monitored the International Code of Marketing of Breast-milk Substitutes and resolutions for 20 years, and had noted that two new problems had arisen recently: first, health claims made by companies and, secondly, Internet advertising. Companies were increasingly "medicalizing" normal infant feeding behaviour and making claims directly contravening the spirit of the Code, while claims for products were made blatantly on the Internet, which had no respect for national boundaries or laws. A resolution stating that such promotion was contrary to WHO policy and to the provisions of the Code would be invaluable in underscoring the universality of that policy. The independence of monitoring was also of concern, and WHO should be totally clear in its guidelines and recommendations. However, paragraph 2(5) of the draft resolution contained an important contradiction: how could a monitoring body be "transparent, independent and free from commercial influence", while at the same time being asked to work especially with the private sector? The controversial issue of vertical transmission of HIV had been brought into sharp focus when the United States and Swiss media had attacked UNICEF for refusing to accept corporate donations of milk substitutes for their pilot studies on HIV, an approach that completely ignored the risks of artificial feeding. Industry involvement in research could distort health policies and public perceptions of them, and she was glad that the British Medical Journal and other media had since highlighted the falsity of the situation. While many babies might have contracted HIV through breastfeeding, a much larger number had died from the lack of it. Finally, only further research, including research that was completely independent of any wealth-generating motives, could help to resolve the terrible dilemma posed by transmission of HIV through breastfeeding and produce an answer that would be more feasible and culturally appropriate for the disadvantaged, who were most at risk. She would be happy to share her concerns about the draft resolution and other parts of the report with the Board. Ms STEVENS (Save the Children Fund), speaking at the invitation of the CHAIRMAN, said that her organization welcomed the draft resolution, which would strengthen global efforts to protect the health of the most vulnerable members of the world's communities. She strongly endorsed the renewed emphasis on the promotion of exclusive breastfeeding for about six months. Introduction at earlier ages of complementary foods, particularly when they were contaminated, carried grave risks for children. The dissociation of WHO from resolution WHA47.5 had caused confusion in the global policy arena, with the result that manufacturers still refused to acknowledge that food products marketed for children under six months of age were de facto breast-milk substitutes, and therefore came under the provisions of the International Code of Marketing of Breast-milk Substitutes. That

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continued to be a major obstacle to the protection of infant health, and it was to be hoped that the draft resolution would lead to a global recommendation that would be put into practice by WHO, UNICEF, governments, nongovernmental organizations and the private sector, working together. She welcomed the endorsement of the International Code. Its incorporation into effective national legislation and its implementation were essential for ensuring in the long run that breastfeeding practices were not undermined by corporate interests. Monitoring in Brazil had shown that many companies, especially multinationals, failed to respect the Code and the relevant resolutions. Governments should make greater efforts to protect the most vulnerable sectors of the population in the climate of increasing globalization. She also welcomed the recognition in the draft resolution of the problem of advertising on the Internet, which should indicate to global corporations that the Code was a global minimum standard rather than a set of recommendations to be applied only to developing countries. She also welcomed the recognition that health claims on the labels of breast-milk substitutes contravened the spirit of the Code. The draft resolution would assist efforts to ensure that the Code was applied to all breast-milk substitutes, and that health workers and parents were not misled by claims that would inevitably promote use of those products. The forthcoming Health Assembly should provide an opportunity for governments to demonstrate consensus about the need to protect the rights of mothers and their infants and the protection and promotion of the health of infants. Dr BRONNER (International Special Dietary Foods Industries), speaking at the invitation of the CHAIRMAN, said that the industry was dedicated to improving the health and well-being of infants and young children through proper nutrition, and devoted considerable resources to research and to the development of suitable foods. The International Association of Infant Food Manufacturers supported the development of a scientifically-based global strategy on infant and young child nutrition. The technical consultation organized by WHO in conjunction with UNICEF would lead to a comprehensive strategy and plan of action for implementing sound nutritional policies, and the multicentre growth reference study currently under way would provide an invaluable contribution to evidence-based solutions. She welcomed the constructive process that had been initiated, and endorsed the report. The means of ensuring that all infants and young children were adequately fed should continue to be the evidence-based policies adopted by WHO, the international body responsible for setting health policy. The CHAIRMAN suggested that the Executive Board should set up a drafting group on infant and young child nutrition open to participation by all Member States, as requested in decision WHA53(1 0), to prepare an appropriate draft resolution, under the chairmanship of Mr Chowdhury (India), a nomination supported by Ms WIGZELL (Sweden). Mr TOPPING (Legal Counsel), responding to a point raised by Professor GIRARD (France), said that the drafting group would base its discussions on the draft resolution proposed by Brazil at the Fifty-third World Health Assembly, with the relevant amendments. Other proposed texts could also be taken into account. The CHAIRMAN suggested that discussion of item 3.1 be suspended pending the outcome of the work of the drafting group. It was so agreed. (For adoption of the resolution, see the summary record of the twelfth meeting, section 5.)

SUMMARY RECORDS: SECOND MEETING

Health promotion: Item 3.2 of the Agenda (Document EB107/4)

Invited by the CHAIRMAN to introduce document EB 107/4 on health promotion, prepared in pursuance of resolution WHA51.12, DrYACH (Executive Director) said that WHO recognized health promotion as a core function in the advancement of public health. The report responded to requests from Member States for a clear description of how WHO intended to implement health promotion, as it was crucial to move beyond general definitions towards specific action with a clear focus on improving health. It had become clear that a certain tension existed between those seeking a broad definition of health promotion that included the principles embodied in the Ottawa Charter for Health Promotion and upheld at subsequent meetings, and those seeking greater precision. On the basis of past experience, realistic, pertinent areas of emphasis had been defined, with a stronger, better coordinated approach to improving the behaviour of young people, increasing health literacy through the use of a wide range of communication channels and giving higher priority to health promotion skills and approaches within existing health services. The focus on youth would cover both school and non-school components, such as entertainment, media, sports and recreation, and would target behaviour associated with unsafe sex, tobacco, alcohol and drug abuse and violence. Emphasis would also be placed, within health services, on improving health-promoting messages for patients receiving care, and on encouraging compliance with therapy for, for instance, HIVI AIDS, tuberculosis, diabetes, hypertension and schizophrenia. Such measures would not require new institutional arrangements but would be based on existing strengths within WHO. A forum for the discussion of health promotion would be established and its first meeting would be convened at the invitation of the International Union for Health Promotion and Education, a nongovernmental organization, at its XVIIth World Conference on Health Promotion and Health Education (Paris, July 2001 ). The forum would enable the main players to define how best to focus their specific capabilities and ensure coherence in tackling health promotion issues on a broad scale. The CHAIRMAN stressed that health promotion was one of the main tasks facing WHO in the twenty-first century. It called for clearly defined strategies. Dr THIERS (Belgium), welcoming the conciseness and depth of the report, concurred that health promotion was central to WHO's responsibilities in both developed and developing countries. In developed countries, including his own, young people between the ages of 15 and 25 were exposed to a wide range of risks, including road traffic accidents, tobacco, drug or alcohol abuse, unsafe sex and deafness caused by excessive noise, which could lead to high rates of mortality and of mental or nervous disorders. He drew attention to paragraph 8 of the report, which referred to the often harmful effects of the media and of the leisure industry, although also highlighting the positive influence of sports and recreation. He supported the proposal in paragraph 16 that a forum for health promotion should be established with nongovernmental organizations and the private sector, which should also include a dialogue with the leisure and tobacco industries with regard to the long-term effects of their policies. Had such dialogue been established with the latter 30 years previously, the problem of tobacco consumption would not have reached its current proportions. Dr DI GENNARO (Italy) regretted that there had been insufficient time at the previous Health Assembly to discuss health promotion, which remained a cornerstone of WHO policies and actions. She welcomed the reference in the report to the synergy between health promotion and adherence to preventive and curative interventions. Health promotion should cut across all WHO programmes, while maintaining its own identity, role and dimension. She would have appreciated a sharper focus in the report on the new concepts of health determinants and investment for health that had been underlined at the Fifth Global Conference on Health Promotion (Mexico City, June 2000). She noted that fruitful collaboration had been established in the field of health promotion between the European Regional Office and Italy, which would result in the establishment of a health promotion centre in Venice.

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Dr SADRIZADEH (Islamic Republic oflran) said that, although health promotion had been one of the main components of the health-for-all strategy, it had hitherto not been accorded the priority it deserved. Fortunately, WHO was once again taking it up as a priority. Promotion of healthy lifestyles and reduction of risk factors contributing to ill health were among the most cost-effective interventions for prevention and control of both communicable and noncommunicable diseases. WHO should not only support evidence-based health promotion activities but should also assist countries in strengthening their national capacities for community empowerment, partnership development, media ownership, promotion of health system research and planning, and monitoring and evaluation of national health promotion programmes. Dr SHINOZAKI (Japan) commented that rapid ageing of the population was one of the most serious issues facing his country. Japan had recently launched "Health Japan 21 ", a national health promotion initiative for the 21st century, setting out evidence-based indices of targets for lifestyle improvement covering five areas: food and nutrition, physical exercise, mental health, smoking and alcohol consumption. He fully supported the report. Dr GRABAUSKAS (Lithuania) said that document EB107/4 contained much useful information on strategic lines of action in health promotion. However, in his view, it would benefit considerably from the inclusion of more concrete recommendations. For instance, it would be helpful to Member States if examples were provided of the "evidence base" referred to in paragraphs 4 and 14. Thus amended, the document would carry greater weight when presented to Member States at the next Health Assembly. Dr AL-JABER (Qatar) said that health promotion could not be accorded the priority it deserved unless proper account was taken of health research. Consequently, paragraph 14 of the report, which made that point, should be accorded greater prominence, since health research was non-existent in many countries and regions. Countries that had not yet established a strategy and priorities for health promotion should be urged to do so forthwith; priorities differed from country to country, as was the case with communicable diseases in developing countries and noncommunicable diseases in developed countries. Professor ALl (Bangladesh), citing paragraph 12 of the report, said it had to be acknowledged that failure was usually attributable not to lack of ability or knowledge but to an absence of will, dedication and discipline. The attitudes of health personnel worldwide had to be changed. Dr NOVOTNY (United States of America) said that he was pleased that health promotion was to be considered at the forthcoming Health Assembly. Health promotion was a critical investment for sustainable health development, and WHO and Member States needed sufficient time for thoughtful reflection and discussion. A sound evidence base would be necessary for defining health promotion policy, which should be derived from relevant public health indicators. For example, in his country the lack of efficacy of tobacco prevention programmes in schools in the absence of a strong anti-tobacco milieu posed a fundamental challenge to progress on the issue. Health promotion could not be left to teachers alone; political, economic and regulatory approaches must also be adopted. As many determinants of health status lay outside the health sector, the traditional boundaries should be expanded to include a wide array of partnerships and alliances with the private sector, the entertainment industry, and the judicial and political sectors of government. Support for health promotion should be justified as cost-effective and seen as part of health system reform. That would require creativity and strategic thinking. In the Baltic States and some states in the United States of America, health promotion was financed as part of sickness funds from taxes on consumer products such as tobacco.

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His country remained committed to health promotion as a cornerstone of public health policy and strategies. Its agencies had worked closely with WHO in the past and looked forward to future collaboration. He strongly encouraged WHO's continued leadership in that area. Dr FETISOV (Russian Federation) said that he considered health promotion to be one of WHO's most important priorities. In his country, morbidity and mortality rates had increased among all age groups of the urban and rural populations during the past decade owing to excessive stress, deteriorating living standards, disregard for the environment and a sharp increase in migratory flow. Well-targeted preventive and health promotion measures were needed to safeguard and improve public health and to inculcate healthy lifestyles. Steps were being taken to return to a focus on prevention, which had been neglected over the past decade, through provision of basic medical care by general practitioners, training of non-medical personnel in public health and a reorientation of the health system towards primary and secondary prevention, drawing on domestic potential and foreign expertise and involving the mass media and the population as a whole, particularly young people. He endorsed WHO's priorities in the area and emphasized the need to take account of health promotion practices worldwide and of success achieved in the strategic orientations. He supported the proposal to establish a forum for health promotion dialogue, which should advance understanding of the development, delivery and assessment of health promotion programmes. Dr CABRERA MARQUEZ (Guatemala) said that the report highlighted issues of great importance to his country, including adolescent health, health systems and, in particular, health promotion and communication. Those issues currently enjoyed political prominence in Guatemala as they formed part of the national health plan for the years 2000-2004 and of the Health Code. Practical measures being undertaken included health promotion activities within the new reproductive health programme and the establishment within the Ministry of Health of a national office for health communication and promotion. Welcoming WHO's commitment to cooperate with Member States in strengthening their capacity for health promotion and for incorporating it into national plans, he expressed his support for the report. Ms LIU Guangyuan (adviser to Mr Liu Peilong, China) welcomed the activities of WHO in the field of health promotion, which included hosting global and regional conferences and other measures to enhance awareness of public health as an essential factor in development. That was particularly important for developing countries, which had limited resources to expend on public health and faced the challenge of how to develop economical but effective health programmes to create sustainable public health systems. She hoped the Organization would strengthen research and pilot programmes in developing countries based on their economic situation and cultural traditions, and would help them to develop evidence bases for health promotion and to train and extend the capacity of practitioners and professionals. She noted the particular focus of the Organization on youth in health promotion activities. There was scope for involving many different partners, in particular the mass media and the entertainment industry, so as to ensure that they had a positive influence on young people. Since 1995, China's public health programme had targeted 900 million farmers, and public health promotion programmes had been conducted in schools. She supported the initiative to establish a forum for health promotion dialogue with other organizations of the United Nations system, which would stimulate cooperation and coordination and help promote more effective utilization of limited resources. The ageing of the world population and the related increase in the incidence of chronic disease was placing an increasing burden on the developing countries. That problem should also be addressed by the Organization, but without detriment to its focus on youth. Dr LOPEZ (alternate to Dr Abreu Catala, Venezuela) agreed that health promotion was a strategy conducive to the health of communities, as stated in the report, but considered that a public health policy should be applicable at local, municipal and national levels. In the first place, a legal framework should be established, and secondly health services should develop strategies to include

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health promotion as an integral part of their work on a horizontal basis. His country had chosen a strategy of integrated health care for the benefit of all citizens collectively, and its experience had led to changes in the structure of the Ministry of Health to enable it to adopt a multidisciplinary approach, as distinct from the traditional programme-based approach. He supported the health promotion strategies and the forum to promote dialogue on that matter which would enable countries to extend their programmes. Ms WIGZELL (Sweden) said that the Organization had consistently worked towards a health-promoting society. The Fifth Global Conference on Health Promotion had demonstrated that much inspiring work was being done, in particular with regard to improving the health of vulnerable populations. She agreed with the proposed streamlining of health promotion in three main areas - young people, health communications and health systems - and drew particular attention to the need to work with young people on problems such as drugs, alcohol and sexual and reproductive health. WHO was tackling a variety of key public health issues, such as tobacco control, macroeconomics and health, and poverty and health, and she considered that that fuller picture should be described in the report on health promotion that would be submitted to the forthcoming Health Assembly, making it clear that the Organization was not decreasing its contribution to health promotion but was, instead, moving forward in new ways. Health and development must always be one of WHO's main focuses. It was important to outline the Organization's future work with regard to health determinants and to determine how it could best promote health within the broader framework of environmental, economic and social factors, as reflected in strategic direction 4. Professor YUNES (Brazil) pointed out the increasing awareness that health promotion could do much to enhance quality of life. The document under consideration would reinforce the healthy cities and communities movement as a major agent of health promotion and would serve to increase the participation of other important sectors such as local authorities, including the mayors of cities. Health promotion had been defined as a priority area on World Health Day in 1996. The support of PAHO was essential for developing the strategy, just as it had been for the creation of the national network of healthy cities in his country. Dr N'GAINDIRO (Central African Republic), commending the report, agreed that health promotion was a central component of health policies and programmes in that its principles, strategies and methods were not restricted to a specific health activity but were relevant to various population groups and diseases, both communicable and noncommunicable, and to a variety of contexts. Health promotion was of the greatest interest to the developing countries, particularly those of Africa, which had a greater need than others to strengthen their health systems. The approaches currently being implemented by African countries focused in some cases on health education, in others on information, education and communication, and in others on social mobilization. In spite of the differences between countries, it would be highly desirable to adopt a common approach and terminology to assist them in strengthening their health systems and, more importantly, to permit comparisons of results. Thus conclusions could be drawn that would be of benefit to the entire region. Dr Ponmek DALALOY (Lao People's Democratic Republic) commented that the causes of communicable and noncommunicable diseases affecting developing countries were linked to basic acts of everyday life and were also bound up with misconceptions, superstitions, bad habits and inappropriate lifestyles. The importance of health promotion lay in the fact that it required the conscious participation of every individual, every family, every school and every organization in a country. Individuals, particularly young people, should be made aware of the facts and be persuaded to adopt appropriate attitudes and lifestyles. That objective was attainable even if it initially appeared to be a difficult and long-term undertaking: it would require the active participation of all, and massive

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information, education and communication efforts. He strongly supported those speakers who had urged the strengthening of health promotion. Dr ALLEYNE (Regional Director for the Americas) remarked that it was generally agreed that the Fifth Global Conference on Health Promotion in Mexico had been an outstanding success. One of the key points made at that conference was that health promotion must not remain an academic subject but must result in an improvement in the health of populations. Emphasis had been placed on national plans of action, and in that connection a sub-regional meeting was scheduled to be held in Chile. He agreed with Professor Yunes on the importance of involving the mayors of cities; that was another of the initiatives planned in the Region of the Americas. He also agreed that the focus should not be confined to lifestyles and, above all, that individuals should not be made to feel guilty, an approach which had been shown to be counterproductive. A point made at the conference concerned the usefulness of skills not commonly used in health institutions, such as marketing. Persons in that discipline could make a considerable contribution to health promotion. Dr Y ACH (Executive Director), referring to the focus on youth, which had been mentioned by many speakers, said that the key challenge was to promote alternatives and positive attitudes rather than merely to say "no" to unhealthy behaviour. One of the first initiatives in that connection would be with the International Olympic Committee, the Federation Internationale de Football Association, the Federation Intemationale de 1' Automobile and other bodies and would cover the area of physical activity. On the subject of ageing, to which Ms Liu Guangyan and Dr Shinozaki had referred, he said that opportunities for prevention and health promotion could be found at all stages of life. That would be even more clearly emphasized in future work on healthy ageing. Regarding evidence of effectiveness, one of the best documents had been produced jointly by the International Union for Health Promotion .and Education and the European Commission. It would be complemented by documented case studies from throughout the world. WHO would also meet the request of Dr Grabauskas for details of best practices that had resulted in real declines in risks of death and disease. It had been useful to be reminded by Dr Novotny of the complexity of many health promotion initiatives. The point raised by Dr N' gai"ndiro about the need to standardize terminology in the field of health promotion needed careful consideration, as there was no doubt that a more coherent, consistent terminology would be of great assistance to policy-makers. Ms Wigzell had pointed out the importance of placing greater emphasis on the broader determinants of health, and had suggested that the cross-sectional nature of WHO could usefully be emphasized. Those and other points made during the debate would be taken into account in amplifying the document for submission to the Health Assembly. (For continuation of discussion on technical and health matters, see summary record of the third meeting, section 2.)

The meeting rose at 17:30.

THIRD MEETING Tuesday, 16 January 2001, at 9:30 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

EXPRESSION OF SOLIDARITY WITH THE SALVADORAN PEOPLE

The CHAIRMAN agreed that, in accordance with the suggestion of the member of the Executive Board designated by Guatemala, Dr CABRERA MARQUEZ, a declaration of solidarity should be addressed to the people and Government of El Salvador and sympathy extended for the loss of life and extensive damage suffered as a result of the recent earthquake. He expressed the Board's condolences. The following message would be conveyed through the Secretariat. The Executive Boa_rd, having been informed of the tragedy that recently befell the Salvadoran people, victims of an earthquake whose magnitude has caused considerable loss of life and extremely severe damage to the country's general infrastructure, with obvious repercussions on the national economy and health situation, expresses solidarity with the Salvadoran people. The Board urges the international community to provide the relief, aid and support needed to overcome the crisis and rebuild the country. Finally, it desires that such concern be reflected in the summary records.

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued from the second meeting)

Communicable diseases: Item 3.3 of the Agenda • Global health security: epidemic alert EB107/5 Corr.l and EB107/INF.DOC./7) and response (Documents EB107/5,

Dr HEYMANN (Executive Director) gave an illustrated presentation on the WHO global alert and response network in the context of the revision of the International Health Regulations. He showed that between 1996 and 200 1 there had been many outbreaks of infectious diseases in all parts of the world, some of which had been due to new infectious agents, such as new variant CreutzfeldtJakob disease. Some diseases had re-emerged, for instance Ebola haemorrhagic fever and cholera. These emerging and re-emerging diseases were transported around the world very rapidly, and often had considerable economic impact as a result of trade barriers and the destruction of livestock and goods. Moreover, there was growing concern that biological agents might be released intentionally. After 1996, WHO had sought to strengthen global outbreak alert and response capacity by setting up a mechanism, the global outbreak alert and response network, to collect information on reported public health risks, to verify it confidentially with Member States, and then to ensure that appropriate containment measures were taken. Sources of information included electronic discussion sites. Only 23% of reports to WHO were provided by countries, while the most significant source was the Global Public Health Information Network of Canada. It was most important to avoid the repercussions for countries of inaccurate rumours, and WHO had already successfully done this in some recent instances. In order to strengthen the network to obtain better and more timely information,

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WHO was seeking additional sources of funding to strengthen public health surveillance in developing countries. One possibility was by working with other partners in the framework of Article VII of the draft Protocol of the Biological and Toxin Weapons Convention referred to in paragraph 17 of the report. The International Health Regulations adopted in 1969 had sought to combine maximal security against the spread of diseases with minimal disruption of travel and trade. Routine preventive measures, applied to all countries, were already in force for travellers and for transportation of goods. All countries were required to notify to WHO cases of cholera, plague and yellow fever, and to apply pre-set public health measures selected from the International Health Regulations. WHO then reported these cases in the Weekly epidemiological record. Unfortunately, however, there was no official mechanism for reporting outbreaks of any other diseases. The International Health Regulations were currently under revision, with the aim of ensuring that all public health risks of urgent international importance were reported, and that adequate public health measures were recommended. If such a system had been in place at the time when AIDS emerged, its rapid spread might have been prevented. The overall objective of the Regulations would remain unchanged, but their coverage would be broader. Preventive measures at points of entry into countries would be updated and expanded. In addition, potential urgent public health risks would be reported by all countries as well as by WHO's global outbreak alert and response network. All information would be confidentially verified with countries, and a decision-tree analysis would be used to determine whether the risk was of urgent international importance. Collaborative risk-based public health measures would be identified with countries and recommended by WHO. He looked forward to endorsement by the Executive Board and Health Assembly of the directions taken in the revision of the Regulations. A draft revised text would be prepared by the end of 2002: regional working groups would meet to evaluate the applicability of the new text to Member States by the end of2003, and the new text would be submitted at the latest to the Fifty-seventh World Health Assembly for review and adoption. Dr FETISOV (Russian Federation) welcomed the report contained in documents EB107/5 and EB107/5 Corr.l and the additional information supplied by Dr Heymann in his presentation. He emphasized the importance of WHO's work in the fields of epidemic alert and response and of epidemiological surveillance. The principles followed by WHO in those areas were also applied by the State Epidemiological Surveillance Service in his country through more than 2000 epidemiological surveillance centres. He approved WHO's decision to establish a mechanism for identifying and confirming information on epidemics, based on close cooperation between such centres and other participants in a worldwide outbreak alert and response network. Communicable diseases were currently of particular importance because they were being spread increasingly rapidly throughout the world as another form of globalization. Thus, they could not be combated or controlled without international cooperation and a clearly defined conceptual approach. Implementation of a programme based on international efforts would strengthen epidemiological surveillance and would improve the diagnosis, treatment and adoption of preventive measures for such diseases, as well as strengthening the training of specialists. In addition, it would ensure transparency and openness in research, which in turn would reduce the risk for unforeseen release of biological substances. The principal purpose of such efforts would be to improve the quality of life and social conditions of populations. He welcomed the revision by WHO of the International Health Regulations. He noted the proposal that a final version of the revised Regulations would be submitted to the Fifty-seventh World Health Assembly, following a step-by-step review process beginning in 2001. He supported the draft resolution contained in document EB107/5. Professor GIRARD (France) emphasized that the coexistence of infectious agents and the human race required energetic action to ensure that high priority was given to combating infectious diseases. He recalled that the situation had changed radically since the first publication of the International Health Regulations, even though they had subsequently been revised. At that time,

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specialists in infectious diseases had resolved the problem on their own. Half a century later the issue had become inter-sectoral, with the involvement of many different ministries at the national level. WHO would have to confront that aspect of the problem by forming new partnerships, in recognition of the fact that health professionals were no longer capable of managing the problem of infectious diseases by themselves. It would therefore be necessary to define the core function of WHO in that area, which was the assessment of the health risks due to infectious diseases however they might be contracted. He expressed entire approval of the proposed approach to the revision of the International Health Regulations, which was to establish as precisely as possible the methods and procedures to be used and not to confine efforts, as in the past, to listing diseases or situations requiring specific measures. A list of diseases would, by its very nature, never be definitive. He also emphasized the importance of rapid response. Rapidity depended on the means available, and it should be recalled in that connection that there were still countries and places without access to the Internet and with inadequate human resources. Training in epidemiology, field surveys and laboratory work was a prerequisite for success. The revision of the International Health Regulations was an ambitious, difficult and controversial project, and must therefore be undertaken with prudence. For that reason, he approved of the proposed schedule whereby work would continue until 2003 or 2004. It was necessary to allow sufficient time for the review process and to allocate the human and material resources required to ensure that a viable system was developed for combating infectious diseases. Dr SHINOZAKI (Japan) said that, in the context of the strong commitment of the Group of Eight to strengthening capacity and action for the control of communicable diseases, Japan recognized the growing need for international cooperation and national capacity-building. He therefore welcomed the report. He also supported the continuation of work on revision of the International Health Regulations; however, he noted that the definition of an urgent event of international public health importance should be examined closely by each Member State in order to ensure the consistency of the Regulations with domestic measures. He noted that the revision had fallen behind the original proposed schedule, and suggested that WHO should re-examine its proposed work plan. Dr SADRIZADEH (Islamic Republic of Iran) said that emerging and re-emerging diseases currently posed a real threat to both developed and developing countries. Many of the diseases had the potential to develop into epidemics, and therefore to threaten the lives of millions of people worldwide. The very serious nature and the deadly comeback of infectious diseases were illustrated by the ongoing scourge of HIVIAIDS, the return of malaria, the devastating epidemics of meningococcal meningitis in African countries in the meningitis belt, the emergence and spread of deadly haemorraghic fevers, as well as the resurgence of tuberculosis, combined with multidrug resistance and the partnership between HIV and Mycobacterium tuberculosis. The principal contributing factors to their emergence and re-emergence included globalization, rapid population growth, increased travel and migration, global warming, social, cultural and behavioural changes, transformations in food processing and nutritional habits, and the weakness of health systems in the prevention and control of infections. Infectious diseases posed a heavy burden on the economy of developing countries, thereby widening the gap between the "haves" and the "have-nots" and leaving millions the victims of disability and premature death. In response, WHO should accord high priority to the prevention and control of infectious diseases at the global level. It should accelerate international action by developing partnerships and strengthening technical cooperation between industrialized and developing countries. He reaffirmed that many countries suffered from weak surveillance systems and a lack of national capacity for disease prevention and control. Capacity-building was therefore required in clinical, epidemiological, diagnostic and laboratory sciences. Epidemic preparedness and response also needed further strengthening. He therefore welcomed the WHO objective of global health security, including epidemic alert and response, and looked forward to the establishment of an alliance for global

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monitoring, research and training in control of infectious diseases as another successful WHO initiative. He supported the draft resolution. Dr AL KHARABSEH (Jordan) welcomed the comprehensive report, which had highlighted the main issues relating to emerging diseases. One of the most important problems encountered at the national level in the surveillance of such diseases and the prediction of outbreaks was the lack of laboratory capacity for early diagnosis. He therefore requested WHO to expand the already existing mechanisms and to use them within the framework of a practical method that. would allow countries with inadequate laboratory facilities easy access to the networks of WHO collaborating centres. In most cases, national health authorities were uncertain which laboratory they should contact and what practical measures should be taken in areas such as the shipment of laboratory samples. Such difficulties led to delays, which exacerbated outbreaks of infectious diseases. Dr AL-JABER (Qatar) drew attention to the high rate of emergence of many viral zoonoses. In his region, two countries had been affected by the introduction of Rift Valley fever, which had become endemic and had resulted in a mortality rate exceeding 1% of infected persons. He thanked WHO for its assistance in endeavouring to control the disease. He drew attention to some aspects of the problem, including the reasons for the high mortality rate, the difficulty in obtaining necessary reagents rapidly, and the efficiency of WHO in providing information and notification of such diseases. He supported the action of WHO in the field of epidemic alert and response. Mr CHOE 11 (alternate to Dr Kim Won Ho, Democratic People's Republic of Korea) raised several questions with regard to the report. He understood that WHO's activities in the field of epidemic alert and response were designed to combat the spread of disease at global level. In the event of an epidemic, WHO would obtain information on it, coordinate strategy at the international level and support countries in containing the epidemic. A clearer explanation should be given of how that process would work in practice. He asked what would be the precise arrangements between WHO, the regions and Member States for obtaining the necessary information. He also sought clarification about how developing countries could be helped to benefit from the system. He supported the draft resolution. Ms WIGZELL (Sweden), speaking on behalf of the European Union, said that she would be submitting some amendments to strengthen the draft resolution and clarify the action to be taken. Although the wording had not been finalized, the amendments would include the addition of two subparagraphs to paragraph 2 calling for the development of training for staff involved in epidemic alert and response and for the exchange of good practices between specialists, and calling upon Member States to update regularly the information on the means at their disposal for the surveillance and control of infectious diseases. Concerning the action to be taken by the Director-General, a further paragraph would be added calling for the outbreak verification lists to be made available to designated focal points for the International Health Regulations in all Member States and to competent intergovernmental organizations. Professor ZELTNER (Switzerland) expressed his support for the proposed revtston of the International Health Regulations. Infectious diseases had become a sensitive issue and, as Professor Girard had said, it was important to take whatever time was necessary for the revision. Reliability and credibility were important, but it was not easy to respond rapidly, reliably and credibly at the same time. WHO should consider carefully how best to deal with that dilemma. Infectious diseases were one of humankind's oldest problems, and yet they were at the forefront of scientific and technical development; both developing and highly developed countries were concerned. He concurred with the proposals of Ms Wigzell for amendment of the draft resolution.

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Dr NOVOTNY (United States of America) said that he favoured a resolution similar to the draft contained in document EB107/5 and supported many oftheamendments put forward by Ms Wigzell. He endorsed WHO's efforts to revise the International Health Regulations, since the current ones were obviously insufficient to deal with today's large-scale international migration flows, emerging infections and threats of bioterrorism. The revised Regulations must be flexible and must specify the conditions in which it was appropriate to restrict movement of humans, animals and cargo in order to contain the spread of disease. A careful balance was needed between disease containment, the infringement of individual liberties and a nation's right to engage in international trade, commerce and global migration. Parallel efforts were under way to revise and update foreign and domestic quarantine regulations in his country. Surveillance data gathered by national and regional health authorities should be used not only to detect outbreaks but to drive national public health programmes, decision-making and capacitybuilding. It was also essential to evaluate the progress of current WHO-led global health initiatives against HIV/AIDS, tuberculosis and malaria. Stressing the need for field epidemiologists and educational programmes as a key to the detection of and response to global infectious diseases, he said that the United States was committed to continuing strong support through various bilateral efforts and had supported the TEPHINET system since its inception in 1997. Within the United States, the Centers for Disease Control and Prevention were working with many partners to develop a global infectious disease strategy, emphasizing the indispensable role of WHO in fostering international cooperation to address emerging infectious diseases. Over the previous five years, the United States had upgraded some 30 of its WHO collaborating centre laboratories specializing in infectious diseases. He encouraged Member States and WHO to support laboratory development. Professor YUNES (Brazil), stressing the importance of the WHO initiative on epidemic alert and response, said that Brazil too was formulating policies to detect, investigate and respond to emerging diseases, setting up a network of laboratories and supporting training programmes for field epidemiologists. He urged ministries of health in other countries to coordinate the work of national laboratories in order to strengthen national capacity. His country formed part of a WHO/PAHO working group for testing the new Regulations in countries with long multiple borders, intense tourist activity and international trade. Brazil was actively participating in negotiations on a protocol to the Biological and Toxin Weapons Convention and was keen to ensure that effective scientific and technological cooperation was established for peaceful purposes. He proposed that a new subparagraph should be added to paragraph 3 of the draft resolution contained in document EB 107/5, reading: "to establish an official channel for exchange of information with the Ad Hoc Group of States Parties to the Biological and Toxin Weapons Convention (BWC), with a view to providing information to Member States of WHO on efforts to monitor infectious diseases which are relevant to the BWC and to obtaining information regarding the pace of the negotiations, as well as to exploring possible mechanisms for technical cooperation so as to avoid duplication of efforts once the future organization is established;". Dr KARAM (Lebanon) pointed out that, as classic examples of diseases that transcended boundaries, infectious diseases were a major concern for WHO. The Organization's role was to shed light on facts, since fiction often spread faster than disease, and to help countries to establish proper surveillance, laboratory testing, capacity-building and prevention. Dr N'GAINDIRO (Central African Republic) said that the report focused the Board's attention on a major health problem. While all countries were susceptible to infectious diseases, the developing countries, and particularly those in Africa, were worst affected. In 2000 alone, many African countries had suffered epidemics of cholera, meningococcal meningitis and viral haemorrhagic fever, yet many lacked the resources to respond effectively. Epidemiological surveillance should therefore be strengthened in developing countries in general and in Africa in particular. Although some initiatives had been taken by the Organization, such as the establishment of the WHO project office in Lyon,

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France, for global surveillance and response to communicable diseases, that project currently concerned only six countries in the African Region. He hoped that resolution AFR/RC48/R2 on the integrated surveillance of diseases, adopted by the Regional Committee for Africa at its forty-eighth session, would be implemented. The meetings of health and interior ministers organized by the Regional Office for Africa since 1996 had led to the establishment of groups of epidemiologists which should be rendered more operational. If those commendable initiatives were strengthened, WHO's activities in the countries would help develop their potential for epidemic alert and response. He supported the draft resolution, but proposed that the conclusion of paragraph 3(2) should be amended to read " ... laboratory diagnostic competence, training in intervention epidemiology in the most exposed countries and the establishment of secure stocks of medicines". Dr MSA MLIVA (Comoros), reiterating that a large proportion of the reported epidemics worldwide occurred in Africa, confirmed the presence of cholera in Comoros, on the island of Anjouan. He urged WHO to make the fight against epidemics one of its priorities, since, in the era of globalization, no country could be considered exempt. In Comoros, epidemics were currently detected only slowly and the response was therefore slow and containment difficult. The Comoros had not one clinical pathologist or biochemist in its entire territory, no laboratory able to carry out epidemiological surveillance, no analytical laboratory and no information or epidemiological statistics system. The country could therefore not implement epidemic alert or response. He unreservedly endorsed the report and urged the Board to adopt the draft resolution. He expressed his gratitude to WHO for having selected Comoros as one of the first countries to benefit from the work of the WHO project office in Lyon, and urged the Director-General to make available the financial and technical support necessary to ensure the project's success. Previous speakers had emphasized the need for specialist training, and he hoped that Comoros would be among the first beneficiaries. Dr MBAIONG (Chad) concurred that communicable diseases remained a serious threat to public health; false reports could have a negative impact on trade, travel and tourism and were therefore a threat to economic development at the international level. Early reporting was the best method of controlling such diseases. He cited several examples to illustrate that African countries were the most seriously affected by communicable diseases. Detection and response in those countries were usually delayed because they lacked the means of detecting an epidemic in time to alert the international response network. He asked WHO to support developing countries in general, and the African countries in particular, in setting up and equipping proper laboratories for early diagnosis. There should also be a focus on appropriate training, and technical and material support to enable the developing countries to tackle the various new emerging, and re-emerging epidemics. Dr LOPEZ (alternate to Dr Abreu Catala, Venezuela) emphasized the need for WHO to encourage neighbouring countries to take joint action in respect of the alert and response system. In the Region of the Americas, PAHO had supported training and the establishment of surveillance systems in frontier towns, the majority of which were in poor areas that were difficult to reach and had few resources available. Further joint action and effective measures were nevertheless needed in areas on both sides of borders so that outbreaks could be controlled. That aspect might usefully be discussed by a drafting group. The proposed list of example diseases also needed to be clarified to prevent difficulties arising between countries in the future once problems were identified. She supported all the actions undertaken in connection with the revision of the International Health Regulations. Dr THIERS (Belgium) commented that the debate went to the heart of public health, which had had both major successes, as with immunization, and major setbacks, as with HIVI AIDS. He endorsed the need for properly equipped diagnostic and reference laboratories, highlighted by several speakers. Progress had been made in intervention epidemiology, at least in Europe: a training centre was

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operating in France. The European Union had also recently financed a Belgian initiative for a European rapid intervention project for communicable diseases, in cooperation with WHO. Similar initiatives were undoubtedly needed in other regions. It was particularly important that the revision of the International Health Regulations should not be rushed so that their feasibility and their implications for the regions could be properly tested. Dr DI GENNARO (Italy) welcomed WHO's activities in relation to its global outbreak alert and response network, noting especially the appreciation by the Italian institutions responding to the outbreak of Ebola virus infection in Uganda of WHO's leadership in coordinating the international response. WHO's renewed attention to the possibly deliberate and intentional use of infectious agents was also welcome. In that regard, risk assessment and a supporting rapid response mechanism were essential. She acknowledged the informal exchange of information between WHO and the Ad Hoc Group of the States Parties to the Biological and Toxin Weapons Convention of 1972, particularly in respect of Article VII of the draft Protocol which might result in new resources to strengthen global public health surveillance of communicable diseases in the most vulnerable countries and regions. WHO should continue its work on the partnership programme within the mechanism provided by Article VII, as outlined in document EB 107/5 Corr.l. Italy supported the idea of collaboration with military resources referred-to in paragraph 11 of document EB107/5. The steps proposed in connection with the revision of the International Health Regulations were valid, particularly the proposal to expand the scope of diseases to cover all urgent events of international public health importance. A definition of "an urgent event of international public health importance" should also be made. She was ready to participate in a drafting group to revise the draft resolution. Mr CHOWDHURY (India) said that his country's response to international health concerns and the enforcement of International Health Regulations critically depended on the quality of the disease surveillance network in India. Until five years ago, India's network had largely been the responsibility of an administrative unit at district level; linkages with other levels of the public health network had been minimal. As a result, focal outbreaks had been difficult to map and the progression of the disease difficult to predict, and hence to prevent. Those limitations had both hampered the implementation of international health guidelines and handicapped the public health programme itself. To remedy that situation, an integrated disease surveillance network was being implemented in 100 districts, covering a population of some 150 million. Its most significant components were its standardized reporting format, standardized database architecture, infrastructure for rapid communication of information, analysis of the likely progression of the disease by trained personnel, and specific linkages between different administrative areas and laboratories that gave priority to the samples obtained as part of the activities of the national disease control network. Integrated information was currently available at national and state levels, so that the spread of any disease could be charted and preventive action taken. The system would in the near future be extended countrywide, covering 600 districts and almost 1000 million people. In that context, India welcomed WHO's initiative in establishing procedures and taking up the issue of global health reporting and the revision of the International Health Regulations. Mr LIU Peilong (China) welcomed the report and its emphasis on public health security. He supported WHO's efforts to establish an epidemic alert and response system, and to build national capacities. With regard to the revision of the International Health Regulations, he would like a clearer definition of what was to be reported, namely, the types of disease, the extent of their spread and the content of reports. While it seemed reasonable to broaden the scope of the Regulations as part of the revision, when considering the types of diseases to be reported, the focus should be on significant diseases which affected the global economic situation. The broadening process should not be unlimited. As for preventive measures against such diseases, it should be a cardinal principle of the revision process to keep to a minimum the burden placed on Member States. To facilitate the

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implementation of the Regulations, as many Member States as possible should take part in the revision. Referring to paragraph 2 ofthe draft resolution set out in document EB107/5, he asked what the procedures would be for "verification and validation of data". Professor NAMA DIARRA (Cote d'Ivoire) also welcomed the report, which was a salutary reminder that the destinies of countries in the northern and southern hemispheres were interlinked. Paragraph 2 of the report contained a timely reference to the growing risk of intentional use of infectious agents, concerning which the Organization must exercise greater vigilance. She welcomed the proposed revision of the International Health Regulations, and the new initiatives under way to support countries in that respect, such as the establishment of the WHO project office in Lyon. The report emphasized the development of training in laboratory skills and applied epidemiology, but it did not say enough about the steps to be taken in poorly equipped countries to strengthen the identification and reporting of diseases subject to compulsory reporting. Laboratories in the African Region tended to suffer from maintenance and supply problems. Because of the shortcomings of national surveillance, a community approach should be taken in regard to measures initiated by WHO in the Region. While endorsing the draft resolution contained in document EB107/5, she would like greater emphasis to be placed on the request to the Director-General, in paragraph 3(2), to support the development of laboratory diagnostic competence and training in intervention epidemiology. Dr ABIA NSENG (Equatorial Guinea) said that, in his country, communicable diseases had proliferated for decades, and efforts to eradicate them had succeeded only in reducing mortality and morbidity. They were still the chief causes of ill-health among the population. However, in recent years the international and institutional networks established by WHO had improved the epidemiological situation. He was grateful to the WHO project office in Lyon for the training opportunities that would be available to personnel from his country in epidemic alert and response skills. He fully supported the work being done to revise the International Health Regulations. Mrs ABEL (Vanuatu) also welcomed the proposed revision and expressed appreciation of the Organization's support for national capacity-building. She requested that, in the latter process, it should investigate how public health legislation operated in practice. WHO collaborating centres in Australia were not readily accessible to small Pacific countries, which, because of resource constraints, tended to rely on their own public health rules and legislation in the first instance when dealing with emergency situations. In so doing, they were better prepared to implement the International Health Regulations. Dr Ponmek DALALOY (Lao People's Democratic Republic) recalled that many people travelled through his country en route to other countries in the Mekong delta. It was therefore highly vulnerable to infectious diseases and epidemics, and was also prone to facilitate their spread. It was therefore fully aware of the importance of epidemic alert and response. The report and the presentation gave a clear picture of the difficulties encountered by poor countries, such as the lack of accurate data, the inconsistency of the information available, shortage of resources, and the absence of appropriate mechanisms. He strongly supported the draft resolution, and requested further support from WHO in reinforcing his country's capacity, especially in the verification and validation of data concerning health emergencies with a regional or worldwide dimension. Dr GRABAUSKAS (Lithuania) also welcomed the report. The Baltic region had recently become a popular site for international tourism and trade, thus posing a new threat to public health as a result of its potential for transmission of emerging or re-emerging diseases to the international community. He expressed full support for the proposed revision of the International Health Regulations, and emphasized the urgency of enhanced training of personnel engaged in laboratory diagnostics and the epidemiology of communicable diseases, as well as the importance of managerial aspects such as timely reporting.

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Dr STAMPS (Zimbabwe), speaking at the invitation of the CHAIRMAN, 1 said that his country supported any improvement in the handling of international health concerns. Referring to the use of toxins as weapons and their potential for international biological warfare, he said that, in Zimbabwe, recent outbreaks of anthrax had been traced to three sites associated with hostilities during the 1970s, indicating use of biological agents against the local population by the illegal regime for the purpose of destroying cattle, the source of wealth in Zimbabwe. The anthrax spores had remained in the soil and had come to light again only recently during agricultural operations. As for the potential for international genetic warfare, in the light of ongoing research into genetic modification techniques, he felt that the scope for the use of such warfare against specific ethnic groups had been underestimated. A consignment of 10 tonnes of tinned beef and beef soup contaminated with pathogenic Escherichia coli had recently been detected in Zimbabwe, thanks to rigorous inspection. The consignment, a gift from the International Federation of Red Cross and Red Crescent Societies, would otherwise have been distributed for consumption in the south-east of the country. On the question of depleted uranium, he felt that, in view of the exposure of populations in theatres of war, the issue should be dealt with more effectively than in the past. International health regulation should not be confined to infectious diseases. The spread of HIVIAIDS in sub-Saharan Africa was taking place on a scale which defied normal biostatistical analysis, and warranted further investigation in case it represented an attempt to suppress the population. Dr HEYMANN (Executive Director) thanked the members of the Board for their support and guidance. When starting to revise the International Health Regulations, WHO had attempted to proceed rapidly, using a syndromic approach. Board members had drawn attention to some of the implications of the review, such as those involving trade and human rights, and even the fact that national legislation was not always conducive to a general approach to reporting. The present approach was to build partnerships systematically for a global alert and response system, to strengthen diagnostic capacities and laboratory and epidemiological capacities within countries, and to build links with WTO and other appropriate organizations. More intensive work was being planned with countries in developing the way reports were to be presented, through a decision tree. It was important not to miss new diseases as they occurred, and to take account of zoonotic infections, xenographic transplants and infections from other sources, such as those mentioned by Dr Stamps. As the revision continued, work by WHO would focus on strengthening epidemiological and laboratory capacity, especially in developing countries and with an emphasis on Africa. As the last stage of the revision proceeded, WHO would endeavour to work more proactively with countries, exchanging information electronically, and to incorporate their recommendations into the review. The CHAIRMAN noted that the drafting group convened to revise the draft resolution would be coordinated by Professor Zeltner. (For adoption of the resolution, see summary record of the eleventh meeting, section 5.) • Control of schistosomiasis and soil-transmitted helminth infections (Document EB107/31)

Dr SADRIZADEH (Islamic Republic of Iran) praised the report and observed that schistosomiasis and helminth infections placed a heavy burden of ill-health on hundreds of millions of people. Appropriate strategies to deal with those infections were available in almost all the affected countries, so that their control and elimination were quite feasible. However, there was a need for political commitment and support to that end. The Executive Board might therefore wish to formulate a resolution on the subject for submission to the Fifty-fourth World Health Assembly. He would be glad to take part in the drafting of such a resolution. 1

By virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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Dr SHINOZAKI (Japan) commended the report, noting that it continued the work begun in 1998 with the launching of the global parasitic disease control initiative (the Hashimoto Initiative), which had been further discussed and strengthened during the Okinawa International Conference on Infectious Diseases in December 2000. Dr CABRERA MARQUEZ (Guatemala) expressed satisfaction with the report, since it would contribute towards a stepping up of the current efforts to combat schistosomiasis and soil-transmitted helminthiases, especially among high-risk groups in rural areas in Guatemala, where parasitic diseases were widespread. Dr FETISOV (Russian Federation) said that the problem of schistosomiasis did not exist in his country, but the phenomenon of soil-transmitted helminthiases was widespread and caused various pathologies, including reproductive system disorders among women. The report was therefore relevant for his country. He endorsed the validity of the issues raised in paragraphs 7, 8 and 9 of the report, and hoped that cooperation with WHO in those areas would be stepped up. Dr MBAIONG (Chad), commending the report, noted that the population of Chad, especially schoolchildren, was plagued by those helminth infections, as in many other least developed countries. From a practical point of view, he wanted to know the precise methods used by those countries that had succeeded in reducing morbidity and mortality due to such parasitic diseases. Mr LIU Peilong (China) endorsed the report and noted with particular satisfaction the strategy outlined for controlling schistosomiasis and soil-transmitted helminthiases and the current status accorded to such parasitic infections by WHO, which he hoped would be upgraded still further for the benefit of vulnerable populations. In China, fifty years of effort to control those helminth infections had resulted in a low general level of disease, although in certain lake areas such parasitic infections were still highly prevalent and posed a serious public health problem requiring the continued support of the international community. He requested clarification as to whether the targets set out in paragraph 7, namely an 80% reduction in morbidity and a regular administration of chemotherapy to 75% of school-age children, covered both schistosomiasis and soil-transmitted helminth infections. Dr AL KHARABSEH (Jordan) observed that schistosomiasis and soil-transmitted helminth infections were more than just a public health burden; they also had serious economic and social consequences. Often they had to compete with other diseases for priority status, but the fact remained that they afflicted hundreds of millions of people, particularly young people, in disease-endemic countries. Although schistosomiasis was not prevalent in Jordan, there was a constant threat that migrant workers from disease-endemic countries could spread the disease there. In that respect, he welcomed the work of WHO and the control strategies outlined in the report. Dr DI GENNARO (Italy) said that the report provided a valuable update on the current burden posed by schistosomiasis and soil-transmitted helminth infections, which were still spreading among the poorest sections of disease-endemic regions. There was a clear need for stronger commitment to control activities, particularly for high-risk groups. She supported the view that the administration of regular chemotherapy to high-risk groups, particularly to school-age children, reduced morbidity if given before chronic irreversible pathology had been established. Furthermore, the cost of antihelminthic drugs was very low: they were on the Essential Drug List, and should therefore be made available at peripheral level, in every area of high endemicity. Such a goal could be easily achieved if WHO maintained and pursued its policy of forming partnerships with international and bilateral agencies, nongovemmental organizations and the private sector. She supported Dr Sadrizadeh's proposal that a resolution should be drafted for submission to the Fifty-fourth World Health Assembly.

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Dr LOPEZ (alternate to Dr Abreu Catahi, Venezuela) observed that her country had for several decades been providing, through intersectoral collaboration, treatment for schistosomiasis and soiltransmitted helminth infections to children in schools, with excellent results. Although the treatment was extremely cost-effective, developing countries where such parasitic diseases were endemic could still not afford to tackle the problem. She, too, therefore supported the proposal that a resolution should be drafted, to include provision for fmancial support to the most disadvantaged countries in order to increase their access to tb:e necessary treatment. Dr KARAM (Lebanon) noted the Organization's responsibility for educating Member States in the control and eradication of diseases such as schistosomiasis and soil-transmitted helminth infections, and expressed support for the preparation of a resolution on the subject.

Dr AL-JABER (Qatar) called upon the Board to agree on the need to eradicate schistosomiasis and soil-transmitted helminth infections, as it had done in the case of a number of other diseases. He would support any project aimed specifically at that end. Dr HEYMANN (Executive Director) thanked the Board for its many valuable contributions and for its support for the strategy proposed. Although in many countries parasitic infections were accepted as an inevitable ·part of daily life, a cost-effective strategy existed which had shown that mortality, morbidity and, where applicable, transmission could be reduced. It needed the commitment of governments to ensure that the strategy was included as a priority in all their health care services, and to create a willingness on the part of those infected to seek out available treatment. The CHAIRMAN called upon Dr Di Gennaro to coordinate, among all interested Board members, the drafting of a resolution on the control of schistosomiasis and soil-transmitted helminth infections. (For adoption of the resolution, see summary record of the eleventh meeting, section 5.)

