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Executive Board 109th session, Geneva, 14-21 January 2002: summary records

December 31, 2002 World Health Organization

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EB 109/2002/REC/2

WORLD HEALTH ORGANIZATION

EXECUTIVE BOARD 109TH SESSION GENEVA, 14-21 JANUARY 2002

SUMMARY RECORDS

GENEVA 2002

EB 109/2002/REC/2

WORLD HEALTH ORGANIZATION

EXECUTIVE BOARD 109TH SESSION GENEVA, 14-21 JANUARY 2002

SUMMARY RECORDS

GENEVA 2002

ABBREVIATIONS

Abbreviations used in WHO documentation include the following: ACHR ASEAN CEB - Advisory Committee on Health Research - Association of South-East Asian Nations - United Nations System Chief Executives Board for Coordination (formerly ACC) - Council for International Organizations of Medical Sciences - Food and Agriculture Organization of the United Nations - International Atomic Energy Agency - International Agency for Research on Cancer - International Civil Aviation Organization - International Fund for Agricultural Development - International Labour Organization (Office) - International Monetary Fund - International Maritime Organization - International Telecommunication Union - 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 UNEP - United Nations Environment 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 WFP World Food Programme WIPO World Intellectual Property Organization WMO World Meteorological Organization WTO World Trade Organization

CIOMS

FAO

IAEA IARC ICAO IFAD ILO IMF IMO ITU OAU OECD

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.

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PREFACE

The 109th session of the Executive Board was held at WHO headquarters, Geneva, from 14 to 21 January 2002. 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 published in document EB 109/2002/REC/1.

-Ill-

CONTENTS

Page Preface.............................................................................................................................................. Agenda............................................................................................................................................. List of documents............................................................................................................................. List of members and other participants ........................................................................................... . Committees and working groups ....... .. .. ........ .... .. .. ........ .... ... ........... .. .... ...... .... .. .... .. ... .. .. ... ... ... .. .. .... 21 iii tx xiii

SUMMARY RECORDS First meeting Opening of the session and adoption of the agenda......................................................................... 23

Second meeting 1. 2. 3. 4. Opening of the session and adoption ofthe agenda (continued) ....... ... ..... ..... ........... .. ..... .. ... Membership of the Jacques Parisot Foundation Selection Panel........................................... Report by the Director-General ........ .. ........... ... ....... ... ................ .... .......... .. .......... ............. .... Discussion on issues raised......................................................................................... Health strategy matters Public-private interactions for health: WHO's involvement....................................... 31 31 31 33 41

Third meeting Health strategy matters (continued) The role of contractual arrangements in improving health systems' performance................................................................................................................. Assessment of health systems' performance: report of the peer review...................... WHO medicines strategy • Expanding access to essential drugs........................................................................

45 49 56

-V-

Page

Fourth meeting Health strategy matters (continued) WHO medicines strategy (continued) • Expanding access to essential drugs (continued)..................................................... • Revised procedure for updating WHO's Model List of Essential Drugs................ The health of children and adolescents........................................................................ Food safety and health................................................................................................. Diet, physical activity and health................................................................................

60 64 72 74 76

Fifth meeting 1. 2. Health strategy matters (continued) Diet, physical activity and health (continued) ............................................................ . Other management matters Governing body matters • Review of working methods of the Executive Board .............................................. . Health strategy matters (resumed) Intensifying the response to the conditions associated with poverty, including the Global Fund to fight AIDS, Tuberculosis and Malaria ........................ .

Sixth meeting Health strategy matters (continued) Intensifying the response to the conditions associated with poverty, including the Global Fund to fight AIDS, Tuberculosis and Malaria (continued)...... Quality of care: patient safety...................................................................................... Infant and young child nutrition • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes................................... • Global strategy for infant and young child feeding ........... ....... ...............................

96 100

106 106

Seventh meeting Health strategy matters (continued) Infant and young child nutrition (continued) • Childhood nutrition and progress in implementing the International Code ofMarketing of Breast-milk Substitutes (continued)............................................................................................................... • Global strategy for infant and young child feeding (continued) ................. ................................................................................ ...... ........ Violence and health..................................................................................................... Dengue prevention and control ... ... ............. .. ........ ........ ... ... .. .................... ......... ... .... .. Deliberate use of biological and chemical agents to cause harm................................ Smallpox eradication: destruction of variola virus stocks...........................................

111 111 113 118 120 126

Eighth meeting 1. Health strategy matters (continued) Smallpox eradication: destruction ofvariola virus stocks (continued)....................... Global health sector strategy for HIV/AIDS ...............................................................

128 130

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Page 2. Other management matters (continued) Governing body matters (continued) • Review of working methods of the Executive Board (continued)........................... Report by the Director-General (continued) Consideration of draft resolutions ..... .. ... ...... .. ...... .. .. ... ... ........ ...•..... ....... ....... ... ... .. ...... Health strategy matters (resumed) The role of contractual arrangements in improving health systems' performance (continued) Consideration of draft resolutions..................................................................... Human resources Reform of human resources management ........... .. .. ...... .... .. ... ................ ......... .... ........ Matters for information Annual report on human resources.............................................................................. Human resources (resumed) Statement by the representative of the WHO staff associations..................................

136 141

3. 4.

144 145 147 147

5. 6. 7.

Ninth meeting 1. Other management matters (continued) Appointment of the Regional Director for the Eastern Mediterranean ..... .. .. .............. Reports of the Executive Board Committees • Awards..................................................................................................................... Human resources (continued) Statement by the representative of the WHO staff associations (continued) .............. Amendments to the StaffRules................................................................................... Press coverage ofthe current session ofthe Executive Board............................................... Health strategy matters (continued) Quality of care: patient safety (continued) ........ .... ........ .. ............................................ WHO medicines strategy (continued)......................................................................... Infant and young child nutrition (continued) • Global strategy for infant and young child feeding (continued).............................. Programme and budget matters Meeting oflnterested Parties, 2001 .................... ........ ...................... ............ ....... ........ Priorities for the biennium 2004-2005.. ...... ......... ................................................... .. ...

151 153 154 155 157 157 158 161 164 166

3. 4.

Tenth meeting 1. 2. Programme and budget matters (continued) Miscellaneous income................................................................................................. Financial matters Assessed contributions • Status of collection................................................................................................... • Assessments for 2003 ........................ ......... ....... ........ ......... .. ..................... .............. Revolving and other long-term funds.......................................................................... Other management matters (continued) Reports of the Executive Board Committees (continued) • Programme Development Committee...................................................................... • Administration, Budget and Finance Committee..................................................... • Audit Committee...................................................................................................... • Nongovernmental organizations.............................................................................. • WHO/UNICEFIUNFP A Coordinating Committee on Health................................. Reports of the Joint Inspection Unit............................................................................ Governing body matters (continued) • Future sessions......................................................................................................... -VII-

171

171 172 173