The meeting rose at 12:35.

FOURTH MEETING Tuesday, 16 January 2001, at 14:10 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued) Health systems performance assessment: Item 3.6 of the Agenda (Document EB107/9) • The world health report 2000 • The world health report 2001 Mr SALM (alternate to Professor Yunes, Brazil) congratulated the Director-General on her initiative in opening up such a complex subject as methodologies for health systems performance assessment for discussion by all Member States, following problems identified in The world health report 2000. Brazil believed that the use of a single overall health system attainment index was excessively reductionist, since it had no real meaning and failed to provide any useful information. Its validity as a measure of the effectiveness of health systems was doubtful, since it failed to include an indicator for access to and use of health services, and it took no account of the technical efficiency of health care services or of the extent of public spending on health. Five distinct indicators had been aggregated into a single value that was difficult to understand and interpret, and those five indicators were themselves of doubtful validity. There was no scientific evidence that changes in health status reflected the way in which health systems operated: rather, they reflected social and economic conditions. In summary, the report failed to define valid parameters for monitoring health systems. Only five of the 191 countries evaluated - including Brazil - had been able to provide the necessary data, and consequently health systems performance had been assessed on the basis of socioeconomic indicators such as income and education levels. He strongly supported the proposal that regional meetings should be convened, with wide participation by Member States and by representatives of the scientific community, to review the basic concepts and methodologies used for assessing health systems performance. Dr SADRIZADEH (Islamic Republic of Iran) said that, although health systems generally had made remarkable progress over the past two decades, in many countries they suffered from poor political commitment, shortage of resources, inadequate intersectoral collaboration, weak community involvement and an uncontrolled private sector. Managerial weaknesses and a lack of mechanisms to assess performance were the main obstacles in tackling the problems of health systems. WHO should continue to provide technical support to the countries concerned to enable them to strengthen their managerial capacities in all aspects of health systems development. Dr NOVOTNY (United States of America) welcomed the Director-General's suggestions for wider consultation on the development of an analytical framework for the evaluation of health systems performance. He agreed with Mr Salm that a better understanding of the validity and reliability of the criteria used, the data on which they were based, and the methodologies adopted was required. He urged WHO to take the time necessary to conduct a rigorous scientific review which would involve both Member States and experts from relevant disciplines such as epidemiology, health services research, statistics and economics.

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He suggested that evaluations should be made of those processes that had been shown to improve the impact of health interventions, and that the Director-General should report back to the Board on the results of those evaluations. It was important to understand why, over time, some countries performed well while others fell short despite comparable resource inputs. Dr FETISOV (Russian Federation) said that The world health report 2000 introduced a new approach to health systems performance assessment which had attracted great interest among health professionals and been given wide coverage in the press. It undoubtedly represented a milestone in the Organization's development. Effective improvement of performance of health systems depended on choice of indicators, self-assessment by Member States and the quality of data used. The main difficulty in understanding the report was the fact that it covered both political and scientific aspects; for the purpose of analysing the performance of health systems, emphasis on the scientific aspects would seem to be more effective. Some kind of worldwide comparative analysis of the performance of health systems was carried out each year. Indicators that had been used in the past and had produced fairly reliable results included healthy life expectancy at different ages, infant and maternal mortality rates, and causes of morbidity and mortality. Although the proposed approach undoubtedly represented a real breakthrough in improving the effectiveness of health systems, the attempt to gauge performance on the basis of a common scale of assessment for all Member States seemed somewhat premature, and moreover resulted in harsh and therefore invidious comparisons. It presupposed the provision by all countries of high-quality aggregated data on morbidity, invalidity, mortality and the performance of their health systems, and hence the use of disaggregated data of lesser quality from countries which did not have identical health systems would cause problems. The report defined three health system goals. Many of the arguments put forward in connection with the second goal -responsiveness to the legitimate expectations of the public - were questionable and required further research. The third goal - fairness of financial contribution - was difficult to assess in a Russian context. How those different goals were subsequently combined to produce an overall indicator for health systems performance was unclear, and it was also questionable whether the performance of such a complex system as a health system could be properly assessed on the basis of a single indicator. At the present juncture it would therefore seem to make sense to adopt a more gradual approach, and not to overlook the indicators that had hitherto proved useful. He suggested that pending the refinement of the new approach, official comparisons should be made using traditional indicators. The report contained in document EB 107/9 showed that the Secretariat was paying heed to the comments of Member States. He was pleased to note that WHO intended to continue cooperating with experts and holding consultations with Member States on the subject; the Russian Federation was willing to participate in those efforts. Dr ABREU CATALA (Venezuela) supported the view expressed by Mr Salm that the methodology used in the report should be transparent and credible if it was to serve as a reference point for other sectors. She noted that PAHO had helped its member governments to develop the technical capacities needed to identify indicators and to pinpoint regional and sub-regional imbalances. She doubted the value of ranking health systems in order of merit, which could stigmatize certain countries and create further problems for their development. Professor GIRARD (France) said that the topic was of particular interest since it had brought the subject of health and the role of WHO to the forefront of the preoccupations of political leaders and health professionals. The risk entailed in producing the performance assessment had therefore proved to be worthwhile: indeed, lack of criticism might have made a first endeavour of that type suspect. He expected The world health report to fulfil three requirements: transparency, credibility and a clear definition of responsibility. The first entailed a clearly understandable method which went beyond purely technical considerations; the second involved credibility of the method used and

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reliability of the information on which it was based; and the third required that sources of information be guaranteed. On the question of credibility, he wondered what should be the role of governments in preparing the report: even the most apparently democratic of them might be tempted to exercise some control over the health information required or to claim that particular sources of information served particular interests and were therefore not necessarily credible. Hence both technical and political credibility of sources was of prime importance. In regard to responsibility, it was clear that although Member States could provide input, in order to avoid any ambiguity only the Director-General could be responsible for the report. Finally, he pointed out that in the seven months since publication of The world health report 2000 the principle of producing such a document had not once been queried. In his view, that was already sufficient evidence of its success. Dr CICOGNA (alternate to Dr Di Gennaro, Italy) said that the assessment of health systems performance was welcomed and appreciated. The attempt in The world health report 2000 to identify and evaluate indicators of health system performance and data permitting the assessment to be made had generated a great deal of interest and support, as well as criticism. It was a brave and necessary initiative concerning a complex and sensitive issue. He considered that there was need to improve the methodology used, the availability of reliable data and the choice of indicators and their evaluation; to guarantee a participatory process that would involve Member States more in the formulation and design of methodology; and to ensure wide participation by the research community in the review of the present model. Italy was willing to collaborate in that work. Dr KARAM (Lebanon) noted that the ranking of health systems had created controversy: the exercise was a challenge that could be applauded or criticized, but could not be ignored. Concern had been expressed about the methodology and data. It was true that health authorities might overrate the health systems they themselves had promoted and applied, yet an open mind towards evaluation as shown by the Director-General was a healthy way of approaching such a delicate issue, which required unbiased arbitrators and uniformly acceptable indicators and data. Ultimately, the need to evaluate health systems was inescapable, since their status would be reflected in the health status of peoples. He hoped that the shock wave generated by The world health report 2000 would prove constructive for WHO. Dr AL-JABER (Qatar) said that although the report had given rise to a number of questions it would contribute to promoting health worldwide. He emphasized that not all the five essential indicators on which the assessment was based applied to all countries: for example, he did not see how it was possible to assess the elements listed in paragraph 14 of document EB 107/9 relating to fairness of financial contribution in countries that had not applied them to date. Health costs and services in many countries depended on the overall government budget. The estimates used might not always be well founded since, in many countries and regions, with the best will in the world, it might be very difficult to obtain accurate information of the type required by WHO for such a comparison. Obviously close collaboration between the Organization and the authorities in the countries concerned was needed before the report was issued, in order to make both the information and the whole process credible and reliable. Furthermore, the sensitivities of the parties involved should also be taken into consideration, so that difficulties of the type raised by earlier speakers could be avoided in future. Dr GRABAUSKAS (Lithuania) said that, despite certain reservations relating to methodology, his country congratulated the Director-General on her initiative in preparing The world health report 2000. Regardless of the ranking of health systems, Lithuania considered the report to be a stimulating approach to self-assessment of performance and to health care reform. The report had generated much interest countrywide at political and academic levels, leading to a constructive dialogue on how limited resources could be spent in a more rational and effective way. One outcome of the dialogue had been that Lithuania had agreed to be one of the case countries contributing its national data to the

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fairness of financing project. Cooperation with the other Baltic countries on the improvement of methodologies for data analysis and of scientific backup would be helpful. He supported the Director-General's approach, while fully endorsing the comments made by other speakers in regard to the need to improve the quality of the work done and thus to increase the credibility of WHO in presenting it. He associated himselfwith the proposal made by Mr Salm. Mr LIU Peilong (China) said that in recent years WHO had attached great importance to health systems development, which was one of the four strategic directions of the Organization. Many countries, including his own, were carrying out reforms in the health sector and he hoped that China could receive more guidance from WHO in that endeavour, including cooperation to improve assessment capacities. He fully supported the new assessment framework, which he considered to be a brave and innovative initiative providing many insights and encouraging new ideas on how to improve performance. However, assessing a country's health system was a complex process that had to take account of differences in cultures and value systems as well as differences in economic development levels. Reliable and accurate data sources were needed in order to ensure that assessment was sufficiently accurate and objective, and in that regard he considered that there was much room for improvement in the report. Member States should be allowed to participate fully in the exercise, and his Government was willing to cooperate with WHO in that respect - indeed, a seminar had been held in December 2000 with WHO officials to discuss assessment indicators and methodologies. Performance assessment should be done in combination with the reform and development of the public health sector and in collaboration into the Member States concerned. It should be integrated into Member States' data collection systems, so as to ensure more efficient use of resources and more reliable results. He proposed that further study should be made of ways of simplifying data collection, as many of the present data required family-based surveys which were not common practice in developing countries. Efforts should be made to strengthen technical support to such countries in order to increase their capacities for data collection, processing and analysis. Dr SHINOZAKI (Japan) stressed that the basic objective of health systems performance assessment was to achieve an effective policy dialogue aimed at improving the efficiency of health systems. Global application of the indicators used would show how resources were being allocated, where priority areas existed and what steps governments should take. He fully supported the major effort made by WHO in the field of assessment. The world health report 2000 had had considerable impact, for example in mobilizing new partners and resources for improving health care systems. However, the sources of data and the specifications used by WHO were not sufficiently clear and should be made more transparent and credible. Moreover, as the results were linked directly to the assessment of specific health systems, the impact on the situation in Member States was considerable; they should therefore be treated with great care and established in consultation with Member States themselves. He was confident that such improvements would be made in future world health reports. Mr JANG Chun Sik (alternate to Dr Kim Won Ho, Democratic People's Republic of Korea) welcomed the introduction of health systems performance assessment and supported the new assessment framework in principle. He suggested that The world health report might in future include a summary of the health policies followed and challenges faced in each country, so as to give a clearer picture of its health system. In his own country, for example, free medical care for all was provided by the State, but successive natural disasters in recent years had resulted in poor-quality medical services which seriously affected public health. If such aspects of the background of a country's health system were not explained, an accurate assessment could not be made. It was important that the methodology of health systems performance assessment should be improved through broad consultations with Member States. Insufficient consultation had taken place between WHO and Member States during evaluation of the indicators, with the result that some of the statistical data used were incorrect. Since the report contained both technical and political components, as in the case of life expectancy,

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statistical data should be confirmed through consultation with the Member States concerned before being published. Professor NAMA DIARRA (Cote d'Ivoire) said that, although she had some reservations about the methodological approach taken, she considered that the report was relevant to the future improvement of health systems. She noted that measures were to be taken to improve the methodology used and to involve Member States more closely in the collection of data for the assessment exercise. Mr CHOWDHURY (India), welcoming the report, stressed the need to establish and define a methodology and to ensure the accuracy and validity of the data base. The health systems performance assessment had been based on four components, two of which (responsiveness and fairness of financial contribution) constituted 50% of the weight. He was not satisfied that the scale of indices or samples of data used were always representative of the country to which they related; such a weakness would throw doubt upon the whole exercise. The methodology should be developed on the basis of discussions with Member States and it should be verified that countries met the minimum requirements upon which the indices for assessment could be based. The weight given to the various components was the same for many countries, despite considerable variations in, for instance, socioeconomic factors and literacy levels. In his view countries should be divided into five or six categories that were sufficiently similar for a common scale of indices to be developed. He also felt that some of the components of the index used did not relate to the actual situation in countries like his own. Those relating to responsiveness, for example, might be applicable in other countries but would not deserve the same weight when applied to India. He therefore urged that the exercise of ranking of countries be suspended until an accurate methodological and statistical base had been established to provide fully relevant indicators. Dr THIERS (Belgium) said that, although his country's Ministry of Social Affairs, Public Health and Environment had expressed general satisfaction with the report, some epidemiologists and experts in the field of health services research had commented that certain figures gave a false impression. The Institute of Tropical Medicine at Antwerp had expressed disappointment at what it perceived as undue influence on the part of the World Bank. It had also cast doubt on the value of such an exercise for the developing countries, especially the poorest, and had expressed the view that the approach taken was over-technocratic. Attention should be paid to the criticisms made, and he suggested that, before the next version of the report was issued, an evaluation should be made of the use made of the results by various countries, notably developing countries, in order to judge whether the type of methodology used was appropriate for solving the everyday problems they faced in operating their health services. He considered that the Director-General had properly shouldered her responsibilities in taking an initiative that was inevitable, and had stood up to criticism. The work of assessment should continue with increased emphasis on consensus. Professor ZELTNER (Switzerland) said that, in scrutinizing the report, Board members had been scrutinizing the past. He wanted to comment on the lesson the report held for the future. As a Member State, Switzerland looked for four qualities in the Organization and in its Director-General. First, both should have a strong personality and should exhibit the qualities of reliability, credibility, and resistance to undue influence. Yet it had been suggested that some aspects of the report's methodology were such as to discredit the Organization, and with it the DirectorGeneral. Secondly, the Organization and its Director-General should be innovative, and thirdly, they should be courageous. In his view, by placing The world health report 2000 on the political agenda the Director-General had exhibited both those qualities. Last but not least, the Organization and its Director-General should be supportive of its Member States, especially of the poorest and of those in which health problems were most prevalent. It was in that regard that a lesson needed to be learned for the future. As the report related to WHO's strategic direction 3, namely, "developing health systems

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that equitably improve health outcomes, respond to people's legitimate demands, and are financially fair", the question arose as to how WHO could best support Member States in the future, so as to enable them to improve on their assessed performance and to develop their health systems. A second, related question was where that measurement exercise and the report belonged in the context of evaluation of progress towards attainment of the goal of better health through that strategic direction. Professor ALl (Bangladesh) said that The world health report 2000 had prompted reactions from unaccustomed quarters. In response, the Organization's leadership had shown proof of its willingness to engage in discussion with Member States in order to review the concepts and methodologies used. However, in the light of the criticisms made, he supported the proposals for improvements made by Mr Salm and Mr Chowdhury. Dr Ponmek DALALOY (Lao People's Democratic Republic) said that, although health systems performance assessment and reporting of information on the health of populations were separate agenda items, he wished to consider them together, for it was through proper management of information that a basis for assessment and comparison of health systems performance could be established. Information management was one of WHO's essential functions. As a global organization it was faced with the massive task of providing accurate and scientifically reliable information - a task that was not merely technical, but also political. The Organization thus wielded great power in that regard. He found The world health report 2000 to be a praiseworthy first attempt. Despite the diverse reactions it had provoked, that attempt should be continued, in a spirit of perseverance, flexibility, creativity and adaptability. It should be borne in mind that while the world was unified in terms of globalization it remained diversified in terms of geography, ethnicity, history, culture and levels of development. A diversified world called for diversified solutions, strategies and methodologies. There was room for consensus, which should be sought in the interests of health throughout the world, but at the same time care should be taken to avoid extremes. One such extreme was a refusal to seek new ways of managing information or to base assessment on scientific information. Another extreme was an undue technical rigidity divorced from actual situations or a mechanical recourse to facile generalizations. At the recent retreat for members of the Board, a consensus had emerged on the great importance and value of health systems performance assessment. The thorniest problems raised had related to technical matters such as criteria, indicators, data compilation methods, and pre-assessment coordination. Those problems could be resolved, not overnight, but gradually. While manifold, they were not new, unexpected or surprising, and had already been touched upon at the previous year's ministerial round table. The most striking problems to have emerged from the discussions had already been incorporated into the framework adopted for the assessment, namely the results obtained by health systems in terms of reduction in mortality, morbidity and incapacity, increased life expectation, improvement in the quality of life and reduction in, or gradual eradication of, poverty. That assessment could not be divorced from consideration of the general socioeconomic development of a country and of its region. A second factor in the assessment was provision of health services, in terms of quantity and quality of medical personnel, health infrastructure, the existence and use of appropriate technology and operational and management mechanisms, including legislation. A third factor was financing systems, with their corollaries: state financing, community and private sector participation, and increased recourse to international partnerships and alliances. The fourth factor was stewardship to ensure good governance. All those factors were inextricably linked, and account should be taken of the relationship between them. Thus, the relationship between stewardship and equitable financing, and between stewardship and provision of health services, must also be taken into account. All those aspects were already more or less covered by the eight criteria adopted in The world health report 2000. Nonetheless, those criteria seemed to emphasize the level and quantity of performance, at the expense of other characteristics. It was thus necessary to determine whether the

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stewardship was in harmony with the results obtained. Such an assessment must be conducted, first and foremost, by Member States themselves. WHO would make its own assessment, and the two assessments should be compared and discussed with each country individually under the procedure already established, and thereafter discussed at regional and global levels. Such a procedure would, however, require time, and a period of two to two-and-a-half years seemed not unreasonable. The aims and objectives of the assessment should be diversified. Prominent among the proposals for a fairer assessment was the proposal to subdivide each WHO region into groups of developed and developing countries. Recent requests for information had failed to take into account the situation of the latter, which lacked the technological resources to respond to such requests in a timely manner. His country could not hope to emerge from underdevelopment before the year 2020, or to overcome relative poverty until 2010 or 2015. To do so, it must continue to work with the information available, which was not totally reliable but which was improving day by day. It was therefore to be hoped that WHO would send a mission to study his country's problems in the field. If performance assessment was to play its proper role in improving health systems, WHO's leadership must take account of countries' real problems and find the best ways of resolving them. That was a complex task relating not only to the health sector, but also to other objective and subjective variables. He supported the Director-General's wish to accord increased attention to strengthening health systems, particularly in the developing countries, and hoped his country would soon have an effective and reliable information system. Ms WIGZELL (Sweden), praising The world health report 2000 as an important advocacy document, said that the initiative to include in the Statistical Annex an overview of health systems performance in addition to the traditional health outcomes measured in terms of infant mortality and other vital health parameters was therefore welcome. That would enable the report to reflect more effectively the health sector's responsibility to meet health needs by strengthening and reforming its infrastructure. The decision to present tables of health systems performance on a regular basis was of strategic interest to the governing bodies, for several reasons: The world health reports were the Organization's primary instrument for communication with the world at large in its advocacy for health; the themes selected reflected priority issues; health systems performance data reflected priorities approved by both the Board and the Health Assembly; and the framework for the assessment of performance contained a strategic element in the selection of the parameters chosen and the methods used. Such an exercise required substantial resource allocation by WHO, and placed demands on Members States in relation to provision of data. The Organization was fully responsible for the provision of reports based on scientific evidence: that was not a matter for the Board, but for the Director-General as executive head of the Organization. Finally, a participatory approach to the development of a measurement system was the key to long-term success. Working with countries in different resource settings on the initiative to enhance the performance of health systems was one way of testing potential solutions. Consultations with experts, including relevant international agencies, would provide further advice on how to improve the measurement system. Dr CABRERA MARQUEZ (Guatemala) said that the developing countries tended to take a more simple and pragmatic view of the assessment exercise, perhaps because of the fact that when one was ranked among the last it was difficult to aspire to be among the first. He considered that The world health report 2000 was an innovative document that fulfilled the objective for which it had been created; in its initial form it had some weaknesses that would need to be remedied, in particular with respect to the framework for assessment and the methodology in general. WHO should take into account the observations made by various countries, and incorporate suggested changes in subsequent reports in order to secure the agreement and support of the majority of Member States.

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Dr EDWARDS (Trinidad and Tobago) commended The world health report 2000, and supported those speakers who had emphasized the importance of making the methodology scrupulously accurate and ensuring that the analysis made was of benefit to countries. Member States should be able to assimilate the information the report contained in a way that would enable them to improve their health care systems. He felt it necessary to emphasize that point because he came from a part of the world where health care systems were influenced directly by the state of the economy, which in turn was affected by the fact that no tourists would wish to visit any part of the Caribbean unless they had confidence in its health care system. Although most of the comments on the report had been directed at the statistical element, the textual element also contained many valuable ideas which should not be lost sight of. Ms BENNETT (Australia), speaking at the invitation of the CHAIRMAN, 1 said that The world health report 2000 represented ground-breaking work. Its release, although not without controversy, had been a positive development, which would result in an improved description of the performance of Australia's health system and would allow more standardized comparisons between countries. For Australia the findings were broadly as expected with respect to outcomes in relation to outlays, but one surprise had been performance relative to potential, having regard to the country's resources, including non-health factors. It was unfortunate that the methodology used in that connection was difficult to understand or explain, especially as that particular performance indicator had been the one of most interest to the media. It was a matter of judgement whether the benefits of focusing the attention of commentators on the report outweighed the inevitable criticism of the methodology and lack of consultation prior to publication. The report had, however, undoubtedly provided an impetus to work on measuring outcomes and evaluating the impact of health policies. In Australia, as well as in other countries, the debate had focused on methodology rather than on WHO's broader objectives. Professor Girard's reminder that there were policy and political aspects as well as technical aspects to be considered was timely in that respect. She acknowledged WHO's willingness to refine the measures used and to improve data input, and welcomed the Director-General's commitment to establish a technical consultation process involving Member countries to ensure the selection of the best data available and confirm the validity of WHO's conclusions, as well as to establish an advisory group. Comments on the wisdom of leaving that consultation process until after the report's publication had clearly been heeded by the Secretariat. The importance of performance measurement as a basis for health system improvement was recognized not only by Member States, but also by other organizations that wished to contribute to that improvement. The steps announced by the Director-General would allow WHO to draw on their expertise, experience and support in developing a performance measurement system that was credible and accepted by Member States. Her country looked forward to participating in that process. Dr FRENK MORA (Mexico), speaking at the invitation of the CHAIRMAN/ said that his Government was initiating an effort to assess the performance of the national health system. The framework of reference developed by WHO offered a set of useful tools for making an accurate diagnosis of the situation and defining and quantifying goals. Prior to publication of The world health report 2000, the subject of equitable financing had not figured largely in public policy debates. However, an analysis made on the basis of the WHO framework had shown that equitable financing was perhaps the major challenge faced by the Mexican health system. As a result, precise goals were being set and a programme was being established to ensure that financial protection was available to the entire population, thereby ensuring that the Government was made more accountable. In addition, the need to provide innovative information had become a means of improving national information systems. Careful implementation of the framework for the assessment of health systems performance would also provide a means of documenting the effects of different public policies, thus strengthening 1

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the empirical basis for decision-making. It was crucial to be able to make comparisons between one country and another, and he therefore welcomed WHO's proposals to strengthen comparative studies and carry out in-depth technical discussions. Mexico was willing to contribute to that process and to put its experience at the disposal of all Member States. Dr ANTEZANA (Bolivia), speaking at the invitation of the CHAIRMAN, 1 welcomed the Director-General's statement of the previous day and endorsed the comments of Mr Salm and Mr Chowdhury. Although the assessment of health systems performance was a complex process, he nevertheless hoped that WHO would devise a flexible approach enabling all 191 Member States to understand and apply the methodologies used. As Professor Girard had pointed out, the exercise had a political dimension that should be recognized. The instruments provided by the assessment framework should not be used merely to secure a higher place in the rankings, but to ensure that the most needy populations could see that defects in their health systems were being remedied. Thus, indicators should measure countries' efforts to improve their situation, bearing in mind that a tiny increase was laudable in a poor country and that social and human indicators counted as well as monetary ones. The assessment process should also help countries to find ways of improving their systems. All countries, irrespective of their ranking, should be capable of providing their people with better services and better health. Mr NENE (South Africa), speaking at the invitation of the CHAIRMAN/ said that The world health report 2000 had generated a widespread and frequently hostile reaction. That was hardly surprising, since clearly the decision to rank countries in league-table fashion would result in the dissatisfaction of most Member States. Nevertheless, he supported the principle of periodic, independent and objective assessment of the performance of health systems in different countries. Since performance assessment was an integral part of South Africa's national health policy, the exercise was seen as a valuable opportunity to learn from the experience of others. He applauded not only WHO's intent in drafting the report, but also its prompt and sincere response to the many queries and requests made subsequently, including a two-day mission to South Africa for high-level consultations. The purpose of The world health report 2000 was not to embarrass countries by exposing the shortcomings of their health systems, but to identify where and how improvements could be made. Nevertheless, that purpose could be equally well served through a more general categorization of the perceived performance of countries' health systems. Furthermore, a collective review of the choice of indicators and overall methodology used was required. Individual countries should be consulted in order to identify reliable sources of data: many of the data used in the assessment of South Africa's health system were outdated and related to the apartheid era. It had only been during the bilateral consultations that the Government had become aware of the weighting given to inequity in calculating overall health system performance. It had therefore been aggrieved not only at being held accountable for the misdeeds of the previous regime, but also at not being given credit for attempts to remedy them. Communication should have been better, but closer collaboration on future reports had now been promised. Although South Africa was not currently entitled to designate a Board member, it wished to express its support for the overall thrust of the draft resolution submitted by Mr Salm. The Executive Board was competent to sanction and manage the changes proposed in that resolution. The matter should be resolved at Board level, leaving the Fifty-fourth World Health Assembly free to deal with what was already a heavy agenda. Dr STAMPS (Zimbabwe), speaking at the invitation of the CHAIRMAN, 1 said that he regarded The world health report 2000 as a very important document and a long overdue attempt to assess how Member States were performing in relation to the Organization's objectives and vision. However, one 1

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important aspect mentioned in the report had been omitted from the statistical computation. The countries of northern Europe and North America had built upon progressive environmental and occupational health achievements during the period of their industrialization and colonial exploitation, financing public health costs by plundering the resources of their colonies in Africa, Asia and South America. In addition to forcing communities into slavery or poverty and promoting drugs such as alcohol and opium, they had also destroyed indigenous medical systems and introduced formerly unknown diseases, such as syphilis, measles and tuberculosis. The health systems set up had been largely suited to the needs of settlers. He therefore supported Mr Chowdhury's view on the need for regional rather than overall rankings. What The world health report 2000 failed to provide was a solution to the increasing inequities in health fuelled by new epidemics, including HIVIAIDS, and compounded by the breakdown of communities and the greed of manufacturing companies in the developed world. As a direct consequence of the publication of the report, the budgetary allocations for health previously agreed upon between the Zimbabwean Ministry of Health and Child Welfare and the Ministry of Finance, which had been based on a fairly extensive analysis of perceived needs, had been reduced by almost 25%. There had also been substantial political reaction. Unfortunately, in WHO's assessment of Zimbabwe's health system performance, some of the available data had been overlooked, while other data had been included which were positively laughable, such as the UNAIDS claim that 136% of deaths-in Zimbabwe were due to HIV/AIDS. He was still confident in the fundamental values of WHO and in its intrinsic technical integrity. The outcomes of the report had to be analysed, and not only in statistical terms. He therefore requested that Zimbabwe should be involved in the analytical work for selected countries, in order to refine the assessment approach and to make it a useful tool in the attainment of health for all in the twenty-first century. The DIRECTOR-GENERAL said that she had taken note of the concerns expressed, as well as the positive comments made and the considerable support for the position she had outlined in her opening address to the current session. The debate had provided useful input for continued joint efforts in the assessment of health systems, and had reaffirmed the importance of an exchange of views in the further refinement of the data and methodology to be used for that purpose. The CHAIRMAN recalled that, at the first meeting, Mr Nogueira Viana had proposed the establishment of a drafting group to consider a proposed draft resolution on future developments in relation to WHO's assessment of health systems performance. The members of the Executive Board designated by Brazil, Belgium, China, France, Lithuania, Qatar and Sweden had signalled an interest in participating. He suggested that the drafting group be composed of those members, and invited others to attend as observers. It was so agreed. (For adoption of the resolution, see summary record of the tenth meeting, section 3. For continuation of the discussion of Technical and health matters, see summary record of the eighth meeting, section 2.)

The meeting rose at 16:30.

FIFTH MEETING Wednesday, 17 January 2001, at 9:30 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

PROPOSED PROGRAMME BUDGET FOR THE FINANCIAL PERIOD 2002-2003: Item 4 of the Agenda (Documents PPB/2002-2003, EB107/34, EB107/INF.DOC./1, EB107/INF.DOC./2, EB107/INF.DOC./3, EB107/INF.DOC./4, EB107/INF.DOC./5 and EB107/INF.DOC./8) General programme of work, 2002-2005 The CHAIRMAN, introducing the item, emphasized the importance of the proposed programme budget in planning WHO programmes and initiatives and the use of the Organization's resources. The Executive Board would begin its consideration of the item by discussing the proposed general programme of work which was set out in document EB 107/34 and reproduced in the policy framework section of the Proposed programme budget 2002-2003 (document PPB/2002-2003). Mr CHOWDHURY (India), speaking as Chairman of the Programme Development Committee (PDC), said that at its seventh meeting on 11 and 12 January 2001, the PDC had reviewed the proposed General programme of work, 2002-2005, and the Proposed programme budget 2002-2003. The PDC had welcomed the new format of the general programme of work, and in particular its shortened timeframe, the closer link with the budget and the greater focus on clearly identified priority areas. It had requested that information on the results of monitoring and evaluation over the course of the four years covered by the general programme of work and further details on the work planned for 2004 and 2005 should be provided to the Executive Board at its 109th session. The PDC had also prepared a draft resolution for consideration by the Executive Board on the general programme of work, which read as follows: The Executive Board, Having reviewed the draft General programme of work, 2002-2005; 1 Noting that the Executive Board would review at its 109th session developments and evaluation affecting the General programme of work, 2002-2005, particularly in relation to the elaboration of the Programme budget for 2004-2005, 1. ENDORSES the draft General programme of work, 2002-2005, for submission to the Fifty-fourth World Health Assembly for consideration; RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Having considered the draft General programme of work, 2002-2005, submitted to it by the Executive Board, in accordance with Article 28(g) of the Constitution;

Document EB107/34.

-63-

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Mindful of the challenges of the rapidly evolving context of international health and the need for WHO to adapt accordingly; Aware of the strategic directions and core functions set out in the corporate strategy' developed by the Director-General and endorsed by the Executive Board, and of the close interrelationship of priority setting, programme planning and budgeting as products of this strategy; Noting the greater coherence and closer linkage between the general programme of work and the Proposed programme budget 2002-2003; 2 Welcoming the introduction of a process of programme planning supported by evaluation and prepared closer to the time of implementation as part of WHO's efforts to become a more efficient and productive organization, APPROVES the General programme of work, 2002-2005. Dr NOVOTNY (United States of America) expressed support for the overall proposed budget level. He also supported the proposed general programme of work and the proposed strategies, which were essential for the development of such a comprehensive programme on the basis of WHO's core functions. He emphasized that priority-setting and the limitation of the number of priorities set would enhance WHO's excellence, attract additional investments and better address the Organization's future human resource challenges. However, child health, which cut across several of the priority areas identified, merited greater attention. Professor GIRARD (France) proposed that in the French version of the penultimate paragraph of the resolution recommended in the draft resolution proposed by the Board, the phrase soutenu par une evaluation et etabli a une date plus proche de la mise en oeuvre should be amended for greater clarity. Dr DI GENNARO (Italy) expressed appreciation of the proposed general programme of work and its role in translating policy into practice, in accordance with the proposed programme budget and WHO's operational plans. With reference to WHO's six core functions, which represented the most important activities to be carried out at all levels of the Organization, she welcomed the attempt to eliminate the traditional dichotomy between WHO's normative functions and technical cooperation. However, such an approach needed to be handled with caution in order to avoid misunderstanding and confusion as to roles and competencies. She endorsed the Organization-wide priorities and the criteria used for priority-setting. The temptation in listing areas of major emphasis was to include too many issues. However, as had been emphasized at the last session of the Regional Committee for Europe, environment and health, health of the elderly and accidents should also be considered as priorities. Substance abuse was another area that needed to be given increased attention. Professor ZELTNER (Switzerland) congratulated all those who had been working over the years on clarifying the approaches that were reflected in the proposed general programme of work. The discussions had started with strategic directions and had then moved on to core functions and priorities. However, difficulties continued to arise in matching the Organization's structure with its priority areas of work, particularly in the regions. Headquarters was now organized in such a way as to reflect priority areas of work in its structural setting, but he would appreciate clarification as to whether any major problems were envisaged in achieving the same structural adaptation at the regional level, and what the timeframe for that adaptation would be.

1 2

Document EB105/3. Document PPB/2002-2003.

SUMMARY RECORDS: FIFTH MEETING

Dr BODZONGO (Congo) welcomed the proposed General programme of work, which met the concerns of the African Region and the priorities endorsed by the Regional Committee for Africa and by WHO in general. While he supported the draft resolution in general terms, he wondered whether the inclusion of the phrase "noting the greater coherence and closer linkage between the General programme of work and the Proposed programme budget 2002-2003" in the final preambular paragraph of the resolution recommended therein was not somewhat premature, since the Executive Board had not yet examined the proposed programme budget. Dr ABREU CATALA (Venezuela) also expressed unease at adopting the draft resolution before the examination of the proposed programme budget. Mr LARSEN (Budget and Management Reform), responding to Professor Zeltner's question about matching regional structures with the Organization's priorities, confirmed that the 35 areas of work appearing in the proposed programme budget corrt"sponded well to the current structure at headquarters. In the regions, however, WHO was facing an adjustment period. All the regions would be reporting under the same 35 areas of work in the biennium 2002-2003. Efforts had been made to avoid the situation experienced during the current biennium, in which all the regions had been virtually forced into the headquarters cluster structure, which had raised problems relating to a feeling of lack of commitment and ownership. Following widespread discussion, it had been decided that the way forward was to identify common areas of work cutting across the Organization as a whole. The 35 areas of work so identified, which appeared as budget headings in the proposed programme budget document, could be regarded as building blocks, which the regions would all assemble in different fashions according to their structures. However, all of them would report in the same manner, as would be clarified in the operational planning for 2002-2003, which would take place later in 2001. No major problems were envisaged, although the adjustment period was likely to take between three and six months. The CHAIRMAN recalled that the draft resolution had been proposed by the PDC, a Committee of the Executive Board itself, and he therefore invited the Executive Board to adopt it, as amended, without further delay.

The resolution, as amended, was adopted. 1 Overview Mr LARSEN (Budget and Management Reform) introduced the Proposed programme budget for 2002-2003, which, being the first in which the Director-General had been involved from the beginning, was a cornerstone for the new policy framework for the whole Organization and a key instrument in the reform process towards one WHO. There were significant differences in the way it had been prepared compared with the previous biennium: the principles of results-based budgeting requested by Member States had been fully incorporated; the budget had been developed through a truly Organization-wide process linking staff from the regional offices with staff from headquarters; and the global programme budget document had, for the first time, been reviewed in its entirety in draft form by all the regional committees, and their comments had been incorporated in the document before the Executive Board. A main focus of that work had been to produce a common strategic budget which flowed naturally from the WHO corporate strategy endorsed by the Executive Board at its 105th session in January 2000. One of the key concerns in developing the programme budget had been to ensure that it could be formulated in a way that would retain a link to the 2000-2001

Resolution EBI07.Rl.

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programme budget, in order to provide continuity and to show the progress made over the two bienniums. The programme budget should not be seen in isolation; an extensive review of the overall managerial framework of the Organization was being conducted, involving several discrete but interlinked processes. The first step in the managerial framework was the corporate strategy, with its basic elements of four strategic orientations, six core functions and eleven priorities, which was expressed through the general programme of work. The corporate strategy provided the impetus for the strategic planning process, expressed through the programme budget, whose elements were the 35 areas of work cutting across the whole Organization. Each of those 35 areas of work had development goals, WHO objectives and expected results. Closer to implementation and later in the year, the operational planning stage would begin, during which biennial work plans would be developed geared to breaking down the expected results into products and clear activities. With the start of the new biennium, the implementation phase would begin, with regular reporting of human and financial resources. That information would be fed back into monitoring reports and programmatic evaluation to complete the process and lead into the budgeting process for the following biennium. Considerable efforts had been made to establish a clear hierarchy of objectives in the programme budget and to define clearly how the Organization contributed, together with other partners, to development objectives, as well as to define what WHO could be held directly accountable for. Consequently, a broad developmental goal - the higher and long-term development objective to which the work of WHO would contribute- had been formulated for each of the 35 areas of work, which constituted the common building blocks for the entire Organization. From that goal were derived the WHO objective (what WHO hoped to influence directly over the medium term, and what it was committed to) and, subsequently, the expected results for the biennium for which WHO would be directly responsible. The expected results were statements of intent, or commitments, concerning how the Director-General intended to spend the regular budget and other resources entrusted to her by Member States for a particular biennium. The operational planning stage would follow, involving further breakdowns into products and activities, which would be reflected in the work plans and guide the day-to-day operations of the Organization throughout the biennium. The expected results were the common denominator in strategic planning and operational planning, being at the lowest level in the programme budget for the new biennium and the highest level for the operational work plans to be developed later in the year. Each of the 35 areas of work was covered in a two-page spread in the proposed programme budget document, which set out the issues and challenges, the overall development goal, the WHO objective, the expected results and, linked to each of the expected results, the indicators that would be used to measure progress towards those results. Proposed budget allocations were also given. Summary tables at the back of the document recapitulated the figures given at the end of each area of work. A particular feature of the Proposed programme budget for 2002-2003 was the strong focus on priorities: 11 priorities had been endorsed by the Executive Board at its 105th session. At the beginning of the planning process, the Director-General had withheld part of the allocations for all programmes and all regions. Those resources had been reoriented to the 11 priorities. As a result of that reallocation, the regular budget allocation for the 11 priorities had increased from US$ 108 million in 2000-2001 to US$ 132 million for the following biennium, representing an increase of 22%. The Executive Board needed to bear in mind that, at the current stage at least, the overall regular budget was subject to zero nominal growth. A significant increase in allocations to the 11 priorities from other sources was also projected. The forecast was for a 33% increase in total resources for the 11 priorities over the forthcoming biennium, from US$ 329 million to US$ 439 million. Although substantial, those amounts were in fact conservative underestimates since they only represented the resources allocated directly. An effort had been made in the proposed programme budget to indicate the estimated contribution by other areas of work to each priority; that information was given in the document after each two-page spread for the area of work in question. Taking the case of tuberculosis as an example, the two-page spread could be found in document

SUMMARY RECORDS: FIFTH MEETING

PPB/2002-2003, pages 28 and 29, and an assessment of the extent of contributions by other areas of work appeared on pages 30 and 31. Turning to the expenditure plan for the new biennium, he recalled that it had been prepared on the basis of zero nominal growth for the regular budget, although the Director-General reserved her position on the extent to which she would include provisions for cost increases and exchange rate movements later, before the budget was submitted to the Fifty-fourth World Health Assembly. A 15% increase was projected in funds from other sources, from US$ 1237 million in the current biennium to just over US$ 1400 million. Regional committees had questioned the reliability of the estimates of funds from other sources. By way of illustration, the projection at the time the programme budget for 2000-2001 had been presented to the Executive Board in January 1999 had been US$ 958 million. That had subsequently been increased to US$ 1237 million, reflecting the best estimates as of July 2000. Preliminary figures seemed to suggest that the increase was realistic, and initial calculations indicated that expenditure for 2000 alone would be roughly US$ 600 million. Moreover, with health coming to the forefront of the development agenda and with the increasing interest of private foundations and bilateral agencies, the US$ 1400 million projection for 2002-2003 was not unreasonable, and possibly somewhat conservative. The figures would be reviewed prior to submission of the proposed programme budget to the Health Assembly. Finally, in response to some questions that had arisen at the recent joint meeting of the Programme Development Committee (PDC) and the Administration, Budget and Finance Committee (ABFC), he explained that the traditional or resource-based budgeting started with defining what could be delivered with the financial and staff resources available. Results-based budgeting, on the other hand, started by defining the expected results and only when they had been agreed, defined the financial and staff resources required to attain them. The new approach had been introduced in response to requests by the Executive Board and the Health Assembly in 2000. Since the proposed programme budget had been formulated up to one and a half years before implementation, it was not useful, before the operational planning stage, to try to give a detailed breakdown of the Organization's overall planned expenditure pattern in terms of staff costs, contractual services, supplies and equipment, etc. In any case, those aspects would be covered in the financial report for the biennium, after completion of the biennium. As noted in the introductory pages to the proposed programme budget document, the process of preparing country programmes would henceforth take place closer to the time of implementation. In order to have a consistent programme for the whole Organization, the Director-General's policy was that the country programme should take its inspiration and point of departure from the collectively agreed policies adopted by the Executive Board and the Health Assembly. Detailed country programming would therefore be initiated on the basis ofthe 35 areas of work and developed by each regional office in consultation with the WHO representatives and national counterparts, starting immediately after the current session of the Executive Board. Reporting to the regional committees would take place in September 2001, if so decided by the regional director concerned. A few errors had unfortunately occurred in the budgetary tables at the bottom of the two-page spreads for the 35 areas of work. However, the summary tables at the back of the document on pages 11 0-113 were all correct. To facilitate the discussion, the page numbers of the proposed programme budget document were identical in all six language versions. Mr CHOWDHURY (India), speaking as Chairman ofPDC, said that that committee and ABFC had reviewed the Proposed programme budget for 2002-2003 at their joint meeting on 11 January 2001. The Committees had welcomed the new format of the programme budget, especially its clarity of presentation and the overview of funds from all sources. They had noted that, as voluntary contributions continued to increase, assessed contributions accounted for a decreasing proportion of the total budget. Members had expressed concern that, as a result of that trend, some important health issues that might not be attractive to donors could suffer from a lack of resources. That possibility

EXECUTIVE BOARD, 107TH SESSION

should be taken into account in reviewing the allocation of assessed contributions in the context of the estimated total budget for each area. The Committees had highlighted the importance of ensuring that cross-cutting priority issues, such as child health, should be afforded an adequate funding priority. Several members had noted with concern the zero-level allocations for some budget lines in the Regions. The Secretariat had explained that the new budget structure based on 35 areas of work was not always matched area by area with similar activities in the regional offices, which accounted for some of the zero-level allocations. In view of the complexity of the issues concerned, the Committees had requested a brief paper for the current session of the Executive Board, explaining the zero-level allocations; that request had been complied with (document EB 107/INF .DOC./8). While members had welcomed the increases for selected priority areas, they had expressed concern about the reductions indicated for nutrition in view of the magnitude of the problem of malnutrition, especially among children, in many developing countries. Dr FETISOV (Russian Federation) welcomed the integrated character of the proposed programme budget, which clearly set out all the activities of the Organization at headquarters, in regional offices and in countries, irrespective of the sources of funding. Moreover, the priorities defined by the Executive Board had been reflected in the proposed activities and allocations. It was also to be welcomed that some funds had been transferred from administrative activities to substantive programmes, especially at country level. Health promotion, disease prevention, and the global surveillance of communicable diseases were important areas of work. WHO should support Member States in examining factors that had a negative impact on national demographic situations, in formulating useful indicators in those areas, and in looking into the economic impact of various health promotion activities. Further work was also required to ensure that priorities were reflected in budgetary allocations. Despite the fact that more resources were to be allocated to priority programmes over the next two years, it remained the case that less than half the budget would be spent on such programmes. Programmes should be further examined with a view to making them more effective and reducing administrative costs. Moreover, the priorities established should undergo periodic review so that the necessary adjustments could be introduced. In that regard, greater emphasis should be given to the health of the elderly. Efforts to improve transparency should continue. Further information should be provided on the exact amounts that would be spent on particular areas and on particular programmes at the national level, so that Member States could form a realistic idea of the support that could be expected in practice. Moreover, clearer indications should be provided on the staffing situation for such areas. He hoped that such information could be provided to enable the Board to analyse the budget in greater detail before it took any decision. If not, its decision should perhaps contain a request for provision of the desired breakdowns, with details of staffing resources, for confirmation by the Executive Board at its 109th session in January 2002. He hoped that before the Health Assembly the expected results and indicators would be more precisely defined, in accordance with the Board's proposals. In relation to the area of work concerning governing bodies (pages 94-95), he noted the reference in the third indicator to the translation of documents into the most used languages of the Organization. Referring to previous Executive Board debates concerning multilingualism, he emphasized the need to translate documents and provide interpretation into all the official languages. In conclusion, he expressed support for the Proposed programme budget for 2002-2003. Overall expenditure should remain at the level of the current biennium, with zero nominal growth. More information would clearly be required on inflation rates and currency fluctuations before he could give a final opinion. Dr AL-JABER (Qatar) fully endorsed the Proposed programme budget for 2002-2003, and the 11 priorities. However, cuts of varying degrees of severity in the resources allocated to the regions would disrupt the progress of programmes. He requested that the 3% cut for the Eastern Mediterranean Region, the severest of all, be reduced to 2% or 1% to enable that Region to implement its

SUMMARY RECORDS: FIFTH MEETING

programmes fully and efficiently. Furthermore, he hoped that the Eastern Mediterranean Region would receive a percentage of the expected increase in extrabudgetary resources to enable it to implement delayed programmes. Lastly, he hoped that the health indicators used in assessing country allocations from the regular budget, which had led to zero nominal growth of some country allocations, would be reviewed. Or SAORIZAOEH (Islamic Republic of Iran) fully supported the 11 priority areas in the Proposed programme budget for 2002-2003. However, he too was concerned by the cuts in regional budgets, which would affect implementation of programmes at regional and country levels. Although budgetary constraints were expected to be offset by increased efficiency and the mobilization of extrabudgetary resources, some regions were faced with a shortage of extrabudgetary resources as well. As the previous speaker had said, the Eastern Mediterranean Region was a case in point. He endorsed the suggestion that the cut for that Region should be reduced to 1% or 2% at most. Or SHINOZAKI (Japan) welcomed the concise presentation of WHO's goals, objectives and indicators in each area of work in line with the Organization-wide priorities, and emphasized the importance of discussing and defining the detailed contents of the expected results and indicators with Member States to ensure appropriate monitoring and evaluation. By maintaining the regular budget at the same level in recent bienniums, the Health Assembly had recognized that in terms of number of staff members, budget level and regional and country presence WHO was still able to absorb cost increases through efficiency gains, like other major intergovernmental organizations. The efforts made under the regular budget for 2000-2001 to improve efficiency throughout management were highly appreciated. Nevertheless, it was important to maintain zero nominal growth for the regular budget for the 2002-2003 biennium. Mr LIU Peilong (China) welcomed the reforms that had been introduced into the regular budget and, in particular, the increases for the 11 priority areas and country-level activities. Improvements could be made however. For example, although expected results were shown for each area of work, resources were only shown for total budget lines, and, in the absence of budget distributions, the Executive Board could not analyse or comment on priority areas within any given area of work. The problem would be remedied if a breakdown by expected results was also included. Furthermore, while the pairing of expected results with indicators provided a reliable presentation, some of the indicators were too vague. On page 76 of document PPB/2002-2003, for example, on immunization and vaccine development, the indicator for the third expected result, relating to the accelerated introduction of under-utilized vaccines, particularly hepatitis B and Hib vaccines, was shown as the proportion of countries that had introduced the vaccines, without any indication of what an acceptable vaccination rate might be. Similar indicators appeared elsewhere in the document. With regard to communicable diseases, paragraph 9 of Annex 2 of the Report of the fourteenth meeting of ABFC (document EBABFC14/2) stated that the new structure ofthe programme budget, of which the 35 areas of work were the building blocks, had not always been matched, area by area, with similar activities in the regional offices, and that the differences had resulted in the allocation of zero values to several budget lines in the regions. That made analysis difficult: technically it should be possible to find ways of permitting conversions and integrations between the regional and headquarters budgets. Further explanation of the matter was therefore requested. It was gratifying to note that the request made by China at the regional committee meeting in September 2000, namely that the priority diseases budget should be included in the programme budget, had been met. However, while the figure on page 15 of document PPB/2002-2003 was welcome, there was some inconsistency between the expenditure which it showed for poliomyelitis and the statements in paragraphs 18 and 19

EXECUTIVE BOARD, 107TH SESSION

of Annex 2 of EBABFC 14/2. 1 The figure also showed a large reduction in the leprosy budget, and an explanation of that point was also requested. With regard to the distribution of Executive Board documents, while many could be accessed via the Internet, downloading difficulties sometimes occurred, as in the case of the proposed programme and budget document, which consequently had only been obtained on arrival in Geneva. Such important documents should be mailed rather than transmitted by the Internet alone. Ms WIGZELL (Sweden) said that the budget format provided for greater transparency than in previous years, and the links with the general programme of work were an added advantage. Having been jointly prepared by the regional offices and by headquarters, it could reasonably be expected to serve as a key instrument in the reform process towards one WHO. It was extremely important for results to be monitored and evaluated in a regular, systematic and transparent manner to enable Member States to exercise their governance function. The timely and extensive evaluation of a results-oriented budget was a valuable and necessary tool for the formulation of future budgets and programmes of work. In addition, the inclusion of various performance indicators in the budget should facilitate an evaluation of programme implementation and the degree of attainment of the Organization's objectives. The balance between the extrabudgetary and regular resources available to the Organization also deserved attention. For the Organization to carry out its proposed activities and achieve the desired improvement in the convergence of WHO and donor/recipient country health priorities, it was of utmost importance that donors should target their extrabudgetary contributions to programmes included in the strategic budget. If voluntary resources were given in support of such programmes, the desired simple budget could be realized, which result would facilitate planning, the setting of priorities and interaction with donor countries. Sweden would continue to allocate extrabudgetary resources only to such activities and was prepared to engage in discussions on additional donor coordination, which might also include the question of long-term resource mobilization. Sweden was also prepared to examine the level of the regular budget, if that were necessary for the purposes of programme implementation. In order to address some of the world's most pressing problems, the United Nations had, over the past 10 years, convened nine world conferences that had defined key approaches to development. She had examined the proposed programme budget with those approaches in mind. Following the 1990 World Summit for Children, child and adolescent health had been reflected in different areas of WHO's work, but not always to the most desirable extent. Special aspects such as children and smoking, children and rehabilitation and the sexual and reproductive health of adolescents should form part of WHO's mainstream activities. The improvement of the status of women had also been identified as a key approach to development, but although bringing gender into the mainstream had probably been considered, that shift in emphasis was not adequately reflected in the proposed challenges, issues and expected results for the various areas of work. 1 With regard to reproductive health and rights, although the goals set out in the budget were demanding, the lack of progress in achieving them was well-known, particularly the reduction of maternal mortality and HIV transmission, and those areas clearly needed special focus. Professor ALl (Bangladesh) said that in the South-East Asia Region, which had 25% of the world's population and 40% of its disease burden, countries such as his own found it difficult to understand the continuing decrease in the regular budget and the increasing reliance on extrabudgetary resources, which put control of an increasing number of activities in the hands of donors. It was vital that WHO should maintain its leadership role at country level. Countries had appreciated having the opportunity to discuss the budget in the Regional Committee, which had given them a greater sense of participation. The problem would be to translate the proposed programme of work into action in the 1

For response, see summary record of the sixth meeting, section 2.

SUMMARY RECORDS: FIFTH MEETING

years 2002 and 2003, when country priorities might have changed and regular budget funds might have become even scarcer. Or NOVOTNY (United States of America) expressed support for the overall budget level of US$ 2260 million for 2002-2003, which maintained the Organization's regular budget at the 2000-2001 level of US$ 842.7 million. He hoped that any adjustments due to currency fluctuations or inflation would be absorbed within the regular budget, and that the Health Assembly would not be presented with a proposal for any increase. For some years, WHO had operated under no-growth regular budgets, and had done so remarkably well, although there were still some areas in which further efficiency savings could be made. While supporting the projected programme increases in the overall budget level, especially those made possible owing to a 15% increase in extrabudgetary resources, he was concerned that some programmes might have to be curtailed if those resources failed to materialize. Part 11 of the proposed programme budget, Strategic orientations 2002-2003 by area of work, included indicators of performance. That was commendable, but he hoped the Organization would continue refining the indicators to enable them to measure more accurately whether the objectives were being achieved. The last of the indicators for tuberculosis, for instance (page 29) was defined simply as "Access of countries to new diagnostic tools for tuberculosis", and did not specify how the tools were to be devised and tested. Part 11 was set out according to the priorities accepted by the Executive Board for 2002-2003: the priority areas of work reflected major international health concerns, and the proposed budget represented a significant shift of resources towards them. However, he noted that in the case of poliomyelitis, spending was being cut back, and pointed out that in view of the recent outbreak in Hispaniola it was important to maintain adequate levels of surveillance and immunization so that the disease could be eradicated by 2005. 1 As well as thematic evaluations, a regular assessment should be made of the delivery and impact of the current programme budget. He would like reports on results in terms of the achievement of objectives, which would show whether expectations should be maintained or altered, and whether resources were being used in the most appropriate way. Such information was needed to enable the Health Assembly to make future programme and budget decisions. WHO had made an excellent start by including objectives, indicators and expected results in the budget for 2002-2003. He would expect an interim report in 2002, and a further report in 2003 when the next programme budget was due for consideration. Professor GIRARD (France)· recalled that for some years his delegation had objected to the principle of zero nominal growth, preferring the principle of zero real growth, although he was not entirely satisfied with the attempts made to find a more satisfactory solution. It was surprising that at a time of expanding health budgets in all the developed countries, WHO was experiencing difficulty in making allowance for inflation and exchange rates. He was also conscious of the growing imbalance between the regular budget and extrabudgetary contributions. Because of the strict adherence to zero nominal growth, undue reliance was being placed on extrabudgetary resources, which endangered programmes that were inadequately funded from the regular budget. He recalled that WHO's Global programme on AIDS, which had been of great strategic importance and high symbolic value for the Organization, had had to be closed down because its funding had come exclusively from extrabudgetary contributions. Such imbalances lead to instability. As to the breakdown of the budget between the regions, he believed that Africa and Europe merited special attention. He was concerned to hear that some countries were seeking to change from one region to another in order to get extra money, which seemed to him a dangerous trend. However, he welcomed the approach adopted for the new programme budget, namely to allocate funds on the basis of objectives. That approach would be more likely to persuade other 1

For comment, see summary record of the sixth meeting, section 2.

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international institutions to contribute where the objectives were in line with their own development policies. Within the programme budget, he welcomed the emphasis placed on communicable diseases and on an integrated approach to the control of epidemics. However, inputs in regard to specific diseases, or improvements in access to drugs, would not be sufficient to create the health systems which were needed in developing countries. The main focus should continue to be on the effort to support health services. Finally, he would find the presentation of the budget easier to follow if it were based on a simple pie chart showing how the budget was apportioned. Dr N'GAINDIRO (Central African Republic) welcomed the proposed programme budget, which reflected the Organization's new corporate strategy and the priority areas of work adopted by the Executive Board at its 105th session. The continued application of zero nominal growth had resulted in productivity gains. He was glad to note that the "budget for one WHO" announced by the Director-General at the Executive Board's 105th session brought headquarters and the regional offices together for the first time in the pursuit of shared objectives. He was also pleased to see that great importance was attributed to the needs of Member States, since the country offices were to receive more than either regional offices or headquarters. In the African Region there were still major problems to be resolved, notably the control of serious diseases and the strengthening of health systems in a context of sustainable development. The Region was therefore anxious to know the specific allocations each country would receive once the budget had been approved. Finally, he noted that priority areas of work were described as being supported by activities conducted under other areas; he would like to know whether non-priority areas of work also benefited from such support. Dr THIERS (Belgium) said that his experience of programme budgeting derived from running a public health research institute, which had been plunged into crisis ten years previously when Belgium had overnight become a federal State. The process of negotiating the budget with different governments had resulted in the imposition of a single programme budget similar to the one used by WHO, which had proved an excellent management tool. One difference, however, was that in the WHO budget resources for the governing bodies were presented as corresponding to programme objectives, whereas in his own Institute management resources were distributed across the programmes in order to reflect their actual cost. Next time the budget was presented, he hoped they could be shown in that way. On the question of priorities, he was aware that an increase in one area would have to be offset by a decrease in another. Although some had criticized the 10% increase allocated to tobacco, which was a major priority for the Director-General, as being too small, he felt it was reasonable because it was not WHO but governments that should be increasing their efforts. Whereas in general he was satisfied with the budget, he felt that in the area of HIVI AIDS the imbalance between regular budget funds and extrabudgetary funds was too great, and, as Professor Girard had said, that posed a threat for the future. Finally, he welcomed the provision made for evaluation in the budget and the inclusion of indicators for that purpose. Professor ZELTNER (Switzerland) welcomed the new format of the proposed programme budget, which would make it easier for both the Executive Board and the Health Assembly to identify and implement priorities and to track achievements. Although it was gratifying to see a projected total budget increase of 9%, the budget still remained relatively small, considering the magnitude of the task which the Organization was expected to undertake. Like Professor Girard, he was concerned about the imbalance between regular budget and extrabudgetary resources. A shift in the source of funds from regular to extrabudgetary threatened to undermine the authority which the Executive Board and the Health Assembly should exert over the budget process.

SUMMARY RECORDS: FIFTH MEETING

With respect to reporting on strategic orientations, it was not clear how simply adding up results in the 35 areas of work could produce an overall result for each orientation. 1 He had also been concerned for some time that insufficient attention had been given to budgeting for environmental health and for sustainable development: those were areas where advocacy and normative work produced good returns for comparatively little outlay and should therefore be designated as priorities. Without advocating a reassessment of priorities, he nevertheless believed that healthy ageing was a very important area and should be dealt with specifically under mental health, given that in global terms the mental health of the ageing population constituted a major problem. With reference to paragraph 22 of Part I of the proposed programme budget, he said it was not clear whether regional offices had now been given responsibility for carrying out their own normative work. Mr CHOE 11 (alternate to Dr Kim Won Ho, Democratic People's Republic of Korea) drew attention to the serious health situation in South-East Asia, which was one of the most densely populated regions in the world with a high incidence of endemic diseases, including leprosy and HIV/AIDS. Even though it had been agreed by the Regional Committee the previous year that the level of budgetary allocation for the region for 2002-2003 should remain unchanged, he noted that there had nevertheless been a slight reduction. When determining priorities in future programme budgets, WHO should consult fully with the regional offices in order to ensure that the actual health needs of the various countries and regions were met. Dr DI GENNARO (Italy) welcomed the new budget format, which would guarantee greater transparency. However, she too regretted that neither environmental health nor healthy ageing had been included among the priorities identified despite the fact that they met the criteria laid down in paragraph 25 of Part I. She was also concerned at the delay in redistributing the regular budget among the regions. For example, the European Region, which included several countries in transition with acute needs, had still not received its full budget allocation. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil) requested clarification regarding the apparently privileged status of Evidence and information for policy (EIP) within the Organization's budgetary structure. That cluster, which had been responsible for devising the system of indicators introduced by WHO, had received the second largest regular budget allocation in both the 1998-1999 and the 2000-2001 budgets, while others that were directly responsible for health programmes had been dependent on extrabudgetary sources to carry out their activities. Moreover, in the 2000-2001 budget, EIP had received an increase of 117% in its extrabudgetary allocation and an overall budget increase of 43%. Dr FETISOV (Russian Federation) said that he shared the concerns expressed regarding the redistribution of regular budget allocations among regions, in particular Africa and Europe. Dr MBAIONG (Chad) welcomed the new programme budget format, which took account of the Organization's principal strategic orientations, while maintaining zero nominal growth. He pointed out that the 35 areas of work and the 11 priorities represented problems that were particularly acute in Africa, and therefore some flexibility in the allocation of extrabudgetary resources might be considered. In that way, donors could benefit WHO as a whole and at the same time assist countries of the African Region to provide health care to poor and underprivileged populations. Professor NAMA DIARRA (Cote d'Ivoire) broadly welcomed the proposed programme budget and noted with satisfaction the 10% increase in the allocation to the African Region, which reflected a 1

For comment, see summary record of the eighth meeting, section 1.

EXECUTIVE BOARD, 107TH SESSION

recognition of its needs. However, when shared out among the different countries, the amounts received by each would be insignificant. She therefore called upon the Director-General to make available extrabudgetary funds to safeguard priority programmes, to improve data and information systems underpinning health policies, and to enable countries to tackle new problems associated with development. Mr CHOWDHURY (India) expressed concern that the regular budget was static while extrabudgetary resources were increasing, which meant that more activities were now being carried out which did not come under the scrutiny of WHO's governing bodies. It was even more disturbing that the regular budget was shrinking in real terms. He would accordingly urge the Director-General to persuade international funding agencies and other donors to provide untied funds for absorption into the regular budget. Since in fact the allocation of regular budget funding between the different regions was not related to their disease burdens, any additional funding secured by the Director-General should be used to rectify that situation. Professor GIRARD (France) expressed surprise at Professor Zeltner's suggestion that healthy ageing should become a priority under mental health: ageing was not a disease, and certainly not a mental disease. Dr STAMPS (Zimbabwe), speaking at the invitation of the CHAIRMAN, 1 noted that no mention had been made of health ministers in the proposed programme budget and associated documents. He wondered whether that implied that they no longer had a role to play in health. The CHAIRMAN, speaking as the Executive Board member designated by Chile, said that with regard to the imbalance between regular and extrabudgetary funding, one solution might be to impose a kind of tax on extrabudgetary funds which could then be transferred to the regular budget. He supported Professor Girard's suggestion that in future a pie chart might be included to show the distribution of budgetary and other resources by region and whether or not progress had been made. He drew attention to the table of detailed allocation by area of work given on pages 112-113 of the programme budget document and in particular to the last line, which showed how allocations were distributed between headquarters and the regions. Mr LARSEN (Budget and Management Reform), thanked members of the Executive Board for their comments and words of encouragement. In reply to the request made by Dr Fetisov for a detailed breakdown of expenditure in terms of staff costs, contractual services, supplies and equipment, he said that there were real practical problems in providing such information at the present time. Before allotments were issued, it was not possible to ascertain how much would be spent on any particular item. However, the issue would be clarified once the operational planning stage had been concluded in the autumn, and it should be possible to make projections of itemized expenditure by category by January 2002. Many speakers had raised the question of regional allocations. That issue had been covered in resolution WHA51.31, which called for a comprehensive reassessment of the entire system of regional allocations. The new model was no longer based on past practice but on solid indicators taken from the UNDP Human Development Index. It was possible that as the economic situation improved in eastern and central Europe, the current preferential allocation to Europe would start declining, whereas it might increase again in the eastern Mediterranean or South-East Asia in the light of economic circumstances. The resolution provided for reductions of up to 3% per annum, but in order to soften the impact on those regions which would be receiving less money, the Director-General had reduced that amount to 2% per annum. 1

By virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

SUMMARY RECORDS: FIFTH MEETING

In reply to Dr Shinozaki, who had drawn attention to the need for refinement of the indicators used, he said that the Director-General and her staff would be working on that issue before putting forward a revised proposal to the Health Assembly. Dr Shinozaki had also mentioned the need for reviews, in order to enable reductions to be made in programmes when objectives had been met. That point would be discussed at greater length in the context of document EB107/INF.DOC./3 on the framework for programme evaluation. In response to the suggestion by Mr Liu Peilong that a breakdown of budget provisions by expected results should be included in the budget, he said that the general opinion in WHO was that that would not be practical at the present stage; it would be preferable to consider the issue at the operational planning stage. The implication was that allocation by expected result would not be approved by the Executive Board, but would be dealt with in the respective regional committees. For instance, a full country programme for the Western Pacific Region would be presented at the next regional committee meeting in September 2001. In reply to his query about the decline in the allocation to leprosy, he said that the decrease in funding was commensurate with the lower incidence of the disease. The budgetary allocation of US$ 197 million to poliomyelitis was based on an estimate of the input from all other areas of work to poliomyelitis during the coming biennium. Further details would be provided subsequently. He assured Mr Liu Peilong that hard copies of the programme budget document had in fact been sent out to Executive Board members well in advance, before 1 December 2000. However, the mailing list would be checked. Dr Novotny had suggested that efficiency savings could still be made even with zero nominal growth, but in fact the Organization had gone as far as it possibly could in cutting costs. It would be reporting on the 2% to 3% efficiency savings, but part of the amount withdrawn and allocated to priorities would in all likelihood turn out to be a budget cut. He agreed wholeheartedly that there was an imbalance between the regular budget and the extrabudgetary funds. Because the regular budget had declined in real terms over the previous decade, WHO was forced to seek more extrabudgetary resources. He supported the proposal that a pie chart should be used for summary tables. In reply to Dr N'gai"ndiro, he said that all35 areas of work did in fact receive support from other areas. It would be possible to make estimates of inputs for all those areas, but he did not feel that a comprehensive presentation of them would be particularly useful, as such estimates were only indicative. Responding to Dr Thiers, he said that for transparency's sake the governing bodies had been presented as an area of work so as to show how large a proportion of the Organization's resources was allocated to it. In reply to Professor Zeltner, he said that certain modalities had been prepared for aggregate reporting in document EB107/INF.DOC./3. However, although it would theoretically be possible to prepare routine reports for every biennium, that would require an enormous amount of staff input, and it was doubtful whether such time would be well spent. In answer to the query on paragraph 22 of part I of the budget document, he explained that normative work was not the exclusive preserve of headquarters, but involved all parts of the Organization. The issue of the privileged status of Evidence and information for policy would be dealt with later in the budget discussion. He pointed out, however, that the Director-General had taken office in 1998 on a platform of strengthening evidence for policy, and that the issue was one of considerable importance. Lastly, he agreed with Mr Chowdhury that there was a need for unearmarked funds to compensate for the shift from regular to extrabudgetary resources. It was encouraging that there were now more unearmarked funds than in the past, which gave the Organization greater flexibility. The Chairman had suggested a possible tax on extrabudgetary funds which were to be diverted to the regular budget. Programme support costs included a 13% overhead charge, which should in fact be set much higher, in the order of 30%, if the full administrative cost of managing extrabudgetary programmes were to be covered, although it would be difficult to obtain the approval of the Health Assembly for such an increase. That situation meant that the Organization was actually subsidizing extrabudgetary programmes through the regular budget, since the administrative charges they involved were much higher than the receipts. The DIRECTOR-GENERAL, replying to Professor Zeltner's question, said that work within the regions had to be consistent with WHO's global strategies. If one region went ahead in an important

EXECUTIVE BOARD, 107TH SESSION

area such as environmental health, WHO would welcome such an initiative, which might be a source of inspiration to other regions, provided that it was consistent with WHO's overall framework. That would constitute a typical example of what was meant by building on the strength and totality of the regions to act as one WHO. In answer to Mr Nogueira Viana, she pointed out that evidence formed the basis of the work of all WHO clusters in assisting Member States to advance public health. Hence improvement in that area had been a priority for the new administration from the outset and it had received full support. Since it had been ascertained in 1998 that the evidence base was seriously underfunded, resources had been shifted to form a new cluster, with the objective of making an intense effort to advance that base. It covered a wide range of issues that went well beyond the assessment of health system performance, also including an assessment of the costs and benefits of the 200 most important health interventions, forecasts of population health, burden of disease analysis and magnitude of risk factors, international classification of diseases and injuries, national health accounts and quality of care measures, as well as the building of national capacities to undertake services and conduct sampling. Thus a very broad area of core functions was included, functions that were central to WHO's global role. Dr DANZON (Regional Director for Europe) pointed out that it was very difficult to make forecasts in regard to the human development index. The Organization was accordingly obliged to base its estimates for the future in Europe on the figures available at the present time. Dr ALLEYNE (Regional Director for the Americas) said that, in view of the late hour, he would revert to the issue of monitoring and evaluating strategic directions and the use of indicators at a later stage. However, he wished to congratulate the Director-General and her staff on having succeeded in putting together the programme budget so efficiently in such a short space of time. (For continuation, see summary record of the sixth meeting, section. 2)

The meeting rose at 12:45.

SIXTH MEETING Wednesday, 17 January 2001, at 14:30 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

PROCEDURE FOR TECHNICAL BRIEFINGS

Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil), speaking on a point of order, suggested that technical briefings should be chaired by one of the vice-chairmen. The format of the briefings should also be changed; discussion of the issues required a great deal of time and it was not sufficient merely to ask questions and receive replies. Professor GIRARD (France) said that in his view the technical briefing should have been chaired either by a member of the Secretariat or by a person designated by the Chairman of the Board. Notwithstanding the good fellowship that reigned on the Board, it was not appropriate that any one person should appoint himself or herself to chair such a meeting. The issue that had been considered was a sensitive one on which discussions had not yet been concluded, and every Board member had the right to his or her own position on it. That was why no compromise had yet been reached. He was of the opinion that the Board should resume its usual method of working. The CHAIRMAN regretted that he had not foreseen the problems referred to by Mr Nogueira Viana and Professor Girard. He understood their comments to indicate that they wished technical briefings to be so organized that they offered a guarantee of dialogue which could lead to general consensus. He would seek an appropriate formula and trusted that the next briefing session would take place in the most friendly atmosphere possible.

PROPOSED PROGRAMME BUDGET FOR THE FINANCIAL PERIOD 2002-2003: Item 4 of the Agenda (Documents PPB/2002-2003, EB107/34, EB107/INF.DOC./l, EB107/INF.DOC./2, EB107/INF.DOC./3, EB107/INF.DOC./4, EB107/INF.DOC./5 and EB107/INF.DOC./8) (continued from the fifth meeting)

The CHAIRMAN invited the Executive Board to continue its consideration of the proposed programme budget, section by section, reminding members that the pagination of the document was identical in all language versions. Part II. Strategic orientations 2002-2003 by area of work Communicable diseases Dr ENDO (alternate to Dr Shinozaki, Japan) noted the increased resources made available to the area of control of global communicable diseases, especially HIVI AIDS, malaria and tuberculosis, as a result of increasing commitment from many stakeholders, including governments of developed and developing countries, the private sector and nongovernmental organizations. Those resources, although they were not necessarily sufficient, must be combined with WHO's limited resources in the most efficient and effective manner. The key to success was coordination, particularly at country level. -77-

EXECUTIVE BOARD, 107th SESSION

In that context, under the principles of ownership and new partnership, he would like WHO to make further efforts at coordination with other stakeholders in order to make optimal use of resources. On the question of leprosy control, he noted that in Table 3 both the regular budget and planned resources from other sources for the area of Communicable disease prevention, eradication and control had been reduced. In particular, according to the figure on page 15, the indicative estimate of expenditure on leprosy had been reduced by more than half. Since efforts to eradicate leprosy were continuing, that reduction might jeopardize attainment of WHO's goal. He therefore requested an explanation. Dr BODZONGO (Congo) drew attention to the increase in resources allocated to Africa for surveillance in contrast to a decreased allocation for prevention, eradication and control. Although not questioning the value of surveillance, he wondered whether the balance should not have been reversed. Prevention included immunization and, as was well known, poliomyelitis was still prevalent in Africa. An emphasis on surveillance rather than prevention might result in failure to attain the desired objectives. Mr LIU Peilong (China) noted that the Proposed programme budget document referred to the challenge of raising tuberculosis from a technical issue to a political one at national, regional and global levels. He supported that analysis, and believed that the approach advocated would assist Member States in which tuberculosis imposed a heavy burden to obtain political commitment and financial support. He hoped that WHO would continue its unremitting efforts in that regard. He had noticed that both the section on "Issues and challenges" and the section on "WHO objectives" (page 28) contained references to research and development of a tuberculosis vaccine, and that page 31 contained mention of a contribution for promotion of such development. However, he noted that no reference was made to tuberculosis vaccine development in the expected results there or in the area of Immunization and vaccine development (page 77). He sought clarification on that matter, and also in regard to the global indicator to be applied to the stated goal of providing support to enable countries to reach and maintain global control targets by 2005. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) said that he had already emphasized the importance of treatment and prevention and of epidemiological surveillance, particularly with respect to communicable diseases. Unfortunately, the information provided showed that, for the European Region, there was a zero regular budget allocation, and he asked for an explanation of that fact. The report of the recent joint meeting of the Programme Development Committee (PDC) and the Administration, Budget and Finance Committee (ABFC) contained a recommendation that the Secretariat should provide the Executive Board at its current session with a brief document explaining the zero allocations for certain budget lines. He asked when that document would be available. Professor ALl (Bangladesh) drew attention to the high death toll attributable to communicable diseases, particularly in developing countries, and noted that the resource table on page 23 nevertheless showed a drop in proposed regular budget allocations to South-East Asia from US$ 281 000 to US$ 100 000. In the area of communicable diseases two factors were particularly important: poverty and vaccine development. He considered that a great deal of money and even greater prioritization should be given to research and development for many communicable diseases. Dr N'GAINDIRO (Central African Republic) noted from page 24 of the document that malaria currently caused more than 300 million episodes of acute illness and over one million deaths each year, mostly in Africa. It was therefore perhaps the most serious disease in that continent. Secondly, malaria was one of the 11 priorities set the previous year by WHO, around which the proposed budget had been designed. Thirdly, the stated goal in the budget was to halve the burden of malaria by 2010.

SUMMARY RECORDS: SIXTH MEETING

He therefore failed to understand why resources for it were to be reduced, and requested an explanation. Dr HEYMANN (Executive Director), replying to Dr Endo, said that there were three reasons for the decrease from US$ 46 million to US$ 19 million for leprosy: first, in the past, the Nippon Foundation of Japan had provided funding for leprosy drugs each year. That funding was no longer required because the Novartis pharmaceutical company was donating the drug at no cost, and hence there was no need for drug purchasing to be included in the estimated expenditure. The Foundation's contribution could therefore be used for programme activities rather than drugs. The second reason was the expectation that, by the end of the current biennium, the number of countries in which leprosy was highly endemic would reduce from 12 to 7. Five countries therefore no longer required intensified action, reducing the proposed budget in those countries, while the seven remaining countries would have higher budgets. Increased funding would be provided to those countries from headquarters. Also a new, stronger alliance against leprosy had been concluded, providing up to US$ 60 million for use in a coordinated effort by nongovernmental organizations working against the disease bilaterally with countries. Though the budget appeared to have decreased, it had actually increased by millions of dollars. In regard to the question by Dr Bodzongo on the decreased allocation of funds to control of diseases and an increased amount to surveillance funding in the budget of the Regional Office for Africa, rather than vice versa, the reason was that a great many more resources were available bilaterally for disease control, and WHO therefore provided more funding for the latter. In reply to Mr Liu Peilong, he explained that tuberculosis vaccine research was covered in an inter-cluster vaccine research initiative. All research in that area was coordinated. In its research for vaccines, WHO identified where it should invest and where others were doing so. In the past year, the Bill and Melinda Gates Foundation had provided over US$ 25 million to tuberculosis vaccine development. Government agencies in various countries had also increased their budgets for such research. The vaccine research initiative was thus enabled to invest less in that area and to use its resources for other types of vaccine development for which there were funding gaps. The answer to Mr Chernikov's question was to be found in document EB107/INF.DOC./8. Supplementary information on zero allocations would be provided by the Regional Director for Europe. Responding to Professor Ali, he explained that the decrease in research resources in the South-East Asia Region had occurred because research was mainly supported through the Special Programme on Research and Training in Tropical Diseases, a joint World Bank, UNDP and WHO programme that relied completely on extrabudgetary resources and did not therefore appear in the WHO regular budget. There had actually been an increase in funding to that programme, and an extension of its mandate to cover tuberculosis and dengue fever in addition to the usual diseases. Finally, replying to Dr N'galndiro, he said that the decreasing budget for malaria reflected the regular budget situation, not the extrabudgetary situation: the Roll Back Malaria project was funded largely from extrabudgetary resources, and also by bilateral partners in the project within countries. It had become clear in discussions that extrabudgetary resources for malaria in the African Region were increasing, with the result that pressure on the regular budget for malaria was reduced. Dr DANZON (Regional Director for Europe), replying to questions raised on areas of work with zero budget allocation, pointed out that there were some zero allocations in every region. The areas of work were different for each regional budget, and it had therefore proved difficult to make each budget line correspond. Furthermore, in the Regional Office budget the proportion of the budget corresponding to staff salaries was very high, and staff movements therefore caused considerable budget fluctuation. The internal structural changes that had been made in the Regional Office for Europe explained why staff costs had appeared to decrease, because under the new structure the staff member previously paid from that part of the budget was now responsible for a much wider area. He stressed that the total budget for communicable diseases had in fact increased. A further element to consider was that the programme budget did not reflect the total country allocation which, for the

EXECUTIVE BOARD, 107th SESSION

European Region, had in fact increased, as could be seen from pages 110-111. Communicable diseases was an area that attracted extrabudgetary funding, a fact which gave hope for increased funding in future. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) suggested that, before submission to the Health Assembly, the Proposed programme budget for 2002-2003 might include a footnote with relevant explanations based on document EB107/INF.DOC./8 clarifying zero budget allocation in the 2002-2003 biennium. Noncommunicable diseases and mental health

Dr GRABAUSKAS (Lithuania) drew attention to some discrepancies between certain budget lines and the declared priorities of the Organization. Lithuania belonged to a group of countries where noncommunicable diseases (in particular cardiovascular diseases, cancer, diabetes and respiratory diseases) constituted the main health problems and the major causes of mortality. Ill-health conditions relating to noncommunicable diseases accounted for the major part of the health budgets of those countries and had a substantial impact on their economies and overall development. He expressed appreciation that, in various statements, the Director-General had identified noncommunicable diseases as a priority health problem globally. Ill-health related to those diseases also constituted a considerable proportion of the 11 priorities in the proposed programme budget, and forecasts showed that such conditions were likely to rank among the top 10 causes of mortality. It seemed, however, as though the budget figures for some regions ran counter to the declared priorities. He requested clarification concerning the discrepancies between the declared and the real priorities in relation to the budget appropriations for the European Region, where (with the exception of mental health and substance abuse) considerable cuts had been made. As the only Executive Board member from the central and eastern European region, he would find it difficult to explain the rationale for cuts in regular budget allocations to governments of countries where noncommunicable diseases constituted the main health problem. Dr JEANFRAN<;OIS (alternate to Professor Girard, France) supported that statement. She requested clarification concerning the regional distribution of the budget allocated to prevention and management of noncommunicable diseases. While the total funds allocated to noncommunicable diseases as a whole were on the increase, page 33 showed a decrease from US$ 677 000 to US$ 328 000 for their surveillance, prevention and management in the European Region. Professor ALl (Bangladesh) requested clarification regarding the decrease in the regular budget allocation to Research and programme development in reproductive health for the South East-Asia Region (page 11 0). Ms WIGZELL (Sweden), referring to disability/injury prevention and rehabilitation, agreed with the statement on page 42 that the main challenge when tackling disability was to take a human rights standpoint and to raise awareness in order to modify attitudes towards people with disabilities. She asked whether work was being done on a comprehensive WHO policy on disability. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation), expressing concern that the regular budget for health promotion in the European Region had been cut by almost half, asked what priority was being given to health promotion, to which his Government attached considerable importance. Dr YACH (Executive Director), replying to questions raised, agreed that the impact of noncommunicable diseases in central and eastern Europe was among the highest in the world, regardless of the corresponding risk factor profiles. There had been a modest increase in the total

SUMMARY RECORDS: SIXTH MEETING

regular budget across the regions and in headquarters, which should enable WHO to move ahead on the basis of its initial work in the area of research and policy development, with a view to establishing policies and programmes that would subsequently attract extrabudgetary financing for WHO and for countries that required such assistance. Even though the regular budget funding lagged behind the extrabudgetary resources, it was hoped that an increase in extrabudgetary resources would take place over the next five to 10 years once the programmes had shown what they could deliver. Earlier in the discussion questions had been raised concerning health problems related to ageing, which were part of the work of noncommunicable disease prevention and expressly mentioned under the section on Health promotion on page 40. In response to Dr Di Gennaro's comment in the previous meeting 1 on substance abuse, he informed the Board that WHO had increased emphasis within the mental health programme to the management of substance dependence and to further crosscutting work on management and policy development relating to alcohol and nicotine and tobacco abuse. Regarding disability, he confirmed that considerable progress had been achieved in finalizing appropriate policies, including an implementation plan on disability which should shortly be available. Activities regarding health promotion were taking place across the whole of the Organization. The figures contained in the programme budget highlighted only the more visible areas. Dr DANZON (Regional Director for Europe) said that his earlier remarks were also applicable to the questions concerning noncommunicable diseases. Most of the budget for his Region was earmarked for salaries. Thus, in most cases the reductions were attributable to staff movements under the new organizational chart. It could be seen from the table on pages 112-113 of the document that the reduction in the total allocation for areas of work, from US$ 44.205 million to US$ 41.106 million, was offset by an increase in the country-level allocation, from US$ 7.494 million to US$ 11.665 million, with a transfer from the areas of work budget to the country-level budget. The country-level budget was higher because the intercountry budget had decreased. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) said that in the preparation of future budgets greater transparency would result if a separate budget line were devoted to country-level activities under each of the 35 work areas. Family and community health

Dr SADRIZADEH (Islamic Republic oflran), referring to the resource tables on page 51, asked why the regular budget of the Eastern Mediterranean Region had been reduced by almost two-thirds for Research and programme development in reproductive health. Dr BODZONGO (Congo) welcomed the inclusion of a regular budget allocation for Africa under the area "Making pregnancy safer". UNFP A had undertaken a substantial programme in the area of reproductive health, and confusion had subsequently arisen as a result of overlaps between the activities of UNFPA, WHO and country health ministries. While health was not exclusively WHO's preserve, the Organization had a role to play as a world leader in health issues. It was thus important to determine the respective competencies of each of the partners in the field of reproductive health. Dr ENDO (alternate to Dr Shinozaki, Japan) said that the HIV/AIDS epidemic posed a challenge to which the health sector alone could not respond effectively. A multisectoral response was crucial to success, and, to that end, preparations for a new global framework under the United Nations system's strategic plan for HIV/AIDS for 2001-2005 were under way. It was his understanding that the proposed programme budget would be in line with the UNAIDS unified work plan and budget. Japan urged that that budget should be effectively utilized in order to enable WHO to fulfil its role in

See summary record of the fifth meeting.

EXECUTIVE BOARD, 107th SESSION

the framework of UNAIDS, exploiting its advantages m comparison with those of other United Nations bodies. Professor NAMA DIARRA (Cote d'Ivoire) asked why, given that research into reproductive health was being promoted in Africa, the budget allocated to that Region for research in reproductive health had been reduced by almost a third. Dr AL-JABER (Qatar) said that in the Eastern Mediterranean Region the Research and product development budget for communicable diseases was zero, while in the case of reproductive health it had been reduced by about two-thirds. Nutrition was a very important programme for a foodimporting region. He therefore wished to know the reason for the reduction in the allocation for nutrition to the Region from US$ 344 000 to US$ 261 000 for the 2002-2003 period. Mrs ABEL (Vanuatu) asked why, in view of the efforts made by countries of the Western Pacific Region to address the issue of women's health, there was a zero budget allocation in that area for 2002-2003. Dr TORMEN (Executive Director), responding to the question raised concerning the lack of resources devoted to child health, 1 said that children were a priority in all programme areas, given the annual figure of 10 million child deaths globally. WHO was working on a comprehensive strategy on child and adolescent health and development, and ongoing work would involve all concerned departments and clusters, including the regional offices. In 2001 all expected outcomes and indicators would be refined to reflect that state of affairs. There would also be a global focus on child health through the Special Session on Children of the United Nations General Assembly in September 2001, the aim being to intensify and sustain the advances made in child health, and also to work on the neglected areas of the health of newborn children and adolescent health. Those areas would be refined in the programme budget. In response to comments by Ms Wigzell, she said that work on bringing gender into the mainstream of health was a priority for WHO, but one that posed complex challenges. The DirectorGeneral had recently decided to combine that work with women's health, so as to enable WHO's technical programmes to deal better with gender issues, with new enthusiasm and resources. Dr Sadrizadeh had asked why allocations for research and programme development in reproductive health had been reduced in the Eastern Mediterranean Region. That reduction was offset by an increase in the "Making pregnancy safer" component and was thus an issue of prioritizing funds. As to the comment ofDr Bodzongo, WHO's main strength in comparison to other organizations lay in health policies and normative work, whereas UNFPA's strength lay in operationalization of programmes at country level. Lastly, she assured Dr Endo that WHO's efforts in the field of HIVI AIDS would be in line with the unified work plan and budget of UN AIDS, a body of which WHO was a cosponsor. Dr CABRERA MARQUEZ (Guatemala) said that at the previous week's joint meeting of PDC and ABFC satisfactory explanations had been provided of areas of work with zero budget allocation in the 2002-2003 biennium. Those explanations should now be circulated to the Executive Board in the form of a document. The CHAIRMAN confirmed that the information referred to was available m document EB 107/INF.DOC./8. Dr SAMBA (Regional Director for Africa) said that the budget reduction for research in reproductive health referred to by Professor Nama Diarra was offset by the significant increase, to 1

See summary record of the fifth meeting.

SUMMARY RECORDS: SIXTH MEETING

US$ 2.098 million, in the allocation to Africa under the area "Making pregnancy safer". The two areas worked together, so that there was actually a net increase in the funding for them at regional and country levels. Dr GEZAIRY (Regional Director for the Eastern Mediterranean) said that, as the budget was not being increased, priorities could be addressed only if funds were taken from other areas. Although part of the regular budget was set aside for research, no staff were available to work on research as such. He pointed out that if nutrition were considered together with food safety, there had been an increase in the budget. The Eastern Mediterranean Region was at the forefront in the field of micronutrients: it was the first Region to have brought iodine deficiency diseases under control, largely through the addition of iodine to salt, and most of the countries of the Region now had access to flour fortified with iron and folic acid. He was therefore not unduly concerned at the reduction in allocation for nutrition, particularly as some extrabudgetary resources were available for that purpose as well as for micronutrients. Dr OMI (Regional Director for the Western Pacific), replying to the question from Mrs Abel about the zero budget allocation for women's health in the Region, said that because of budgetary constraints it was not possible to cover all 35 areas of work. Instead, the Regional Committee had agreed on 17 priority areas. The issue of women's health was being given attention, as could be seen from the detailed allocation by area of work, which showed that US$ 593 000 had been allocated to "Research and programme development in reproductive health" and US$ 200 000 to "Making pregnancy safer". Country allocations would be discussed at the forthcoming session of the Regional Committee, when care would be taken to ensure that women's health was not neglected. Sustainable development and healthy environments

Mr CHOE 11 (alternate to Dr Kim Won Ho, Democratic People's Republic of Korea) expressed concern about the reduction in allocations for nutrition for the forthcoming biennium. Malnutrition was still a major problem in developing countries and threatened the lives of vulnerable sectors of the population, especially children. According to the proposed programme budget for 2000-2003, the overall allocation for nutrition was to be reduced by 13%, and that for South-East Asia by nearly 50% when compared with the current biennium. He requested an explanation for the reduction, and reconsideration of the matter with a view to a possible increase in budgetary provision. Dr STAMPS (Zimbabwe), speaking at the invitation of the CHAIRMAN, 1 said that the section on food safety on page 68 did not reflect earlier discussion at the Health Assembly. Foodborne disease was not limited to the problem of contaminated food causing diarrhoea. Additives could cause serious problems for some special groups (for example, aspartame in the case of people suffering from phenylketonuria, sucrose in the case of diabetics). Contaminants such as aflatoxins were important in the development of chronic and neoplastic liver disease, especially in immunocompromised persons such as those suffering from malnutrition, and heavy metals in food could cause brain and renal damage. Resolution WHA53.15 on food safety, which was not specifically mentioned in the documents under consideration, also referred to the need for proper storage, packaging, spoilage prevention, transport and appropriate labelling to identify potential hazards. None of those factors was clearly enunciated under "Issues and challenges". He also drew attention to links between changes in the food chain and the etiology of some foodborne diseases: 30 years earlier, the hazards of pesticide residues, especially chlorinated hydrocarbons, had resulted in major changes in the production of food for human consumption, and seven years earlier the presence of prions in beef had resulted in grave international concern in connection with new variant Creutzfeldt-Jakob disease. Phthalates in milk, with their effects on the 1

By virtue of Rule 3 of the Rules of Procedure of the Executive Board.

EXECUTIVE BOARD, 107th SESSION

future fertility of young male children, and hyperiodation of food in Australia as a result of the use of iodized substances for sterilization were other examples of reduced food safety. There would undoubtedly be new challenges, and he considered that a purely classical gastrointestinal approach to food safety based on simple epidemiology would prove inadequate. He suggested that the "Issues and challenges" section should be recast to reflect those concerns, and that the wording of"Goal" should be amended to read "To effectively protect human beings from the risks of unsafe food in all its aspects". The section on "WHO objectives" should include "progress towards the elimination of foodborne risk", and the expected results and indicators should be .appropriately adapted to reflect the new goal and objectives. Mrs KERN (Executive Director), replying to questions, said that nutrition had to be considered in combination with food safety and to some extent with the environment. Nutrition was an important aspect of overall health of peoples, particularly the poorest, and would therefore receive considerable attention. However, unless the regular budget were extended, any additional funds for nutrition would have to be taken from other areas of work. Similarly, there was no doubt that the environment was becoming an increasingly prominent issue, as had been pointed out by several speakers in the opening debate. Those comments had been noted, but again it should be borne in mind that any additional allocation would have to be taken from elsewhere in the regular budget. Referring to the statement by Dr Stamps, she said that the wording of the section on food safety would be reconsidered by the relevant clusters in the light of his remarks prior to the Fifty-fourth World Health Assembly. She agreed that the present wording might be somewhat narrow. Health technology and pharmaceuticals

Dr ENDO (alternate to Dr Shinozaki, Japan) said that pharmaceuticals were clearly among the most cost-effective tools for medical intervention. It should therefore be reaffirmed that the programmes on pharmaceuticals were the foundation for implementation of WHO's flagship projects, including interventions in major communicable diseases and in mental health and improvement of health care systems. To ensure the sustainability of those core programmes, the area of pharmaceuticals should receive a higher proportion of the regular budget. While recognizing the necessity and effectiveness of alliances and wide-ranging fundraising, he considered that WHO policies and projects should remain neutral and fair, and should therefore be financially independent of the pharmaceutical companies. Thus, the regular budget allotment to cross-sectoral programmes should at least ensure maintenance of the status quo. Dr QI Qingdong (alternate to Mr Liu Peilong, China) welcomed the increase in the budget for health technology and pharmaceuticals as compared with the previous biennium. However, he noted that although WHO was developing a global strategy for traditional medicine, which he understood was to be reviewed and endorsed by the governing bodies in 2002, no reference was made to that strategy. He hoped that it would be reflected in the section on "WHO objectives". Traditional medicine was mentioned in several places in the proposed programme budget, but it was not clear whether there were any indicators by which to measure its expected results. No resources had been allocated for traditional medicine, nor was there any reference to the increase in its use. In view of the increasing importance and development potential of traditional medicine in many countries, WHO's work in that area should be strengthened. Dr N'GAINDIRO (Central African Republic) referring to the area oflmmunization and vaccine development (pages 76 and 77), noted that total allocations had fallen with successive bienniums, and that the allocation for the African Region had also been reduced in spite of the importance of vaccines in disease prevention. Certain diseases, in particular HIVI AIDS, were not currently curable by drugs, and it was therefore essential that a vaccine be found. In the face of reduced allocations, he asked how such a vaccine would be developed.

SUMMARY RECORDS: SIXTH MEETING

Mr CHOWDHURY (India) said that the most cost-effective contribution to public health was disease prevention. A relatively small investment in vaccine development would obviate the requirement for greater expenditure in the long term. He urged the Director-General to use her good offices to persuade international funding agencies to take a longer-term view and to invest in such development, and also urged her to use WHO's extrabudgetary resources for that purpose, even at the cost of funding for disease control. Dr AL-JABER (Qatar) said that since half the population of Africa and Asia had no access to drugs and vaccines, WHO should increase its spending in that field, thus saving lives. New vaccines were being added to the Expanded programme on immunization, at additional cost. It was all very well to urge companies to develop new vaccines, but, in view of the rising costs due to the protection of intellectual property rights, countries might not be able to afford them. WHO must redouble its efforts to come to an understanding with pharmaceutical companies so that affordable prices could be set. Dr ABREU CATALA (Venezuela) endorsed the comments ofDr Endo: both WHO and PAHO had to be seen to be independent of the pharmaceutical industry and to respond to national requirements and initiatives. Pharmaceuticals by their nature were intersectoral, with impacts on health and health services worldwide, particularly in poor countries. WHO's regular budgetary resources for that area must therefore be sufficient and be independent of other areas. Dr AL KHARABSEH (Jordan), referring to the fourth indicator on page 76 of the document, asked why trials of HIV candidate vaccines were to be carried out only in developing countries. Dr SUZUKI (Executive Director), responding to Mr Liu Peilong about the apparent discrepancy between the information in the figure on page 15 of the document, 1 which showed an increase in expenditure on poliomyelitis in the next biennium, and the table of resource allocations for Immunization and vaccine development on page 77, which indicated a reduction in the overall budget allocation, said that the explanation lay in the targets of certifying eradication of poliomyelitis by the year 2005 and halting poliovirus transmission within the next 12-24 months. As a result, poliomyelitisrelated activities, and therefore the resources needed for them, would peak around the year 2002 and tail off thereafter. Currently, about 80% of the funds allocated to Immunization and vaccine development were for poliomyelitis-related activities. The figure on page 15 provided indicative estimates of expenditure on five diseases, representing the aggregate resources for disease prevention and control, and covered both health systems and surveillance. As poliomyelitis was gradually eradicated, more resources would become available for other immunization activities and for health care delivery and health systems. With reference to Dr Novotny's remarks about the outbreak of poliomyelitis in Hispaniola, 1 he said that to date there had been one confirmed case in Haiti and six in the Dominican Republic, all of which were vaccine-derived. That proved the importance of maintaining high immunization coverage and high-quality surveillance systems. Undoubtedly, WHO needed to step up its poliomyelitis control activities in countries where the disease was endemic and in those where outbreaks occurred. Nevertheless, despite the fact that the outbreak had occurred in a region where the disease was thought to have been eradicated, he considered that an overall reduction in resources for Immunization and vaccine development in the next biennium was justified, because as more and more countries eradicated poliomyelitis, there would be less need to carry out costly resource-intensive national immunization days. At the Global Polio Partners Summit held in New York in September 2000, it had been estimated that a total of US$ 1000 million would be required for poliomyelitis-related activities, including those to be carried out by the Organization, up to the year 2005. On the basis of pledges made so far, around US$ 550 million had already been secured; however, more than half of the remaining amount was needed for activities before the year 2002. The estimated resource requirement 1

See summary record of the fifth meeting.

EXECUTIVE BOARD, 107th SESSION

did make provision for situations such as the Hispaniola outbreak. What was more, the resource requirements would be reviewed for each country by the key partners every six months, and were therefore open to change as necessary. Turning to Dr Endo's comments, he acknowledged that extrabudgetary resources were used to support some of WHO's core functions, including pharmaceuticals. As more extrabudgetary resources were being made available, the relative balance with the regular budget was changing. Every effort had been made to maintain and in some cases even increase the resource allocations in the regular budget for the next biennium for core activities, such as pharmaceuticals. Similarly, WHO was doing its utmost to protect the scientific integrity and impartiality of its views and recommendations and to avoid any possible conflict of interest. In reply to Dr Qi Qingdong, he said that the global strategy on traditional medicine would be finalized in the course of 2001 and duly reflected in the general programme of work for the next biennium. No specific indicators of the expected results of traditional medicine had been included in the proposed programme budget, partly owing to lack of space, but indicators for traditional medicine were referred to in the strategic plan for Essential drugs and medicines for 2000-2003 1 for both countries with a national policy on traditional medicine and countries with laws and regulations relating to herbal medicine. Resources allocated to traditional medicine had increased from US$ 930 000 for the 1998-1999 biennium to more than US$ 1.45 million for the current biennium and that amount was expected-to increase to US$ 1. 7 million in the next biennium. Endorsing comments on the importance of vaccine development, he said that with the recent establishment of the Initiative for Vaccine Research, WHO's vaccine activities would no longer be scattered over several work areas; that step would allow better coordination and joint mobilization of external resources. Furthermore, the Global Alliance for Vaccines and Immunization had agreed to enhance research and development in the area, focusing on vaccines against meningitis and rotaviral and pneumococcal diseases. Work was also under way to improve techniques for vaccine delivery and immunization. Responding to Dr Al-Jaber's remarks about the need for greater accessibility to essential drugs and vaccines, he said that the issue of access should be addressed through the four strategies: affordability, rational selection, sustainable financing, and a functioning health and logistic system. The Organization was working with Member States and with the pharmaceutical industry to establish preferential pricing arrangements and to find ways of reducing taxes and duties on drugs and vaccines, as well as the costs of transport, storage and dispensing, in order to lower their retail price. Dr ALLEYNE (Regional Director for the Americas), enlarging upon Dr Suzuki's comments, said that vaccine trials were carried out in developing countries because those were the countries in which the diseases were endemic. It was sometimes difficult to separate items in the budget. For example, Dr Suzuki had referred to the outbreak of poliomyelitis in Haiti and the Dominican Republic, yet that outbreak had been detected owing to the presence of a surveillance system. Surveillance systems, which appeared in another part of the budget, were not restricted to communicable diseases. With regard to the expected results of the introduction of under-utilized vaccines, he said that it was theoretically feasible to eliminate measles from the Americas: there had been 1600 cases of measles in the whole of the Americas in November 2000, as compared to 250 000 eight years previously; some 1300 of the 1600 cases had occurred in Hispaniola. It was his dream to free the world's children from measles by having them all vaccinated within the same month; that long-term goal deserved consideration.

1 WHO Medicines Strategy Framework for Action in Essential Drugs and Medicines Policy 2000-2003 (unpublished document WHO/EDM/2000.1), Geneva.

SUMMARY RECORDS: SIXTH MEETING

Evidence and information for policy No comment was made on the budget allocations for Evidence and information for policy. External relations and governing bodies Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) suggested that the last indicator for Governing bodies, on page 95 of the document, should be amended to reflect the decision of PDC and ABFC on multilingualism. The phrase "the most used languages of the Organization" should be replaced by "all the official languages of the Organization and possibly other frequently used languages". The indicator should also mention the need to provide simultaneous interpretation in all the official languages. He also suggested the insertion of an additional expected result and an additional indicator referring to the timely preparation of documentation for sessions of governing bodies, in order to avoid situations in which documents on items on the agenda were submitted directly to the governing bodies during their sessions. Dr ASAMOA-BAAH (Executive Director) said that he could only concur with the comments on the timely dispatch of documents, and apologize for any shortcomings in that respect. He noted that the Director-General was an enthusiastic supporter of multilingualism. He agreed that indicators of performance on those two issues would be useful. General management Dr JEANFRANCOIS (alternate to Professor Girard, France) said that she recognized that WHO's work was based on expertise, and that the allocation for personnel therefore represented a large proportion of the budget. Nevertheless, she noted that the allocation for human resources development in the European Region was to increase from US$ 1.9 million in 2000-2001 to US$ 2.3 million in 2002-2003, and requested clarification. Dr NOV01NY (United States of America), referring to the area of lnformatics and infrastructure services, asked what proportion of the total would be spent on informatics alone. Further to the Secretariat's explanations to PDC, he requested up-to-date information on ".Health", WHO's plan for prescreened health sites on the Internet. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation), referring to the area of Human resources development, suggested that in the third indicator on page 101 "Recruitment of highly qualified staff as soon as possible" should replace "Retention of highly qualified staff aided by personal development opportunities". Referring to the area of Financial management, he suggested the addition of further text in the second indicator on page 103, which would read: "Obtaining the unqualified opinion of the External Auditor on financial accounts and the approval of financial reports by the governing bodies". Either in the same area or in the area of Director-General's and Regional Directors' offices, another expected result should be added, which would read "Implementation of recommendations of the oversight and audit bodies". The relevant indicator to be added for that expected resuh could read: "Approval by the governing bodies of the Director-General's reports on such matters". Under the area oflnformatics and infrastructure services, he suggested that for the sake of consistency with the third expected resuh it would be more appropriate for the third indicator on page 105 to refer to a reduction in expenditure for a given volume of procurement. Dr AL-JABER (Qatar), referring to Human resources development, requested the Director-General to ensure a more balanced geographical representation at management level.

EXECUTIVE BOARD, 107th SESSION

Mr MANI (Executive Director ad interim), replying to Dr Jeanfranyois, recalled that the Regional Director for Europe had explained that the increase in the spending on human resources development arose essentially from training requirements following reorganization. He suggested that he discuss Dr Novotny's query with him individually. Lastly, he assured Mr Chemikov that his comments would be taken into account when the budget was reformulated, and told Dr Al-Jaber that the matter of geographical representation at management level would be considered.

The meeting rose at 17:35.

SEVENTH MEETING Thursday, 18 January 2001, at 11:30 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

PROPOSED PROGRAMME BUDGET FOR THE FINANCIAL PERIOD 2002-2003: Item 4 of the Agenda (Documents PPB/2002-2003, EB107/INF.DOC./1, EB107/INF.DOC./2, EB107/INF.DOC./3, EB107/INF.DOC./4, EB107/INF.DOC./5 and EB107/INF.DOC./8) (continued) Part IT. Strategic orientations 2002-2003 by area of work (continued) General management (continued) Dr DANZON (Regional Director for Europe) replying to a question raised earlier by Dr Jeanfran~ois, explained that the increase in the human resources development budget for the European Region did not imply that new staff could be recruited. Indeed, in common with other regional offices, the Regional Office for Europe was suffering from staff shortages; for example, it had only one professional for noncommunicable diseases. The increase was required to finance staff training in the wake of a reform of the services of the Regional Office for Europe. Mr AITKEN (Senior Policy Adviser), in response to a point raised at the sixth meeting by Dr Novotny, explained that WHO had asked to be considered for a new top-level domain of access to the Internet, ".Health", with the general aim of offering greater certainty to Internet users seeking information on health. Although WHO's application had not been successful, it was still pending. Work was continuing on WHO's other initiatives to provide access to health information through the Internet. Director-General, Regional Directors and independent functions Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) suggested that WHO should give further consideration to the indicator for the third expected result (page 107), which as currently formulated, sounded intermediate in character. At the joint meeting of the Programme Development Committee (PDC) and the Administration, Budget and Finance Committee (ABFC), he had put forward several suggestions for a more specific indicator, such as detection of cases of abuse or fraud, and had offered to help in finding a better formulation. Dr NABARRO (Executive Director) said that WHO was indeed reviewing the issue, which was a difficult one, and would welcome discussion of it. The third expected result was being considered in a broader frame by the Headquarters Cabinet and the Global Cabinet. Professor ALl (Bangladesh) asked why regular budget resources for the area under consideration for the South-East Asia Region had been reduced from US$ 1 101 000 to US$ 956 000. Dr UTON RAFEI (Regional Director for South-East Asia) explained that the cut was attributable to staffing reductions in the Regional Office.

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EXECUTIVE BOARD, 107TH SESSION

Mr SELIM-LABIB (Egypt), speaking at the invitation of the CHAIRMAN,' emphasized the importance of WHO's collaboration in the field of sustainable development. He welcomed the Proposed programme budget 2002-2003 and endorsed the views expressed by earlier speakers that regular budget allocations should meet the real health needs of countries in the Eastern Mediterranean Region. He joined with Dr Al-Jaber and Dr Sadrizadeh2 in reaffirming the importance of limiting as far as possible any reduction in the budgetary allocation to the Region, with a view to ensuring maintenance of ongoing programmes for improving health. In that regard, he reaffirmed the importance of Resolution EMIRC47/R.3, adopted by the Regional Committee for the Eastern Mediterranean at its Forty-seventh meeting, in relation to the proposed programme budget, particularly paragraph 5.3, concerning the development of a specific formula for ensuring that the allocation of extrabudgetary resources was flexible, transparent and equitable, and paragraph 5.4, calling for a review of the criteria used in allocating regular budget funds. The Regional Committee had also adopted Resolution EMIRC4 7/R.l, calling for allocation of additional resources to promote health services in Palestine so as to ensure effective assistance in that dangerous and grave health situation and with a view to strengthening the role played by WHO in that regard. He commended Dr Al-Jaber's statement on the need to review the geographical distribution of staff at WHO. The required balance had not been achieved, particularly as far as representation of Arab citizens in high-level posts was concerned, despite the fact that the Region was well endowed with highly qualified persens who could well fill such posts. Country programmes

The CHAIRMAN drew the Executive Board's attention to the country programme component in the table on pages 112-113 of the Proposed programme budget 2002-2003. In view of the significant change in the way the budget had been prepared, the basis of the country programmes for 2002-2003 would be the policies agreed by the Executive Board and the World Health Assembly. Therefore, country programming would start only after the Executive Board had completed its review of the proposed programme budget at its current session, and would be reported to the regional committees only in September 2001. Discussion on country programmes at the present stage would thus be premature, although Regional Directors might wish to indicate to the Board how they intended to proceed in the months ahead. Dr OMI (Regional Director for the Western Pacific) said that several initiatives had been taken in consultation with headquarters over the past two years regarding the programme budget of the Western Pacific Region, as part of the overall reform process. The first initiative had been to determine country allocations in an objective, accountable manner by determining 60% of the total country allocation for the region on the basis of the UNDP Human Development Index, and the remaining 40% of the allocation in accordance with three principles: first, the allocations for least developed countries would be maintained to ensure that they suffered no budget cuts; secondly, certain developing countries would be given zero or the minimal allocation amounting to no more than US$ 50 000 per biennium; thirdly, the specific needs of individual countries would be taken into account. The second initiative had been to reduce the number of programmes from the previous 51 to 17 regional focuses, which were fully in line with global priorities. The third initiative had been to urge Member States to allocate their resources to priority areas rather than spreading them too thinly over a large number of programmes. Full account would be taken of global and regional priorities in addressing countries' needs, so that they could contribute to the attainment of the Organization's objectives and goals. The Regional Committee at its meeting in

By virtue of Rule 3 of the Rules of Procedure of the Executive Board. See summary record of the sixth meeting.

SUMMARY RECORDS: SEVENTH MEETING

September 2001 would discuss the strategic country programme budget to ensure that those three principles were properly reflected. Dr KARAM (Lebanon) said that now that the Executive Board was concluding its discussion of the budget, and bearing in mind the global rate of inflation and the increase in the world's population, he felt bound to ask whether the diseases that afflicted humanity were on the decline or whether the international community was giving up its fight for sustainable good health for all peoples of the world. He questioned whether a sum of US$ 0.40 per person per year was sufficient to permit WHO to carry out its work: its goal was to fight poverty because poverty damaged health, but unfortunately the necessary resources were lacking. Even more unfortunately, the least affluent nations spent more on armaments than on health, in order to engage in wars that were not merely harmful to health but brought new health hazards. The direct costs of the Gulf War had amounted to over US$ 60 000 million; the cost of the Balkan war was not yet known but would undoubtedly be astronomic, while the health hazards of depleted uranium were not yet quantifiable. Every new war generated new health syndromes, which WHO was called upon to address. It was essential therefore that governments and donors should work together to increase the Organization's budget and restore it to sound financial health, thus enabling it to combat poverty and disease. The CHAIRMAN said he took it that the Executive Board would wish to forward the Proposed programme budget 2002-2003, together with its recommendations, to the Fifty-fourth World Health Assembly for approval. It was so agreed.

Aspects of financial management Approaches to cost increases and exchange rates (Document EB 107IINF .DOC./1) Miscellaneous income (Document EB107/INF.DOC./5) Mr CHOWDHURY (India), speaking as Chairman of PDC, said that document EB1071INF.DOC./1 described the approaches taken in previous bienniums to cost increases and exchange rate assumptions in the regular budget, and the simplifications to be made in future budget discussions. For 2002-2003, the Director-General suggested limiting the application of the exchange rate facility for headquarters and the Regional Office for Europe, where the need to protect against the possibility of a weaker dollar was most likely. In addition, the maximum amount of the exchange rate facility that would be included in the appropriate resolution would be capped by purchasing exchange rate insurance in the form of a currency option. The Director-General would also use a simpler method of calculating cost increases. An independent external source would assess inflation and the exchange rate assumptions incorporated in the 2002-2003 budget. That source was a company called Consensus Economics, which at regular intervals published consensus forecasts of future exchange and inflation rates, representing the arithmetical average of individual forecasts made by up to 250 economists from banks, educational institutions and national and supranational organizations. Ms BLACKWOOD (alternate to Dr Novotny, United States of America) said that the United States supported use of miscellaneous income for the exchange rate facility for headquarters and the Regional Office for Europe, but sought further information on how exchange rate fluctuations were to be handled in the other regional offices. The foreign exchange option would be useful as an insurance policy to protect the Organization from negative currency movements, but she requested further information on how that proposal would be implemented and the cost of implementation. Specifically, she wondered whether the US$ 31 million limit on the exchange rate facility might be lowered, given that it was being applied to only a portion of the WHO budget.

EXECUTIVE BOARD, 107TH SESSION

Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) reiterated his statement of the previous day that the budget should remain unchanged. 1 Mrs ZIKMUNDOVA (alternate to Dr Thiers, Belgium) said that document EB107/INF.DOC./5 referred to several items of budgeted expenditure, such as the exchange rate facility and the Real Estate Fund. However, following confirmation by the Executive Board of the new rules of financial management, expenditure under those headings should be incorporated into the Proposed programme budget 2002-2003, since the new financial structure would imply a single budget, with no separate budget for miscellaneous income. Ms WILD (Financial services), replying toMs Blackwood's question, explained that in regions other than the European Region currencies tended to weaken against the United States dollar, and there was a compensating factor between that weakening and inflation. Over a period of time, what emerged was a self-balancing mechanism, so it had been proposed to use the exchange rate facility only for headquarters and the European region. The question of a foreign exchange option was connected to the possibility of lowering the exchange rate facility from US$ 31 million. The purpose of purchasing a foreign exchange option was to enable that to happen. The Organization would continue to work on ascertaining the appropriate level at which the exchange rate facility should be set, fixing that level by using a foreign exchange option. Such an option operated rather like an insurance policy, whereby the cost might exceed the amount insured, but the reimbursement would be for the latter amount. As for the point raised by Mrs Zikmundova, a budget for miscellaneous income was discussed in document EB 107/INF .DOC./5 owing to the fact that the Organization was in a transitional phase. In the next budget cycle, that information would be presented either in a single document as a single budget, or in two documents as two items of the same budget. For the period 2004-2005, there would be only one budget document. The CHAIRMAN said he took it that the Executive Board wished to note the developments described in documents EB107/INF.DOC./1 and EB107/INF.DOC./5. It was so agreed.

Allocation and utilization of extrabudgetary resources during the biennium 1998-1999 by programme, region and country (Document EB107/INF.DOC./4) Mr CHOWDHURY (India), speaking in his capacity as Chairman of PDC, said that document EB107/INF.DOC./4, prepared in response to a request by a member of the Executive Board, indicated that the Organization's income and expenditure was communicated to Member States and donors in reports submitted or made available to the Executive Board and the Health Assembly. The use made of extrabudgetary resources was explained in those reports according to appropriation section, programme, region and source of funds. One Executive Board member considered that, because the reports were so voluminous it was difficult for Member States to identify the information they wanted, and that the allocation of extrabudgetary resources should be made clearer in the programme budget. Dr ASAMOA-BAAH (Executive Director) explained that the document was based on an imperfect understanding of the request from the Executive Board member. Now that voluntary contributions made up a significant proportion of the Organization's total resources, the fundamental issue was to ensure that they did not distort its priorities and its integrity, subvert the authority of the governing bodies, or indeed foster the emergence of a parallel system for managing funds and people. The Organization had been founded on the premise that the bulk of its resources would come from 1

See summary record of the fifth meeting.

SUMMARY RECORDS: SEVENTH MEETING

guaranteed assessed contributions, and all its programmes and plans had been based on that premise. Over the past two decades, as the volume of extrabudgetary contributions had grown, the Organization had had to devise different methods of dealing with them. As a result, discussions in the Executive Board now centred on the regular budget, while another set of bodies discussed the voluntary contributions. An attempt was being made to develop a common system; that was not easy, as different groups of people were involved in making decisions with regard to the two kinds of contributions, even within the same country. However, the Organization was making progress in two respects. Because funds could not be allocated as long as the amount, the source and the accompanying conditions were unknown, discussions with donors of extrabudgetary resources were now being initiated before the start of the biennium to which they related, not during it. Fortunately, the response was proving positive. The second difficulty with voluntary contributions was that they tended to be earmarked. That was not objectionable in principle, but it was important to know the criteria for the earmarking and its extent, for instance where contributions were tied to specific programmes, periods of time or inputs from specific countries. The Organization was therefore working with its partners to reduce the degree of earmarking of voluntary contributions, and some partners were agreeing to do so. One lesson learned was that donors were anxious to be assured that the Organization would evaluate its own performance and would be willing both to innovate and to admit to mistakes made. On that basis, it was possible to move towards resource-based budgeting and programming. For the Health Assembly, summary reports would be provided on expenditure which would be both less voluminous and more informative than before. The CHAIRMAN said he took it that the Executive Board wished to note the information contained in document EB107/INF.DOC./4. It was so agreed.

Efficiency savings, 2000-2001, and management reviews (Document EB107/INF.DOC./2) Mr CHOWDHURY (India), speaking on behalf of the Chairman of ABFC, recalled that in May 2000 the Health Assembly had adopted resolution WHA52.20, requiring the Director-General to identify 2% to 3% of additional efficiency savings for reallocation to high-priority programmes. ABFC had noted that the resolution had been complied with; US$ 26.9 million had been made available to the priority areas identified by the Director-General after consultation with the Regional Directors. A further US$ 24.6 million, as a provision against expected cost increases in 2000-2001, would be absorbed across the Organization over the biennium. It had noted that in each region and at headquarters, efficiencies had been achieved with respect to travel, procurement, study tours and fellowships, publications and documents during the first six months of the biennium. It had welcomed the progress made and encouraged continuation of those and other measures in future years. It had noted that the Executive Board would receive regular progress reports on efficiency savings, which should make clear whether the saving of US$ 26.9 million had in fact been achieved through efficiencies, or whether reallocation had resulted in cuts in technical programme budgets. Dr LEFAIT-ROBIN (alternate to Professor Girard, France), referring to paragraph 9 of document EB 107/INF .DOC./2, said that, while she was in favour of making savings, the Organization should be vigilant that the proposed 15% reduction in expenditure on fellowships did not adversely affect either the quality of training or the number of people being trained. Mrs ZIKMUNDOVA (alternate to Dr Thiers, Belgium) recalled that provision had been made for efficiency savings of US$ 51.5 million in the 2000-2001 budget, partly to cover increased costs and partly for reallocation to high-priority programmes. That goal had not yet been reached, and she urged WHO to continue to pursue it.

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Dr NOVOTNY (United States of America) expressed satisfaction that the Director-General had identified the 3% of efficiency savings in accordance with resolution WHA52.20. However, more quantitative information was needed on how those savings were being realized. For example, it was not clear what the revised policy on per diem mentioned in paragraph 7 actually entailed or what it would achieve. It appeared that Executive Board members were still being reimbursed at 140% of per diem instead of 100% as he thought had been agreed. It appeared that the areas where efficiency savings could be made were almost exhausted, so it would be helpful to know whether the targets would be reached and where other potential savings could be made. Dr ENDO (alternate to Dr Shinozaki, Japan) welcomed the efficiency savings that had been identified in response to resolution WHA52.20, for example the arrangement mentioned in paragraph 12 whereby a mutually agreed separation exercise between management and staff would enable the Organization to shift US$ 13.1 million of the regular budget to other activities in the budget proposals for 2002-2003. Similar measures should be carried out throughout the entire structure of the Organization. He recalled that the Executive Board, at its 105th session, had adopted resolution EB105.R6 on language diversity. Although he agreed with the principle of language diversity, it would be helpful to have an interim evaluation of the cost implications of the measures contained in the resolution, .in order to avoid any negative repercussions for programme activities. Professor ALl (Bangladesh) considered that there should be no further efficiency savings, since ultimately they had a negative impact on programme activities in countries. Mr LARSEN (Budget and management reform), replying to questions raised in the debate, said in response to Dr Lefait-Robin that training remained an essential part of capacity-building and would not therefore be affected by efficiency savings. Regional training centres would be upgraded to enable better training to be provided at local level, thereby obviating the need for study trips abroad. Replying to the point raised by Dr Endo and Dr Novotny, he said that a rigorous and comprehensive monitoring exercise was being carried out to measure progress in achieving the savings in each of the areas identified in document EB107/INF.DOC./2 by means of six-monthly reports from regional offices and headquarters. However, it was still too early to give accurate details on the levels of savings .achieved so far. For example, the revised per diem policy had only been implemented in September 2000. Formerly, within WHO, the per diem had been individually fixed for every city in the world, in accordance with the practice followed throughout the United Nations system. However, it had been decided, by adopting resolution WHA52.20, to change to the system used by PAHO, whereby the actual cost of accommodation, up to a ceiling, was reimbursed, but only 50% of the per diem was given to cover incidental expenses. WHO had projected its own efficiency savings on the basis of PAHO's figures. However, in his view, the results could turn out to be less substantial than Executive Board members might have wished, given the extent of the efforts made previously to achieve such savings. A full report would be available to the Executive Board at its 109th session in January 2002. In response to a further point raised by Dr Novotny, he confirmed that Executive Board members were paid a per diem of 140%, whereas the norm was 100%. That preferential rate had been laid down in resolution WHA22.5, adopted in 1969. In order to make any change, the Executive Board would have to propose a new resolution for adoption by the World Health Assembly. He agreed with Professor Ali that there should be no further calls for efficiency savings. He pointed out that the proposed reallocation of additional efficiency savings to high-priority programmes had,· in fact, taken place. The question was whether it would be possible to compensate for that through efficiencies in other programmes, or whether a de facto budget cut was unavoidable. He reiterated that it was still too early to predict the outcome, but that it would not be easy to make further economies.

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Dr AL KHARABSEH (Jordan) noted that the table of efficiency savings by region contained in document EB 107/INF .DOC./2 showed the same figures in the first and second columns for the Eastern Mediterranean Region, with the result that no resources remained to be shifted to priority programmes. He requested clarification on that point. Dr GEZAIRY (Regional Director for the Eastern Mediterranean) drew attention to the fact that his Region was among those which had been able to reduce expenditure over the past several years. As a result, the necessary measures had already been taken. At the same time, the Regional Office had been confronted with cost increases. As the Health Assembly had not agreed to an increase in the budget for the· Region, the only remaining option had been to use the efficiency savings achieved to cover cost increases elsewhere. Nevertheless, as indicated the previous year in the discussion of the budget, any further reduction in expenditure for the Region would have the impact of a reduction in programme activity. Illustrations of the savings made included the fact that the most recent Regional Committee had met for only four days and that the length of the meetings of committees of experts and periods of employment of consultants were also being shortened. It was felt to be impossible to make further savings, despite making every effort to do so. The very small amount of savings achieved in the past year had been used to cover certain increases in expenditure in the Region. Mr AITKEN (Senior Policy Adviser), responding to the concerns raised by Dr Endo, assured all those interested in multilingualism that much hard work had followed. the Director-General's statement at the 105th session of the Executive Board in order to implement the measures she had announced. Those measures had been financed out of efficiency savings, some of them made within the language services themselves. He was confident that the right balance had been struck between implementing the Director-General's recommendations and ensuring that the·technical programmes were not suffering. The CHAIRMAN said he took it that the Executive Board wished to note the information contained in document EB107/INF.DOC./2. It was so agreed.

The meeting rose at 12:35.

EIGHTH MEETING Thursday, 18 January 2001, at 14:40 Chairman: Dr G. THIERS (Belgium)

PROPOSED PROGRAMME BUDGET FOR THE FINANCIAL PERIOD 2002-2003: Item 4 of the Agenda (Documents EB107/INF.DOC./3, EB107/INF.DOC./8 and EB 107/INF .DOC./9) (continued)

Aspects of financial management (continued) Framework for programme evaluatioa (Document EB107/INF.DOC./3) Dr ASAMOA-BAAH (Executive Director) introduced document EB107/INF.DOC./3, containing an initial progt;ess report concerning the framework for programme evaluation, which had been requested by the Executive Board at its l 05th session. With a view to developing and applying an evaluation system that would allow for a more systematic and objective assessment of WHO's performance and its contribution to world health, the Secretariat had prepared a framework for evaluation based on a strong planning, programming and budgeting system. The document was intended to provide an opportunity for commentary by the Board on the progress made. Evaluation components had been included in the Proposed programme budget for 2002-2003, thus establishing performance indicators as an aspect of the beginning of the planning and programming process rather than as a process at the end. That was part of a cultural change in planning. An effort had also been made to establish a corporate information system enabling evaluation results to be taken into account when allocating financial and human resources to each programme. All the programmes in the Proposed programme budget 2002-2003 had been prepared in such a way as to make their evaluation possible. He recognized that there was still further work to be done on refining the goals, objectives, and expected resources, as well as on improving the information technology; the approach presented was not the final system, but a framework. Mrs ZIKMUNDOVA (alternate to Dr Thiers, Belgium) said that evaluation was an essential component in the new objective- and results-based approach of the programme budget. The new evaluation mechanisms were aimed at linking evaluation systematically with strategic planning, programme management and budgeting. It was therefore to be hoped that the evaluation results would be integrated in future programme budgets. Ms BLACKWOOD (alternate to Dr Novotny, United States of America) welcomed the development of a culture of evaluation within the Organization; progress had been made in outlining a framework of how to proceed with programme evaluation, an area to which her country attached great importance. She wished to restate strongly the request for systematic programme evaluation, which she believed had only been partially addressed in the document. That assessment should encompass not only the major themes but also a regular evaluation of the delivery and impact of the current programme budget. She also requested reports based on the indicators set out in the programme budget on how well programme results had been achieved and on whether those expectations should be maintained or adjusted, which would show whether optimum use was being made of budgetary resources. Such information was essential for future programming decisions in the Health Assembly. An excellent start had been made in including objectives, indicators and expected results in the

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proposed programme budget. She would, however, appreciate an interim progress report in 2002 on the evaluation system, and another in 2003 when the next programme budget was considered. Dr ALLEYNE (Regional Director for the Americas) welcomed the fact that, whereas evaluation was often a post-programming review, it would now be possible to evaluate programmes in advance, as the new programme structure had a built-in evaluation component. It was real progress to have a programme structure that allowed a clear perspective on responsibilities. Furthermore, evaluation was not restricted to one part of WHO but covered all the Organization's technical cooperation programmes. The point had been raised earlier in the discussion that it might be difficult to conduct evaluations with respect to every expected result at each meeting of the governing bodies. A decision could be taken to evaluate some selected programmes, or to provide a composite evaluation of what had or had not been done. It should be possible to present a report with some indication of progress in developing and testing evaluation instruments and of whether those instruments fulfilled their respected functions. As to the question, also raised earlier/ by Professor Zeltner, as to whether it was possible to evaluate the strategic directions, it should be borne in mind that they had not been designed with the strict indicators that would make such an exercise possible. They could be reviewed, but the evaluation system now proposed was focused on programme evaluation. Dr KARAM (Lebanon) said that, to be successful, a programme had to be evaluated so as to strengthen its positive features and eliminate its weaknesses. Although evaluation could be carried out on completion of a programme or periodically during its implementation, it was his view that continuous evaluation would give the best results. The CHAIRMAN said he took it that the Board wished to note the information contained in EB107/INF.DOC./3 and the comments thereon. It was so agreed.

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued from the fourth meeting)

Strengthening health services delivery: human resources Strengthening nursing and midwifery (Document EB 107/6) The CHAIRMAN drew attention to a draft resolution on strengthening nursing and midwifery proposed by the Executive Board members designated by Brazil, Chad, India, Islamic Republic of Iran and Qatar, which read: The Executive Board, 2 Having considered the report on strengthening nursing and midwifery, RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly,

1 2

See summary record of the fifth meeting. Document EB107/6.

EXECUTIVE BOARD, 107TH SESSION

Having reviewed the report on strengthening nursing and midwifery; Recalling resolutions WHA42.27, WHA45.5, WHA47.9, WHA48.8 and WHA49.1 which recommended action aimed at strengthening nursing and midwifery; Recognizing the importance of accessible health systems in efforts to improve the health of populations as highlighted in The world health report 2000; Recognizing the importance of using appropriate resources, including human resources, in the provision of health services; Aware that nurses and midwives play a crucial and cost-effective role in reducing excess mortality, morbidity and disability and in promoting healthy lifestyles and concerned that further action is needed to maximize this contribution; Concerned about global shortages of nurses and midwives; Recognizing the importance of integrating nursing services and midwifery services into the health system and into national health; Mindful of the continuing need to work with the full range of partners whose work impacts on the health of the population, on health promotion and on health care, 1. URGES Member States: ( 1) to further the development of their health systems and to pursue health sector reform· by involving nurses and midwives in the framing, planning and implementation of health policy at all levels; (2) to review or develop and implement national action plans for health and models of education, legislation, regulation and practice for nurses and midwives, and to ensure that these adequately and appropriately reflect competencies and knowledge that enable nurses and midwives to meet the needs of the population they serve; (3) to establish comprehensive programmes for the development of human resources which support the recruitment and retention of a skilled and motivated nursing and midwifery workforce within health services; (4) to develop and implement policies and programmes which ensure healthy workplaces and quality of the work environment for nurses and midwives; (5) to underpin the above measures through continuing assessment of nursing and midwifery needs and by developing, reviewing regularly, and implementing national action plans for nursing and midwifery, as an integral part of national health policy; (6) to [build up the evidence base, in order to direct] enhance the development of nursing and midwifery services that reduce risk factors and respond to health needs, based on sound scientific and clinical evidence; REQUESTS the Director-General: ( 1) to provide support to Member States in setting up mechanisms for inquiry into the global shortage of nursing and midwifery personnel, including the impact of migration, and in developing human resources plans and programmes, including ethical international recruitment; (2) to provide support to Member States in their efforts to strengthen the contribution of nurses and midwives to the health of the populations; (3) to ensure the involvement of nursing and midwifery experts in the integrated planning of human resources for health; (4) to continue to cooperate with governments to promote effective coordination between all agencies and organizations concerned with the development of nursing and midwifery; (5) to provide continuing support for the work of the Global Advisory Group on Nursing and Midwifery, and to take account of the interest and contribution of

SUMMARY RECORDS: EIGHTH MEETING

nursing and midwifery in wider aspects of the development and implementation of WHO's policy and programmes; (6) to develop and implement systems and uniform performance indicators at country, regional and global levels to monitor, measure, and report progress in achieving these goals; (7) to prepare a plan of action for the strengthening of nursing and midwifery; (8) to keep the Health Assembly informed of progress made in the implementation of this resolution, and to report to the Fifty-eighth World Health Assembly in 2005. Professor ALl (Bangladesh) expressed appreciation of the in-depth analysis of the issue. Timely action needed to be taken to achieve the aims set forth in the report (document EB 107/6), and Bangladesh therefore wished to join the list of sponsors of the draft resolution. Dr KIM Won Ho (Democratic People's Republic of Korea) said that, although nursing and midwifery played an important role in the provision of public health care, there was a widespread and increasing shortage of nurses and midwives, particularly in the developing countries, where low salaries and poor working conditions were forcing qualified personnel to emigrate, mainly to developed countries. He thus supported the recommendation that more attention should be paid to seeking practical solutions to the global problem of staff shortages and emigration. Dr AL-JABER (Qatar) said that nursing and midwifery constituted an important component of health services delivery, and nursing care was crucial for a properly functioning health service. Even smaller countries such as his own were suffering from a shortage of trained nurses and nursing staff. Among the reasons for that state of affairs were low salaries and the fact that nurses and nursing staff tended to be held in low regard, so that they were driven to seek work abroad. Ms STEPHENSON (adviser to Dr Novotny, United States of America) welcomed the update on implementation of resolution WHA49.1 and noted the issues requiring additional special attention. The public health workforce faced daunting global challenges, many of which could best be addressed collaboratively by governments, professional organizations, universities and the community. However, without a clear understanding of the composition of a national workforce and clear policy delineation of the essential public health services provided in each individual country, it was difficult to improve the knowledge and skills of public health personnel, especially within a multi-faceted public health environment. The globalization of markets was also expected to have an impact on human resources for health, resulting in expanded mobility of public health professionals and increasing gaps in the workforce. Nurses and midwives were at the core of any public health delivery system, and they should therefore be at the centre of the policy dialogue concerning workforce changes. For example, in her country and in the United Kingdom, unless appropriate measures were taken, the ageing of the nursing and midwifery workforce would create shortages unlike any experienced in the past. The nursing supply would decrease at the same time as needs for health care increased as a result of the concomitant ageing of the population. In developing countries, shortages of nursing and midwifery services could be attributed to the impact of disease, war, civil conflict and migration, in addition to the factors referred to by Dr Al-Jaber. As a result, those countries with the greatest health needs also had the greatest difficulties in meeting health challenges. WHO could support Member States in selecting and defining relevant public health workforce problems, evaluating the integrity and comparability of data, and understanding how those data illuminated ethical, political, scientific, economic and overall public health issues. They would then be better able to decide how to implement policies and programmes to address workforce challenges. WHO could also contribute to the strengthening of professional capacities through curriculum development, standardization of credentials and capacity-building.

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The Organization had several resources at hand, including WHO collaborating centres and expert groups such as the Global Advisory Group on Nursing and Midwifery, and she urged it to take maximum advantage of that Group's critical core of expertise. Lastly, she noted that the Fifty-fourth World Health Assembly would provide an opportunity to raise awareness of global workforce challenges, especially in the areas identified in the report as needing more attention - not only the problems faced by nurses and midwives, but also those faced by the larger global public health workforce. Mr LIU Peilong (China) agreed that developing countries were experiencing a shortage of trained nurses and midwives. Such personnel could not readily be involved in the formulation of national health policies, and in-service training was not adapted to the development needs of public health. Consequently, China strongly supported the emphasis laid in paragraph 13 of the report on the need for collaboration between developed and developing countries, and for an increase in the number of collaborating centres in the latter. The establishment of a WHO network of collaborating centres for nursing would play an important role in helping developing countries formulate their own plans and guidelines. He wanted to know what specific measures WHO envisaged for the setting up of that network, and how it was intended to increase the participation of developing countries in it.

Dr FETISOV (Russian Federation) recognized that nurses, midwives and paramedical staff were an important resource for improving the provision of health care. As part of its national health policy, his country was implementing a programme to strengthen nursing and midwifery, taking account of the Munich Declaration on Nurses and Midwives (June 2000) and the recommendations of the Second WHO Conference on Nursing and Midwifery. With support from WHO, the system for training nurses had been reformed and federal standards set. A ministerial council of nursing and midwifery had been established to provide advisory services to national bodies as well as to WHO's Global Advisory Group. He welcomed the work done by WHO in implementing resolution WHA49.1, and also the recommendations of the Global Advisory Group. Mr CHOWDHURY (India) conceded that the nursing and midwifery sector had been somewhat neglected in the past. In his country, the professional skills of nurses varied, and their numbers were inadequate: those who had the highest level of competence were in many cases lost to the developed countries. The norm for nursing personnel in hospitals was one nurse for every five beds, but in reality the ratio was far lower than that. During the past five years there had been a new emphasis in his country on involving nurses in the making of health policy, and for the first time, under India's tenth five-year plan, an independent working group had been set up to plan the activities of the nursing and midwifery sector. He too welcomed the report, which was evidence of a new emphasis being given to a sector that had often been neglected in favour of other more specialized sectors. He also welcomed the revival by WHO of the Global Advisory Group on Nursing and Midwifery and was confident that its deliberations would provide new perspectives. His country wanted WHO expertise in such areas as the standardization of teaching curricula, the training of specialist nurses for intensive care units, and psychiatry. There were adequate numbers of qualified doctors in India, but they were unevenly distributed, and because most of them preferred to work in the larger cities the peripheral areas were relatively underserved. His Government therefore intended to use nursing personnel and auxiliary nurse midwives to increase the delivery of medical services at the decentralized level. With that objective in mind, it was identifying different types of procedures and medical services that could be entrusted to such nursing personnel in more remote areas of the country so that at least a modicum of medical services would be available even in the absence of fully qualified doctors. In the course of that process, full account would be taken of the level of education of the nursing personnel and of the need to ensure the safe delivery of services. He was glad that attention had been focused on that somewhat less prominent sector of public health, and was pleased to cosponsor the draft resolution.

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Professor NAMA DIARRA (Cote d'Ivoire) commented that nurses and midwives were at the forefront of the implementation of the primary health care strategy and bore both clinical and public health responsibilities in rural areas. One important point was that, because of the need to reduce the wages bill as a result of structural adjustment programmes in Africa, countries such as Cote d'Ivoire had to face staff shortages in spite of the high number of nurses and midwives who had been trained. It would be desirable to add that fact to the list of reasons for the shortage given in paragraph 5 of the report. The French-speaking countries of Africa, like the English-speaking countries, should have the support of a WHO collaborating centre, and she urged the Regional Office to make a start on the procedure for the identification and accreditation of such a centre. Dr N'GAINDIRO (Central African Republic) observed that nursing and obstetric care were the very foundation of day-to-day medicine, and nurses and midwives therefore played a vital role in health care. Although the importance of the role played by nurses and midwives was common knowledge, there was a growing shortage of them througho11t the world, particularly in the developing countries, and in the African Region that shortage was exacerbated by the emigration of skilled personnel as a result of low wages and poor working conditions. The management of such personnel sometimes raised problems when it was a matter of assigning them to certain health districts. In his own country, for example, it was extremely difficult to assign midwives to the interior of the country, and because of the seriousness of the problem the Government had decided to train a new category of personnel, namely birth nurses. These were young people who received the same training as midwives but who could more easily be assigned to rural areas. All those problems showed that nursing and obstetric care, which was a common feature of everyday medical practice, was not always easy to manage because of the shortage of the necessary human resources. For that reason his country, while commending the continuing efforts made by WHO in the area of human resources development, would urge it on the one hand to give greater support to Member States in strengthening their nursing and obstetric care services and on the other hand to assist them in drawing up a strategy to stem the flow of human resources from the countries of the South to countries of the North, which offered more attractive wages and working conditions. The Central African Republic wished to cosponsor the draft resolution. Ms WIGZELL (Sweden) maintained that the important issue of nursing and midwifery should be linked to the budget goals of reducing maternal mortality and ensuring that primary health care and family planning facilities provided a full range of safe and effective reproductive health services. The availability of qualified midwives and nurses was, indeed, a vital prerequisite for progress in that area. She therefore welcomed the report and the activities identified as needing further attention. Mrs ABEL (Vanuatu ), commending the report, expressed full support for the call for the strengthening of nursing and midwifery through the participation of nurses and midwives in the development of health policies. Vanuatu was one of the Pacific nations that had undertaken a comprehensive national reform programme. It had done much to involve its health personnel in the overall reorganization and restructuring of health systems, and had encouraged them to develop corporate and business plans. In so doing, the Government and the Ministry of Health, in order to assess the capacity of the country's nurses, had carried out a "skill audit" of its health workers which had revealed major deficiencies in the management capacity of nurses at all levels, a problem to which no satisfactory solution had yet been found. One challenge the country was facing was that of inadequate in-service training. There was also a need to review teaching materials, including reference materials that were essential in both basic and post-basic training programmes. One of the difficulties was that of providing high-quality training to students who lacked basic education. It was essential to review the curriculum for those who provided training for nurses to take account of modern technology and new approaches and strategies in nursing education, and to design, possibly in collaboration with WHO, an in-service training package which would ensure high-quality nursing services.

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Mrs VARET (alternate to Professor Girard, France) suggested that in order to tackle the problem of the general shortage of health professionals providing frontline health care, a three-year work plan should be drawn up based on the conclusions drawn from resolution WHA49.1, which would identify precisely the areas where progress was needed and their order of priority. Consideration of that matter should be taken still further, and should involve a socioeconomic analysis of the constraints faced by nurses in order to identify the most relevant factors, notably their career aspirations and opportunities within a rapidly changing health care system. Those changes included the policy of restricting the duration of stays in hospital, which would require the further development of health care in the home and of care for the elderly. Nurses and midwives should be given responsibility for planning and for health-care strategy within a multidisciplinary team, and their work should be re-evaluated accordingly. An effort should also be made to identify incentives that would encourage them to work in depressed or rural areas and in poor urban districts. That was a very important task for the Organization, which should put health care systems at the heart of the war against poverty, offset the adverse effects of structural adjustment and enable a start to be made on planning measures to establish an effective and geographically balanced nursing system in each Member State. Dr CABRERA MARQUEZ (Guatemala) welcomed the report, which demonstrated that nurses and midwives were an .important resource for strengthening health services, especially in the developing countries. It was a matter of urgency to protect that resource and address the current shortages, and he therefore supported the draft resolution. Dr BODZONGO (Congo) said that nursing and midwifery were an essential part of the health-care system and that their strengthening was of crucial importance, particularly in the developing countries, which currently faced serious human resource shortages, especially in rural areas. In Congo, most qualified nurses and midwives preferred to remain in urban areas and lack of decentralization meant that there were no established posts in rural areas. However, nurses newly qualified from nursing colleges frequently joined the ranks of the unemployed since, on account of structural adjustments, the government was unable to recruit new staff to replace those who had died or retired. A further problem was the pitifully low salaries offered to such staff in developing countries. It was only natural that a person with good qualifications and experience should look elsewhere to make a decent living. However, he doubted that WHO was competent to resolve the problem, even in the long term. If the draft resolution were adopted, to what extent would the implementation of its recommendations be monitored? Perhaps a more realistic approach to the matter was required. Dr KARAM (Lebanon) stated that it was impossible to discuss human resources in the area of health without mentioning the vital role played by nurses and midwives in health service delivery. Some of the obstacles hindering capacity-building for the two disciplines included misconceptions about the role of nurses and midwives among the general public and, regrettably, some health leaders and policy-makers, a lack of incentives, inadequate funding for their curricula and unequal remuneration, which led to their migration from the needy communities to the more rewarding ones. It was the responsibility of those who devised health strategies to enhance their value and the role of WHO as the custodian of health to help remedy current shortages. He was therefore ready to lend his support to a draft resolution along those lines. Dr GRABAUSKAS (Lithuania) explained that, like other countries in central and eastern Europe, Lithuania had embarked upon an extensive programme of health care reform. Nurses and midwives had always formed an integral part of the national health system, but admittedly they had all too often been viewed merely as doctors' assistants. In the past decade the situation had changed with the opening of a nursing faculty at Kaunas University and the introduction of curricula that met international standards in existing nursing colleges. In that connection he acknowledged the close

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cooperation of several teaching centres in European countries, including Denmark and Sweden, as well as assistance received from WHO's nursing programme through the Regional Office for Europe. The problem currently facing Lithuania was the risk of losing well-trained staff to other countries, when their services were required to improve home care, long-term care and community nursing services at national level. The only way to resolve the problem was by providing good working conditions and salaries. He therefore supported the draft resolution. Dr Ponmek DALALOY (Lao People's Democratic Republic) stated that the strengthening of health-care services was a national priority in his country. Nurses, midwives and auxiliary nurses accounted for almost two-thirds of the health workers who delivered these services. As primary health care was expanded under the new organization of the health system, it was important to have adequate numbers of suitably qualified staff. With support from WHO, a development plan had been devised, curricula had been reviewed, resources had been mobilized, and nurses and midwives were as a result more involved in the development and implementation of the national health policy. Growing numbers of nurses and midwives had also been sent abroad for further training. Greater attention would be focused in future by the Organization on mobilizing support for such efforts. He endorsed the draft resolution on the subject. Dr SADRIZADEH (Islamic Republic of Iran) said that nurses and midwives were the backbone of the primary health care system in Iran and had played a major role in all aspects of its development, including planning, monitoring and evaluation of services. He therefore wished to be included as a sponsor of the draft resolution. The CHAIRMAN, speaking in his capacity as the member designated by Belgium, said that his country had declined to sponsor the draft resolution, not on the grounds of its substance, but because it believed that resolutions were not necessarily the best work tools for the Executive Board. He expressed appreciation of the concise report, and in particular the reference to the training of nurses and midwives for research. Belgium had considerable experience of research into hospital infections and, in his view, nurses were better qualified than doctors to carry out such research. With regard to comments about the need for a stronger action plan, he drew attention to a useful initiative undertaken by the Belgian Government: as of 1 April2001, a three-year nursing training programme would be offered to various categories of less qualified hospital staff on full salary. Dr DANZON (Regional Director for Europe) recalled the successful Second WHO Ministerial Conference on Nursing and Midwifery held in Munich in June 2000. The conference Declaration had highlighted salaries, diplomas and the role of nurses and midwives in relation to other health professions, and might prove useful to the Health Assembly's work in that field. There had been encouraging initiatives in the European Region. For example, in an endeavour to stem the outflow of qualified personnel, the Netherlands and Poland had recently signed an exchange agreement on nursing training. Dr ALLEYNE (Regional Director for the Americas) acknowledged the problems resulting from the movement of qualified nursing staff, which occurred within his Region as well as between regions. Regional cooperation in that area was very productive and should continue. One reason for the shortage of nurses was that it was a profession dominated by women, and women's professions tended to be lower paid. While WHO might be unable to remedy such gender discrimination, it could develop mechanisms to allow certain duties that did not need to be done by qualified nurses to be carried out by other health care workers. Similarly, it could undertake studies to determine the extent to which trained nurses could advance to other jobs in the health service. Dr MURRA Y (Executive Director ad interim) acknowledged the broad interest of the Board in nursing and midwifery services. With regard to the migration of nurses and midwives, he said that

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WHO was seeking to facilitate studies, in both developing and developed countries, to quantify the extent of that migration between countries, between regions and globally, and to understand the factors driving it. With regard to Mr Liu Peilong's query, he was pleased to announce that there were already more WHO collaborating centres for nursing and midwifery in the developing countries than in the developed ones, and that developing countries from all regions were represented in the Global Network of WHO Collaborating Centres for Nursing and Midwifery Development. WHO sought not only to expand the network's membership but also to work closely with the Global Advisory Group on Nursing and Midwifery for policy advice on all issues related to nursing and midwifery services. Mrs BRAUEN (International Confederation of Midwives), speaking at the invitation of the CHAIRMAN, stated that the vision statement of her organization, "Healthy women, healthy babies, healthy nations", was fully in tune with WHO's goal of health for all. Such a goal required a strong, healthy workforce of health care professionals, and midwives and nurses formed the majority of that workforce. Although progress had been reported since the adoption of resolution WHA49.1 on strengthening of nursing and midwifery, a further resolution was needed to keep attention focused on the issue. The recruitment, education, deployment and retention of midwives and nurses could not be taken for granted; effective policies must be put in place, supported and regularly evaluated. She urged WHO and its partners to increase their efforts to secure the provision of quality care to current and future generations. The meeting of the Global Advisory Group on Nursing and Midwifery in November 2000 had identified many serious problems, such as the failure to recruit young people, migration to more affluent regions and governments' short-term solutions to national problems, which often caused problems for other nations. She reiterated her call for WHO, governments and others to work together in finding solutions to such worldwide problems. National and international nongovernmental organizations could make a contribution but were unable to provide solutions on their own. A sound plan was needed that addressed both international and national issues, and progress in implementing the plan must be monitored. Midwives and nurses must be involved at all stages. Current policies should be evaluated and repositioned, and new mechanisms should be developed to deal with issues such as remuneration, retention, economic incentives and socioeconomic status, again with input from health professionals themselves. WHO should strengthen its efforts, building on its leadership role and increasing its collaboration with professional health and labour organizations, to keep those issues firmly on the agenda. Dr GHEBREHIWET (International Council of Nurses), speaking at the invitation of the CHAIRMAN, said that his organization had worked closely with WHO for 52 years to improve the health of the world's peoples. Strengthening nursing and midwifery was a necessary, legitimate strategy for achieving that goal, and he therefore welcomed the report and the draft resolution. The ability to train, deploy and retain competent, motivated personnel was critical to effective health systems performance. Nurses, more than 11 million of them worldwide, were uniquely placed to make a difference in the delivery of health services, through cost-effective, ethical and high-quality care. He welcomed the improvement in the status of nursing and midwifery in some countries. However, as noted at the November 2000 meeting of the Global Advisory Group on Nursing and Midwifery, there were serious problems in many countries. The nursing workforce was ageing, with some countries reporting an average age for nurses of 40 years or more; a new generation of nurses must be recruited. Migration, leading to imbalances and inequities, was a trend that must be reversed, in particular by strengthening nursing and midwifery at national and regional levels. He urged WHO, together with governments, to develop indicators that would facilitate the assessment and monitoring of the progress of national and regional plans. It was particularly important to examine ways and means of attracting and retaining health workers, through appropriate remuneration and working conditions, support services, economic and social incentives, and professional development. At both WHO and national level, nursing and midwifery input should inform policy and decision-making on health care delivery. Strengthening nursing and midwifery was a key means of achieving better health for the world's people. Strategic partnerships between WHO and associations such as the International Council of

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Nurses were vital, particularly in view of the ability of such associations to mobilize millions of professionals. Given the severity of the situation and the slow progress to date, it was critical for governments, WHO and its governing bodies to monitor future progress at regular intervals. Mr LIU Peilong (China) said that he supported the draft resolution. He reiterated his plea that the number of WHO collaborating centres in developing countries should be increased, and wished to see it reflected in the draft resolution. Accordingly, he proposed the addition of the words "and to take the necessary measures to increase the number of collaborating centres for nursing and midwifery in developing countries" in the text of paragraph 2(2) of the resolution contained in the draft resolution. It was so agreed.

Dr BODZONGO (Congo) considered that the seventh preambular paragraph of the draft resolution proposed by the Executive Board, which read "Recognizing the importance of integrating nursing services and midwifery services into the health system and into national health", was not logical since those services were already part of the health system, at least in his own country. He therefore proposed that the paragraph be deleted. Dr AL KHARABSEH (Jordan) suggested that it might be preferable to delete only the word "integrating". It was so agreed.

Dr BODZONGO (Congo) further suggested that paragraph 1(4) was very restrictive, since workplaces should be healthy for all health-care staff, not only for nurses and midwives. The text should be expanded to embrace all medical and paramedical staff. The CHAIRMAN pointed out that the draft resolution was devoted to nursing and midwifery, and that references to other categories of personnel might therefore be inappropriate. In his view, therefore, the existing text was perhaps preferable. It was so agreed.

Mrs VARET (alternate to Professor Girard, France) proposed the addition of a new subparagraph in paragraph 1 of the draft resolution worded as follows "to prepare plans to evaluate nursing services". She further suggested the addition in paragraph 2(7) of the word "rapidly" after "prepare" and of the words "and to provide for external evaluation at the conclusion thereof' after the word "midwifery". It was so agreed.

Ms STEPHENSON (adviser to Dr Novotny, United States of America) asked whether the draft resolution had any financial implications that were not addressed in the programme budget.

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Dr MURRAY (Executive Director ad interim) replied that there might be some implications for Member States. In regard to the WHO programme budget, some of the actions requested, notably in paragraph 2(5) of the resolution contained in the draft resolution, were already covered, but that in paragraph 2(1) might require some extrabudgetary resources to sustain the inquiry.

The resolution, as amended, was adopted. 1

The meeting rose at 16:20.

Resolution EB107.R2.

NINTH MEETING Friday, 19 January 2001, at 9:40 Chairman: Dr G. THIERS (Belgium)

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued)

Strengthening health services delivery: Item 3 .4 of the Agenda (continued) • Partnerships with nongovernmental health care providers (Document EB 107/7) Dr MBAIONG (Chad) introduced a draft resolution, entitled nongovemmental health care providers," proposed by his country, which read: "Partnerships with

The Executive Board, Having considered the report on partnerships with nongovemmental organizations, 1 RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Noting the inadequate performance of health systems in their attempts to improve the health of populations, ensure fair financial contribution and meet the needs of the population (including respect for the dignity and freedom of persons and confidentiality of information); Considering that the reasons for that situation - which include poor collaboration among health workers at all levels of the health system - are many and complex, the number of agents having increased under the combined effects of development of the private sector, decentralization and democratization; Noting that The world health report 2000: Health systems: improving performance shows the need to strengthen the role of government in guiding health systems, which means giving clear guidance in health policy, regulating that policy, evaluating the performance of various aspects of the health system, and supplying information to all concerned, so as to enhance interactions among those in the public and private sectors who provide support to national health policies; Recognizing that all those who are active in the field of health, especially those who deliberately operate in the context of national health policy, play important roles in the organization and provision of health services, 1. AFFIRMS that arrangements must be made for developing new partnerships with specific goals and responsibilities in order to contribute to the development of health systems, and that such arrangements constitute a means of enhancing health system performance;

Document EB I 0717.

- 107-

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CONSIDERS that: ( 1) in order to improve their efficacy, quality and fairness, health systems should be organized in such a way as to encourage the efforts of all concerned, in the public and private sectors, provided that they agree to situate their action within the national health policy of the country in which they operate; (2) pactnership among those parties should be based on shared values that promote the delegation of decision-making, while respecting the identity and autonomy of each; (3) the health authorities and all those working in health should agree on a system in which each party recognizes the relevance, quality and efficiency of the health services; (4) the terms of collaboration should be negotiated and formalized in a contractual agreement based on trust, responsibility and openness, and clearly indicate the objectives sought, the commitments of each party, and the way in which those commitments are to be respected; (5) in order to avoid fragmentation and ensure the coherence of the health system, the contractual arrangements must accord with the contractual policies that serve as a reference for all contractual arrangements; at country level, the basic principles of contractual policy should be defined (6) for the health system and adapted to the specific needs of each context: a priority health intervention (such as integrated management of childhood illness), a health problem (tuberculosis, malaria), a given population (people living with AIDS), another function of the health system (systems for sharing of risk, drug distribution), or a geographical area (organization of a health district); (7) although the State, and the ministry of health in particular, is responsible for the formulation, implementation and evaluation of contractual policies, this stewardship would be more effective if it were exercised in conjunction with all health care providers; URGES Member States: (1) to make all partners in health aware of the opportunity to develop partnerships based on contractual relations so as to benefit from the efforts of all those who situate their work in the context of national health policy; (2) to develop, in conjunction with all concerned, procedures for identifying and recognizing those who align their activities with national health policy; (3) to develop coherent contractual policies and evaluation mechanisms that can assess impact on health system performance; (4) to create a legal framework to facilitate contractual arrangements; (5) to ensure that all concerned have the technical wherewithal to put such tools to the best use; ( 6) to ensure that the ministry of health has the capacity to monitor and guide contractual arrangements in a way that respects national health policy; REQUESTS the Director-General: ( 1) to draw the attention of Member States and partners in health to the potential of partnerships based on contractual relations as a strategic option for improving the organization of health systems; (2) to support countries in formulating contractual policies that can serve as a reference for all contractual arrangements; to draw the attention of Member States and partners in health to the (3) limitations of ad hoc contractual arrangements, and to encourage them to work together to produce coherent contractual policies;

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(4) to provide support for development of the capacities and expertise of all partners, especially by strengthening the stewardship function of the ministry of health in implementation and evaluation of such policies; (5) to foster exchange of experience and expertise and to help establish an evidence base and set of good practices as a guide to future action; (6) to keep the Executive Board and the Health Assembly informed of the impact of such policies on the organization and performance of health systems. Explaining the background to the resolution, he said that it was extremely difficult for developing countries to make reforms in their health systems because they lacked the means to provide high-quality services. The private sector, on the other hand, did deliver high-quality health services, but only to part of the population, and it usually operated in isolation, with disparate objectives and practices and with no coordination. Better collaboration would make it possible to capitalize on the entire network of health care providers. The scope of the draft resolution was wider than that of the report (document EB107/7) because it considered partners of all kinds. It did not envisage privatization or disengagement on the part of the State, but rather the organizing of a partnership between all elements of the health sector. A partnership based on contractual relations would be a profound change for the developing countries. It was a new form of management or stewardship that was not customary in the health sector or in any other sector, and efforts would have to be made to convince political leaders, opinionmakers, and partners who had hitherto worked in isolation or mistrusted the State, of its advantages. Contractual relations between health service providers had become the norm in many developed countries, but the developing countries still had a long way to go in that direction, and the adoption of a resolution would help to highlight the practice as a tool with obvious benefits. At the same time Member States needed to be aware of the limitations of ad hoc or piecemeal contractual arrangements, which in the long run would have no real impact on the organization or performance of their health systems. The approach needed to be applied wisely and within a policy framework clearly defined in consultation with partners who had agreed to operate in line with national health policies, thus ensuring harmonization in the provision of health services. The resolution was needed to enable health ministers properly to exercise their stewardship role and to ensure that the contractual relations established conformed to national health policies. WHO had already helped developing countries to realize the potential benefits of contractual partnerships, but many would need technical support to help them establish the necessary operational framework. WHO was well placed to provide such support, and developing countries, for their part, would need to evaluate their experiences so that lessons could be learned and pitfalls avoided. Mr BERMUDEZ (alternate to Professor Yunes, Brazil) introduced a draft resolution proposed by his country entitled "Strengthening health sector delivery: partnership with nongovernmental organizations" which read: The Executive Board, RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Considering the report on partnerships with nongovernmental organizations which stresses that lack of capacity to deliver health services is responsible for the limited coverage of such services in many countries; 1

Document E107/7.

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Recognizing that exclusive provision of health services by the public sector may not ensure universal access to health; Noting that the organization of health systems is changing considerably, and that ministries of health in developing countries are increasingly building partnerships with the private sector and civil society in order to build up capacity for service provision and to improve access to care; Recalling resolutions WHA39.27, WHA41.16, WHA43.20, WHA45.27, WHA47.12, WHA47.16, WHA47.17, WHA49.14 and WHA52.19; Recognizing that the proper delivery of drugs and of other medical supplies that are essential for health is fundamental both for the good functioning of the public health system and for the health care measures initiated by nongovernmental organizations, and that it can, thus, create common ground for the development of partnerships among these actors; Taking into account the report on the revised drug strategy/ noted by the Fifty-third World Health Assembly, which highlights challenges related to international trade agreements, access to essential drugs, drug quality and rational use of medicines, and considering the document WHO medicines strategy: framework for action in essential drugs and medicines policy 2000-2003, 2 both of them recalling the strategic importance of rational drug procurement practices within access to health services; Considering the importance that WHO and governments are conferring to formulation, implementation and monitoring of national drug policies in accordance with WHO guidelines and the rapidly growing number of initiatives between governments and United Nations bodies on the one hand and nongovernmental organizations on the other; Noting that the trade issues that were addressed and that require a public health perspective have been scarcely evaluated in most regions of the world; Commending the strong leadership that WHO has shown in re-emphasizing the essential drug concept and in highlighting trade and pricing concerns that mainly have implications for access to medicines in developing countries; Noting the increasing ongoing and solidly-funded initiatives led by nongovernmental organizations and related to the revised drug strategy, such as the campaign of Medecins sans Frontieres for access to essential medicines and drugs for neglected diseases; the project of Management Sciences for Health; the Bill and Melinda Gates Foundation for defining and measuring access to essential drugs; the project of Health Action International and the Rockefeller Foundation for analysing drug prices and their impact on health in low- and middle-income countries; PAHO's agenda for health shared with the World Bank and the Interamerican Development Bank that includes the pharmaceutical sector jointly with Management Sciences for Health, United States Agency for International Development and the United States Pharmacopoeial Convention, that are being planned and implemented worldwide; Recalling the terms of resolution CD42.Rl3 adopted at the 42nd Directing Council of PAHO, proposing a computerized database on prices of government procurement of antiretroviral drugs for the Region of the Americas, and noting that this database would be feasible and of low cost, since successful experiments have been carried out elsewhere that are open for general research through the Internet and have greatly decreased the cost of governmental purchases, raised government accountability and improved the quality of products;

1 2

Document A53/10. Document WHO/EDM/2000.1.

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Congratulating the Director-General on the report on progress achieved, problems encountered and recommendations for action related to implementation of partnerships with nongovemmental organizations for strengthening health services delivery, 1 1. URGES Member States: ( 1) to ensure maximization of the contribution of private health care providers and civil society, through nongovemmental organizations, to publicly guided policies aimed at expanding health care services and access to health care and essential drugs; (2) to reaffirm their commitment to Health Assembly resolutions on the revised drug strategy and to ensure that the necessary action will be taken within their national health policies in order to guarantee public health interests and equitable access to medicines; (3) to make use of indicators developed by WHO in order regularly to evaluate progress on the different issues implicated in equitable access to health care and essential drugs, especially for poor and low-income populations; (4) to collaborate at national level in the collection of pricing data for essential drugs and medical devices, and to share information with other countries through WHO; (5) to collaborate with the WHO Secretariat in order to establish a computerized database that would provide Member States and nongovemmental organizations with information on prices of essential drugs and medical devices; REQUESTS the Director-General: ( 1) to further support Member States in implementing, in partnership with nongovemmental organizations, systems for monitoring drug prices and a consolidated worldwide database, and to lead the discussion aimed at implementing "equity-pricing" in order to make it feasible, especially for leastdeveloped countries, to have equity in access to essential drugs within their health systems; (2) to strengthen the implementation of drug monitoring systems in order better to identify adverse reactions and misuse of drugs within health systems, thus promoting rational use of drugs; (3) to continue the development of methods for monitoring the pharmaceutical and public health implications of trade agreements; (4) to promote, together with Member States, development of infrastructure and technology for the adoption of common strategies on essential drugs and medical devices that should include facilitating the sharing of information about databanks that have pricing information on essential drugs and medical devices; ( 5) to establish an ad hoc working group of the Executive Board, with representatives of Member States and major nongovemmental organizations, meeting twice a year with the support of the WHO Secretariat, in order to ensure that governments, nongovemmental organizations and United Nations bodies jointly implement the framework for action related to the revised drug strategy for the period 2001-2003.

The report (document EB 107/7) noted that inefficiencies in health service delivery were responsible for limited health care coverage, particularly in developing countries. Those countries therefore needed to establish and implement additional mechanisms that would ensure better coverage.

Document EB 10717.

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One strategy for expanding health service delivery capacity, successfully implemented by some Member States, was the establishment of cooperative mechanisms with nongovernmental organizations concerned with public health and with the non-profit-making private sector. One such partnership in Brazil was between the Ministry of Health and a religious nongovernmental organization, the Pastoral da Crianya, which offered primary health care to some 1.5 million pregnant mothers and to their children up to the age of six, thereby making a major contribution to improving maternal and child health and reducing infant mortality. Another factor crucially important for the proper functioning of the health services and the efficacy of their action was the delivery of drugs and other essential health supplies in quantity and quality sufficient to meet the needs of each country. Issues related to drug supplies were currently priority items on the health agendas of all WHO Member States. Recent initiatives in Brazil included the revision of the national Essential Drugs List, the decentralization of resources for primary pharmaceutical care, the creation of a national regulatory agency, the enactment of a law regulating generic drugs, and the establishment of a drug price database, published on the Internet, that made the Government's procurement process more transparent and hence reduced costs. Several nongovernmental organizations had taken initiatives in that area: thus, Medecins sans Frontieres had invested the proceeds of its 1999 Nobel Peace Prize in a project to access drugs for neglected diseases, and Health Action International had launched a comparative pricing study of drugs in developing countries in collaboration with the Rockefeller Foundation. It was crucial that such initiatives should be combined with those currently being implemented by WHO and by Member States in a joint effort to implement the strengthening of health services and the revised drug strategy for the period 20012003. He recalled that at the Fifty-third World Health Assembly Brazil had proposed the establishment of a worldwide drug price database to assist Member States in the procurement of essential drugs and to ensure greater transparency in the procurement process. In Argentina, Bolivia, Chile, Paraguay and Uruguay a drug price database similar to that used in Brazil had already been established. Since access to drugs was fundamental to health-related actions, he proposed that the Executive Board should establish an ad hoc working group consisting of representatives ofMember States and of nongovernmental organizations concerned with public health, with a view to coordinating efforts and ensuring that initiatives relating to the revised drug strategy and the strengthening of health systems were effectively implemented in all regions. It was crucial that WHO should continue to promote its essential drug policy and revised drug strategy independently and energetically, and should include the issue of drug supplies within health services on the agenda of the Fifty-fourth, Fifty-fifth and Fiftysixth World Health Assemblies. Dr QI Qingdong (alternate to Mr Liu Peiling, China) said that in the process of reform currently under way in China the Government's functions were being decentralized, nongovernmental organizations were being developed and the management and stewardship of the health sector were being strengthened. The Executive Board's discussion was therefore timely and provided an opportunity to consider such questions as the optimum mix of public and private provision, ways in which nongovernmental organizations could play a more positive role, and the functions of the Government under the reformed system. The information given in the report on contractual relations, the sector-wide approach and the stewardship of the health sector was welcome, and it was to be hoped that WHO would provide further guidance to Member States. He supported the draft resolution proposed by Dr Mbaiong, but proposed that in the first preambular paragraph the words "in many countries" should be inserted after the words "Noting the inadequate performance of health systems". Dr AL KHARABSEH (Jordan) said that there was no doubt, especially in view of the high cost of drugs, that the public sector could not meet everyone's expectations for health care. He fully understood the need to ensure that nongovernmental and private sector organizations played a role in health care provision, especially in countries and regions where the role of governments was limited or where governments were not fully functional. However, excessive participation by the private sector

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could be harmful. If the public sector were to withdraw altogether from the provision of health care, the majority of the population in many countries would be unable to afford private treatment, which was often very expensive. In recent years the number of nongovernmental organizations had exploded. Most had started out for praiseworthy purposes and on a non-profit-making basis, but unfortunately in some countries the results achieved were not always as good as might be expected, because they tended to confine their efforts to a single type of activity and also to compete with one another. Moreover, they occasionally engaged in profit-making activities, and were not always concerned exclusively with the welfare of the public. He concluded that, even where the private sector played a predominant role in health care, the primary responsibility must rest with the public sector. Or ENDO (alternate to Or Shinuzaki, Japan) agreed that, in order to achieve the best outcome from health systems, the public and private sectors should cooperate. He was concerned, however, that, according to the footnote to the document, the private sector included both profit-making and non-profit-making entities. If profit-making agencies established medical institutions, they would tend to concentrate on high-paying patients in urban areas, and on more attractive specializations. As a result, rural patients would be deprived of access to services, and the equity of the health system would be undermined, leading to increased costs. The Executive Board should therefore be aware of the risk posed by health organizations working for profit, except where they were engaged in nonmedical activities of the type mentioned in paragraph 11 of the report. Or NOVOTNY (United States of America) endorsed the sector-wide approach and the idea of partnership between the public and private sectors in health care provision. Under the guidance of WHO, a framework could be established for such a partnership, thus overcoming the difficulties involved in achieving coordination among donors. However, the partnership need not necessarily be at global level, and the draft resolution proposed by Or Mbaiong required further discussion, in order to determine how the framework could be adapted to the regional and subregionallevels. The draft resolution proposed by Mr Bermudez included a recommendation that WHO should carry out work on access to drugs. That was a separate issue, already dealt with in Health Assembly resolutions WHA52.19 on Revised drug strategy and WHA53.14 on HIV/AIDS. As for data on drug pricing, it appeared that PAHO had achieved positive results through collaboration with several Member States in the Region, and was posting drug prices on its web site. It was useful for countries to share information on drug prices, but he did not favour the idea of WHO establishing a computerized database on the subject. That would be a costly exercise in terms of resources, and moreover it would be difficult to guarantee the continuing accuracy of the data or the comparability of the prices listed. The resolution proposed by Mr Bermudez also referred in paragraph 2(4) to the adoption of common strategies on medical devices. It would of course be useful to know which devices worked and which did not, but gathering such information and reporting on the implementation of relevant Health Assembly resolutions was in any case the responsibility of the Director-General, who would in turn report to the Health Assembly. Or SADRIZADEH (Islamic Republic of Iran) said that the multi-faceted nature of health demanded greater involvement in health care by civil society, and especially by nongovernmental organizations. The emergence and re-emergence of serious infectious diseases such as malaria, tuberculosis and HIVI AIDS, together with an acute shortage of resources, called for the establishment of partnerships with the private sector. Given goodwill and locally guaranteed commitments, the public sector would be able to tackle health problems in a more cost-effective and efficient manner. However, where commercial enterprises were involved there might be a conflict of interest. WHO should avoid relationships with enterprises whose activities were incompatible with its work, while encouraging those which conformed with its policies and improved public health.

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Professor ALl (Bangladesh) commented that the question of how resources were channelled through nongovernmental organizations called for careful study. Such organizations commanded significant resources and tended to wield considerable influence in developing countries, including his own. They criticized State-run health systems without realizing the extent of the input contributed by governments, which regarded it as their duty to reach out to people and areas deprived of services. Nongovernmental activities were often uncoordinated and duplicated services to the same groups; as a result, when disasters occurred, aid was often concentrated on areas that had been given television publicity, and other areas were neglected. At a recent conference in Jakarta, for instance, he had learned that the favourite policy of one international nongovernmental organization was to make a variety of small grants, and funds were collected for that purpose from donors, who remained unaware of the total raised and how it was spent. Because governments were the custodians of future generations, it was important for them to retain some form of control over policy. Partnership between the public and private sectors was certainly important, but the values of fairness, justice, integrity and commitment must be safeguarded. More independent analysis was needed of the role of the private sector in health provision before any conclusions were reached. Dr N'GAINDIRO (Central African Republic), welcoming the report, said that health services had long been the exclusive preserve of the public sector, which had barely tolerated the intrusion of private organizations. Conflict between the two sectors had not been to the advantage of public health. In the developing countries political and economic factors, including cuts in health budgets, had eroded health systems and made way for greater participation by nongovernmental organizations, which were being encouraged by governments to play a role in meeting health service targets. However, that was only achievable within a collaborative framework that clearly defined roles, responsibilities and mechanisms for evaluation and follow-up. The African Region was greatly concerned with the issue, and he welcomed the initiative taken by WHO in organizing an international conference (Dakar, February 1998) on partnership between governments, nongovernmental organizations and WHO. The increased collaboration that had been the aim of that conference was also the purpose of the draft resolution introduced by Dr Mbaiong, which he warmly supported. Dr FETISOV (Russian Federation) said he was grateful to Dr Mbaiong for proposing the draft resolution. In his country, the development of the private sector was governed by a constitutional provision allowing for the co-existence of public and private ownership. The conditions for developing a private health sector were still far from ideal, but current policy decisions provided for a system of private health care in which businesses would play a role. He supported WHO's approach, which was to use the potential of the private sector in health care under the supervision of the State. Mr CHOWDHURY (India) said that it was impossible for large countries like India to provide health services exclusively through the public sector, and therefore cooperation with the private sector, especially with non-profit-making nongovernmental organizations, was essential. In India, such partnerships had enabled considerable progress to be made in implementing national disease control programmes. For example, directly observed therapy short-course (DOTS) centres for the treatment of tuberculosis patients, at which drugs were supplied free of charge, had been handed over to private practitioners and nongovernmental organizations; and in the treatment of malaria, link workers were employed at village level to distribute curative drugs and take blood samples. Nongovernmental organizations were largely responsible for advocacy and counselling services for people with HIVI AIDS; some were authorized to perform cataract operations, paid for by the Government; and others had been involved in controlling leprosy since before independence. Nevertheless, the transfer of decentralized public health functions to such organizations was limited by their capacities and by their degree of motivation. India's policy was to involve nongovernmental organizations in the running of primary health centres if they were willing and had the necessary experience, but comparatively few had undertaken the responsibility of doing so on a contractual basis. There was also scope for contributions from the private sector in urban hospitals.

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Health insurance was affordable by only some 15% of the population, and State expenditure on health was only US$ 2 per capita per annum. However, the Government had tried to involve the private sector wherever possible, and substantial progress had been made in operating a scheme established for Government employees under which certain private institutions were paid to undertake specific medical procedures, thereby reducing the workload of State institutions. In view of the low level of access to medical care currently available to most of the population, it had to be recognized that the State would continue to be predominantly responsible for improving health services. However, the report provided useful information on how partnerships with nongovernmental organizations could be developed. He supported both draft resolutions, and suggested that they might be combined. Dr ABREU CATALA (Venezuela) said that access to essential drugs and medicines was a major issue at national and international levels, and WHO should therefore undertake to report on the progress made in implementing the relevant resolutions. The draft resolution proposed by Mr Bermudez called for specific action to foster cooperation between governments and nongovernmental organizations. The health needs of developing countries were often not adequately met owing to their limited capacity to negotiate, promote cooperation and mobilize technical assistance on a sufficient scale to correct the accumulated inequities that put vast populations at a disadvantage. With regard to the report, she believed that it should have defined what constituted a nongovernmental organization. As laid down in Article 3.1 of the Principles Governing Relations between the World Health Organization and Nongovernmental Organizations, the aims and activities of such organizations should be free from concerns that were primarily commercial or profit-making. Given the importance assigned to the drugs issue during the course of the debate, she proposed that discussion of agenda item 8.3, Guidelines on working with the private sector to achieve health outcomes, be postponed until the discussion on the item now under consideration had been concluded. Professor GIRARD (France) said the main focus of the discussion was on partnerships with nongovernmental organizations, and in his view it was inappropriate to try to include in it the very important issue of drugs. With regard to the relationship between nongovernmental partners and State health services, he agreed that in certain circumstances, notably in developing countries, collaboration with nongovernmental organizations and private organizations was justified. However, he was not sure that in the case of developed countries such collaboration produced good results. In such countries there was a high level of investment in health, and health care systems depended on well-established public infrastructures and strong stewardship by government rather than on input from the private sector. In establishing public-private health partnerships in developing countries, careful consideration had to be given to how they would be managed, evaluated and controlled, and to whom they would be accountable. The general view was that health problems should be dealt with at community level and there was therefore a danger that actions by nongovernmental organizations would be seen by local populations as outside interference. Although there was a difference between nongovernmental organizations and the private sector, their functions were sometimes perceived as virtually the same. Concerning the draft resolution proposed by Mr Bermudez, he agreed that there was need for follow-up to resolutiol). WHA52.19, which in his view had not adequately addressed the problem of access. WHO should be asked to submit a comprehensive report on how that follow-up could best be effected to the Fifty-fourth World Health Assembly. Ms WIGZELL (Sweden) said the establishment of a dialogue with civil society and the building of partnerships with nongovernmental organizations was a vital element in strengthening democracy. The draft resolution submitted by Mr Bermudez touched on many important issues, and, for the Executive Board to be able to adopt a position on those issues, updated information was needed. She therefore supported the proposal that a report be submitted to the Fifty-fourth World Health Assembly.

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She endorsed the draft resolution submitted by Dr Mbaiong but proposed the addition of a new paragraph 3(7), reading "to take into account specific conditions and needs in regions and countries". Dr AL-JABER (Qatar) said that, as was clear from the report, nongovernmental organizations were increasingly providing preventive and clinical services in many countries. There was widespread concern, however, that health services might be taken over by profit-oriented entities serving the interest of a minority, especially in developing countries lacking a health insurance system. He supported the two draft resolutions, but stressed the importance of a system of checks and balances, together with WHO involvement in the building of partnerships with nongovernmental health care providers. Professor ZELTNER (Switzerland) said that there was currently a tendency to contract out more of what in the past had been regarded as core functions in the public domain. He welcomed the fact that WHO was taking a stand on the matter in relation to health and also that the Director-General was adamant that stewardship of the health sector constituted a core function of governments. He agreed with Dr Novotny on the need for a flexible approach, in view of widely diverse situations in different regions and countries. With the current multiplicity of partners, public resources were decreasing and decentralization was increasingly the norm, so that contracting was becoming a useful instrument. Member States and nongovernmental organizations increasingly needed WHO guidance in that area. He agreed with the principles and values expressed in the two draft resolutions. However, he wanted to propose amendments to the draft resolution proposed by Dr Mbaiong to reflect the need for greater flexibility, and would be willing to submit written proposals or participate in a drafting group to revise the text. In regard to the draft resolution proposed by Mr Bermudez, he endorsed the comments made by Professor Girard. Furthermore, he felt that it would be useful for a report to be submitted to the Health Assembly on how access to drugs might be improved. Any such report should provide details of how far discussions with the pharmaceutical industries had progressed. Dr Ponmek DALALOY (Lao People's Democratic Republic) said that in view of the importance of partnerships with nongovernmental providers in improving health systems, especially in developing countries, it was essential to develop and improve regulatory mechanisms for establishing contractual relations between countries and providers. He accordingly welcomed the draft resolution proposed by Dr Mbaiong. His country, like many others, was applying a policy of renewal and reform involving all groups within society, whether public, private or a combination of the two. Health was the responsibility of society as a whole and efforts had to be pooled to ensure that everybody was moving in the same direction and following the policy most appropriate for the country concerned. The coordinating role of the State was crucial, and mechanisms were needed to strengthen the capacity of developing countries in that area. His country had made progress on several major health priorities. He was optimistic that over the next few years, by improving the coordination of health policies, it would be able to escape from underdevelopment and poverty. Mrs ABEL (Vanuatu) expressed her support for the draft resolution proposed by Dr Mbaiong. Her country had established satisfactory partnerships with local and international nongovernmental organizations, which had participated successfully in various health projects, in particular in the fields of primary health care, the improvement of infant nutrition, and the health of women and young people. Although it was important to make maximum use of such organizations' expertise, her Government had recently been reluctant to approve some projects because of problems experienced as a result of competition between nongovernmental organizations, and the launching by them of projects that were not in line with national policies and priorities. Vanuatu would therefore welcome WHO support in monitoring and evaluating the work of nongovernmental organizations and, in particular, the impact of the services they provided to target populations.

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Or MSA MLIVA (Comoros) expressed support for the draft resolution proposed by Or Mbaiong. In Comoros, as in most developing countries, health care provision for most of the population was inadequate, and it would be logical to assume that nongovemmental organizations could help improve local health services. However, countries had sometimes lost control over certain of the activities of such organizations, which in some cases had intervened in health services without the Ministry of Health being aware of their presence. That was sometimes the fault of governments, which were unable to impose their views in the absence of clear models for partnerships. The situation was all the more serious in that certain donors were only willing to provide funds through nongovemmental organizations, yet there was no transparency in the latter's programme development and the impact of their projects was often minimal in relation to the sums of money mobilized. On those grounds, partnerships as outlined in the draft resolution were indispensable and were in the interests of both parties. The resolution also deserved support from donor countries, which were providing the funds for projects that often achieved unsatisfactory results. Or CABRERA MARQUEZ (Guatemala) agreed with previous speakers that partnerships with nongovemmental organizations were important. From 1986 onwards, after a long period of war and within a context of democracy, a new model for health care provision had been created in Guatemala. The objective was to improve health care coverage, which at that time had been only 44%. Recent reform of the health sector had included the establishment of partnerships with nongovemmental organizations, which had resulted in considerable improvements in health care provision. Institutional health services were complemented by integrated primary health care services provided by a wide network of non-profit-making nongovemmental organizations. During 2000, the Health Ministry had transferred economic resources to a large group of nongovemmental organizations representing health care providers and administrators, and had established regulations and a certification scheme for those entities to ensure the quality of the services they provided. The information provided in the report confirmed Guatemala's view that it should continue that strategy. He supported the draft resolutions before the Executive Board and agreed with Mr Chowdhury that the two texts might be combined. Or GRABAUSKAS (Lithuania) welcomed the report as a constructive attempt to support Member States in their efforts to mobilize all possible resources conducive to improving health care delivery. Although at present 90% of health provision in Lithuania was State-funded, the legislative basis for involvement of the private sector in health care delivery had been adopted as early as 19911992. At the present time, all pharmacies and three-quarters of dentists' practices were private and general practice was also being increasingly privatized, while almost all inpatient care remained in the public sector. Those proportions would naturally change with the overall development of the country, and Lithuania welcomed initiatives that stimulated partnerships with nongovemmental organizations and the private sector as one of the components in the democratic development of the country. Nongovemmental organizations and the private sector should, however, respect and operate in conformity with national health policies. He was therefore opposed to attempts to develop the private sector at the expense of public-sector health care systems, and favoured careful monitoring of the balance between the two. He supported the draft resolution proposed by Or Mbaiong. Or BODZONGO (Congo) remarked that the scope of health issues exceeded the competence of ministries of health, and the question of partnerships with nongovemmental organizations was therefore highly topical. However, the fundamental issue was not the relation between WHO and nongovemmental organizations, but rather those between Member States and such organizations. Health policy was determined by the State with the contribution of its partners, and each partner had a role to play in that policy. However, the ministry of health, as the representative of the State, was clearly the regulatory authority and private health care providers should only operate with State authorization. A national health system was thus made up of public and private sector partners, the latter consisting of profit-making non-profit-making entities. The State bore responsibility for maintaining discipline and establishing the norms and standards applying to relations with partners. If

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health objectives and policy were clearly defined, there should be little difficulty except in exceptional or urgent cases with regard to the conformity of nongovernmental organization partners. If such organizations in a country failed to observe regulations, as was sometimes the case, they should be reminded of their place and, where necessary, prevented from taking action, especially if their interventions fell outside national priorities. The report clearly indicated that the main issue was the capacity of States to set and enforce the necessary rules. The draft resolution proposed by Dr Mbaiong had given rise to an interesting discussion, and, should perhaps, as suggested, be reviewed by a drafting group in the light of the Executive Board's comments. He endorsed the views expressed by Professor Girard concerning the draft resolution proposed by Mr Bermudez. Dr DI GENNARO (Italy) shared the views expressed by previous speakers concerning the growing involvement of civil society in activities that until recently had been confined to public institutions, in particular in the social and health sectors. She therefore agreed that it was opportune to enhance partnerships with nongovernmental organizations and representatives of civil society, as called for in the draft resolution proposed by Dr Mbaiong, provided that WHO gave clear guidelines on contractual policies that would assure continued State stewardship. She requested information on the participation of WHO in the People's Health Assembly 2000 held in Bangladesh in December 2000: it had been suggested that WHO had not played an authoritative or supporting role in the conference. In relation to the point raised by Dr Novotny on the draft resolution proposed by Mr Bennudez, she considered that a database on essential drug prices was a vital tool for equity. She therefore supported its development by WHO, especially for HIVIAIDS drugs. However, the subject should not be taken up in the context of a resolution focusing on partnership with nongovernmental organizations. Professor NAMA DIARRA (Cote d'Ivoire) agreed that nongovernmental organizations were essential partners, but pointed out that the mechanisms of partnership were not always satisfactory. She therefore supported the draft resolution proposed by Dr Mbaiong which sought to strengthen such mechanisms, provided that the preponderant role of the State was clearly reaffirmed. With regard to the draft resolution proposed by Mr Bermudez, she endorsed the comments made by Professor Girard. The CHAIRMAN, speaking as the Executive Board member designated by Belgium, welcomed the debate on a new subject which, as shown by the discussion, responded to a real need. He agreed with the reservations of previous speakers about the draft resolution proposed by Dr Mbaiong, which he feared was somewhat ideological. However, with appropriate amendment, it could be made acceptable to all. He endorsed Professor Girard's comments on the draft resolution proposed by Mr Bermudez. Dr ANTEZANA (Bolivia), speaking at the invitation of the CHAIRMAN/ referring to the draft resolution proposed by Mr Bermudez, joined previous speakers in calling for a comprehensive report on access to drugs to be submitted to the Health Assembly. The report should provide sufficient material for an in-depth discussion as a basis for future action by WHO. With regard to nongovernmental organizations, he emphasized that, if health for all were to be achieved, participation would be required by both the public and the private sectors. Nevertheless, it was the function of governments to guide and regulate health systems with a view to their sound development. Previous speakers had rightly referred to the need for WHO to provide countries with model contracts or agreements to determine their relations with nongovernmental organizations, whether or not they were profit-making, although it should be noted that many such organizations were in practice financed by governments. The draft resolution proposed by Dr Mbaiong, with the amendments proposed, was of

By virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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relevance not only to developing countries, but also to developed countries. In a period of privatization, it was important for governments to be able to exercise adequate oversight, for example, through health service contracts with private entities of a national or international nature. Unfortunately, the process of privatization was proceeding much more rapidly and with much greater dynamism than the regulatory function. WHO therefore had a very important role to play. Ms EWEN (Consumers International), speaking at the invitation of the CHAIRMAN, indicated that she was speaking on behalf of Consumers International and of Health Action International, and that her statement had been endorsed by Medecins sans Frontieres, CMC-Churches' Action for Health, Oxfam Great Britain and World Vision International. She said that relevant nongovernmental organizations were currently actively involved in several policy dialogues and projects involving WHO. At the WHO/Public Interest NGO Pharmaceuticals Roundtable, nongovernmental organizations had provided input on technical and policy issues. Because of joint concerns about access to essential medicines and equity drug pricing, WHO, Health Action International and Oxfam Great Britain had commenced a project to develop a methodology for comparing drug prices in low- and middle-income countries. Over 600 consumer and nongovernmental organization representatives had gathered at the Consumers International Sixteenth World Congress (Durban, November 2000), where they had endorsed key resolutions on improving access to essential medicines. The campaign launched by Medecins sans Frontieres for access to essential medicines and drugs for neglected diseases had been important in defining key problems and in urging WHO to provide leadership and take action. Such examples illustrated nongovernmental organization involvement in identifying needs and in developing, implementing and monitoring WHO policy on essential drugs at both the national and international levels. In her address to the Executive Board, the Director-General had drawn attention to the massive gap between the resources needed to help poor communities to tackle different causes of illness, and the funding and human capacity currently available. For HIV/AIDS, WHO estimated that an additional US$ 3000 million a year were needed to step up prevention, treatment and support in Africa alone, excluding the cost of antiretroviral drugs. The need to increase access to essential medicines, including new medicines, had been reaffirmed by a series of WHO resolutions. The WHO Model List of Essential Drugs had been and remained one of the most important public health tools available to increase access to needed medicines and to promote their rational selection and use. As affordability was a criterion for inclusion on the list, most of those drugs were no longer covered by patents and, in most cases, multiple generic sources were available. As mentioned in a letter sent by Medecins sans Frontieres to Executive Board members, there was an urgent need to update the essential drugs list concept and to clarify and prioritize criteria for inclusion on the list. She therefore welcomed the news that work in that area was under way. She also welcomed WHO's commitment to encourage equitable pricing for patented medicines. Moreover, she called on WHO to expand its work on databases of prices of essential drugs and raw materials. The sources of drugs needed to be validated for assured quality by WHO, in collaboration with other relevant United Nations bodies. Work with WIPO would provide information on the patent status of drugs. Countries were currently changing their trade laws, often under great pressure, to go beyond the requirements set out in the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights. For that reason, WHO urgently needed to provide Member States with model laws and regulations on compulsory licensing and other legal measures to overcome barriers that limited access to expensive drugs. Operational research was required at the national level to determine the rationality and cost-effectiveness of key therapies in field conditions. In addition, WHO should play a leading role in defining a needs-driven research agenda to assist policy-makers, funding agencies and the research community in setting priorities for the pharmacotherapeutic needs of developing countries. With a view to reaffirming commitment to its revised drug strategy and encouraging implementation at the national level of strategies safeguarding public interests and equitable access to

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medicines, she urged WHO to provide annual progress reports on the implementation of the revised drug strategy. Dr MURRAY (Executive Director ad interim) said that the comments of Board members on both the content and scope of the report had been carefully noted. The report had focused on the provision of health services by nongovernmental organizations through contractual relations, using public finance but had also considered some aspects of partnerships that were not necessarily based on contracts. Moreover, while some members of the Executive Board had suggested a broader role for nongovernmental organizations in the financing of health services, there was no convincing evidence that all financing should be privatized, and The world health report 2000 emphasized public financing. The evidence on the performance of different financing mechanisms was, however, insufficient to enable definitive conclusions to be drawn. Several speakers had drawn attention to the critical role of stewardship by governments, including regulation of all the actors in the system, and the draft resolution proposed by Dr Mbaiong stressed the importance of accreditation of nongovernmental organizations as providers. The evidence base for judgements on the most appropriate role for nongovemmental organizations and on the regulatory mechanisms that were most effective in contributing to the overall objectives of health care services was weak but growing; for example, national health accounts were demonstrating that nongovernmental organizations already played an enormous role in the provision of health care in the developed and developing worlds alike. Moreover, their role as funders and providers was greater in the poorest countries. Both the report and the ensuing debate had indicated a need to build up better evidence on the extent of the role and involvement of nongovernmental organizations in the provision of health services. Replying to Dr Di Gennaro, he confirmed that WHO had been actively involved in the discussions that had led to the People's Health Assembly 2000. Contrary to expectations, it had not been possible for WHO to be represented at the conference by the Director-General, but the Organization intended to remain actively involved in the follow-up. Dr SUZUKI (Executive Director), referring to the draft resolution proposed by Mr Bermudez, recalled that in accordance with the request contained in resolution WHA52.19 on the Revised drug strategy, the Director-General had reported to the Fifty-third World Health Assembly on progress made. Since then, there had been several developments: an initiative on the part of five companies had been launched in May 2000 leading to substantial consultations and arrangements with countries; WHO had explored ways of increasing the availability of generic drugs and diagnostics; studies had been initiated together with key collaborating centres to assess the potential impact of trade agreements on public health; WHO was working with other United Nations and nongovernmental organizations to ensure that pricing information was made widely available to countries and communities; and, lastly, a meeting had been scheduled for March 2001 to consider how the essential drug list could be made more appropriate in order to improve access to and ensure the quality and safety of pharmaceuticals. Of the 24 subparagraphs directed to the Director-General in resolution WHA53.14 on HIV/AIDS six related to pharmaceuticals, including three (on drug pricing information, drug quality monitoring and the public health implications of trade agreements) which coincided with the main operative paragraphs ofthe draft resolution. Although resolution WHA53.14 did not contain any specific reporting requirement, the Director-General was willing to report to the Fifty-fourth World Health Assembly, as proposed by Dr Novotny and Professor Girard, about progress made on the revised drug strategy, in particular regarding access to drugs and work with nongovernmental organizations in that regard. Mr BERMUDEZ (alternate to Professor Yunes, Brazil) said that resolution WHA52.19 on the Revised drug strategy had reconciled several conflicting points of view and had underlined the importance for WHO of holding a position that was independent of the pharmaceutical industry. He thanked speakers for their support and said that, on the understanding that the item would be placed on

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the agenda of the Fifty-fourth World Health Assembly as well as on that of the two subsequent Health Assemblies and a full report made, he was willing to withdraw the draft resolution. It was so agreed.

Professor ALl (Bangladesh), referring to the draft resolution proposed by Dr Mbaiong, reiterated that more evidence-based analysis was required before a final conclusion could be reached on issues that had far-reaching implications for the future health care of the entire world. He suggested that WHO should study the subject further and a draft resolution should be presented to the Executive Board for adoption at its 109th session in January 2002. Dr NOVOTNY (United States of America) praised the draft resolution for pinpointing critical issues and initiating an important process. He was in favour, however, of allowing sufficient time to consider the evidence and the various options available, and therefore supported Professor Ali's suggestion. Dr MBAIONG (Chad), thanking members of the Executive Board for their expressions of support, emphasized that the draft resolution endeavoured to take account of countries' individual characteristics. It was intended less for countries with more advanced health systems than for developing countries, which might be led to adopt the contractual approach as a means of improving their health care provision. He was not advocating State disengagement or privatization: monitoring and evaluating the work of nongovemmental providers should remain the responsibility of the State. While not opposed to the suggestion by Professor Ali, he had been encouraged by many speakers to hope that the draft resolution could be amended and adopted by the Executive Board. The CHAIRMAN thanked Dr Mbaiong for the initiative he had taken. It had not only given rise to an interesting debate, but also heralded a new era in WHO's policy of collaboration with nongovemmental organizations and the private sector. The Executive Board now had two options before it: to request the preparation of detailed documentation on which a consensus could be reached at a later date, in accordance with the suggestion by Professor Ali; or to amend the draft resolution, possibly in a drafting group, with a view to reaching consensus. Professor GIRARD (France) observed that both options had their advantages, and it was difficult to decide between them. However, in view of the need to tackle the issues fully, frankly and courageously, he tended to favour postponing the debate in the hope that the fruits of a further year's work would supply answers to the questions of substance that had been raised. That was in no way to deny that extensive and valuable work had gone into preparing the present draft resolution, which provided a basis for what needed to be done. Dr MBAIONG (Chad) said he could find merit in the argument for allowing WHO time to undertake an in-depth study of the issues, and could agree to the consideration of an improved draft resolution at the Executive Board's I 09th session in January 2002. It was so agreed.

(For continuation of discussion of technical and health matters, see summary record of the tenth meeting section 3.)

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PROCEDURE FOR TECHNICAL BRIEFINGS

The CHAIRMAN announced that, following the point of order raised at the sixth meeting concerning the procedure for technical briefings, he had been asked, in his capacity as Vice-Chairman of the Executive Board, to chair the second technical briefing on The world health report 2000. It was so agreed.

The meeting rose at 12:40.

TENTH MEETING Friday, 19 January 2001, at 14:00 Chairman: Dr M.E. MBAIONG (Chad) later: Dr J. JIMENEZ DE LA JARA (Chile)

FINANCIAL MATTERS: Item 5 of the Agenda

Assessed contributions: Item 5.1 of the Agenda • Status of collection, including Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 of the Constitution (Document EB107110) Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of the Administration, Budget and Finance Committee (ABFC), reported that at its meeting the previous week the Committee had considered document EB 107110 and had welcomed the fact that the collection rate for 2000 had been the highest rate for the past 15 years. On 31 December 2000, the amount owing from Member States had been US$ 21 million less than the corresponding figure for 1999, a reduction that was also to be welcomed. It was to be hoped that that trend would continue in 2001. It was also encouraging that 32 Members had paid their contributions for 2001 in full and in advance- twice the number of the previous year. Twenty-three Member States continued to be suspended from voting at the Health Assembly, under the provisions of Article 7 of the Constitution. The voting privileges of a further two Members, namely Nauru and Nigeria, would be suspended unless payment was received before the opening of the Fifty-fourth World Health Assembly. Nineteen other Members were in arrears equalling or exceeding two full years of contributions. Several Members had made good efforts to reduce their arrears, in particular Belarus, Bosnia and Herzegovina, Chad, Cuba and Liberia. Since the Committee's meeting, he had been further advised that certain other countries that were neither affected by Article 7 nor subject to special arrangements were making great efforts to reduce their arrears. Argentina, Brazil and Venezuela were three such countries. The Russian Federation had completely repaid all arrears due to the Organization during the course of2000. Particular thanks were expressed to all those countries. Lastly, it was to be noted that, following the admission of the Federal Republic of Yugoslavia to the United Nations, that country had become a new Member of WHO on 28 November 2000. As a result, the document on status of collection of assessed contributions would in future include a footnote regarding the unpaid assessments of the former Yugoslavia, which had amounted to US$ 5.5 million on 31 December 2000. The Committee invited the Board to note those developments with respect to the status of collection of assessed contributions. The CHAIRMAN said that, in the absence of any comments, he took it that the Board wished to take note of the report. It was so agreed.

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• Special arrangements for settlement of arrears (Document EB 107/33)

The CHAIRMAN drew attention to a draft resolution on Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 of the Constitution: Special arrangements for settlement of arrears, proposed by ABFC, which read: The Executive Board, RESPONDING to the suggestion at the Fifty-third World Health Assembly that the Executive Board should propose a standard procedure for handling requests from Member States for special arrangements for the settlement of arrears in the payment of assessed contributions; 1 DECIDES to recommend to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Recalling previous resolutions of the Health Assembly concerning Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 ofthe Constitution and, in particular, resolutions WHA8.13 and WHA41.7, 1. INVITES Members that are in arrears to an extent which would invoke the provisions of Article 7 of the Constitution, or that anticipate difficulties in meeting their obligations to the Organization, to contact the Director-General to review the status of their accounts; 2. FURTHER INVITES those Members in arrears who wish to reschedule the payment of their arrears as part of an arrangement to have their voting rights restored to address requests in writing to the Director-General, to be received no later than 31 March. The requests should include at least the following information: (i) the total amount due, including the current year's assessment; (ii) the period over which payment is proposed; (iii) the minimum amount of payment that the Member State intends to make each year; and (iv) an indication of whether the Member State expects to request approval from the Director-General to make the payment in local currency, in accordance with the Financial Regulations and Financial Rules; 3. REQUESTS the Director-General to review such requests with the Member States concerned and to submit proposals to reschedule payment of arrears to the Administration, Budget and Finance Committee of the Executive Board at its session immediately before the Health Assembly; and 4. REQUESTS the Administration, Budget and Finance Committee to make appropriate recommendations on behalf of the Executive Board to the Health Assembly for consideration. Professor ZELTNER (Switzerland), speaking in his capacity as the Chairman of ABFC, recalled that at the Fifty-third World Health Assembly in May 2000 it had been suggested that there should be a standard procedure for handling requests from Member States for special arrangements for the payment of arrears of their contributions. In recent years in the days preceding the Health Assembly, 1

See document WHA53/2000/REC/3, summary record of the fifth meeting of Committee B, section 5.

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many such last-minute requests had been made by Members subject to the provisions of Article 7 of the Constitution so that they might have their voting privileges restored. It had become evident that the procedure surrounding such requests was unclear. Document EB 107/33 described how a procedure for handling such requests might operate, and indicated the information that should be provided so that ABFC could make informed recommendations for the Health Assembly to decide upon. The Committee had welcomed the proposals, and had suggested some further improvements regarding the minimum information to be provided and the minimum level of payment the Member State intended to make. Some Committee members had felt that it would be appropriate for additional background information to be provided to explain why difficulties were being experienced in meeting payments. Mr TASAKA (alternate to Dr Shinozaki, Japan) commended the rise in the collection rate for assessments to the highest level in the past 15 years. He supported the proposal regarding settlement of arrears, given the large volume of outstanding arrears that would have to be settled in order to ensure sound financial management and programme activity in a period of budgetary constraint. Dr BODZONGO (Congo) noted from document EB107/10 that his country appeared still to be in arrears in the payment of its contributions. It was his understanding that the Congo had not been required to pay contributions during 2000. He would welcome some clarification in that regard. Dr STAMPS (Zimbabwe), speaking at the invitation of the CHAIRMAN 1 and referring to paragraph 2(iv) of the draft resolution, said that it would be helpful to establish a principle whereby, when expected disbursements by WHO in a country exceeded the annual contribution of that country to the regular budget, payment in local currency should be automatically approved. Currently, the requirement was that payment be made in one particular currency. The costs of the transactions involved reduced the amount available for overall health provision in that country. He recalled the position taken by the United States of America, namely that it was not possible to apply special rules to particular countries. Yet special rules were indeed applied to one country, namely the United States, which - although it did not do so - was permitted to pay its contribution in its own currency. The principle applied to the United States should thus apply to all Member States, and a recommendation to that effect should be made to the Health Assembly. Payment in the local currency equivalent of the United States dollar amount would also facilitate the work of WHO in those countries that had been unable to pay their contributions, as local currency would thereby become available. Dr SADRIZADEH (Islamic Republic of Iran) welcomed the arrangements made to enable countries to pay their annual contributions in local currency. Those arrangements would help to prevent errors and support countries in meeting their obligations in a timely manner. Ms WILD (Financial services), responding to Dr Bodzongo, said that a small balance was still due from the Congo. The Secretariat would be happy to provide him with a full breakdown of the figures. The points made by Dr Stamps regarding the beneficial effect of a facility enabling countries to pay their contributions in local currency, where WHO incurred significant expenditures in that currency, had been noted. It was for that reason that the new Financial Regulation 6.8 had been introduced. As had been requested by Member States, limits and conditions had been included in Financial Rule 104.3 so as to protect the Organization from the risk of devaluation of significant amounts of local currency. That Rule would facilitate management of the situation globally, although it would not always be possible for WHO to accept payment of the assessed contribution in local

By virtue of Rule 3 of the Rules of Procedure ofthe Executive Board.

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currency and to spend it locally. The aim of the revisions had been to provide the necessary flexibility in the Rules and Regulations in balance with good control. Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of ABFC, pointed out that the Fifty-third World Health Assembly had adopted new Financial Regulations, which would have to undergo a further lengthy process of revision if Dr Stamps' proposal were to be adopted. The resolution was adopted. 1 Casual income: Item 5.2 of the Agenda (Document EB107/ll) The CHAIRMAN drew attention to the draft resolution on casual income contained in paragraph 8 of document EB 107/11. Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of ABFC, said that the Committee had noted that document EB107/11 might be the last report on casual income: if the Board confirmed the new Financial Rules, then new Financial Regulations, which had been approved by the Fifty-third World Health Assembly, would come into effect. During the transition period, items of income and expenditure would move from casual income to miscellaneous income. The Committee had noted that integrating miscellaneous income into the programme budget would provide a more inclusive and consolidated financial plan which would be easier to understand, and had requested the preparation of a document explaining the way in which the various components of the financial framework fitted together. The Committee had noted that the balance of US$ 22.2 million available at 31 December 2000 was a tentative estimate. The Committee had supported the proposal to replenish the Working Capital Fund by US$ 4 million and had noted that such action would be consistent with the revised Financial Regulations and with resolution WHA53.5. The Committee had also supported the proposal to retain the estimated balance of US$ 6 million in the casual income account pending its disposition as part of miscellaneous income. In conclusion, the Committee had recommended that the Board should adopt the draft resolution contained in document EB 107Ill. The resolution was adopted.2 Real Estate Fund: Item 5.3 of the Agenda (Document EB107/12) The CHAIRMAN drew attention to a revised draft resolution in which the amendments proposed by ABFC to the draft resolution contained in paragraph 12 of the document EB107/12 were reflected. The revised draft read: The Executive Board, Noting the report of the Director-General on the status of projects being financed from the Real Estate Fund and the estimated requirements of the Fund for the period 1 June 200 I to 31 May 2002 and the possible future WHOIUNAIDS office development in Geneva/ REQUESTS the Director-General to keep the Executive Board informed of further progress in the WHOIUNAIDS office project; and 1

Resolution EB107.R3. Resolution EB107.R4. Document EBI07/2001/REC/1, Annex I.

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RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Having considered the report of the Director-General on the status of projects financed from the Real Estate Fund and the estimated requirements of the Fund for the period 1 June 2001 to 31 May 2002 and the possible future WHO/UN AIDS office development in Geneva; Expressing appreciation to the Swiss Confederation and to the Republic and Canton of Geneva for the continued expression of their hospitality; Recognizing that certain estimates must necessarily remain provisional, 1. AUTHORIZES the financing from the Real Estate Fund of the expenditures indicated under Section Ill of the Director-General's report, at an estimated cost of US$ 3 250 000; 2. APPROPRIATES to the Real Estate Fund from casual income the sum of US$ 2 689 712; 3. AUTHORIZES the Director-General to proceed with negotiations with the Swiss authorities concerning the project outlined in Section II of her report; and 4. REQUESTS the Director-General to report further to the Fifty-fifth World Health Assembly. Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of ABFC, reported that the Committee had expressed general support for the projects described in the report by the Director-General, and for the amended draft resolution. Project specifications should be kept under review so that they continued to reflect actual needs. The Committee had also requested that the Board should be kept informed of progress. The resolution, as amended by ABFC, was adopted. 1 Financial Rules: Item 5.4 of the Agenda (Document EB107/13/ The CHAIRMAN drew the Board's attention to the draft resolution contained in paragraph 11 of document EB107/13. Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of ABFC, said that the Committee had noted that confirmation of the Financial Rules by the Board was necessary in order to give effect to the Financial Regulations adopted by the Fifty-third World Health Assembly, thus fulfilling the requirements of resolution WHA52.20. Some members of the Committee had commented that a grace period starting as early as 31 January (Rule 104.2) might prevent some countries from benefiting from the financial incentive scheme. Others had pointed out that measures to allow countries to pay in local currencies would enable many to pay more promptly than in the past. As the Board had heard from Dr Stamps and Dr Sadrizadeh, that matter was of concern to many countries.

Resolution EBI07.R5. Document EB107/2001/REC/l, Annex 2.

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The Committee had noted that transparency in financial reporting and clear delegation of authority from the Director-General under the Rules were both important elements of financial reform. It had decided to recommend the draft resolution to the Board for adoption, subject to further consideration being given to the date of the grace period for the financial incentive scheme. Mr TASAKA (alternate to Dr Shinozaki, Japan) noted that the purpose of the tricky process of revising the Financial Regulations and Financial Rules was to ensure more effective and economical financial management and to protect the assets of the Organization. He hoped that the amendments would in future make financial management more transparent, for example in the method of annual financial reporting, and that the links between authority and responsibility would be clearer in spite of the decentralization of the Organization. He had one objection. Under Rule I 04.2 of the proposed text, the limit of the grace period to be applicable under Financial Regulation 6.5 was to be 31 January. That meant that, beyond that date, Member States would not be able to benefit from the return of contributions. The fiscal year in his country began on I April and Japan would therefore not be able to benefit from the financial incentive scheme. He hoped that account would be taken of differences in fiscal institutions and other circumstances in Member States, in order to ensure that the financial incentive scheme really did serve as an incentive for all Member States on an equitable basis. He therefore proposed that 30 June might be taken as the limit of the' grace period instead of 31 January. Dr NOVOTNY (United States of America) commended the efforts to update and clarify the Financial Regulations and Financial Rules and said that the resulting document reflected current best practices. He supported the proposal made by Mr Tasaka for a compromise date on the grace period. The DIRECTOR-GENERAL said that the item under consideration was an important one for financial management. The one issue on which opinions were divided was the grace period for the financial incentive scheme. Although the most satisfactory date had been considered to be 31 January, she suggested that in the light of the views expressed in favour of a compromise the grace period might be extended to the end of April, a date that would solve the problem raised by Mr Tasaka and which would also be reasonable. Mr TALLARD-FLEURY (alternate to Professor Girard, France) noted Mr Tasaka's proposal and the compromise suggested by the Director-General. However, France would prefer to keep to the original date given in the document, namely 31 January. Mr TASAKA (alternate to Dr Shinozaki, Japan) noted that it was important to apply the new Financial Regulations and Financial Rules in their totality. He was therefore ready to accept the compromise proposal made by the Director-General. Dr CABRERA MARQUEZ (Guatemala) favoured moving the date forward to 30 April as suggested by the Director-General. Dr THIERS (Belgium) expressed support for the compromise proposal of 30 April, and proposed that an evaluation should be made of the operation of the new arrangements in the future. Mr LIU Peilong (China) said that the Board should take account of the fiscal year cycles of Member States in deciding on the grace period for the incentive scheme. In China, the National People's Congress examined and approved the Government's working budget for the current year in March and it was only in mid-April that the Financial Department could allocate the approved budgets to the various departments of government. He had therefore hoped that the grace period for the incentive scheme could be fixed after that date so as to enable his country to pay its contributions in

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good time. However, the suggestion made by the Director-General to fix the grace period at the end of April was acceptable. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) supported the compromise proposal put forward by the Director-General. Mr TALLARD-FLEURY (alternate to Professor Girard, France) said that the compromise solution appeared to be a wise one in the light of the circumstances. He was therefore ready to join the consensus that had emerged. Ms WIGZELL (Sweden) supported the proposal made by Dr Thiers for an evaluation of the system at a later date. The CHAIRMAN said that, in the absence of further comments, he took it that the Board wished to adopt the draft resolution contained in document EB I 07/13 with the amendment to the date contained in Rule I 04.2 introduced by the Director-General. The resolution was adopted. 1 Mr TASAKA (alternate to Dr Shinozaki, Japan), with reference to the proposal made by Dr Thiers, said that, if an evaluation were to be made, it should cover all provisions concerning arrears of contributions and not merely the grace period, because that would provide a means of more effectively evaluating the effect of the provisions designed to prevent arrears. Professor ZELTNER (Switzerland) congratulated the Director-General on the milestone reached, acknowledging the content and significance of work done on the revision of the Financial Regulations and Financial Rules. The text that had been adopted had important implications for the modernization of the Organization, the benefits of which would be apparent in years to come.

STAFFING MATTERS: Item 6 ofthe Agenda

Human resources: Item 6.1 of the Agenda (Documents EB 107/14, EB 107115, EB 107/15 Add.1, EB107/16, EB107/16 Add.l and EB107/17) • Annual report (Document EB107/14) Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of ABFC, said that document EB107/14 was the second consolidated report on the WHO workforce; it had been welcomed by the Committee. He pointed out that the data on occupational groups contained in the report related to posts and not staff skills. A robust Information Management System was planned which would make accessible information on the professional competencies and qualifications of the staff, thereby making it possible to monitor overall progress and ensure balanced representation of different disciplines in the Organization. Referring to paragraph 3 of the document, he said the Committee had suggested that the use of an earlier reference date would facilitate a more timely distribution and review of the report. Dr TRIERS (Belgium) said that some of the tables contained in the document provided a great deal of interesting information on staffing, showing in particular that the age pyramid was similar to

Resolution EB107.R6.

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that found in the majority of public services, the age categories between 40 and 50 years being strongly represented. He had been surprised to find that certain countries he had believed to be overrepresented were not in fact so. It was, however, a matter of concern in WHO, as in many other organizations, that the replacement of staff was not assured. It was necessary to be flexible and to make considerable use of short-term contracts. He expressed appreciation for the document which provided a clear picture of the staffing situation both at headquarters and in the regions. Mr LIU Peilong (China) commended the report, which improved transparency and gave a good picture of the current staffing situation and also of changes and trends in distribution of staff by sex and other matters. With respect to the geographical representation of staff, a matter which had frequently been discussed in the governing bodies, he noted that only 35% of professional staff recruited during the past year were nationals of under-represented or unrepresented countries and that the number of overrepresented countries was much higher than that of adequately represented countries. That kind of recruitment policy was hardly conducive to improving geographical representation, and was a matter of considerable concern. He hoped that effective measures would rapidly be taken to reverse the situation. He asked for a specific reply about what WHO intended to do to improve the geographical representation of staff. Secondly, many short-term contracts had been signed in WHO during the past year. Table 11 b showed that considerable differences existed in the recruitment of short-term staff at headquarters and in the regional offices, with the highest number being recruited in Africa and the lowest number in the Western Pacific Region. He asked for an explanation of such marked discrepancies, and for an outline of the principles governing the recruitment of short-term staff. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) appreciated the steps taken to carry out the wishes of Member States. He also commended the report, while expressing regret that it had been submitted rather late. He reaffirmed his country's support for the aspects of the Organization's personnel policy which were apparent from the report, particularly the moratorium on career service appointments and measures to ensure the recruitment of new talent from outside the Organization. Professor NAMA DIARRA (Cote d'lvoire) welcomed the fact that the percentage of women in the professional category had increased from 21.8% in 1990 to 31.9% by 2000. She noted, however, that further efforts were required in the African Region. She pointed out that in Table 3 Cote d'Ivoire was listed among the over-represented countries, whereas in Table 4a it had a total of eight professional staff for its range of 1-8 staff. She therefore requested clarification of the term "overrepresentation". Dr THIERS (Belgium) said that he had a request similar to that made by Professor Girard, who had advocated the use of pie charts in the proposed programme budget. It would be useful to present the age pyramid graphically: such a presentation would add considerably to the interest and userfriendliness of the document. Ms STEWARD-GOFFMAN (ad interim, Human resources services) said that the annual report on human resources was by no means finalized, and could still be improved upon. Some useful suggestions made regarding its layout, form, content and timing had already been taken into account. In response to Mr Chernikov, she said that the report had been issued rather late, owing to the request that 31 December 2000 be used as the reference date. Subsequently ABFC had suggested using an earlier reference date. While that option would facilitate the Board's discussion, the report data would then not tally with the budget data. Replying to Mr Liu Peilong, she said that in response to policy directives from the Board on gender balance and geographical distribution, a consultant had recently been commissioned to help

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develop tools for use by recruitment staff, as well as to help improve the Organization's outreach to prospective candidates: a computerized recruitment network had been set up for that purpose. WHO was also looking into ways of mobilizing the support of the Board, as well as of regional and country offices, in identifying suitably qualified candidates. As for the query by Professor Nama Diarra, she would follow the matter up. If there had been an error, an appropriate corrigendum would be issued. The CHAIRMAN said that, in the absence of any further comments, he would take it that the Board wished to note the annual report on human resources for the year 2000. It was so agreed.

• Policy development (Documents EB I 07/15 and EB I 07 /I5 Add. I ) 1 Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of ABFC, said that human resources was the fourth area to be tackled in a series of management reforms in the Organization. The Director-General's Task Force on Human Resources Management Reform had developed a strategic plan to support WHO's corporate strategy, which included mechanisms to ensure the right mix of staff to deliver the Organization's goals now and in the future, and to provide a working environment that would make WHO an employer of choice. The Director-General was committed to the comprehensive reform of human resources management; a swift completion of contract policy reform was foreseen so that proposals could be submitted to the Board in 2002. Human resources reform was an evolving process and, although major impetus had been provided by the Task Force, some changes had been introduced before its establishment, including new recruitment and selection procedures and annual reporting on the status of staffing in the Organization. No doubt other changes would be proposed in future. The implementation of the reform package included improvements in human resources information technology, the introduction of a new performance management system, the development of tools to improve geographical distribution and balance between the sexes, grievance procedures, and matters relating to the balance between work and home life. Contract policy issues had been foreseen as the centrepiece of the human resources reform package, and the Task Force had developed a variety of contractual tools; however, so far it had not been possible to find a solution that met the concerns of the parties involved. Providing information on a variety of issues that had prompted questions at the ABFC meeting, and were likely to be of interest to Board members, he explained that the two terms "strategic framework" and "strategic plan" were interchangeable. The new performance management system was a standard performance management model, which rated staff against key objectives linked to WHO work plans, based on that successfully implemented in PAHO and similar to the United Nations performance appraisal system. Regarding psychological harassment in the workplace, a new policy and related procedures had been developed, based on a survey of best practices in the United Nations system and in other international organizations. The proposals for paternity leave were cost-neutral, since direct additional costs would only arise in the event of staff replacement- extremely unlikely for a five-day period. Individual development plans would not replace performance appraisal, but complement it. The singling out of certain categories of staff for priority in staff development would not split the staff, since although some groups were cited for priority treatment, it did not necessarily mean that others would be set aside. All staff would be encouraged to evolve and learn. The continuation of work on a senior executive service or senior management group did not imply that there was general agreement on the matter; concerns voiced had been duly noted. That issue was currently under consideration by the International Civil Service Commission. Further work was

Document EB107/2001/REC/l, Annex 3.

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required on the question of departing from the traditional labelling of staff categories as general services, professional and directors. ABFC recommended that the Board should take note of the Director-General's report and confirm the proposed amendments to the Staff Rules by adopting the draft resolution contained in document EB 107/15 Add.1. A more comprehensive revision of the Staff Rules and Staff Regulations to consolidate agreed changes was foreseen for the future. Dr AL-JABER (Qatar), after expressing appreciation of the report, requested the Director-General to correct the inequitable geographical distribution of staff, particularly for seniorlevel posts. At present some regions were seriously over-represented, and that imbalance must be redressed. Professor ALl (Bangladesh) welcomed the report, which gave an indication of the Organization's strategy for its primary resource- its staff. He understood that the strategy was a longterm one and that changes would be introduced over two or three bienniums. Referring to the ideas expounded on workforce planning in paragraph 9 of document EB107/15, he suggested that greater consideration should be given to creating posts at regional and national levels, thereby allowing for greater staff rotation and mobility. At present, although it was not difficult to transfer staff from headquarters to the regions, a transfer in reverse was not so easy because of the lack of comparable posts. He would welcome further information on what exactly was implied by staff rotation and mobility in that context. He applauded the revision of measures to reward high staff performance and the possibility of non-monetary compensation for them. Although all staff were equal in some respects, they were not all equal in others. Good performance warranted recognition. In order to achieve the Organization's aims, staff motivation was essential, and it had to be admitted that under the current circumstances of dwindling funds and major reform, WHO staff did not always work in ideal conditions. He was appreciative of how much was being achieved under those circumstances. New health problems were arising in different Member States all the time, many of which were not exclusively within the Organization's domain and required coordination with other organizations. However, the latter often failed to grasp that WHO was a technical and not a financial organization and expressed surprise that it could only make a small financial contribution. Unfortunately a modest financial outlay meant that WHO had less influence in such matters. He requested that all the points he had raised should be borne in mind when further developing the human resources policy. Mr TASAKA (alternate to Dr Shinozaki, Japan) welcomed the Director-General's efforts to reform the Organization's human resources policy, including overall staff deployment and establishment of the Task Force on Human Resources Management Reform. Nevertheless, he was not wholly satisfied, since the direction of the policy was not clear and the strategic framework being prepared had not been finalized. The direction should be more clearly defined and translated into action without further delay, lest staff morale be jeopardized. In that connection, he sought clarification of the role of the management support units, which he understood were intended to rationalize human resources management and make it more efficient. Had those goals been achieved? Over the past two decades, Health Assemblies had consistently stressed the importance of geographical representation, and WHO had stepped up its efforts in that regard. Notwithstanding, according to document EB 107114 a third of Member States were still under-represented or unrepresented on WHO staff. The number of Japanese professional staff represented less than a third of the desired range for Japan, and the situation was not improving. He agreed with Dr Al-Jaber that steps should be taken to improve geographical representation on the basis of Health Assembly resolutions that accorded priority to the matter in the Organization's human resources policy. Mrs JOHNSON (adviser to Dr Novotny, United States of America) also welcomed WHO's review of its human resources policy and the work of the Task Force, which would help to make the Organization a more attractive employer, able to recruit highly skilled, motivated staff. She endorsed

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human resources initiatives that were cost-effective, likely to increase productivity, and create a supportive working environment, and were in accordance with current International Civil Service Commission (ICSC) standards. However, WHO's reform measures must be confined to matters that fell within its sphere of competence, and the Organization must coordinate and consult with ICSC on matters relating to the common system. Such an approach would ensure the speedy approval of any possible consequential amendments to the Staff Rules. According to the Director-General's report, the proposed measures would entail additional costs, but those should be considered in tandem with the reform measures. Ms WIGZELL (Sweden) expressed support for the innovatory proposals for paternity leave and shared maternity leave, which were of great symbolic value for an organization that promoted the health and well-being of children. They were also of practical use: an organization that wished to recruit highly skilled staff, with a modem outlook, must make itself attractive to the younger generation. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) thanked the Chairman of ABFC for his introductory remarks, which had shed light on a number of issues in the Director-General's report that had raised concern. In the light of those clarifications, he was now in a position to support the human resources policy outlined therein as well as the work of the Task Force. In particular, he welcomed the cautious approach adopted in the pursuit of decisions, taking into account the experience, both positive and negative, of other international organizations. He endorsed the comment of Dr Al-Jaber concerning equitable geographical representation. Dr MSA MLIVA (Comoros), congratulating the Director-General on the report, said he trusted that the issue of geographical representation would be examined closely. Perhaps then the Comoros might one day be represented. Mrs JOHNSON (adviser to Dr Novotny, United States of America) supported the work/family policy adopted by the executive heads of the organizations of the United Nations system and said that WHO was rightly at the forefront in advocating health-conscious human resources practices. She proposed a further change to the amendment to Staff Rule 650, replacing the words "close relative" by "immediate family member", which was the wording used in the United Nations common system. She was unsure whether the entitlement described in Staff Rule 760 fell within that system's standard. At the United Nations, a new father could take up to seven days' uncertified sick leave, plus annual leave, plus the unused portion of the mother's maternity leave when both were United Nations employees. Since WHO sought to set a precedent, the policy must be equitable and well thought out. It would be advisable for the Board to review the procedures for implementation of the new benefit before changing the Staff Rules. There were some unresolved questions, for example whether paternity leave would apply to unmarried fathers, and also certain financial and programming considerations. In order to maintain the integrity of the common system and to allow time to consider the implications of setting a precedent, she proposed that WHO adopt the United Nations entitlement in the short term, and review the entitlement to paternity leave after a study of costs, effects on morale, and guidelines for implementation, and confirmation that the benefit fell within the scope of the common system. Ms WIGZELL (Sweden) asked for confirmation that a minor deviation from the rules of the United Nations common system would be allowed. It was desirable for WHO to set a precedent. She took it for granted that paternity leave would also apply to unmarried fathers. Dr THIERS (Belgium) noted that his country had an active policy of promoting equality between the sexes, and also equality between mothers and fathers with regard to family responsibilities. That appeared to be a general social trend, at least in many countries. The United

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Nations, however, had not yet reached that point. Since WHO was part of the United Nations system, it should take the lead in introducing more family-friendly rules throughout that system. Mr TALLARD-FLEURY (alternate to Professor Girard, France) said that the amendment to Staff Rule 740.2 concerning additional leave for a reason other than the death of a close relative, and the introduction of paternity leave, must remain in line with the United Nations common system. Nevertheless, WHO could be a pioneer with respect to paternity leave, on the basis of precedents in France and other northern European countries. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation), responding to the comments of Mrs Johnson, pointed out that paternity leave was not directly regulated by the rules of the United Nations common system. Dr AL-JABER (Qatar) noted that Convention Cl83 of the IL0 1 entitled women who had given birth to at least 14 weeks maternity leave. Would leave of that duration be applied at WHO as of 2001? Ms STEWARD-GOFFMAN (ad interim, Human resources services), replying to the questions on geographical representation raised by Dr Al-Jaber, Mr Chernikov, Dr Msa Mliva and Mr Tasaka, said that WHO was actively working on a strategy to redress the balance. Professor Ali had made many useful comments which would be taken into account. With regard to Mr Tasaka's query about the apparent lack of an overall strategic direction, she assured him that, although the DirectorGeneral's report was succinct, the report of the Task Force spelt out in detail how the human resources strategic plan was linked to the main directions of the overall corporate strategy. The plan had two main objectives: to provide WHO with a workforce enabling it to meet the Organization's goals efficiently, and to attract and retain the necessary staff. With regard to Mr Tasaka's query about management support units, she noted that human resources was the fourth in a five-part series of management reforms initiated by the Director-General, covering restructuring, the budget, financial reform, human resources and information technology, a series which was being tackled in order of increasing complexity. Under those reforms, day-to-day work on human resources had been devolved to the management support units, with policy support from the central service. The system was being monitored and would be further assessed in the light of reform of information technology. In reply to various questions about whether paternity leave was consistent with the common system, she reiterated the comment of Mrs Johnson that, within the United Nations system, seven days' uncertified sick leave could be taken for other purposes, including paternity leave. The Task Force had found that that was not an appropriate solution for a health organization and had initially recommended 10 days' leave, which had been reduced to five days on review. The Task Force had deemed it appropriate for WHO to be a pioneer, so that it would be the first organization within the common system to include paternity leave in its Staff Rules, although a similar proposal was on the table at the ILO. As had been pointed out by Mr Chernikov, maternity leave and paternity leave were not regulated by the ICSC, and practice varied. She assured Mrs Johnson that her various questions had already been considered, and provision made for them in the relevant documentation. Other organizations were already giving paternity leave in practice, and its implementation by WHO would not break new ground. Replying to Dr Al-Jaber, she stated that the length of maternity leave within the United Nations system was currently 16 weeks' paid leave. Mrs JOHNSON (adviser to Dr Novotny, United States of America) reiterated her unequivocal support for paternity leave, but said that she wished to maintain the integrity of the United Nations common system in order to avoid a situation in which organizations entered into competition with one

C183 Maternity Protection Convention, 2000.

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another with regard to benefits in order to attract staff. In a spirit of compromise, she proposed that the draft resolution contained in document EB107115 Add.l should be amended by deleting the words "and paternity" and adding a further sentence, to read "Also CONFIRMS in accordance with Staff Regulation 12.2 the amendment to Staff Rule 760 made by the Director-General with effect from 1 January 2001 regarding paternity leave on a trial basis for two years, to be reviewed by the 111 th session of the Executive Board in January 2003, particularly in the light of any developments in the common system." Without departing from the common system, that wording might trigger appropriate action system-wide. Mr CHERNIKOV (adviser to Dr Fetisov, Russian Federation) said that he had no objection to the proposal of Mrs Johnson, bearing in mind that at its session in November 2000 the Governing Body of ILO had adopted almost all its decisions with regard to human resources policy on an experimental basis, with the possibility of review within two years. Ms FILIPSSON (alternate toMs Wigzell, Sweden) also accepted the proposal. She trusted that in two years' time it might be possible to increase the number of days of paternity leave. Dr AL-JABER (Qatar) pointed out that ILO Convention C183 did not refer to a trial period or to a review within two years. Once ratified, it would have to be implemented. He asked why WHO wished to implement its policy on a trial basis. The CHAIRMAN said that no change in the length of maternity leave had been proposed. He invited the Board to adopt the draft resolution contained in document EB 107115 Add.1, on the understanding that the amendment to Staff Rule 760 was being introduced on a provisional basis. On that understanding, the resolution was adopted. Dr Jimenez de la Jara took the chair. Professor GIRARD (France) said he wished to place on record the Board's thanks to the representatives of the WHO staff associations, who, in view of the exceptional circumstances, had agreed to postpone their customary statement until later in the session.

3. TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued from the ninth meeting, section 1)

Health systems performance assessment: Item 3.6 of the Agenda (continued from the fourth meeting) The CHAIRMAN invited the Board to consider the following text, entitled "Health systems performance assessment", proposed by a drafting group: The Executive Board, Having analysed The world health report 2000: health systems: improving performance, published on 24 June 2000, which included a health system performance index and an overall attainment index as exercises comparing the performance of the health systems of WHO's 191 Member States;

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Taking note of the report on assessment of health systems' performance 1 and of the report by the Chairman of the Executive Board;2 Considering the importance ofhea1th in the development and well-being ofpopulations; Bearing in mind the importance of health systems in improving health conditions and the quality of life; Recognizing the important role of evaluation of the performance of national health systems in improving quality, equity, and other criteria relevant to these systems; Appreciating the potential for such evaluations to raise awareness of the needs of health systems and the main policy issues faced, and to help seek additional resources for health; Aware that such evaluation exercises should be based on science and evidence and be as participatory as possible, seeking inputs from all Member States; Bearing in mind the resolution of the United Nations Economic and Social Council entitled "Basic indicators for the integrated and coordinated implementation of and follow-up to major United Nations conferences and summits at all levels", dated 28 August 2000, which emphasized that such basic indicators should be developed with the full participation of all countries and approved by the relevant intergovernmental bodies; 3 Noting the presentations made by the Secretariat during the 103rd and 105th sessions of the Executive Board on trends and challenges in world health; 4 Taking account of resolution CD42.R5, entitled "The world health report 2000", adopted by the 42nd Directing Council of the Pan American Health Organization and by the 52nd Session of the Regional Committee of the Americas on 26 September 2000, and resolution EMIRC4 7/R.2 of the Regional Committee of the Eastern Mediterranean Region; Bearing in mind that the first stage of such comparative assessment should be a broad agreement on its framework, design and data sources, that seeks inputs from all Member States; Taking account of the many methodological considerations and technical improvements that have already been introduced by Member States on the framework, design and data sources used in order to compile indexes on the performance of Member States' health systems published in The world health report 2000: health systems: improving performance; Aware of the technical difficulties and political sensitivities associated with comparing the performance of national health systems; and Recognizing that WHO, within its mandate, has a historical and important role to play in conducting these evaluations and issuing recommendations on health policy; Further recognizing that evaluation of performance of national health systems has relevance for health systems planners and policy-makers, 1. TAKES NOTE with satisfaction of the measures proposed by the Director-General to help Member States contribute to the WHO assessment of their health system performance regularly, namely: ( 1) to establish a technical consultation process, bringing together personnel and perspectives from Member States in different WHO regions, supported jointly by staff from WHO at country, regional and global level; (2) to ensure that each Member State is consulted on the best data to be used for assessing health system performance, and is provided advance information on the indicator values that WHO obtains using these data;

Document EB107/9. Document EB107/35 Rev.l. Resolution E/2000/27. Documents EB103/3 and EB105/4.

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(3) to establish a small advisory group, including some members from the Executive Board and the Advisory Committee on Health Research, that can help monitor WHO's support for the assessment of health system performance; (4) to compile a report on the performance of Member States' health systems every two years; (5) to complete the next draft report by May 2002 for publication, after consultation, in October 2002; (6) to ensure that Member States receive the compilations before they are made available to the general public; 2. REQUESTS the Director-General: (1) to initiate a scientific peer review of health systems performance methodology as part of the technical consultation process including updating on methodology and new data sources relevant to the performance of health systems; (2) to ensure that WHO consults with Member States and shares the results of the scientific peer review and its recommendations; (3) to develop a multi-year plan for further research and development of the framework and its relevant indicators to assess the effectiveness and efficiency of health systems as part of the technical consultation process; (4) to develop a plan to improve data quality to be used to assess health systems performance; (5) to report to Member States on the impact of health systems performance reports on Member States' policy and practice; [(6) to ensure that health authorities of Member States receive the reports 15 days before the intended date of publication.]

Professor GIRARD (France) emphasized that no decision had yet been made on the status of the text, namely whether it should be a resolution or take some other form. In his opinion, its purpose was to clarify the responsibilities of the Director-General and of Member States in relation to the essential activity of producing the report on health systems performance. If there were the slightest ambiguity, the report would not survive as a continuing activity of WHO. The text went into considerable detail on the subject because it concerned a fundamental aspect of the Organization's work. He believed that there was general agreement that the text could be adopted in the form of a resolution, but only if its meaning was absolutely clear; paragraph 2(6) had been placed within square brackets because the drafting group had considered it somewhat ambiguous. Dr AL KHARABSEH (Jordan) stressed that consultations with Member States in order to obtain the best information for assessing health systems should not constitute a pretext for delaying issue of the report since unanimity was not always the best formula for reaching a conclusion. The Director-General should be left some discretionary power in regard to issuing the report. Of course, Member States had to be consulted, either through the regional offices or directly, but they should be asked to give their opinions briefly and quickly. In order to gain time, the first draft of the report should perhaps be sent to the Regional Directors, who could consult the appropriate authorities in the region and report to the Director-General on the acceptability of the report to Member States. Dr BODZONGO (Congo) said that the text represented a new departure with regard to both the relationship between the Director-General and Member States and its content. He considered that it should be adopted in the form of a resolution. Dr AL-JABER (Qatar) recalled that in the drafting group he had proposed an amendment to the text which had not been incorporated. He wished to add a new paragraph after paragraph 2( 6), reading:

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"to ensure that the establishment of the advisory group referred to in paragraph 1(3) is done with due regard to equitable geographical representation". Dr NOVOTNY (United States of America) considered that the issues had already been sufficiently discussed, and trusted that the guidelines for action set out in paragraph 1 would be followed. He considered that discussions in the drafting group and the commitment made by the Director-General implied that paragraph 2(2) incorporated the aspect referred to by the previous speaker. The CHAIRMAN said that one of the essential principles in all activities of the Organization was equitable geographical representation: it therefore seemed superfluous to reflect that concept in the text. In addition, paragraph 1(1) included the words "regions" and "regional", which he believed covered the legitimate concern expressed by Dr Al-Jaber. Dr SADRIZADEH (Islamic Republic of Iran) proposed the addition of "by all Member States' representatives and experts in relevant disciplines" after "process" in paragraph 2(1 ), and the amendment of paragraph 2( 6) to read "to ensure that ministers of health of each Member State receive the reports, embargoed from publication, at least 30 days before they are made available to the public". Dr DI GENNARO (Italy) said that she could agree that the text should become a resolution, but only if the division of responsibilities between WHO and Member States was made absolutely clear. She suggested that paragraph 2( 6) should be deleted, and that paragraph 1(6) should be taken to mean that the Director-General would ensure that Member States received the report before it was available to the public. Dr Ponmek DALALOY (Lao People's Democratic Republic) recalled that the text produced by the drafting group was intended to resolve the problems raised by the report on health systems performance assessment. Two sources of dissatisfaction had been mentioned: the first related to information, its source and the way in which it had been collected and used; the second concerned the way the assessment had been carried out in terms of transparency and consultation. In order to dispel the dissatisfaction, certain questions had to be answered: what aspects of the global concept of performance should be evaluated and on the basis of which data, indicators and criteria? How should the data be evaluated and at what level - countries, regions or headquarters? If all levels were to be involved, would the exercise be financed centrally, what would be the division of responsibilities, what timeframe would be imposed at each level, how often would the exercise be carried out, and how would the work at the different levels be coordinated? The latest version of the text answered almost all of those questions, but should be better organized. Mr LIU Peilong (China) said that he would prefer to maintain paragraph 2(6) in order to ensure that Member States received the reports before they were accessible to the public. That was one of the commitments made by the Director-General, which had been noted with satisfaction by the Board. In the drafting group, he had endorsed the suggestion that the embargo should be for 30 days but, in a spirit of compromise, he had accepted a period of 15 days. A further problem was the question of languages. He greatly appreciated WHO's undertaking to publish the report simultaneously in all six official languages and hoped that it would be able to fulfil that promise. He emphasized, however, that not only the final version but also the draft versions of the report should be made available in the six official languages. Dr FETISOV (Russian Federation) said that in view of the resolution on multilinguilism adopted at the Fifty-first World Health Assembly, 1 and of the importance of the text under 1

Resolution WHA51.30.

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consideration, he wished a clause to the effect that the report should be issued simultaneously in the six official languages of the Organization to appear in the text. Moreover, he supported the removal of the square brackets and maintenance of the text of paragraph 2(6). Dr THIERS (Belgium) believed that the text should constitute a resolution. As most speakers had attached great importance to paragraph 2( 6), he considered that it should be retained. The members of the Board who wished to delete it were concerned that it indicated a lack of confidence in the Director-General: in order to dispel that impression, he proposed that it be amended to read: "to provide the reports to health authorities of Member States 15 days before the intended date of publication". Dr CABRERA MARQUEZ (Guatemala) considered it important to retain paragraph 2(6) in the form proposed by the previous speaker. The text provided an admirable solution to the controversy aroused by the report, and he proposed that it be adopted in the form of a resolution. Professor GIRARD (France) said that, as one of the participants in the drafting group who had favoured deletion of paragraph 2(6), he regarded the issue as one of responsibility, not of lack of confidence. He fully supported the argument advanced in the drafting group that ministries of health must be informed and have the opportunity to prepare their comments before the reports were made public, but he considered that that point was covered under paragraph 1(6), which constituted a commitment by the Director-General. He proposed that, once all speakers had expressed their views and unless consensus emerged, a vote should be taken on whether paragraph 2(6) should be retained. Thereafter, it would be much simpler to decide on the status that should be given to the text. Professor ZELTNER (Switzerland) urged that the Board should finalize the wording of the text before deciding on its status. Dr NOVOTNY (United States of America) recalled that, during the drafting, paragraphs 2(1) and 2(2) had at one point been combined. However, paragraph 2(1) referred to a rigorous and essential scientific review which WHO would conduct, perhaps with the assistance of experts in Member States, whereas paragraph 2(2) concerned consultations with Member States which might cover political, cultural or ethical issues, which was the reason why they had been separated. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil), Dr CABRERA MARQUEZ (Guatemala) and Dr MBAIONG (Chad) supported the amendment proposed by Dr Thiers. Professor GIRARD (France) remarked that one of the reasons for maintaining paragraph 2(6) had been that paragraph 1(6) included the term "compilations" which had not seemed as precise as the wording of paragraph 2(6) which referred to "reports". He proposed that the other language versions be aligned on the French version, which alluded to "reports" in both cases. Dr NOVOTNY (United States of America) recalled that the Director-General had undertaken to hold consultations with Member States, which would receive intermediate compilations ofthe relevant data several months in advance, so as to ensure the accuracy and consistency of the data they contained. The reports themselves would be received within a specific time-limit before the intended date of publication, so that health authorities were not faced with unexpected results. He supported the amendment proposed by Dr Thiers. The DIRECTOR-GENERAL suggested that, since the difference between "compilations" and "reports" was one of wording rather than of substance, the word "reports" should be used in both paragraphs.

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Ms WIGZELL (Sweden) indicated that, although she had previously favoured the deletion of paragraph 2(6), she would be prepared to go along with the majority who seemed to be in favour of retaining it. In response to a query from Dr BODZONGO (Congo), Professor GIRARD (France) said that in his view the amendment by Dr Thiers added little to paragraph 1(6). It was the Director-General's responsibility to provide the reports at the appropriate moment, and it was not for the Board to encroach upon that responsibility by imposing a deadline. He therefore maintained his position in favour of deletion of paragraph 2( 6). Dr BODZONGO (Congo) pointed out that deadlines were incorporated in many basic documents, and in no way detracted from the Director-General's responsibility. The time-limit indicated would give Member States a period in which to react before the report was published. Dr SADRIZADEH (Islamic Republic of Iran) asked what recourse a Member State would have if it did not agree with the content of the report. The DIRECTOR-GENERAL pointed out that Member States would not be taken by surprise on receiving the reports two weeks before publication, because they would have already seen the data and the basic presentation months earlier. Member States would have an opportunity to explain their positions and provide additional data, if necessary, during continuing consultations throughout the period before publication. Although the final outcome would be her responsibility, the report would be based on a global scientific method developed by consultation. Every effort would be made to improve the accuracy of the data and methods used in the next report. Dr AL KHARABSEH (Jordan) said that, after hearing the Director-General's statement on the terms used, he supported deletion of paragraph 2(6), which was covered by paragraph 1(6). He proposed that a vote be taken concerning paragraph 2(6). The CHAIRMAN invited the Board to vote by show of hands on the proposal to delete paragraph 2(6). The proposal to delete paragraph 2(6) was rejected by 16 votes to 7, with 0 abstentions. The CHAIRMAN invited the Board to vote on the amendment to paragraph 2( 6) proposed by DrThiers. The amendment proposed by Dr Thiers to paragraph 2(6) was adopted by consensus. Regarding the question of the status of the text, Professor GIRARD (France) said that he would not oppose the presentation of the text in the form of a resolution by the Board. The CHAIRMAN proposed that the text should assume the status of a resolution. It was so agreed. The resolution, as amended, was adopted. 1

Resolution EB107.R8.

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Dr AL-JABER (Qatar) expressed concern that his proposal concerning the need for equitable geographical representation in the advisory group referred to in paragraph 1(3) had not been included in the draft resolution. Dr FETISOV (Russian Federation) said he took it that his request for simultaneous publication of the report in the six official languages of the Organization would be taken into account. (For continuation of discussion of technical and health matters, see summary record of the eleventh meeting, section 5.)

The meeting rose at 18:20.

ELEVENTH MEETING Monday, 22 January 2001, at 9:35 Chairman: Dr J. JIMENEZ DE LA JARA (Chile)

TRIBUTE TO THE MEMORY OF DR CHARLES MERIEUX

The CHAIRMAN, supported by Professor GIRARD (France), expressed condolences to the family of Dr Merieux. His death had deprived WHO and the two institutions of which he had been Director, the Institut Merieux and the Marcel Merieux Foundation, of a constant friend and supporter, who had made a significant contribution over the past 20 years to the development of public health.

ORGANIZATION OF WORK

The CHAIRMAN exhorted the Board to use its time more efficiently and effectively when discussing agenda items that were to become the subject of resolutions to the Health Assembly where they would be debated afresh. In the light of the comments made by several members of the Board, he asked for views about concluding the session that day. Dr BODZONGO (Congo), supported by Professor ALl (Bangladesh) and Dr N'GAINDIRO (Central African Republic), said the Board's work should not be unduly rushed. If it took the time that had been programmed to complete its agenda, its draft resolutions might not need revision by the Health Assembly. Professor GIRARD (France) suggested extending the afternoon meeting by two hours, if necessary, in order to complete the work of the session. Dr NOVOTNY (United States of America) supported that suggestion, adding that the Board had already devoted much time and effort to the most difficult problems on its agenda. Professor ZELTNER (Switzerland) agreed with the two previous speakers. The discussions in the session gave a relatively accurate idea of the amount of time that would be needed for revision and adoption in the Health Assembly of resolutions recommended by the Board. For instance, the topic of infant and child nutrition would clearly be further discussed in the Health Assembly, since additional information would be provided at a technical meeting scheduled for March. He suggested that, in future, Board members should exchange views on how the Health Assembly might deal with various items, in order to predict to some extent which topics would require further work and lead to wider discussion. He proposed that the Health Assembly's agenda be discussed early in the session of the Board. Dr MSA MLIV A (Comoros) pointed out that the progress of the Board's work was largely in the hands of the Chairman. The agenda must be respected, and it did not matter whether it was completed on one day rather than another.

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The CHAIRMAN suggested that a decision on when to conclude the session should be reached at the afternoon meeting.

It was so agreed.

STAFFING MATTERS: Item 6 of the Agenda (continued from the tenth meeting, section 2)

Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service: Item 6.2 of the Agenda (Document EB107/INF.DOC./6) Mr BELGHARBI (representative of the WHO staff associations), speaking on behalf of the staff associations of the six regional offices of WHO, requested that in future the Board include the statement by the staff representative earlier on its agenda. Certain decisions on the reform of human resources management had already been taken, but the staff associations had been unable to contribute to the debate and therefore to inform the Board of issues that had been raised during their own discussions on human resources policy. The views of management were not always the same as those of the rest of the staff. The reform of human resources management was supported by all staff, both in principle and in practice. For that reform to be successfully implemented, a concerted approach must be pursued. Proposals had been made by the staff on issues relating to the management of temporary staff, the new types of contract for temporary and non-temporary staff, the elimination of the system of posts with no guarantee for acquired rights, the recruitment of retired staff and of persons who had taken mutually agreed separation, and the introduction of a legal framework for improving the conduct of relations between the administration and the staff associations. He welcomed the fairer, longer-term approach, in compliance with the general principles of labour law, being taken to the management of temporary staff who in some areas of the Organization comprised more than 50% of long-term staff. Proposals had been made to reduce injustice between the different categories of staff, such as the fact that temporary staff members were not entitled to maternity leave or in-grade promotion or even to the health insurance benefits which came with other types of contract. In order to achieve an impact and ensure the consistency of reforms within WHO, certain planned investments must be made in 2001. There were more than 20 types of contract within WHO, and the system of contracts had undergone a process of simplification in order to speed up staff selection and recruitment. The staff associations had taken part in the simplification exercise. There was no need for a wider range of contracts in order to attract skilled staff, but any review of the existing contractual arrangements must be carried out with the active participation of the staff. WHO must comply with the age limit for retirement. At headquarters and in two regional offices, retirees and persons who had been separated by mutual agreement had been improperly rerecruited, an action which the staff associations condemned. At least two years before his or her retirement, each staff member should make provision for a successor, and there should be a ban on recruitment within a certain period of staff whose contracts had been terminated by mutual agreement. The principle of freedom of association was upheld by the Declaration of Principles of ILO, which stipulated that members of staff must be able to associate freely and express their opinions freely, without being subjected to any kind of pressure. Unfortunately, there was no such freedom at the Regional Office for the Eastern Mediterranean. Representatives of the staff there had repeatedly been subjected to administrative and other types of harassment, whose purpose appeared to have been to get rid of the President of the Staff Association, who had finally agreed to separation in spite of occupying an essential post and being well below retirement age. Since the end of 2000, there had no longer been a staff association at that Regional Office. He hoped the Board would recognize and show

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support for freedom of association and expression. It would be appropriate to propose a statute for staff representatives in order to ensure that their careers did not suffer as a result of their activities. Staff representatives should be given more time to carry out those activities and should be provided with financial and logistical support in the form of offices, telecommunications and budgetary resources. There should also be greater recognition of the contribution made by staff associations towards preventing appeals to boards of appeal and the Administrative Tribunal. Several appeals had been averted in the past year, saving the Organization several hundred thousand US dollars. Moreover, the staff associations were seeking ways of raising funds for their activities, thus reducing the cost to the Organization's budget. The Director-General had initiated the Global Staff/Management Council, which had proved to be a valuable forum. In June 2000, the staff associations had submitted a collective bargaining project to that council, in order to ensure that staff were consulted before decisions affecting them were taken. Regrettably, a decision had recently been made to transfer more than 100 staff members of WHO working at the International Computing Centre in Geneva, without any consultation with the staff association at headquarters. Unless the terms of the transfer were reviewed, the Organization was likely to encounter serious legal problems. The staff association had proposed that the decision be reconsidered to enable those persons to preserve their status as staff members ofthe Organization. The situation could readily have been avoided if the kind of collective bargaining advocated by the staff associations had been available. In many countries, such agreements formed the basis of a genuine partnership between administrations and staff. The staff associations strongly urged that they be involved in identifying and preventing staff problems. They had organized a survey of staff motivation, the results of which would be published shortly. In conclusion, he hoped that the Board would support the Director-General in reforming the management of human resources and would provide her with the means to accomplish her task. Dr GEZAIRY (Regional Director for the Eastern Mediterranean) said that freedom of association had always been respected in the Eastern Mediterranean Region. In the case referred to, the staff member concerned had requested a mutually agreed separation for personal reasons; she had also asked for unpaid leave of one year, at the end of which she would be eligible for an early retirement pension. At a recent general staff assembly, a majority of staff members had requested that the staff association committee step down, for various reasons, including failure to organize a general assembly in 1999 and failure to submit a financial report for two years. The current situation had been triggered by efforts to reduce staff numbers to offset a corresponding budget reduction. In contrast to the statement of the representative of the WHO staff associations, temporary staff members in the Eastern Mediterranean Region did benefit from in-grade promotion. Dr MSA MLIVA (Comoros) thanked the representative of the staff associations for his statement, and noted the desire expressed to resolve problems through collective bargaining. The various proposals made deserved consideration, the outcome of which should be reported to the Board at its 108th session. He would welcome details of the reservations of staff members with regard to implementation of the reform of human resources management, and concrete proposals for dealing with them. It was not the first time that the issue of violations of the principles of freedom of association and freedom of expression - fundamental human rights underpinning the entire United Nations system - had been raised in the Board, and it was a matter of urgency to find ways of putting an end to such abuses wherever they occurred in the Organization. Under no circumstances should pressure from any WHO administration result in abolition of a staff association. He proposed that the current situation in the Regional Office for the Eastern Mediterranean might be resolved by setting up a working group composed of representatives of the staff associations, members of the Secretariat and the Board and a mediator, working with the Regional Office in question, to report to the Board at its 108th session on the measures being undertaken. The working group could establish a dialogue with the Regional Director aimed at resolving the problems in a mutually satisfactory fashion.

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With respect to the recruitment of retirees, it was sometimes difficult to find specialist knowledge among younger employees; however, the re-employment of former staff who had accepted a mutually agreed separation could not be justified on such grounds. Moreover, such a practice would ensure that the number of staff members from Comoros remained, and would continue to remain, zero unless the necessary controls were introduced. He had noted the contribution of the staff associations to preventing appeals, but he would like to see precise figures for the savings made. He asked what assistance was given to the associations, and what savings were realised by their activities. With regard to the staff of the International Computing Centre, which was a unique computing and technical tool that enhanced the Organization's image and was wholly self-supporting, he suggested that, in the light of possible staff action and legal repercussions, WHO should review its decision. He asked the representative of the staff associations to submit a report on the situation to the Board at its 108th session. Finally, he urged that the scope of the statement of the representative of the staff associations be extended in future to cover areas such as discipline, conduct and morals, in the context of reforming human resources within WHO as a whole and within the regional offices in particular. Dr DI GENNARO (Italy) expressed appreciation to all WHO staff members for their commitment and hard work, often in difficult conditions. She agreed with Dr Msa Mliva and the representative of the staff associations that retirees and those who had benefited from mutually agreed separation should be re-recruited only in exceptional circumstances. She noted that in some regional offices 60% of staff members were on short-term contracts; such contracts were unsatisfactory both in terms of cost-effectiveness and of fairness to the temporary staff, who did not receive the full benefits package. She supported active involvement of the staff associations in the process of reforming human resources management, and looked forward to publication of the results of the survey on staff motivation that had been mentioned. Professor GIRARD (France) observed that WHO should set an example in all areas of health, including ensuring a healthy working environment for its own staff members. The aims of human resources management reform could not be seen in purely economic terms. High standards of work and scientific accuracy had to be paid for, and it was incumbent on the Organization to ensure that institutional reform, including that of human resources management, encouraged efficiency and was in accordance with international labour law. The reputation of the Organization depended, above all, on the calibre of the staff responsible for ensuring that its work upheld scientific and moral principles. Although The world health report 2000 had been controversial, it was nevertheless of high scientific quality. That was an example of the continued investment that was necessary in order to ensure scientific excellence for the benefit of all Member States. Professor ZELTNER (Switzerland) observed that consideration should be given to the stage in the Board's discussions at which the statement by the representative of the staff associations would be most relevant. If it had been made at the beginning of the debate on human resources, it might have contributed to a more informed discussion. The view of the staff associations might also have been germane to the discussions on human resources management reform in the Administration, Budget and Finance Committee (ABFC). With respect to the proposal of Dr Msa Mliva to set up a working group to study and report on the situation in the Regional Office for the Eastern Mediterranean, while the Board wished to see an early solution to the problem, it might be more appropriate, at the current stage, for the matter to be dealt with by the Director-General and her staff. The Board should be given an updated report at its 108th session. Speaking as Chairman of ABFC, he expressed his appreciation to all WHO staff members for their constructive contribution to the reform process. The Organization depended heavily on their presence at country level to carry out its work of improving the health of populations.

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Dr N'GAINDIRO (Central African Republic) thanked the representative of the staff associations for drawing the Board's attention to a number of problems. Management depended on material, financial and human resources, of which the last named were, beyond doubt, the most important. Hence, WHO should be vigilant over its own staff members. He agreed with Professor Zeltner that the timing of the statement by the representative of the staff associations in the agenda should be reviewed. On the question of harassment, he considered that the complaints procedure should be improved, as the problem affected the effectiveness and productivity of the staff. He welcomed the Director-General's activities on behalf of the staff and encouraged her to continue along such lines, as the future of WHO depended on the quality of its personnel. Dr FETISOV (Russian Federation) also thanked the staff, in particular for their active role in the Task Force on Human Resources Management Reform. He supported the observations and proposals made by Professor Zeltner. Mr BELGHARBI (representative of the WHO staff associations), responding to the points raised, said that the staff remained loyal to the Organization but hoped for greater flexibility in its dialogue with the administration. Referring to the report on policy development (document EB 107/15), he said that the staff association had expressed several reservations on the principles outlined in the report but they had not been reflected in that document. For example, in paragraph 9 on workforce planning, where mention was made of mobility and rotation of staff, the suggestions of the association with regard to use of rotation in respect of staff members in high-level functions had not been taken into account, contrary to the Staff Rules. Further suggestions had been made on performance review and monitoring (paragraph 11 ), which were not being carried out satisfactorily with respect to programme managers and directors. The contribution of the staff associations to the grievance procedure went unrecognized, despite the savings made by avoiding the lodging of some dozen appeals procedures. Another important issue was that of contractual arrangements (paragraph 19), where the staff associations had proposed genuine short-term contracts. There should be no distinction between long and semi-long contracts, which constituted a source of injustice to the staff members concerned. In regard to the system for establishing and managing posts referred to in paragraph 21, studies had apparently been carried out within the Organization, but the staff associations had not been involved or received any documents for comment. The question of staff-management relations was particularly important, as it to some extent defined contractual relationships between the staff associations and the administration in carrying out the new reforms. Again, the associations had made proposals to which they had received no response, and document EB 107/15 likewise failed to mention them. As far as financial implications were concerned, the associations were aware of the need to make savings and to improve performance and had made proposals along those lines; once again, they had expected to be consulted, but that had not been the case. He took issue with the reply of the Regional Director for the Eastern Mediterranean regarding the pressure that had led to the departure of the President of the Staff Association, which was well documented. To show its goodwill, the association had done everything in its power to prevent the press from being informed. It had also made proposals to settle the matter as smoothly as possible, so as to prevent the jobs of staff representatives from being jeopardized, although unfortunately such efforts had proved unsuccessful. Although the Director-General had been supportive and had tried to resolve the problem, no solution had been found. The same Regional Office had recruited a number of retirees aged up to 68 years who were in management positions, thereby blocking access to such posts. That was inadmissible and ran counter to specific Staff Rules. Furthermore, it was inconsistent and unfair for staff members who had received large golden handshakes within a separation agreement to rejoin the Organization shortly afterwards, sometimes working beside staff members who had been denied such payments. In order to redress the injustices to temporary staff members, the associations had made proposals with minimal financial implications, which had yet to be implemented. Although the Regional Director for the Eastern Mediterranean had claimed that temporary staff could receive in-

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grade promotion, they did not have the same status as staff on fixed-term contracts with regard to career advancement. He concluded by thanking members of the Board who had heeded the concerns of the staff associations, which represented thousands of staff members who continued to contribute to the work of the Organization. Mr MANI (Executive Director ad interim), welcomed the exchange of views, which he considered to be an indication of good management/staff relations. Since the Director-General had taken office, several mechanisms had been introduced to improve and maintain relations between management and staff, including the Global Staff/Management Council composed of members of the administration and of the staff associations at headquarters and in the regions. Furthermore, the Director-General had fully involved the staff association in the Task Force on Human Resources Reform. The administration had also involved the staff associations fully in various aspects of contract reform. Replying to suggestions that the statement by the representative of the staff associations should be heard earlier in the Board session, he said that the matter would be considered with a view to proposing a more appropriate timing at the following session. In regard to the issue of collective bargaining, mentioned by several speakers, he assured members of the Board that freedom of association was fully endorsed by the Director-General. However, collective bargaining as practised in the private sector could not be adopted as a procedure for an intergovernmental organization, which was bound by the terms and conditions of service within the United Nations common system laid down by the International Civil Service Commission (ICSC). Referring to comments about the abusive recruitment of retirees, he confirmed the Director-General's determination that retirement at the age of 60 should be scrupulously observed. There were certain circumstances under which retired staff members could be rehired, but only after careful review to establish that that was in the best interests of WHO. As the representative of Comoros had pointed out, certain talents were not easy to find, but might be lying fallow among retirees. Furthermore, very strict rules were applied to the hiring of staff after separation by mutual agreement; nobody could be considered for re-employment until three years after such a separation. It was inappropriate to consider individual cases at the present time: they would be taken up with the staff associations in due course. In response to the question from Dr Msa Mliva about the transfer of WHO staff from the International Computing Centre, he said that the Centre was a jointly financed United Nations venture, of which WHO had agreed to be the host. The transfer to another United Nations organization was an entirely legitimate managerial decision. The rights of the staff concerned would naturally be safeguarded. Replying to the comment of Dr Di Gennaro that short-term staff did not always represent good value, he said that, within the context of human resources reform, possibilities were being considered for absorbing staff employed on short-term contracts into the Organization, so assuring them of certain social benefits. For example, maternity leave had recently been introduced for such staff. He fully agreed with Professor Girard that good employment conditions were inevitably costly. Those at WHO were determined by the common system conditions established by ICSC, and local conditions of employment were based on surveys of the best local employers. He considered it highly unlikely that international organizations would be able to compete with the private sector in the foreseeable future. On the question of harassment, he pointed out that several joint committees and mechanisms already existed within WHO to deal with such cases, without involving members of the Board. The CHAIRMAN said he took it that the Board wished to note the statement of the representative of the WHO staff associations. It was so agreed.

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Human resources: Item 6.1 ofthe Agenda (continued from the tenth meeting, section 2) • Report of the International Civil Service Commission (Documents EB107/16 1 and EB107/16 Add.l) Professor ZELTNER (Switzerland), speaking as Chairman of ABFC, said that document EB107/16 summarized the main points of the twenty-sixth annual report ofiCSC, as adopted by the Fifty-fifth Session of the United Nations General Assembly in 2000. He drew attention to two key issues. The first was an adjustment of salary scale for professional and higher-graded categories in accordance with the established method. That was done on a "no loss, no gain" basis, by increasing the base/floor salary by 5.1% and decreasing the post adjustment by the same amount, and thus ensured that allowances linked to that salary kept pace with inflation. Secondly, ICSC had recommended an increase of 11.89% in dependency allowances. That adjustment had been determined on the basis of tax abatement and social security payments in the seven headquarters duty stations. The recommendations had been approved by the General Assembly and could be expected to be implemented in all the other common system organizations. Two draft resolutions were proposed in document EB 107116 Add.1. The first invited the Board to confirm the amendments to the Staff Rules establishing the new salary scales and dependency allowances for staff in professional and higher categories. The second invited the Board to recommend to the Health Assembly that it adopt a resolution adjusting the salaries of staff in ungraded posts and of the Director-General. ABFC recommended the adoption of both resolutions by the Board. The CHAIRMAN informed the Board of an omission in the second draft resolution contained in document EB 107/16 Add.1. The following paragraph should be added at the end: (3) DECIDES that those adjustments in remuneration shall take effect on 1 March 2001.

The first resolution was adopted. 2 The second resolution, as amended, was adopted.3 • Confirmation of amendments to the Staff Rules (Document EB 107/17t Professor ZELTNER (Switzerland), speaking as Chairman of ABFC, indicated that certain amendments were considered necessary in order to align some of the provisions of the WHO Staff Rules with those of the United Nations and other organizations in the common system. The amendments were based on extensive consultation throughout the Organization. ABFC supported the introduction of the changes, and recommended that the Board adopt the draft resolution contained in document EB107/17 confirming the relevant amendments to the Staff Rules. The resolution was adopted. 5

1 2 3

Document EBI07/2002/REC/l, Annex 4. Resolution EBI07.R9. Resolution EBI07.Rl0. Document EBI07/200l/REC/l, Annex 5. Resolution EB 107.R11.

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COLLABORATION WITHIN THE UNITED NATIONS SYSTEM AND WITH OTHER INTERGOVERNMENTAL ORGANIZATIONS: Item 7 of the Agenda (Documents EB107/18 and EB107/18 Add.1)

The CHAIRMAN invited the Board to consider the reports on collaboration within the United Nations system and with other intergovernmental organizations. Dr SHINOZAKI (Japan) commended WHO's contributions to the activities of the Intergovernmental Forum on Chemical Safety (IFCS) and welcomed the recommendations adopted by IFCS at its third session (Salvador da Bahia, Brazil, October 2000). WHO could provide leadership in various health sector areas included in the recommendations, such as the drawing up of harmonized approaches to risk assessment and the gathering of exposure data, and support to Member States in their efforts to implement the health-related mandates set out in IFCS recommendations. He therefore welcomed and supported the proposals set out in document EB 107118 Add.l. Furthermore, WHO should develop its own action programme and, where necessary, cooperate and collaborate with the other international organizations involved in the Inter-Organization Programme for the Sound Management of Chemicals and the ILOIUNEP/WHO International Programme on Chemical Safety. Mr MACDONALD (UNFPA) conveyed the greetings ofMs Thoraya Ahmed Obaid, Executive Director of UNFPA, and recalled the long-standing collaboration and cooperation between WHO and his organization at headquarters, regional and field levels, and with WHO and UNICEF through the Coordinating Committee on Health. Ms Obaid wished to continue that good tradition of interagency collaboration, and looked forward to fruitful collaboration with WHO, its staff, the Board and, in particular, colleagues in country teams, which she hoped would be strengthened in the future. Mr THINUS (European Commission) said that a new agreement had just been reached aimed at consolidating and intensifying the long-standing cooperation between the European Commission and WHO. The necessary follow-up action was being taken; working arrangements and short-term priorities were being developed, and Commissioner Byrne and the Director-General would be meeting to discuss those issues and agree on concrete steps. The new exchange of letters would make it possible to cooperate much more closely in various areas, such as improving the surveillance of communicable diseases, with particular reference to the fight against the major scourges of HIVI AIDS, malaria and tuberculosis. There were many other diseases for which it was necessary to pool resources and expertise. A major priority was action to reduce tobacco consumption, including working towards the adoption of a framework convention on tobacco control. Another was mental illness, since depression and other mental disorders were fast becoming a major health threat globally. The European Commission would work with WHO during 2001 on mental health. Joint work would also be continuing on health threats from the environment and on better provision of information on health and health risks to the general public, health professionals and policy-makers. Cooperation would be continued and strengthened in giving support to countries applying for membership of the European Union in tackling their major health problems. Finally, joint activities would be developed in other new areas, such as health telematics, with a view to optimizing the pooling of resources. Dr THIERS (Belgium) emphasized the great importance attached by his country to cooperation between WHO and the European Commission, and regretted that it had always developed too slowly and too timidly. While the reasons were not completely clear, it appeared that one obstacle might be the division of primary responsibilities between the organizations. Moreover, both organizations suffered from highly organized structures and rules which slowed the collaboration process. He therefore warmly welcomed the new exchange of letters and hoped that collaboration would henceforth develop in a robust fashion, in particular in the fields of HIVI AIDS, malaria and tuberculosis. Such cooperation was of great importance for developing countries. He proposed that the

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development of collaboration between the two organizations should be monitored, and regular reports made containing detailed information on the projects undertaken and the budgets involved. Dr KEAN (External Cooperation and Partnerships), in reply to Dr Thiers, said that for the current session, the Secretariat had limited itself to submitting two short reports with a view to drawing attention to items of immediate interest to the Board, including the new exchange of letters between WHO and the European Commission. As in past years, WHO would be preparing a more detailed report on collaboration within the United Nations system and with other intergovernmental organizations for consideration by the Health Assembly. In May 2001, and in future years, the report would also cover the rapidly expanding collaboration with the European Commission.

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued from the tenth meeting, section 3)

Communicable diseases: Item 3.3 of the Agenda (continued from the third meeting, section 2) • Control of schistosomiasis and soil-transmitted helminth infections (Document EB I 07/31) (continued from the third meeting, section 2) The CHAIRMAN invited the Board to consider a draft resolution on Schistosomiasis and soiltransmitted helminth infections, proposed by a drafting group, which read: The Executive Board, Recalling resolutions EBS.RS, WHA3.26, EB55.R22, WHA28.53 and WHA29.58 on schistosomiasis; Noting the report on the control of schistosomiasis and soil-transmitted helminth infections; 1 Recognizing that where control measures have been implemented in a sustainable way, as demonstrated in several countries, mortality, morbidity and transmission have decreased dramatically, leading to elimination in a number of countries; Expressing concern that 2000 million people are infected by schistosomes and soiltransmitted helminths worldwide, 300 million of whom have associated severe morbidity, and that schistosomiasis and soil-transmitted helminth infections are invariably more prevalent in the poorest sections of the populations residing in the least-developed countries; Further recognizing that repeated chemotherapy with safe, single-dose, affordable drugs at regular intervals ensures that levels of infection are kept below those associated with morbidity, and improves health and development, especially of children, 1. ENDORSES as the best means of reducing mortality and morbidity and improving health and development in infected communities, the regular treatment of high-risk groups, particularly school-age children, and ensured access to single-dose anthelminthic drugs in primary health care services; 2. URGES Member States: ( 1) to sustain successful control activities in low-transmission areas in order to eliminate schistosomiasis and soil-transmitted helminth infections as a public health

Document EB107/31.

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problem, and to give high pnonty to implementing or intensifying control of schistosomiasis and soil-transmitted helminth infections in areas of high transmission; (2) to ensure access to essential anthelminthic drugs in all health services in endemic areas for the treatment of children, women and other groups at risk of morbidity, with the goal of attaining a minimum target of regular administration of chemotherapy to at least 75% of all school-age children at risk ofmorbidity by 2010; (3) to promote access to safe water and sanitation through intersectoral collaboration; (4) to mobilize resources in order to sustain activities for control of schistosomiasis and soil-transmitted helminth infections; 3. ENCOURAGES organizations of the United Nations system, bilateral agencies, and nongovemmental organizations to intensify support for control of helminth infections, and to take advantage of the synergy that can be created with existing initiatives for the prevention, control and elimination of other communicable diseases; 4. REQUESTS the Director-General: to combat schistosomiasis and soil-transmitted helminth infections by advocating new partnerships with organizations of the United Nations system, bilateral agencies, nongovemmental organizations and the private sector, and by continuing to provide international direction and coordination; (2) · to continue to seek the resources required to support advocacy and coordination activities; (3) to keep the Executive Board and Health Assembly informed of the progress made in controlling or eliminating schistosomiasis and soil-transmitted helminth infections in high- and low-transmission countries, respectively. (1)

Dr DI GENNARO (Italy), speaking as the coordinator of the drafting group, said that the draft resolution was intended for recommendation to the Fifty-fourth World Health Assembly for adoption. The draft should be suitably amended. Furthermore, the final words of subparagraph 4(2) should be changed from "advocacy and coordination activities" to "advocacy, coordination and research activities". Dr SADRIZADEH (Islamic Republic of Iran), an initiator of the draft resolution and a member of the drafting group, seconded those proposals. Mr LIU Peilong (China) proposed that in order to bring the text into line with the title of the draft resolution, paragraph 1 and paragraph 2(2) should be amended by replacing "anthelmintic drugs" with "drugs against schistosomiasis and soil-transmitted infections". Subject to those amendments and to the amendments proposed by Dr Di Gennaro, he could support the draft resolution. The resolution, as amended, was adopted. 1 • Global health security: epidemic alert and response (Document EB107/5) (continued from the third meeting, section 2)

The CHAIRMAN drew attention to a draft resolution on Global health security: epidemic alert and response, proposed by a drafting group, which read:

Resolution EB107.R12.

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The Executive Board, Having considered the report on global health security - epidemic alert and response, 1 RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Recalling resolutions WHA48. 7 on the International Health Regulations, WHA48.13 on new, emerging and re-emerging infectious diseases, and WHA51.17 on antimicrobial resistance; Recalling that public health is a priority for development and that combating communicable diseases, which are a major burden in terms of human mortality and morbidity, provides important and immediate opportunities for progress; Mindful of the globalization of trade and of the movement of people, animals, goods and food products, as well as the speed with which these take place; Recognizing that, as a result, any upsurge in cases of infectious disease in a given country is potentially of concern for the international community, 1. EXPRESSES its support for: ( 1) ongoing work on the revisiOn of the International Health Regulations, including criteria to define what constitutes a health emergency of international concern; (2) the development of a global strategy for containment and, where possible, prevention of antimicrobial drug resistance; (3) collaboration between WHO and all potential technical partners in the area of epidemic alert and response, including relevant public sectors, intergovernmental organizations, nongovernmental organizations and the private sector; URGES Member States: ( 1) to participate actively in the verification and validation of surveillance data and information concerning health emergencies of international concern, together with WHO and other qualified partners; (2) to develop training for the staff involved and the exchange of good practice between specialists in response to alerts; (3) to update regularly information on the resources available for the surveillance and control of infectious diseases; (4) to designate a focal point for the International Health Regulations; REQUESTS the Director-General: (1) to devise relevant international tools, and to provide technical support to Member States for developing or strengthening preparedness and response activities against risks posed by biological agents, as an integral part of their emergency management programmes; (2) to provide technical support to help Member States develop intervention programmes to prevent epidemics and respond to communicable disease threats and emergencies, particularly with regard to epidemiological investigations, laboratory diagnoses and clinical management of cases;

Document EB107/5.

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(3) to make appropriate arrangements for the development of regional preparedness and response plans; (4) to provide support for countries to strengthen their capacity to detect and respond rapidly to communicable disease threats and emergencies, especially by developing the laboratory skills needed for diagnosis and providing training in epidemiological methods for use in the field, particularly in the most exposed countries; (5) to make available relevant information on public health risks to Member States, relevant intergovernmental organizations and technical partners. Professor GIRARD (France) noted that the draft resolution was one of several on which the Board had spent a great deal of time, but which might well have to be reconsidered at the forthcoming Health Assembly. The recurrent problem of how best to transmit resolutions from the Board to the Health Assembly and to coordinate the work of the two governing bodies would need to be addressed. The resolution was adopted. 1

Mr HUSSAIN (Iraq), speaking at the invitation of the CHAIRMAN, 2 drew the Board's attention to recent worldwide concern about the use of depleted uranium weapons in Iraq and the Balkans. The European Parliament had adopted a resolution on 17 January 2001 calling on Member States to propose a moratorium on the use of such weapons pending inquiries into their health effects. He had hoped that such an important topic would have been discussed extensively by the Board and that a reference to it would have been included in the draft resolution. In January and February 1991 Iraq had been the victim of large-scale aggression led by the United States of America and the United Kingdom of Great Britain and Northern Ireland, when depleted uranium weapons had been used for the first time. According to Pentagon sources, a total of 315 tonnes of depleted uranium had been used in 940 000 warheads during the six weeks of the war. In the Balkans, tens of thousands of such warheads containing about 10 tonnes of depleted uranium had been used against targets in Bosnia, Kosovo and Yugoslavia. The terrifying dangers posed by those weapons far outweighed their military advantages, and many scientific and medical authorities, including international bodies, had drawn attention to their insidious effects on the environment and on future generations. In Iraq those effects had shown themselves soon after the cease-fire: tens of thousands of Iraqis had fallen ill, with children accounting for 75% of cases. The incidence of lung cancer, cancers of the digestive system, leukaemia, skin cancer and breast cancer had increased. Deformed births had been recorded as well as congenital deformities never before seen in Iraq. Infertility, thyroid diseases and renal failure were on the increase, and other effects such as sleeping disorders, excitability, depression, exhaustion, muscular dystrophy, loss of consciousness, loss of memory, lack of concentration and mental lassitude had been recorded. According to specialists, radiation from depleted uranium also affected the immune system, and its effects, which were further compounded by malnutrition, would continue for years. A newspaper report (The Guardian, 1 December 2000) had indicated that thousands of veterans of the Gulf war were facing possible death as a result of the use of depleted uranium munitions and that nearly 300 United Kingdom veterans had died since 1995. Veterans in the United States of America were facing a similar fate. Depleted uranium had a terrible toxic impact on human beings and on the environment, and was listed as a banned weapon in several international conventions. Furthermore, its use as a weapon of mass destruction violated international humanitarian law. Both the United Kingdom and United States administrations were responsible, morally and legally, for the use

Resolution EBI07.Rl3. By virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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of depleted uranium weapons against Iraq, and they were also responsible for the clean-up of the affected areas, the cost of which had been estimated by experts as US$ 300 000 million. ' He called on the Director-General and the Board to place the use of depleted uranium in Iraq, the Balkans and elsewhere on the agenda of the Fifty-fourth World Health Assembly. He also called on the Director-General to reply to the message of the Iraqi Foreign Minister about the health and environmental effects of the use of depleted uranium and to conduct an investigation into the reasons behind the serious decline in public health in his country. The DIRECTOR-GENERAL assured the Government and people of Iraq that WHO shared their concerns about any possible public health consequences of the use of depleted uranium munitions in Iraq and elsewhere. WHO had been collaborating with the Iraqi Ministry of Health on that matter since 1995. Several technical missions had been sent to the country and the issue had been discussed regularly with the health authorities of Iraq. As a result, WHO had undertaken several activities to strengthen the country's capacity for cancer surveillance and control, including support in restructuring the Central Cancer Registry, installing the most recent version of the CANREG software and training national counterparts in cancer control. Those steps were necessary to identify the scope of the problem in terms of its human effects. A WHO team was currently in Iraq to explore with the Ministry of Health ways and means of intensifying WHO's support in the field of cancer registration, cancer control and epidemiological surveillance. WHO would continue its collaboration with Iraq in those areas. WHO had just received an official request from the Iraqi Minister of Foreign Affairs to investigate environmental and health effects resulting from the use of depleted uranium in Iraq during the Gulf war. It would address that request comprehensively, and was currently working to arrange a meeting of Iraqi experts with relevant staff members from headquarters, the Eastern Mediterranean Region and IARC as early as possible. Dr GEZAIRY (Regional Director for the Eastern Mediterranean) said that the previous week experts from the Regional Centre for Environmental Health Activities in Amman had visited Iraq to attend an international conference on the health hazards of depleted uranium, and to finalize with government officials the outline of a protocol for a field study on the possible impact of depleted uranium on health and the environment. During the visit Iraqi officials had agreed to a meeting between Iraqi experts and WHO in Cairo or Geneva to discuss that protocol, and an official invitation to the meeting would be sent to the Ministry of Health of Iraq very shortly. He was sure that WHO headquarters and the Regional Office would continue their efforts to examine the issue, and would report back to the Iraqi Government, the Board and the Health Assembly. Dr AL KHARABSEH (Jordan) observed that the effects of Gulf war syndrome on members of the armed forces involved had been known in scientific circles since the early 1990s, yet nothing had been heard about its effects on countries in the theatre of war. Echoing the concerns raised by the representative of Iraq, he called on WHO to undertake a detailed epidemiological study in Iraq or the Balkans to determine whether a danger existed, and called upon the Board to recommend that the subject should be placed on the agenda of the Fifty-fourth World Health Assembly. Dr AL-JABER (Qatar) noted that Qatar, too, had recorded an increase in thyroid gland cancers. He supported the call for a comprehensive study into the effects of the use of depleted uranium weapons in the Gulf region. The DIRECTOR-GENERAL said that since the issue of depleted uranium had become broader and more complex than had been envisaged when the Programme budget for 2000-200 I had been drawn up in 1997-1998 and since detailed studies were being called for, WHO would need to seek external funding to undertake the work. However, the Board should know that recently increased

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attention had been paid to the issue: WHO had sent a team to Kosovo, and later that day would be meeting the Chair of the NATO Alliance Joint Medical Committee. Professor GIRARD (France) said that, in the light of his country's belief in the need for transparency, he could support the suggestion that the matter be considered for inclusion on the agenda of the Fifty-fourth World Health Assembly. However, he doubted whether the intervening four months would allow sufficient time for the information from the planned studies to be gathered or analysed so that an informed debate could be held. It was so agreed.

OTHER MANAGEMENT MATTERS: Item 8 of the Agenda

Reports ofthe Joint Inspection Unit: Item 8.2 of the Agenda (Document EB107/32) The CHAIRMAN reported that the Audit Committee had reviewed the full 1999 cycle of reports of the Joint Inspection Unit (JIU), according to the procedures agreed by the Board at its 106th session. 1 The Chairman of the JIU, attending the Committee as an observer, had raised concerns about the delays in having its reports considered by the governing bodies of participating organizations, a problem that concerned all organizations in the United Nations system and not only WHO. The Committee recognized, however, that sometimes extensive delays were unavoidable, owing to the necessary consultative process within organizations and with the ACC. The Audit Committee had asked that in future each of its members should receive the JIU reports and the comments of WHO and ACC, where applicable, as background material in preparation for its subsequent meetings. The JIU reports would become a regular item on the agenda of the Committee. In the absence of any comments, the CHAIRMAN took it that the Board had noted the report. It was so agreed.

Guidelines on working with the private sector to achieve health outcomes: Item 8.3 of the Agenda (Document EB 107/20) Dr ABREU CATALA (Venezuela) commended the guidelines, which should help ensure transparency and avoid potential conflicts of interest, but raised several concerns. With regard to the section on commercial enterprises, clearer distinction needed to be made between non-profit-making organizations, nongovernmental organizations and profit-making organizations. Furthermore, the text needed to reflect the international and intergovernmental nature of WHO. It should have been stressed that the principal objectives of partnerships should be consistent with the strategic directions of WHO. With regard to the section on general considerations, paragraph 9 of the guidelines referred to the role of the Office of the Legal Counsel in identifying potential areas of conflict of interest. She considered that, since there were ethical and technical aspects to conflicts of interest as well as legal aspects, a different mechanism should be found to fulfil that role. She would also have liked to see reference to commercial enterprises in other areas of concern to WHO, such as the food industry. Paragraph 1O(a), which required relationships to meet the criterion of contributing to improving public health, was somewhat ambiguous: more was needed than good intentions. A precise definition should be made of what constituted an improvement in public health. She also drew attention to

See document EB106/2000/REC/1, pp. 47-48.

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inconsistencies between the English and Spanish versions of paragraph 12 relating to the financial stability and integrity of companies. Financial stability should be defined clearly, so that certain companies would not be unfairly treated. On the subject of donations for clinical trials, she considered that research or development activities should be linked to the strategic priorities of not only WHO but the countries concerned. With reference to paragraph 18, other interests besides commercial interests should be defined. Largescale donations of pharmaceuticals given as contributions in kind should be not only approved by the recipient country but accepted only on condition that the products were registered in that country. She was also concerned that paragraph 34(a) on the safety and efficacy of a donated drug for a certain indication did not cover its possible use for other recognized indications: as presently drafted, it might exclude such other uses. The selection criteria (paragraph 34(b)) should be explicit, meet accepted ethical principles and be acceptable to the recipients concerned. Paragraph 34( d) should be amended to include a reference to drug monitoring and drug efficacy. With reference to paragraph 34(£), agreement on a phase-out plan should be reached before the donation was received. Finally, she strongly supported the comments made earlier by Professor Girard on the importance of pharmaceuticals, and proposed that the subject be included on the agenda of the Fifty-fourth Health Assembly. Dr DI GENNARO (Italy) noted that the proposed guidelines referred to collaboration with the private sector only when the partner concerned contributed technically or financially to WHO activities. She considered that a wider perspective was needed in view of the growing number of initiatives, generically referred to as "partnerships", in which WHO participated as one of the partners. In such instances WHO might have to submit to rules and procedures established outside the traditional institutional framework and operated by governing bodies whose accountability might be called in question. She recognized the opportunities offered by partnerships, but stressed that the participation of WHO in initiatives or partnerships outside the United Nations institutional framework ought not to limit or reduce WHO's leadership and mandate. For that reason, she considered that WHO should elaborate a code of practice for such partnerships. Mr CHOWDHURY (India), commending the guidelines, drew attention to three areas that demanded caution: donations for unspecified programme support or for the preparation of guidelines; the secondment of industry personnel to WHO; and cost recovery for evaluations, which could be interpreted as endorsement by WHO. More specifically, he called for a clearer definition of commercial enterprises, which could range from associations and trusts to any other profit-making legal entity. He considered that in paragraphs 8 and 9 the references to ensuring WHO's reputation and to a step-by-step evaluation, respectively, should be more explicit. A suitable disclosure policy and mechanism to oversee compliance with the WHO guidelines and to deal with breaches of conflict of interest needed to be devised. That mechanism could deal with failure to comply with the guidelines owing to, for instance, inadequate information input, deliberate oversight, error of judgement, failure to remedy conflicts of interest, or failure to comply with the oversight plan. There could be appropriate review procedures and mechanisms of redress. In every case, the responsibility for compliance should be clearly identified. Whatever precautions were taken, it had to be ensured that pharmaceutical companies and other commercial interests, notably the food industry, were not able to influence policy-making in WHO. As a certifying and standard-setting agency, WHO had a crucial role to play in lending legitimacy to any product or standard. In mobilizing resources, whether by accepting donations or by participating in product development, no compromise in the credibility and moral standing of WHO should be allowed.

The meeting rose at 12:30.

TWELFTH MEETING Monday, 22 January 2001, at 14:30 Chairman: Dr J. JIMENEZ DE LA JARA (Chile) later: Dr G. TI-llERS (Belgium)

OTHER MANAGEMENT MATTERS: Item 8 of the Agenda (continued)

Guidelines on working with the private sector to achieve health outcomes: Item 8.3 of the Agenda (Document EB107/20) (continued) Ms BOCCOZ (alternate to Professor Girard, France) said that her country attached great importance to the guidelines in question and considered that, as suggested in the document, rather than simply taking note, the Board should express its opinions. The substance of the document should be discussed further either by the Health Assembly or at a subsequent session of the Board. She formally requested the establishment of a working group to discuss further the many issues raised during the intersessional period. On the guidelines themselves, she underlined the importance of the letters on agreements between WHO and the private sector mentioned in paragraph 10(c); the credibility of the Organization was at stake. It was essential that there should be no suspicion that the Organization had been influenced in any way by its private partners. That therefore needed great transparency and the provision of a great deal of information. As far as seconded personnel were concerned, mention was made in paragraph 37(a) of avoiding clear conflict between the activities of industries and the mandate of WHO; in fact, it was necessary to go further and take account, on a much broader basis, of conflicts that might exist. She was also concerned about ethical problems that might be raised by secondments to WHO from commercial enterprises. Time was needed for much more discussion of the document. Dr TI-llERS (Belgium) fully agreed with the remarks made by Ms Boccoz. The guidelines were not ready for publication or submission to the forthcoming Health Assembly. The issues raised should be discussed in greater depth by a working group and the finished document, in a few years' time, should be approved by the governing bodies of WHO. Mr LIU Peilong (China) associated himself with what had been said by previous speakers about the usefulness of the document. In general, WHO, as an intergovernmental organization, should avoid secondments from commercial organizations. If, for technical reasons, such secondments were necessary, they should be kept to a minimum. He also considered that the implementation of the guidelines should be evaluated, with a view to improving and supplementing them if necessary. Dr NOVOTNY (United States of America) also welcomed the guidelines: as far as possible, they should be applied to other entities besides commercial ones that interacted with WHO. However, he agreed that more work needed to be done on them. Paragraph 9 of the guidelines stated that relationships should be avoided with commercial enterprises whose activities were incompatible with WHO's work. He pointed out that such a broad statement might hinder the work of WHO in some circumstances, since many commercial enterprises and global multinational groups had subsidiaries whose activities might be helpful to WHO. In paragraph 14 there was a similarly sweeping statement concerning the acceptance of funds from commercial enterprises whose business was unrelated to WHO'S work. He pointed out that that - 157-

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provision might be difficult to reconcile, for example, with paragraphs 15, 16 and 18, which specified the types of enterprises from which funds might be sought for clinical trials and in what conditions. There appeared, moreover, to be an inconsistency in paragraphs 20, 21 and 22: contributions from commercial enterprises would not be accepted to support the travel and accommodation of participants in WHO activities, whereas such support would be acceptable for WHO staff. He suggested that donations for financing staff salaries, mentioned in paragraphs 24 and 25, be channelled through some general fund in order to avoid too direct a connection between salaries and the activities of donors. A general problem was the multi-party alliances which were the basis of WHO's major activities, such as Roll Back Malaria and Stop Tuberculosis. It was important to set out the basic rules for those alliances. The document stated that the guidelines were presented for the information of the Board, but he believed that, in view of their importance they should be approved by the Board only once they had been finalized. He proposed that the implementation review mentioned in paragraph 51 should be undertaken periodically by the Board, and should include any changes subsequently made to the guidelines. Dr CABRERA MARQUEZ (Guatemala) supported the proposal by Ms Boccoz that a working group be established to discuss the guidelines. Professor ALl (Bangladesh) commented that the availability of the document on the Internet had been extremely helpful. Since it was vital for WHO to work with many other bodies and institutions, many of them commercial, it was essential to ensure that there was no conflict of interest, either real or perceived. For that reason it was necessary to review the terms of the guidelines very carefully in order to protect the Organization. Dr MBAIONG (Chad) said that the relations between WHO and the private sector should be fully transparent in order to avoid any conflict of interest and to protect the independence of the Organization, including the need for propriety in relations between WHO staff and private sector partners. It was important for relations between the Organization and commercial enterprises to be based on clear objectives, and they must make a contribution to improving health. He too commended the document and wished to see further work done on it. Professor YUNES (Brazil) suggested that if the proposal to set up a working group were approved, a sub-item on criteria for the acceptability of donations of pharmaceuticals should be included under the item of the provisional agenda of the Fifty-fourth World Health Assembly dealing with the Revised drug strategy. Professor NAMA DIARRA (Cote d'Ivoire) supported the proposal to set up a working group to study the document, in particular its implications for developing countries, which were the principal beneficiaries of donations. The interests of the various groups concerned should be clearly identified and defined. Dr BODZONGO (Congo) drew the attention of the Board to paragraph 11 of the document, relating to conformity with WHO public health policies. He pointed out that one of the binding agents used in oral medications was gelatine, which he believed to be a beef product. Although no connection to disease had been made with gelatine in such medications, he suggested that the matter should be considered in the light of the Organization's responsibility to anticipate problems. The CHAIRMAN, speaking in a personal capacity, said that in his view the best rules were those that were not written down and, if they were put in writing, they should be brief. The Constitution of the United States of America was no longer than five pages. The document being considered by the Board in its provisional form was already 11 pages long and, as had been seen, might be considerably extended. An abundance of laws and regulations might serve to encourage

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rather than prevent dishonesty and corruption. He therefore considered that the most important thing was the spirit in which such matters were approached. Dr BALE (International Federation of Pharmaceutical Manufacturers Associations (IFPMA)), speaking at the invitation of the CHAIRMAN, said that many public health challenges appeared to have intractable aspects, and their complex interrelationships with research and development and other issues required those concerned to find ways of working together, although they might not have been accustomed to doing so in the past. The research-based industry, notwithstanding certain legal and competitive constraints, sought to contribute its strengths, in partnership with national and regional governments, organizations of the United Nations system, foundations and responsible nongovernmental organizations, to the effort to find new approaches to improving health worldwide. The Federation welcomed the Director-General's initiatives to work in partnership with key stakeholders, including industry, to help achieve the health goals set by WHO and its Member States. Those partnerships included the Global Alliance for Vaccines and Immunization (GAVI) which, as the Director-General had noted in her opening address, was an example of excellent cooperation between governments, agencies and the private sector. Other such partnership initiatives were the Medicines for Malaria Venture and the Accelerating Access Initiative for HIVIAIDS drugs in which five United Nations bodies, including WHO and UNAIDS, were working together with a number of research-based pharmaceutical companies to accelerate access to HIVIAIDS treatment in the poorest developing countries worldwide. A recent article in The Lancet had compared industry contributions related to that initiative favourably with those of most donor countries. In many instances individual companies were working with international organizations or the public sector in countries to save lives and to treat conditions that particularly affected developing countries, including onchocerciasis, malaria, lymphatic filariasis, poliomyelitis, trachoma, leprosy, and vitamin-deficiency blindness. Clearly, partnership between WHO and the private sector, including the pharmaceutical industry, was important in assisting WHO to achieve its aim of improving health for all. Guidelines concerning cooperation, should therefore support and foster cooperation; they should enhance efforts towards the common goal of improving health, while obviously avoiding conflicts of interest that would compromise the objectives of all parties. IFPMA therefore had no difficulties with the content and direction of the current draft guidelines. Industry had a unique role in discovering and developing most new cures, treatments and vaccines. Many poor populations, however, faced barriers to access to therapies because of lack of financing, lack of infrastructure and the high cost of treatment. IFPMA and WHO had recently produced a joint paper entitled "Improving access to essential drugs through innovative partnerships" with a focus on access to antimalarial drugs in Africa. IFPMA was working with WHO and the Roll Back Malaria project to identify several specific activities in Africa where help was needed in the form of expertise and financing for appropriate pathfinder projects to promote improved access to antimalarial drugs. The pharmaceutical industry was committed to further partnership with WHO, its Member States and other responsible actors in pursuing the goal of improving health care worldwide. All parties involved had particular expertise and resources to contribute towards that effort; the synergies that a successful partnership could offer could bring the goal of health for all within reach. Ms RUNDALL (International Baby Food Action Network (IBF AN)), speaking on behalf of Consumers International and Health Action International (HAI), at the invitation of the CHAIRMAN, said that WHO had been mandated by Member States to ensure equity in health care; it also set standards in many health-related areas. In actively seeking funds from the private sector, WHO was effectively encouraging private sector involvement in its work and sending a message of the inevitability of such involvement. Such action needed to be much more carefully considered as it risked diverting WHO from its mandate and discouraging the search for other sources of support that were more in keeping with the Organization's primary health care goals. WHO's action could also adversely affect the funding policies of many of its other traditional partners. Corporate donors would

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always have a duty to their shareholders to maximize profit; private-sector funding should therefore be evaluated according to public health criteria. The organizations she represented had some concerns about the proposed guidelines, including whether such public-private cooperation would contribute to equity in health care or encourage vertical programmes focused on diseases calling for high-tech, expensive solutions, rather than on those identified as national public health priorities. There was also the fear that such well-publicized cooperation might actually be an image-building, product development and marketing exercise on the part of the donor. Although the guidelines proposed a framework for assessing such forms of cooperation, they fell short in critical areas. First, they failed to define clearly conflict of interest and, as a result, the secondment of staff from the private sector, including pharmaceutical companies, was not perceived as involving such a conflict. The solution proposed seemed to be to involve more companies, which was clearly an inadequate response. Secondly, the guidelines failed to emphasize the risks related to the involvement of the commercial sector in research. The cardinal principle of the guidelines should be complete accountability and transparency. However, they made no provision for an independent evaluation of potential donors and of their compliance with WHO-agreed standards and with international agreements on human rights, the environment, marketing and labour practices. The Organization's contractual agreements with all private-sector donors should be made public, and independent review should be mandatory. Moreover, external monitoring and evaluation of work involving commercial enterprises must be carried out to ascertain whether equitable and sustainable health outcomes were being achieved. At an international seminar entitled "Global Public-Private Partnerships for Health and Equity" (Rome, November 2000), cosponsored by WHO, it had been stated that it was time for WHO to step back from the current situation and reflect on the appropriate role of such partnerships in order to meet public health and equity needs. There had also been a call for an open discussion of the guidelines, involving all interested parties, particularly stakeholders from developing countries. She therefore urged the Board to ensure that the guidelines included a clear definition of conflict of interest, complete transparency on contractual agreements with all commercial enterprises, and an assessment of potential donor companies according to recognized WHO and other international standards. The guidelines should also provide for the regular monitoring and evaluation of all private sector cooperation by an external body, including representatives of governments and civil society; a "whistle-blowing" mechanism allowing people to report problems without damage to their professional position or reputation; and annual reports to the Board on contractual agreements, their implementation and the public health outcomes achieved. Lastly, she called for the Board to review the guidelines in 2002 in order to determine whether such recommendations had been followed and how the guidelines were working in practice. The organizations she represented stood ready to contribute to that review. Mr TOPPING (Legal Counsel), providing background information on the guidelines, said that the Director-General had long been authorized to accept donations from the private sector, provided that the conditions attached to them were consistent with the objective and policies of the Organization. In the 1960s and 1970s it had been the responsibility of the Legal Counsel to advise the Director-General on such matters. However, over the years, as the volume of extrabudgetary contributions had increased, it had been realized that the issues at stake were far more complex than legal questions of conflict of interest. A small committee had therefore been set up to consider such matters and advise the Director-General thereon, while the Legal Counsel continued to provide advice on the legal aspects. In the 1980s, he had drafted a set of general principles, which had served as the Office of the Legal Counsel's internal guidelines on such matters until their recent replacement by the guidelines contained in document EB107/20. In terms of substance, the two sets of guidelines were basically the same. The newer ones had, however, been made more user-friendly by including more concrete examples and using less legal terminology. The guidelines had never been intended as a formal WHO policy statement, but as internal guidance for dealing with problems of conflict of

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interest and other more general aspects relating to the public relations and image of the Organization in the context of donations. The small committee set up in the 1980s had been re-established by the present Director-General and continued to advise her on such matters. Responding to specific comments made during the discussion, he pointed out that paragraphs 2 and 3 of the guidelines were in no way intended to provide a legal definition of commercial enterprises, but rather to highlight the need to assess requests for cooperation with WHO by commercial interests on the basis of the guidelines. He agreed that conflict of interest was not an exclusively legal matter, and that it also involved ethical considerations, which were in fact touched upon in the document. With regard to contributions in kind (paragraph 34), he said that existing guidelines on drug donations drawn up by WHO and other organizations would still apply. However, additional criteria had been established to deal with donations made for subsequent distribution to Member States, with the aim of preventing the Organization from becoming involved in donation schemes that were basically marketing exercises on the part of certain commercial enterprises. It would be advisable for the broader question of partnerships with enterprises other than commercial enterprises to be dealt with in a separate document. The arms and tobacco industries had been cited as the type of commercial enterprises which WHO should be wary of dealing with, although there might be circumstances where cooperation could be envisaged. A member of staff dealing with such a situation should nevertheless turn to the consultation mechanisms of the Organization for guidance. On the issue of the working group, he pointed out that the Board's approval of the guidelines had not been envisaged. In their present form they laid down detailed procedures which once adopted in a formal manner would be difficult to amend, and moreover their further refinement by a working group might involve the Board in a degree of micromanagement which it would not welcome. On the whole the Organization shared the reservations expressed by the Board with regard to the secondment of staff from the private sector. However, there might be circumstances where such recruitment was acceptable. A case in point had been the short-term recruitment of staff from a pharmaceutical company for a transfer of technology to the Organization. He could not agree with Dr Novotny that there was an inconsistency in the criteria set forth in paragraphs 20-22 concerning the use of funds from the private sector to defray meeting costs. Their intent was not to prevent the participation of Member States in such meetings. He offered to provide further details outside the meeting to any interested member of the Board. Regarding Dr Novotny's concerns about the inconsistencies in paragraphs 14-16 dealing with cash donations, he pointed out that it was possible to accept funds from private companies whose business was unrelated to WHO if it was considered that, under most circumstances, it would not give rise to a conflict of interest. A donation by an airline was cited as an example (paragraph 14). Nevertheless it was not possible to accept donations for specific projects from companies that had a direct commercial interest in the outcome of the project concerned (paragraph 15). For example, in the 1980s, when WHO had been promoting the use of psychoactive substances for pain relief in cancer patients, it had rejected a donation from a manufacturer of such substances because of the possible conflict of interest. On the other hand, IFPMA had helped to fund a workshop on drug storage at country level, since WHO had decided that there was only an indirect interest in the outcome of the projects (paragraph 16). The provision of donations for clinical trials more or less amounted to an exception to the general rule (paragraph 17). Where a private company was interested in testing one of its products, WHO would normally seek some sort of collaborative agreement to protect the public interest and to ensure the general availability of the product to developing countries. However, in the absence of such an agreement, a careful assessment would be carried out to ascertain whether there were other reasons to go ahead with the trial. The CHAIRMAN said that the Board had two options open to it, which were not mutually exclusive: to request the Director-General to report back in a year's time, although he doubted whether

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that would solve the issue of transparency completely; or to establish a working group, meeting either face to face or electronically with a view to cost savings. Dr ABREU CATALA (Venezuela) endorsed the working group option, with electronic means of consultation as far as possible. However, she requested the Director-General to ensure that documents were translated accurately, since there had been some problems with the Spanish versions in the past, for example, in the case of document EB I 07/28. Ms WIGZELL (Sweden) said that the Board should avoid micromanagement, and she would therefore prefer to wait a year for a further report. Ms BOCCOZ (alternate to Professor Girard, France) said that she had noted the explanation that interaction with the private sector was a long-standing practice and had been formalized. Since voluntary contributions represented almost 60% of WHO's resources for the forthcoming biennium, it was even more vital for the Organization to achieve transparency and credibility. Even though she agreed that the Board should not micromanage, the subject was an important policy matter, and she therefore favoured pursuing both options suggested by the Chairman. Mr KENGOUYA (alternate to Dr Bodzongo, Congo) remarked that it was commonplace for a rule to be established on the basis of a practice. Management of gifts and bequests should be regulated, and it was most important that a responsible institution like WHO should take account of the need for changes in the Organization's guidelines. Such changes should be set forth in a text adopted by the Board. There was also the fundamental question of the exact legal significance of the guidelines. The matter before the Board was not just one of micromanagement, it concerned official collaboration between an international institution and the private sector. It was important that companies should not be able to justify dubious conduct by claiming that they had made donations to WHO. He would prefer to await a report to be submitted to the Board at its I 09th session, after which responsibilities could be defined. Dr NOVOTNY (United States of America) stated his preference for the Director-General to report back to the Board at a later date. He would be submitting his comments in writing. The CHAIRMAN said that the Board appeared to agree that the Director-General should report back to the Board the following year with a document containing more precise guidelines, and that in the meantime members of the Board should exchange ideas on the issue through a long-distance working group. Members could also submit their opinions in writing. Dr AL KHARABSEH (Jordan) pointed out that the proposal to set up a working group might well be made again at the I 09th session, by which time a year would have been wasted. The CHAIRMAN agreed that it was important not to waste time. He proposed that the matter should be examined in greater detail, taking into account countries' views, which should be gathered in the most economical way possible. In reply to a question from Dr ABREU CATALA (Venezuela), he explained that his proposal combined the two options he had presented earlier: the Director-General would be requested to report back to the Board at its I09th session in January 2002 after further work, which would take into account the Board's comments and include a process of consultation to obtain additional views. The aim would be to refine the guidelines and clarify their legal status. In the absence of further comments he would take it that the Board approved the proposal.

It was so agreed.

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Reports of the Executive Board committees: Item 8.1 ofthe Agenda • Nongovernmental organizations (Document EB107/19) 1 Dr N'GAi'NDIRO (Central African Republic), speaking as Chairman of the Standing Committee on Nongovernmental Organizations, introduced the report (document EB107/19). In addition to its usual task of reviewing relations between WHO and nongovernmental organizations, the Committee had also been invited to comment on the report on the first session of the Intergovernmental Negotiating Body established to draft a framework convention on tobacco control in respect of proposals for extended participation of nongovernmental organizations in the Negotiating Body process (document EB107/30, paragraph 9). The Board was invited to consider the draft resolution and the two draft decisions set out in part IV of document EB107/19. Mr KENGOUYA (alternate to Dr Bodzongo, Congo) commented that, although the Principles Governing Relations between the World Health Organization and Nongovernmental Organizations were set out in the Organization's basic documents, the nature of nongovernmental organizations had altered, along with their fields of competence, and their status was currently very different from that defined in the 1901 Law of Associations. It might therefore be timely for the Board to examine the matter with a view to reviewing the Principles in the light of the current situation. He endorsed the draft decisions and the draft resolution, but considered that the grounds on which they were based should be stated. Terms of reference were needed to justify the decisions on admission and exclusion, especially since they would not be accompanied by an introductory note. The resolution and the two decisions were adopted. 2 • Awards Leon Bernard Foundation Prize Decision: The Executive Board, having considered the report of the Lean Bernard Foundation Committee, awarded the Lean Bernard Foundation Prize for 2001 to Dr Sastri Saowakontha (Thailand) for his outstanding service in the field of social medicine. 3 Sasakawa Health Prize Decision: The Executive Board, having considered the report of the Sasakawa Health Prize Selection Panel, awarded the Sasakawa Health Prize for 2001 to Dr Joao Aprigio Guerra de Almeida (Brazil). The Board noted that Dr Guerra de Almeida would receive an amount of US$ 30 000 for his outstanding work in health development. 4 Dr A.T. Shousha Foundation Prize Decision: The Executive Board, having considered the report of the Dr A.T. Shousha Foundation Committee, awarded the Dr A.T. Shousha Foundation Prize for 2001 to Professor Wagida Anwar (Egypt) for her most significant contribution to the objectives of

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Document EB107/200l/REC/l, Annex 6. Resolution EB107/Rl4 and decisions EB107(l) and EB107(2), respectively. Decision EBl07(5). Decision EB l 07(7).

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primary health care in the geographical area in which Dr Shousha had served the World Health Organization. 1 Francesco Pocchiari Fellowship Decision: The Executive Board, having considered the report of the Francesco Pocchiari Fellowship Committee, awarded the Francesco Pocchiari Fellowship for 2001 to Dr Tay Sun Tee (Malaysia) in order to enable her to carry out the research proposed? Ihsan Dogramaci Family Health Foundation Prize and Fellowship Decision: The Executive Board, having considered the report of the Ihsan Dogramaci Family Health Foundation Selection Panel, awarded the Ihsan Dogramaci Family Health Foundation Prize for 2001 to Professor Mahamoud Fathalla (Egypt) for his service in the field of family health. 3 The Board awarded the Ihsan Dogramaci Family Health Foundation Fellowship to Professor Anne Ormisson (Estonia) to enable her to carry out the research proposed.3 United Arab Emirates Health Foundation Prize Decision: The Executive Board, having considered the report of the United Arab Emirates Health Foundation Selection Panel, awarded the United Arab Emirates Health Foundation Prize for 2001 to Dr Ali Jaffer Mohammed Sulaiman (Oman) and to the Union of Palestinian Medical Relief Committees for their outstanding contribution to health development. The Board noted that the laureates would each receive US$ 20 000. 4 The CHAIRMAN announced that the Ihsan Dogramaci Family Health Foundation Selection Panel, meeting in private, had agreed to amend the Statutes of the Foundation. The amendments would be transmitted to the forthcoming Health Assembly for information. The Selection Panel had decided, moreover, to award the Prize and the Fellowship in alternate years, beginning with the Prize in 2002, and to increase the amount of the Fellowship to US$ 20 000. • Other Report of the Audit Committee of the Executive Board (Document EBAC3/7) The CHAIRMAN, reporting as a member ex officio of the Audit Committee, said that the Committee had held its third meeting on 10 and 11 January 2001, under the chairmanship ofMr Payne (United States of America). The agenda had covered issues related to external and internal audit matters, reports of the Joint Inspection Unit, and a report on the common services in Geneva. The Audit Committee had been requested to review the status of implementation of recommendations made by the External Auditor in management letters issued at WHO headquarters in the past biennium. Such status reports would henceforth be a standard item on the agenda of meetings of the Audit Committee. With regard to Internal Audit matters, agreement had been reached with the Director-General on the Audit Committee's future access to selected reports of the Office of Internal

1 2

Decision EBI07(10). Decision EB 107(9). Decision EBI07(6). Decision EB107(8).

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Audit and Oversight. The next meeting of the Audit Committee had been provisionally scheduled for 10 and 11 May 2001. Mrs ZIKMUNDOVA (alternate to Dr Thiers, Belgium) welcomed the report, but expressed some doubts concerning paragraph 18, which suggested that some internal audit reports might be made available to members of the Audit Committee for the purpose of reviewing the oversight process - an arrangement which might lead to confusion between the functions of the Internal and the External Auditors. It was important that the Internal Auditor should be able to fulfil his functions correctly and report exclusively to the Director-General, so as to be able to respond adequately to any issues that arose. Member States, in turn, should be kept informed through the report of the External Auditor. She could not therefore support the proposal unless it related only to the working methods of the Internal Auditor and not to questions of substance submitted to him. Professor GIRARD (France) supported that view. Dr NOVOTNY (United States of America), recalling that the Board had established the terms of reference of the Audit Committee at its 106th session, said that the Committee had held three meetings, during which it had attempted to reach a clear understanding on the scope of its work. Some concern had been expressed at the lack of information available regarding the work of the Internal Auditor, which made it difficult or impossible for the Committee to discharge its oversight functions. It had therefore requested some flexibility regarding access to internal auditing information, while acknowledging the procedural and confidentiality impediments which that implied. At the same time, the Committee did not wish to make fundamental changes in the nature of the Internal Auditor's work. It was obvious that an effective working relationship would have to be established if the Committee was to carry out its functions. He drew attention to the Committee's terms of reference, which included a review of the detailed audit plans of the Internal and External Auditors as well as of any reports on the scope of their respective audits in the preceding year or financial period. He strongly urged that dialogue be continued with the Audit Committee so as to establish an appropriate working relationship, especially as WHO had led the way within the United Nations system by setting up such a committee. He supported the suggestion made in paragraph 18 of the report. Dr FETISOV (Russian Federation), commending the comprehensive report, fully endorsed Dr Novotny's views and his plea for improved coordination between the Committee and the Secretariat. Ms WIGZELL (Sweden) endorsed the views of Dr Thiers and Professor Girard. It would be difficult for the Committee to support the role of the External Auditor on the one hand and that of the Internal Auditor on the other, as that could cause confusion between their respective responsibilities. Mr TOPPING (Legal Counsel) said that the intention behind the arrangements made for the release of certain internal audit reports had been to enable the Audit Committee to review the process and method of work of the internal audits, but not to review the substance of the work itself, as had been made clear to the Audit Committee by the representative of the Director-General. It should be noted that the arrangement was provisional, pending a review of its implementation in order to ensure that the work of the Internal Auditor was not compromised in any way. The CHAIRMAN asked whether the clarifications provided were acceptable to the Board members who had spoken on the issue. Mrs ZIKMUNDOVA (alternate to Dr Thiers, Belgium) said the clarifications responded fully to the questions that had been raised, particularly in view of the fact that the procedure would only be introduced for a limited trial period.

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(For resumption of discussion, see section 3.)

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (continued from the eleventh meeting, section 5)

Reporting of information on the health of populations: Item 3.5 of the Agenda (Document EB107/8)

The CHAIRMAN invited the Board to consider the item, which had been examined by a drafting group that had met on 20 January under the chairmanship of Dr Grabauskas (Lithuania). He drew attention to a draft resolution which was being submitted by the group to the Board. Dr THIERS (Belgium), speaking on behalf of Dr Grabauskas (Lithuania), chairman of the drafting group, introduced a draft resolution on International classification of functioning, disability and health, prepared by the drafting group, which read: The Executive Board, Having considered the report on measuring and reporting on the health of populations, 1 1. WELCOMES the continuation of research and development on data collection processes together with Member States and other competent international bodies with the aim of establishing comparability of data sources and health measures; 2. REQUESTS the Director-General to submit to the Fifty-fourth World Health Assembly the second edition of the International Classification of Impairments, Disabilities and Handicaps (ICIDH-2) with the title International Classification of Functioning, Disability and Health; 3. RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, 1. ENDORSES the second edition of the International Classification of Functioning, Disability and Health (ICIDH-2); URGES Member States to use the ICIDH-2 in their research, surveillance and 2. reporting as appropriate, taking into account the situation of Member States and possible future revisions; 3. REQUESTS the Director-General to provide support to Member States, at their request, in making use ofiCIDH-2. Dr THIERS (Belgium) said that in the French version the wording of the title of the draft resolution and the corresponding wording in paragraph 2 should be aligned, in order to avoid confusion. He pointed out that paragraph 2 of the resolution recommended for adoption by the Health Assembly did not correspond to the text agreed by the drafting group; it should read: "URGES

Document EB107/8.

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Member States to use the ICIDH-2 in their research, surveillance and reporting as appropriate, taking into account specific situations in Member States, in particular in view of possible future revisions". Mr de AGUIAR PATRIOTA (alternate to Professor Yunes, Brazil), referring to paragraph 14 of document EB 107/8, said that the Board was being asked to endorse different recommendations on: international standards to report mortality and non-fatal health outcomes, basic standards to measure health status in population surveys, and summary measures of population health. Regarding the first, he supported the proposal that the ICIDH-2 should be endorsed and published. Regarding the second, he considered that the so-called basic standards for the development and implementation of a common survey instrument for measuring health states should be regarded as an integral part of health system performance assessment methodology, a subject which had given rise to lengthy discussion in the Board and had led to the adoption of resolution EB107.R8. The same applied to the summary measures of population health, where the Board was being asked to approve a methodology that had not yet even been initially discussed. No decision had yet been taken on the measurement of health states, and he understood that, as indicated in that resolution, the whole health system performance framework was to be subject to a scientific peer review. Dr THIERS (Belgium), also with reference to paragraph 14 of document EB107/8, suggested that in subparagraph ( 1) of the recommendation concerning basic standards to measure health states in population surveys, it might be better to refer to "a common set of survey instruments", and in subparagraph (3) of that same section to "the basis for the development of a set of common survey instruments". The document was of great significance in the context of, for example, studies on the impact of the environment on health, and in his view it could be published immediately without first being approved by the Health Assembly. He suggested that in view of the importance of the issue the Director-General might hold a press conference to draw attention to it. He would like to have seen greater emphasis placed in the draft resolution on better collaboration with international institutions such as the European Commission, the European statistical office (Eurostat) and OECD. Dr SHINOZAKI (Japan), commending the report, endorsed the idea of developing an information system to measure, assess and report on population health in Member States. While he could endorse the first set of recommendations concerning the revised ICIDH-2, he considered that methodologies to measure health states in population surveys and to develop summary measures of population health were not yet sufficiently established. Summary measures had to be feasible and acceptable to all Member States before their application could be discussed. He could not therefore accept the second and third sets of recommendations, since he believed that further careful examination of the issues was required, accompanied by consultations with technical experts. Ms WIGZELL (Sweden) urged the Board to adopt the draft resolution. The extensive preparatory work done, and the fact that 43 Member States had been represented at the meeting in Madrid, together constituted a sound basis for a decision. With regard to surveys, WHO should coordinate its work with that being done in other organizations such as OECD and Eurostat, and should also make use of the results of several regional office activities. Further consultations were needed with experts other than those involved with classifications. As to frequency of surveys, policy issues and costs involved would need to be considered. Professor GIRARD (France) said the discussion posed questions of attribution of responsibility to which attention had already been drawn. Like Dr Shinozaki, he was not sure that Member States should be called upon to adopt a text whose interpretation called for such a high level of technical expertise. WHO should take full responsibility for the texts it produced. In the light of the considerable time devoted to the question by the drafting group, he did not think that amendments of substance ought to be introduced at the present stage. As to form, the word

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"endorses" in paragraph I of the draft resolution should be rendered in French by the word "enterine ", rather than by the word "approuve ". Dr FETISOV (Russian Federation) said that the report clearly showed that WHO was successfully discharging one of its basic functions in preparing international standards and classifications. Given the major challenges facing all countries with respect to protecting and improving health, measurement of the health states of populations and individuals was an important task that called for new indicators and approaches. He thus welcomed the work being done on ICIDH2. Implementation of summary measures of health also seemed desirable, although the underlying methodology was not described in detail in the report. He supported the draft resolution. Dr AL-JABER (Qatar) endorsed both the proposed common framework and the draft resolution, although the Arabic text required some editorial amendments. Mr de AGUIAR PATRIOTA (alternate to Professor Yunes, Brazil) asked for clarification of the meaning of the expression "Having considered the report ... ", in the preambular paragraph to the draft resolution. Mr TOPPING (Legal Counsel) explained that the words simply meant that the Board had read and noted the report, on one specific aspect of which it would thereafter take a decision. There was no implication that the Board had approved the report as a whole. Dr MURRAY (Executive Director ad interim), referring to the involvement of Member States in the development of ICIDH-2, said that all Member States had been invited to the final meeting in Madrid, and 49 official delegates had participated. The draft resolution had commanded a broad consensus. With regard to the linkage between work on classification and measurement of health surveys and the use of results of such surveys on health systems performance assessment, he said that the two bodies of work were distinct. Health status survey measurement had a history going back more than 50 years: it was a core function of the Organization to assist Member States in the development of common standards and instruments for classification of diseases, and for measurement of mortality and of other aspects of health. The report addressed those core functions in an attempt to enhance standards and comparability. The measurement of levels of health must, however, be distinguished from its use in analysing questions such as performance and efficiency. Mr de AGUIAR PATRIOTA (alternate to Professor Yunes, Brazil) proposed adding the words "and recalling resolution EB I 07 .R8" after the word "populations" in the preambular paragraph. The CHAIRMAN requested the Legal Counsel's view as to the acceptability of citing a resolution adopted only a few days previously. Mr TOPPING (Legal Counsel) said that such a procedure, albeit not prohibited, was somewhat unusual. However, given that the resolution concerned had no connection with the specific issue addressed in the draft resolution, he was inclined to think that the addition was unnecessary. Mr de AGUIAR PATRIOTA (alternate to Professor Yunes, Brazil) said that, as paragraphs I and 2 of the draft resolution concerned matters also dealt with in resolution EB I 07 .R8, it seemed reasonable to add a reference to that resolution. Professor GIRARD (France) pointed out that, once adopted, a resolution could be cited immediately. In a spirit of flexibility, and in order to expedite matters, he could agree to the introduction of a substantive amendment on an exceptional basis, in view of the fact that during

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discussions in the drafting group some participants might have been unaware of the adoption of resolution EB107.R8 the previous day. Dr THIERS (Belgium), speaking on behalf of the Chairman of the drafting group, said that, given the tenuous link between the two texts, the formulation "and bearing in mind resolution EB 107 .R8" might be preferable. The CHAIRMAN said that, if he heard no objection, he would take it that the Board agreed to the amendment proposed by Mr de Aguiar Patriota, as further amended by Dr Thiers. It was so agreed.

The draft resolution, as amended, was adopted. 1 Ms BENNETT (Australia), speaking at the invitation of the CHAIRMAN/ said that ICIDH-2 had been developed after a great deal of work by WHO and collaborating centres around the world. An international classification system for functioning, disability and health was essential for collecting data for international comparison, and would also provide a standardized framework for work within countries. The engagement of countries was essential to ensure acceptance of future work, and she was ready to endorse ICIDH-2 and support its immediate publication. Australia was also willing to work with WHO, other countries and collaborating centres to revise the ICIDH periodically in order to ensure the stability of the classification system and to enable new knowledge to be incorporated. She welcomed discussion on moves towards the adoption of common survey instruments, and supported the use of ICIDH domains for the development of standard measures of health states. However, significant conceptual and methodological issues in the selection of domains would need to be discussed with Member States. She also welcomed discussion on summary measures of population health, but would caution WHO against becoming locked into a particular approach without adequate consultation. At the current stage, no one approach on measures of health expectancy and health gaps had gained general acceptance, and certain measures remained controversial. Australia would be pleased to assist with that important ongoing work. She considered that the resolution just adopted effectively addressed the issues raised. (For resumption, see section 5.)

OTHER MANAGEMENT MATTERS: Item 8 of the Agenda (resumed from section 1)

Governing body matters: Item 8.4 of the Agenda (Documents EB107/21, EB107/22 and EB107/35 Rev.l) Dr ASAMOA-BAAH (Executive Director) recalled that the provisional agenda for the Health Assembly was prepared by the Board, after consideration of proposals submitted by the DirectorGeneral, under Rule 4 of the Rules of Procedure of the Health Assembly. The Director-General's proposals for the agenda and timetable for the Fifty-fourth World Health Assembly could be found in the Annexes of document EB107/22. They included one half-day for ministerial round tables on the theme of mental health. 1 2

Resolution EB107.Rl5. By virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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The CHAIRMAN invited the Board to consider the provisional agenda. He noted that, in accordance with resolution EB 107.R15, the International Classification of Functioning, Disability and Health (ICIDH-2) should be included on the agenda for the Health Assembly. Professor ZELTNER (Switzerland) pointed out that the workload assigned to Committee A was heavier than that of Committee B. With reference to item 13.5, he proposed that it be renamed "Tobacco control", with two sub-items entitled "Framework convention on tobacco control" and "Other activities related to tobacco control". Professor GIRARD (France), supported by Dr AL-JABER (Qatar), proposed that an additional item on the use of languages in WHO should be included in the agenda of either Committee A or Committee B. It would be timely for a report to be submitted to the Fifty-fourth World Health Assembly on progress made in the use of languages in WHO, as requested in resolution EB105.R6. Mr LIU Peilong (China) welcomed the marked improvement in the use of all six official languages both at WHO headquarters and in the Western Pacific Region, where an effort was being made to translate documents into Chinese. Nevertheless, there was still room for improvement, and he therefore endorsed Professor Girard's proposal. Dr FETISOV (Russian Federation) endorsed the remarks of the previous speakers on the use of the six official languages in WHO. A case in point was the second meeting of the WHO Advisory Committee on Variola Virus Research to be held at headquarters on 15 and 16 February 2001. The remaining stocks of smallpox virus were held in the Russian Federation and the United States of America and experts from those and other countries had been invited, yet it had been decided that the meeting would be conducted exclusively in English. Dr ASAMOA-BAAH (Executive Director) said that the necessary language arrangements would be made for that meeting so that the Russian experts could play an active role. Dr JOHNS (South Africa), speaking at the invitation of the CHAIRMAN, 1 said that a meeting of health ministers of the 113 countries that constituted the Nonaligned Movement, currently chaired by South Africa, was scheduled to be held at the end of March 2001 and would in all probability culminate in a draft resolution for presentation to the Fifty-fourth World Health Assembly. He suggested that any such resolution could be introduced under proposed agenda item 13.4, which should be named "Strengthening health services delivery", with two sub-items: "Strengthening nursing and midwifery" and "Strengthening health systems in developing countries". That would enable countries of the Nonaligned Movement, at least 20 of which were currently represented on the Board, to present their draft resolution for consideration by the Health Assembly. The suggestion was taken up and made as a proposal by Dr MSA MLIVA (Comoros), Dr AGGARWAL (alternate to Mr Chowdhury, India) and Dr SADRIZADEH (Islamic Republic oflran). Mr HUSSAIN (Iraq), speaking at the invitation of the CHAIRMAN, 1 recalled that the DirectorGeneral and the Regional Director for the Eastern Mediterranean had spoken of concerted efforts made by Iraq and WHO to study the effects of the use of depleted uranium munitions during the Gulf War in 1991. The Regional Director had said that an appropriate report would be submitted to the Fifty-fourth World Health Assembly. He consequently suggested that an item be added to the provisional agenda. The suggestion was taken up and made as a proposal by Dr AL KHARABSEH (Jordan) and Dr AL-JABER (Qatar).

By virtue of Rule 3 of the Rules ofProcedure ofthe Executive Board.

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Mr RISTIC (Yugoslavia), speaking at the invitation of the CHAIRMAN, 1 stressed the important consequences for public health of the use of depleted uranium weapons. That issue had only recently been seriously considered by certain international organizations and States. World media had rightly drawn attention to the serious effects on populations and the environment of contamination from such a source during the military interventions in Bosnia and Herzegovina in 1995 and in Yugoslavia in 1999. His Government requested that all the facts be established as soon as possible and that the consequences be remedied, in particular through the decontamination of polluted areas, with the costs being borne by those responsible for the contamination. His Government considered that international action should be taken to ban the production and use of such weapons and invited other States and intergovernmental and nongovernmental organizations to join Yugoslavia in that initiative. In view of the seriousness of the issue and the urgency for its resolution, as had recently been underscored by a majority of States within the Security Council, WHO should participate in investigations into the impact on public health of the use of depleted uranium. He therefore favoured inclusion of the issue on the agenda of the Fifty-fourth World Health Assembly. Dr NOVOTNY (United States of America) noted that WHO had already undertaken several scientific investigations and epidemiological assessments, reports of which were due to be issued in March 2001. He asked whether sufficient information would be available on the matter in time for a full discussion at the Fifty-fourth World Health Assembly. The DIRECTOR-GENERAL confirmed that further reports would be prepared on the subject of depleted uranium before the next Health Assembly. They would include a report by WHO and UNEP on the scientific background, a report from NATO, and military studies, as well as WHO's plans for an epidemiological assessment. The CHAIRMAN summarized the amendments proposed by members of the Board to the provisional agenda for the Fifty-fourth World Health Assembly. With regard to Committee A, item 13.4 would become "Strengthening health services delivery" and include two points, the first on nursing and midwifery and the second on health systems in developing countries. Two more points would be added to agenda item 13. The first, 13.9, would cover the International Classification of Functioning, Disability and Health; the second, 13.10, would be on the health effects of depleted uranium. Item 13.5 would become "Tobacco control" and be subdivided into "Framework convention on tobacco control" and "Other activities". A new item would be included on the use of languages in WHO. He said he took it that the Board wished to approve the decision contained in paragraph 4 of document EB 107/22, on the understanding that the amendments he had described were included. It was so decided. 1

Date and place of the 108th session of the Executive Board Decision: The Executive Board decided that its 108th session should be convened on Wednesday, 23 May 2001, at WHO headquarters, Geneva, and should close no later than Thursday, 24 May 2001. 2 Professor GIRARD (France), speaking as the longest-serving member of the Board and on the occasion of the termination of his mandate, expressed some concern at recent developments relating to the operation of the Board. Without being unduly pessimistic, those developments led him to wonder 1

Decision EB107(3). Decision EB107(4).

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whether there would still be an Executive Board in five or 10 years, as the Rules of Procedure of the Executive Board did not respond to various situations that had arisen. In recent years, the Health Assembly had become a true democratic forum in which all Member States could express their views. He welcomed the fact that fundamental issues were being decided by the supreme body of WHO, and although he wondered from time to time whether it was reasonable to spend so many hours on a single text, he believed that that was the price to be paid for democracy. However, the existence of one forum for broad debate, namely the Health Assembly, raised questions concerning the role of the Board, which appeared to be functioning along similar lines. For instance, the Board had accepted the request of the Health Assembly to form a discussion and drafting group on infant and young child feeding which would be open to Member States not represented on the Board. He doubted whether that precedent should be repeated, as the discussions in that group would probably be repeated during the Health Assembly. He did not think that the founders of WHO had envisaged that the two organs should play the same role. Furthermore, the Board had just accepted a new agenda item for the Health Assembly on the suggestion of a person who was not a member of the Board. The Board should be a forum for discussion among its membership and it should not extend that membership. He suggested that a working group meet during the 108th session of the Board to reflect on the current evolution of working methods, which, while constituting a form of democracy, were perhaps not optimal. Dr NOVOTNY (United States of America) endorsed those comments. It was a particular responsibility of the members of the Board to focus the work of WHO and to avoid delays caused by discussing every issue repeatedly. Concerning the provisional agenda for the Fifty-fourth World Health Assembly, he requested that the item concerning depleted uranium be entitled "Possible health effects of depleted uranium". The CHAIRMAN indicated that the matter had already been decided. Professor ALl (Bangladesh) considered that the basic issue was constitutional. As the rules stood, individual countries could, by observing the prescribed deadlines, request that an item be placed on the agenda of the forthcoming Health Assembly. Committee chairmen, finding it difficult to bring the ensuing debate to a satisfactory conclusion, often resorted to the establishment of a drafting group or working group, which sometimes referred the item back to the Board for further discussion, before it returned to the Health Assembly. Ultimately, that was the price of democracy. But since all Member States, whether represented on the Board or not, were entitled to speak at Board meetings at the invitation of the Chairman, a procedure whereby items for inclusion on the agenda of the Health Assembly had first to be presented to the Board would, in his view, be preferable. WHO would then have sufficient time to prepare the item thoroughly for debate in the Assembly. Dr BODZONGO (Congo) observed that WHO's basic documents, which dated from the 1940s, should be brought up to date. Moreover, much time was lost at Health Assemblies by delegates who still persisted in describing at length the health situation in their countries. As a result, discussion of some agenda items had to be rushed through or deferred to the next Health Assembly. It should surely be possible for the President to call such delegates to order. The CHAIRMAN drew the Board's attention to document EB107/35 Rev.l, which contained his report on the retreat held for Board members in November 2000. The main body of the text set out some thoughts on the functions and methods of work of the Board and put forward some ideas for making its procedures more efficient, pro-active and up to date, including a proposal for use of modem methods of communication, ensuring more active and timely participation of members and introducing a formal question-and-answer session with the Director-General. Those ideas had received general acceptance. He agreed with Professor Girard that a disproportionate amount of time was often spent in drafting.

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MATTERS FOR INFORMATION: Item 9 of the Agenda

Report on meetings of expert committees and study groups (including report on appointments to expert advisory panels and committees): Item 9.1 of the Agenda (Documents EB 107/24 and EB107/24 Add.1) The CHAIRMAN said that document EB 107/24 contained a report on two meetings of expert committees, and document EB 107/24 Add.1 contained a report on the membership of expert advisory panels and expert committees. He invited the Board to consider first the meeting reports, beginning with the forty-ninth report of the WHO Expert Committee on Biological Standardization. Dr NOVOTNY (United States of America) noted that industry was becoming reluctant to submit dossiers on products, owing in part to the lengthy process involved. He asked whether the delay between the Committee's meeting and the publication of its report could be reduced. In reply, Or SUZUKI (Executive Director) said that a certain amount of time was required between the meeting and final publication for substantial technical editing and to ensure the report's accuracy. Everything possible was being done to expedite the process. The CHAIRMAN invited the Board to consider the fifty-second report of the Joint FAOIWHO Expert Committee on Food Additives, and, in the absence of any remarks from the Board, asked for follow-up on the Committee's recommendations in the implementation of the Organization's programmes. After inviting consideration of document EB 107/24 Add.1, he noted the absence of remarks on that subject. Roll Back Malaria: Item 9.2 of the Agenda (Document EB107/25) Dr SADRIZADEH (Islamic Republic of Iran) said that malaria was a re-emerging infectious disease, with serious health and socioeconomic implications. Although more than 90% ofthe world's malaria cases occurred in sub-Saharan Africa, the situation was serious in Djibouti, Somalia, Sudan and Yemen. Some 95% of all malaria cases in the Eastern Mediterranean Region occurred in those countries, together with Afghanistan. He fully supported the Roll Back Malaria project, and the strategic investment by WHO in developing new tools and approaches for rolling back malaria and strengthening country research capacity through the small-grant scheme, as well as its work in developing a malaria vaccine. WHO rightly attached priority to controlling malaria in the worst-affected countries, such as those in subSaharan Africa and those with damaged health systems or in the grip of complex emergencies. Since five of those countries were in the Eastern Mediterranean Region, he was confident that they would continue to benefit equally from the extrabudgetary resources of the Roll Back Malaria project. In many countries, malaria was under control or had been eradicated. It was vital to support those countries with relatively strong malaria control programmes to eliminate mortality as a consequence of the disease, to prevent and control malaria epidemics and to plan for the interruption of malaria transmission in their territories to the extent feasible. In countries where malaria had been eradicated, efforts should be made to prevent its re-introduction. Because of the ban on the use of DOT for selective residual spraying, most countries where malaria was endemic would be unable to reduce its transmission through vector control, unless alternative strategies based on safe, effective and affordable insecticides or environmentally sound control methods were explored. Mr LIU Peilong (China) asked why there was no mention, in paragraph 16 of the document, of the intercountry malaria control programme operating in the Western Pacific Region, in cooperation with the South-East Asia Region to monitor antimalarial drug resistance and transmission of malaria in

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disease-endemic countries, including China. It was also important to monitor mosquito sensitivity to insecticides, and he hoped WHO would emphasize work on that aspect. Dr SHINOZAKI (Japan) said that the Roll Back Malaria project required both political and financial commitment, and its importance was recognized not only by health professionals, but also by heads of State in both developed and developing countries. The project was being scaled up, and he welcomed the specific actions recorded in the progress report. With regard to the "Facility for Intensified Roll Back Malaria Action" (paragraph 6), he would welcome an example of the kind of action envisaged at country level. The innovative concept of the Facility might be applicable to other infectious diseases. However, he cautioned that a multiplicity of "mechanisms" might create confusion. Dr FETISOV (Russian Federation) welcomed the significance attached by the Organization to the project, as reflected in the "All funds" budget allocation of US$ 105 million, of which US$ 96.5 million were from "Other sources". He would be glad to know in detail how the funds were to be spent. Dr MBAIONG (Chad) said that malaria was a leading cause of mortality, morbidity and incapacity in Africa, with ·over 270 million cases and over one million deaths a year, including 5% of children under the age of five - 11 000 such children in Chad alone, where malaria accounted for 13% to 17% of all deaths. Globally, it caused significant economic losses, estimated at US$ 2000 million in 1997 and US$ 3600 million in 2000. He therefore welcomed the Roll Back Malaria project, and urged members of the Board to support the campaign against one of the most pernicious diseases, after HIVI AIDS, in the African continent. Dr Thiers took the Chair.

Professor NAMA DIARRA (Cote d'Ivoire) referred to paragraph 8 in the English version of the document, according to which increased financial resources were being secured to enable countries successfully to abandon the use of DDT. That did not square with the French version, which stated that WHO, together with UNEP, was investigating ways of lifting the ban on the use of DDT. She would welcome an explanation ofthe discrepancy. Dr BODZONGO (Congo) pointed out that the progress report on Roll Back Malaria had been submitted to the Board for information purposes. So, while clarifications on certain aspects of the report might be sought, at the present juncture it was not advisable to reopen the debate on malaria, which had already been the subject of extensive discussion in the past. The CHAIRMAN noted that most members were in agreement with Dr Bodzongo that it was not appropriate to enter into discussion of the substantive issues raised in the report. Dr AGGARWAL (alternate to Mr Chowdhury, India) said that his country had become a partner in the Roll Back Malaria project, given the existence of well-organized programmes at national level since the launching of the national malaria control programme in 1953. It had brought about a spectacular reduction in the incidence of malaria and mortality rates, leading to the implementation of a national malaria eradication programme. As of September 1997, an enhanced malaria control project had been launched with World Bank assistance in seven Indian states covering more than I 000 primary health centres in "hard-core" malaria areas. The aim of the project was to deal with the most problematic areas by providing additional tools to step up antimalaria activities. Malaria control efforts comprised mainly the introduction of new drugs for the treatment of drug-resistant malaria, continued monitoring of drug resistance, rapid diagnostic methods, epidemic preparedness and response and increased information,

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education and communication on the issue. Malaria control strategies had been diversified through the introduction of insecticide-treated bednets, larviciding and the improvement of management information systems for the early detection of epidemics with the assistance of the Meteorological Department. Greater community and intersectoral involvement was being encouraged through the promotion of district-level control teams, awareness-raising activities, including the organization of workshops, and the participation of nongovernmental organizations in training exercises. Dr TEKLE HAIMANOT (Roll Back Malaria) replying to Dr Sadrizadeh, said that WHO was working closely on all aspects of malaria control with the countries in question in the Eastern Mediterranean Region and in particular with those affected by intensified forms of malaria or which were on the brink of eliminating the disease. In response to Professor Nama Diarra's query on DDT, he said that WHO was working with UNEP to secure a time-limited exemption from the ban on its public health usage for malaria control. However, WHO and its partners would be looking into ways of reducing Member States' reliance on the insecticide and seeking an alternative to it, on the understanding that the necessary capacity-building and funding would be provided. He would provide further clarification on the subject outside the meeting to Professor Nama Diarra. In response to Mr Liu Peilong, he drew attention to the reference to the intercountry initiatives among the six Mekong countries in paragraph 5 of the document. Those countries were receiving intensified support from partners in the Roll Back Malaria project on various aspects of malaria control, including the updating of national drug policies and treatment guidance. In answer to Dr Shinozaki, he said that the "Facility for Intensified Roll Back Malaria Action" was an innovative approach whereby countries would receive assistance for their malaria control efforts by exploring all possible avenues including the public and private sectors, nongovernmental organizations and the communities concerned. It was still only at the proposal stage, but could surely be applied to other diseases too. He concurred with Dr Mbaiong that the gravity of the malaria situation warranted serious consideration and that all partners must be involved in its effective control. Making pregnancy safer: Item 9.3 of the Agenda (Documents EB107/26 and EB107/26 Corr.l)

The CHAIRMAN, after opening the item for discussion, spoke in his capacity as the member designated to serve on the Board by Belgium. He described the title of the report as somewhat misleading, since the area where progress really needed to be made was not so much during pregnancy as during childbirth, with issues such as the availability of qualified staff and access to hospital treatment. Such aspects were, however, only touched upon in the document. Mental health 2001: Item 9.4 of the Agenda (Document EB 107/27)

Dr CABRERA MARQUEZ (Guatemala) asked what methodology was being used to produce the contents of the report on mental health. Dr NOVOTNY (United States of America) said that the report would give WHO and Member States the opportunity to reposition mental health in the mainstream of health system delivery. It also allowed for cooperation with other relevant multilateral bodies, including ILO and UNICEF. In that connection, he drew attention to the statement made by WHO at the preparatory meeting for the Special Session of the United Nations General Assembly on Children to be held in September 2001, which had referred to the Organization's commitment and support to that Special Session on a variety of issues, including mental health. He welcomed the idea of WHO's leadership in that area and requested more information on WHO's cooperation with UNICEF and other organizations in preparation for the Special Session. Under WHO's leadership, Member States could collectively begin to tackle the mental health disease burden. Areas of concern included the need for better research and data, improved evaluation

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of the efficacy of prevention and treatment services, and the development of policies and actions that would reduce and eventually eliminate the stigma attached to mental illness. Or FETISOV (Russian Federation) commented that mental health problems were a major problem in contemporary society; worldwide, they were a leading cause of ill-health, including depression, schizophrenia and the psychological disorders related to epilepsy, which affected around 30 million people. He therefore welcomed the Organization's initiative to organize the World Health Day in 2001 and ministerial round tables at the forthcoming Health Assembly on the theme of mental health, and the publication of a report on that theme. He favoured strengthening aspects of the mental health programme such as the prevention of psychosocial problems of migrants and refugees and disorders related to alcohol and drug abuse. However, he suggested that, when considering the problem of mental health, special attention should be paid to the quality of life. Or AGGARWAL (alternate to Mr Chowdhury, India) said that India's national mental health programme had been approved as early as 1982 although implementation had been slow. Pilot programmes that integrated mental health care into primary health care had been developed and tested in the State of Kamataka, proving to be feasible and cost-effective. Twenty-two districts currently had mental health programmes; others would follow. Minimum standards governing conditions of care in mental hospitals had been established. Referring to the WHO questionnaire on mental health resources, he asked for assurance that the information provided would be used in such a way as to provide the maximum benefit to Member States. Or SADRIZADEH (Islamic Republic of Iran) said that decision-makers neglected mental health in most developing countries, where the problems were most serious. In the spirit of health for all, WHO should act as a catalyst, giving mental health a high priority, disseminating information, raising awareness and supporting countries to develop appropriate legislation, policies and strategies. He was pleased to note that mental health would be the theme of World Health Day 2001 and of the ministerial round tables to be held during the next Health Assembly. Those events would increase awareness and create political commitment. Professor GIRARD (France), on a point of order, said that the item had been placed on the agenda for information and not for discussion. Admittedly, that was frustrating, but he felt that speakers must respect that definition. Or DI GENNARO (Italy) requested preliminary information on the format of the next mental health report, since she had heard that it would include indices based on the questionnaire sent to Member States. Or MBAIONG (Chad) said that the structure of mental health care in Chad had only recently been put in place, but might usefully include traditional medicine. A spring which apparently improved mental health had been discovered there. An analysis of the water was desirable to investigate its potential benefits. Or YACH (Executive Director), replying to the questions from Or Cabrera Marquez, Or Aggarwal and Or Di Gennaro, said that the process had involved a critical review of evidence and intensive regional consultations with strong support given by the regional offices. The report would include the results of a survey of country resources, using information directly obtained from 154 Member States. Such information would provide powerful evidence of the gap in resources and needs. The report would comprise four chapters covering: scope of mental health and its determinants; magnitude and burden of the problem; cost-effectiveness of interventions; barriers to implementation

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and policy. He assured Dr Novotny that there had been collaboration to secure substantive input to the Special Session of the United Nations General Assembly on Children to be held in September 2001. Eradication of poliomyelitis: Item 9.5 of the Agenda (Document EB 107/28) Dr OMI (Regional Director for the Western Pacific) reported that on 29 October 2000 the Global Commission for the Certification of the Eradication of Poliomyelitis had concluded that the transmission of wild poliovirus had been interrupted in all areas of the Western Pacific Region of WHO, and that the Region was therefore certified entirely poliomyelitis-free. That achievement could be attributed to various factors, the most important being the great effort made by Member States, and he expressed his appreciation for all those who had been involved in the process. Regarding the global poliomyelitis eradication initiative described in document EB 107/28, he said the final stage of eradication had been reached; that required more arduous effort than any other because it focused on the last remaining endemic areas, which did not remain endemic by chance. In those areas, infrastructure was generally very weak, certain population groups were more vulnerable and, most important, there had been disruption of peace and order. None of those problems was easy to deal with, but they could nevertheless be overcome when there was strong political commitment. For example, during a conflict, governments might decide to declare a temporary cease-fire to allow immunization to be carried out- a strategy that had proved effective in the Western Pacific Region. Although the poliomyelitis eradication initiative was not currently one of the 11 global priorities, so much had already been invested in it by all players that he strongly believed that, for the coming two years, it should be given urgent attention by all concerned so that the disease could be eliminated by 2002, making it possible to certify its eradication by 2005. HIV/AIDS: Item 9.6 of the Agenda (Document EB107/29) Professor GIRARD (France) observed that the problem of HIV/AIDS was far from being solved. However, in view of the lack of time at the current meeting for the in-depth discussion that the subject warranted, he suggested that the Board should simply note the information contained in the document and debate it fully at its 109th session. Framework convention on tobacco control: Item 9. 7 of the Agenda (Document EB 107/30) Professor GIRARD (France) said that the work done on the framework convention, and particularly the report prepared under the leadership of Professor Zeltner, raised a number of questions. Three points should be noted: first, although the findings of the report related to tobacco they could probably equally well have been made for other areas and were not tobacco-specific; secondly, although many of the proposals made, notably those addressed to WHO, had already been implemented, there were others that concerned transparency in the Organization's work which members of the Board could not fail to support. The third point was the approach to be adopted in applying the principles defined in the report: he was not yet clear what that approach should be. He reiterated that the principles had a wider application than the area of tobacco, and that joint reflection was essential to consider how they should be implemented. Dr NOVOTNY (United States of America) commended the work done to date, but expressed some concerns in regard to the report. Referring to the recommendations by the Committee of experts on tobacco industry documents on transparency of affiliations set out in paragraph 15, he emphasized that governments of Member States were sovereign and had the right to choose their diplomatic representatives freely, based on criteria relevant and acceptable to them. He was also concerned about the proposal to create new procedures to make transparent any affiliations between a nongovernmental organization and tobacco companies, since he believed that WHO's rules of procedure already adequately addressed that type of concern in the criteria for official relations with nongovernmental

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organizations. A specific recommendation was therefore unnecessary. Concerning the recommendation in paragraph 14 that WHO should also monitor tobacco industry activities and make regular public reports on continuing misconduct, his view was that no action should be taken. Dr AGGARWAL (alternate to Mr Chowdhury, India) said that his country and many others held that the framework convention should be a broad agreement, without any binding protocols at the current stage. That would encourage more countries to agree to it, thus providing a common platform for global action. India also considered that interagency partnership on the economics of tobacco control and supply was very important, and that trade issues and the particular concerns of tobaccogrowing countries should be taken into account. He supported WHO's efforts to increase awareness of the ill effects oftobacco. Mr LIU Peilong (China), referring to paragraph 21, said that the invitation by WHO to selected tobacco companies to provide information regarding their perspective on product modification and their efforts to reduce the harm caused by tobacco products appeared to imply that WHO supported such products. He therefore requested clarification of WHO's stand on tobacco product modification and the reason for collecting such information. Dr FETISOV (Russian Federation) said that he appreciated the activities of the Organization in the field of tobacco control and that he believed that its efforts to prepare the framework convention and ensure its adoption were already beginning to bear fruit. He emphasized the importance of the Committee of experts on tobacco industry documents and approved its recommendations, as well as the measures being taken both at WHO headquarters and in the regional offices. Since most work on tobacco control had to be done at country level, cooperation between WHO and countries was to be welcomed. It would be useful to carry out an analysis of the effects of bringing in measures that were not economically restrictive but entailed State control over the export of tobacco products between countries that had acceded to the convention. The serious problem of cross-border smuggling of tobacco products could also be studied: his country was endeavouring to take measures to deal with that problem and could share its experiences if required. The interests of the tobacco industry and of those who produced the raw materials for it should also be examined. Professor ZELTNER (Switzerland) said that Switzerland was not opposed to lobbying activities: in order to reach consensus and make informal decisions, it was important to hear the views of different interest groups. However, the question of avoiding inappropriate affiliations between nongovernmental organizations and tobacco companies was of great importance. Speaking as Chairman of the Committee of experts on tobacco industry documents, he said that the Committee had made 58 recommendations in its report, mostly addressed to the Organization. He congratulated the Director-General on her rapid implementation of those recommendations and welcomed the action taken by other organizations such as PAHO, which had given the report careful scrutiny. He drew attention to the two recommendations set out in paragraph 15 of the document, addressed not to the Director-General but to the Health Assembly, underlining the importance of establishing adequate mechanisms for ensuring transparency of affiliations between delegates to the Health Assembly and tobacco companies, and also transparency of affiliations between nongovernmental organizations and tobacco companies. Switzerland had circulated a draft resolution on the issue for which there seemed to be increasing support, but because some members had been unable to endorse it before consulting with their respective governments it had been decided not to submit it formally to the Board. However, he urged Member States to continue discussions on the two recommendations with their administrations. Switzerland did not share the views expressed by Dr Novotny on the question of transparency. Dr SADRIZADEH (Islamic Republic of Iran) expressed full support for the statement made by Professor Zeltner.

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Dr AL-JABER (Qatar) supported the views expressed by Mr Liu Peilong. He pointed out that measures to induce tobacco companies to modify their products and reduce nicotine content in cigarettes were not sufficient in themselves. Tobacco production was also accompanied in some countries by constant and aggressive advertising, which in the long term encouraged smoking, and that issue too needed to be tackled. Dr ALLEYNE (Regional Director for the Americas), referring to paragraph 12 of the report, said that an evaluation team with impeccable credentials had looked at the allegations in the report of the Committee of experts on tobacco industry documents, but had found no evidence that the tobacco industry had impeded the operation of the Organization in any way. Ms MULVEY (World Vision International), speaking at the invitation ofthe CHAIRMAN, said that her organization, INFACT and the nongovernmental organization Forum for Health urged the Board to support the recommendations of the Committee of experts on tobacco industry documents, and in particular the recommendation that WHO should monitor tobacco industry activities and affiliations, including their lobbying and political contributions, and should make regular public reports on industry misconduct. During the October public hearings on the framework convention, over 150 nongovernmental organizations had testified unanimously that the treaty-making process should be kept free from interference from the tobacco industry. In addition, thousands of people in more than 3 5 countries had joined in an international week of resistance to tobacco transnationals in a show of broad public support for the framework convention. She asked what progress had been made in implementing the recommendations of the Committee, including that concerning disclosure of possible conflict of interest by those with appointments with WHO, and whether there was evidence that any nongovernmental organization in official relations with the United Nations or with WHO might have such conflicts of interests due to their ties with the tobacco industry. Dr YACH (Executive Director), replying to comments, first drew attention to the text of a framework convention on tobacco control (document A/FCTC/INB2/2) which had very recently been issued. Responding to Professor Girard, he said that the inquiry had shown that there were complex ways in which WHO policies were thwarted by multinational corporations, and documentary evidence was available showing that such practices went beyond the tobacco companies. The tobacco industry's documents themselves provided a unique means of looking at the complex links that existed between policies of tobacco, food, chemical and utility companies. In reply to Dr Novotny and Professor Zeltner, he said that certain nongovernmental organizations in official relations with WHO were known to have strong links with the tobacco companies. One of those was the International Organization for Standardization (ISO), which was open about such links and represented the interest of tobacco companies in setting standards for low, medium and high tar and nicotine levels in tobacco products. It should be recognized, however, that those measurements were not based on science; a very recent report from the Imperial Cancer Research Fund had shown that smokers who smoked cigarettes with what they believed to be low nicotine and tar ratings were over-compensating and in fact exposing themselves to levels equivalent to those in products with medium and high contents of nicotine and tar. However, ISO continued to use machines that measured tar and nicotine content in a manner that did not equate to the way in which human beings smoked cigarettes, a fact that had been known for decades. The information on the links between ISO decisions and the tobacco companies was available to the public through various web sites on the Internet. WHO had collated that evidence and had already discussed it with ISO. The second nongovernmental organization with strong links with the tobacco industry was somewhat different: the International Life Sciences Institute (ILSI) had made a valuable contribution to WHO's work in a positive way on food and nutrition policy. However, a review of tobacco company documents between 1983 and 1988 available to the public on the Philip Morris web site

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company documents between 1983 and 1988 available to the public on the Philip Morris web site showed that there had been considerable interaction between ILSI's President, who was a former Vice-President of Coca-Cola and a past member ofPAHO's development committee, and at least two major tobacco companies. One purpose of the interaction, clearly supported by the documents, appeared to be financial transfers from tobacco companies to ILSI for services rendered. There also appeared to have been a sustained effort to downplay the evidence on the health effects of passive smoking. In reply to Mr Liu Peilong, he said that the Scientific Advisory Committee on Tobacco Product Regulation was currently trying to determine whether there was a public health basis for reducing tar, nicotine and other constituents. The Committee, which included representatives from all regions, had taken evidence from tobacco company scientists. If WHO was to understand the science involved and make a difference to public health in the long term, it had to listen to the tobacco company scientists. However, the conditions for such contacts were controlled, and it was made clear in advance to the tobacco companies that the material made available by them would be placed in the public domain. The information provided by some companies showed that there was a substantial research effort being made to produce "reduced-harm" products. WHO would be committing a serious error if it did not recognize the possibility that such products might in the long term lead to a reduction in harm, but there was currently no evidence to indicate that that was the case, as the tobacco companies agreed. Regarding implementation of recommendations, he said that work had begun on introducing conflict of interest forms across WHO; the forms had been developed with the Office of the Legal Counsel, and the first template for monitoring tobacco companies in nine countries had begun to provide information. WHO needed to continue a dialogue with tobacco companies on certain important areas; however, all contacts were being carefully logged. Regarding options for restitution and legal redress for harm caused by tobacco companies, he said that the Regional Office for the Eastern Mediterranean and WHO headquarters would host a meeting in February 2001 on litigation and inquiries. Referring to the comments made by the Regional Director for the Americas, he said that he could not agree with the conclusions of the evaluation team; its report contained serious errors and oversights which he would be drawing to Dr Alleyne's attention. Dr ALLEYNE (Regional Director for the Americas) said that it might have been more appropriate to convey such comments on an internal basis and in advance of the Board's session; there had been ample time for that. Furthermore, it was his view that those comments were based on partial information only. He would have more to say on the matter on another occasion. The CHAIRMAN said that the Board would take note ofDr Alleyne's comments. Injection safety: Item 9.8 of the Agenda (Document EB107/23)

Mrs ABEL (Vanuatu) said that, with a view to ensuring injection safety, WHO and UNICEF had organized the purchase of an incinerator for Vanuatu by Rotary Japan, which would be installed in April 2001. Vanuatu would welcome information on the type of incinerator to be provided, and on the likely costs of maintenance. Dr FETISOV (Russian Federation) noted the absence of any reference in the report to the use of needle-less injection techniques. Russian experts considered that existing techniques should be modernized and new techniques developed so as to enhance injection safety. He would welcome comments on that question. Dr N'GAINDIRO (Central African Republic) said that reuse of syringes was a notorious problem in Africa, leading to the transmission of hepatitis B and C viruses and HIV. He would therefore welcome information on the availability of large auto-disable syringes.

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Dr SUZUKI (Executive Director) replied that, in view of its specific nature, he would discuss the issue raised by Mrs Abel individually. As to Dr Fetisov's question, while needle-less jet injectors were available for use on a small scale in industrialized countries, but safe versions for use in mass vaccination in the developing countries were still at the design stage. Responding to Dr N' ga'indiro, he said that WHO was committed to making large auto-disable syringes widely available, but those, too, were still being developed.

TECHNICAL AND HEALTH MATTERS: Item 3 of the Agenda (resumed)

Global strategy for infant and young child feeding (decision WHA53(10)): Item 3.1 of the Agenda (Document EB 107/3) (continued from second meeting) Dr LARIVlERE (Canada), speaking as the Chairman of the drafting group on infant and young child nutrition, explained that he had chaired the final stages of the deliberations, as Mr Chowdhury had had to leave Geneva. Owing to time constraints, it had not been possible to make the text of the draft resolution agreed by the drafting group available in all official languages. The consensus, a fragile one, had been the result of very hard work. The sometimes inelegant drafting reflected the difficulty that had been experienced in achieving agreement on the substance. He hoped that the Health Assembly would be able to agree on the text of the resolution recommended for adoption by the Fifty-fourth World Health Assembly in the draft resolution, subject to clarification of the wording that appeared in square brackets. He thanked the members of the drafting group for their work. The Board was invited to consider the draft resolution, which read: The Executive Board, Having examined the report on the global strategy for infant and young child feeding; 1 Reiterating the importance of reducing all forms of malnutrition as a central condition for human development, Emphasizing, in particular, the significance of good nutrition for the health and development of infants and young children everywhere, and the crucial role of appropriate exclusive breastfeeding, complementary feeding and feeding practices in protecting and improving their nutritional status; RECOMMENDS to the Fifty-fourth World Health Assembly the adoption of the following resolution: The Fifty-fourth World Health Assembly, Recalling resolutions WHA33.32, WHA34.22, WHA35.26, WHA37.30, WHA39.28, WHA41.11, WHA43.3, WHA45.34, WHA46.7, WHA47.5 and WHA49.15 on infant and young child nutrition, appropriate feeding practices and related questions; Deeply concerned to improve infant and young child nutrition and to alleviate all forms of malnutrition in the world because more than one-third of under-five children are still malnourished - whether stunted, wasted, or deficient in iodine, vitamin A, iron or other micronutrients - and because malnutrition still contributes to nearly half of the 10.5 million deaths each year among preschool children worldwide; Deeply alarmed that malnutrition of infants and young children remains one of the most severe global public health problems, at once a major cause and consequence of poverty, deprivation, food insecurity and social inequality, and that malnutrition is a

Document EB107/3.

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cause not only of increased vulnerability to infection and other diseases, including growth retardation, but also of intellectual, mental, social and developmental handicap, and of increased risk of disease throughout childhood, adolescence and adult life; Recognizing the right of everyone to have access to safe and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be free from hunger, and that every effort should be made with a view to achieving progressively the full realization of this right; Acknowledging the need for all sectors of society - including governments, civil society, health professional associations, nongovemmental organizations, commercial enterprises and international bodies - to contribute to improved nutrition for infants and young children by using every possible means at their disposal, especially by fostering optimal feeding practices, incorporating a comprehensive multisectoral, holistic and strategic approach; Noting the guidance of the Convention on the Rights of the Child, in particular Article 24, which recognizes, inter alia, the need for access to and availability of both support and information concerning the use of basic knowledge of child health and nutrition, and the advantages of breastfeeding for all segments of society, in particular parents and children; Conscious that despite the fact that the International Code of Marketing of Breastmilk Substitutes and relevant, subsequent Health Assembly resolutions state that there should be no advertising or other forms of promotion of products within its scope, new modem communication methods, including electronic means, are currently increasingly being used to promote such products; and conscious of the need for the Codex Alimentarius Commission to take the International Code and subsequent relevant Health Assembly resolutions into consideration in dealing with health claims in the development of food standards and guidelines; Mindful that 2001 marks the twentieth anniversary of the adoption of the International Code of Marketing of Breast-milk Substitutes, and that the adoption of this resolution provides an opportunity to reinforce the International Code's fundamental role in protecting, promoting and supporting breastfeeding; Recognizing that there is a sound scientific basis for policy decisions to reinforce activities of Member States and those of WHO; for proposing new and innovative approaches to monitoring growth and improving nutrition; for promoting improved breastfeeding and complementary feeding practices, and sound culture-specific counselling; for improving the nutritional status of women of reproductive age, especially during and after pregnancy; for alleviating all forms of malnutrition; and for providing guidance on feeding practices for infants of mothers who are HIV -positive; Noting the need for effective systems for assessing the magnitude and geographical distribution of all forms of malnutrition, together with their consequences and contributing factors, and of foodbome diseases; and for monitoring food security; Welcoming the efforts made by WHO, in close collaboration with UNICEF and other international partners, to develop a comprehensive global strategy for infant and young child feeding, and to use the ACC Sub-Committee on Nutrition as an interagency forum for coordination and exchange of information in this connection, 1. THANKS the Director-General for the progress report on the development of a new global strategy for infant and young child feeding; 2. URGES Member States: ( 1) to recognize the right of everyone to have access to safe and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be free from hunger, and that every effort should be made with a view to achieving

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progressively the full realization of this right and to call on all sectors of society to cooperate in efforts to improve the nutrition of infants and young children; (2) to take necessary measures as States Parties effectively to implement the Convention on the Rights of the Child, in order to ensure every child's right to the highest attainable standard of health and health care; (3) to set up or strengthen interinstitutional and intersectoral discussion forums with all stakeholders in order to reach national consensus on strategies and policies including reinforcing, in collaboration with ILO, policies that support breastfeeding by working women, in order substantially to improve infant and young child feeding and to develop participatory mechanisms for establishing and implementing specific nutrition programmes and projects aimed at new initiatives and innovative approaches; (4) to strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding [during the first 4 to 6 months of life][for about 6 months], 1 and to provide safe and appropriate complementary foods, with continued breastfeeding for up to two years of age or beyond, emphasizing channels of social dissemination of these concepts in order to lead communities to adhere to these practices; (5) to support the Baby-friendly Hospital Initiative and to create mechanisms, including regulations, legislation or other measures, designed, directly and indirectly, to support periodic reassessment of hospitals, and to ensure maintenance of standards and the Initiative's long-term sustainability and credibility; (6) to improve complementary foods and feeding practices by ensuring sound and culture-specific nutrition counselling to mothers of young children, recommending the widest possible use of indigenous nutrient-rich foodstuffs; and to give priority to the development and dissemination of guidelines on nutrition of children under two years of age, to the training of health workers and community leaders on this subject, and to the integration of these messages into health and nutrition information, education and communication strategies; (7) to strengthen monitoring of growth and improvement of nutrition, focusing on community-based strategies, and to strive to ensure that all malnourished children, whether in a community or hospital setting, are correctly diagnosed and treated; (8) to develop, implement or strengthen sustainable measures, including where appropriate, legislative measures, aimed at reducing all forms of malnutrition in young children and women of reproductive age, especially iron, vitamin A and iodine deficiencies, through a combination of strategies that include supplementation, food fortification and diet diversification, through recommended feeding practices that are culture-specific and based on local foods as well as through other community-based approaches; (9) to strengthen national mechanisms to ensure global compliance with the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions, with regard to labelling as well as all forms of advertising, and commercial promotion in all types of media, to encourage the Codex Alimentarius Commission to take the International Code and relevant subsequent Health Assembly resolutions into consideration in developing its standards and guidelines; and to inform the general public on progress in implementing the Code and subsequent relevant Health Assembly resolutions; 1 The final text in square brackets will be decided in the light of the outcome of the systematic review ofthe scientific literature, a global peer review, and the conclusions and recommendations of an expert consultation (Geneva, 28-30 March 2001).

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( 10) to recognize and assess the available scientific evidence on the balance of risk of HIV transmission through breastfeeding compared with the risk of not breastfeeding, and the need for independent research in this connection; to strive to ensure adequate nutrition of infants of HIV -positive mothers; to increase accessibility to voluntary and confidential counselling and testing so as to facilitate the provision of information and informed decision-making; and to recognize that when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV -positive women is recommended; that, otherwise, exclusive breastfeeding is recommended during the first months of life; and that those who choose other options should be encouraged to use them free from commercial influences; (11) to take all necessary measures to protect all women from the risk of HIV infection, especially during pregnancy and lactation; (12) to strengthen their information systems, together with their epidemiological surveillance systems, in order to assess the magnitude and geographical distribution of malnutrition, in all its forms, and food borne disease; 3. REQUESTS the Director-General: ( 1) to give greater emphasis to infant and young child nutrition, in view of WHO's leadership in public health, consistent with and guided by the Convention on the Rights of the Child and other relevant human rights instruments, in partnership with ILO, FAO, UNICEF, UNFPA and other competent organizations both within and outside the United Nations system; (2) to foster, with all relevant sectors of society, a constructive and transparent dialogue in order to monitor progress towards implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions, in an independent manner and free from commercial influence, and to provide support to Member States in their efforts to monitor implementation of the Code; (3) to provide support to Member States in the identification, implementation and evaluation of innovative approaches to improving infant and young child feeding, emphasizing exclusive breastfeeding [during the first 4 to 6 months of life] [for about 6 months]/ and the provision of safe and appropriate complementary foods, with continued breastfeeding up to two years of age or beyond, and with emphasis on community-based and cross-sector activities; (4) to continue the step-by-step country- and region-based approach to developing the new global strategy on infant and young child feeding, and to involve the international health and development community, in particular UNICEF, and other stakeholders as appropriate; (5) to encourage and support further independent research on HIV transmission through breastfeeding and on other measures to improve the nutritional status of mothers and children already affected by HIVI AIDS; (6) to submit the global strategy for consideration to the Executive Board at its 109th session in January 2002 and to the Fifty-fifth World Health Assembly (May 2002).

The CHAIRMAN suggested that, in view of the fragile nature of the consensus reached, the Board might wish to adopt the text as submitted. 1 The final text in square brackets will be decided in the light of the outcome of the systematic review of the scientific literature, a global peer review, and the conclusions and recommendations of an expert consultation (Geneva, 28-30 March 2001).

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Ms BLACKWOOD (alternate to Dr Novotny, United States of America) asked for clarification regarding the phrase "subsequent relevant Health Assembly resolutions", which was used several times in the text of the draft resolution. The drafting group's discussions had clearly reflected Health Assembly resolutions that had already been adopted. She could not agree to the inclusion of the word "subsequent" if it might be interpreted as referring to resolutions that had not yet been adopted. The seventh preambular paragraph of the resolution contained in the draft resolution mentioned advertising and specifically referred to electronic means of promotion. In her view, it was not helpful to single out any one sector of commerce; the resolution should stress that there should be no advertising or promotion of any kind. Ms COSTA COITINHO (alternate to Professor Yunes, Brazil) expressed satisfaction with the text produced by the drafting group. The matter that remained undecided was the recommended period for exclusive breastfeeding, which would be resolved by the Fifty-fourth World Health Assembly. With reference to Ms Blackwood's comments concerning electronic methods of advertising, she pointed out that the Internet was a global medium that reached health workers and consumers worldwide. Moreover, the International Code of Marketing of Breast-milk Substitutes was increasingly being flouted by advertisers in that medium. The general consensus in the drafting group had therefore been that there should be a specific reference to electronic advertising in the preamble. Mr TOPPING (Legal Counsel), responding to Ms Blackwood, said that he interpreted the reference in the text to "subsequent relevant Health Assembly resolutions", which followed the reference to the International Code of Marketing of Breast-milk Substitutes, to denote the resolutions cited in the first preambular paragraph which had been adopted following the adoption of the Code. The CHAIRMAN noted that Ms Blackwood was satisfied with that explanation and invited the Board to adopt the draft resolution as submitted.

The resolution was adopted. 1

CLOSURE OF THE SESSION: Item 10 ofthe Agenda After the customary exchange of courtesies, the CHAIRMAN declared the session closed.

The meeting rose at 20:00.

Resolution EBI07/Rl6.

Key facts

Organisation World Health Organization (WHO)

Document type Governing Bodies documents

Adoption date December 31, 2001

Source World Health Organization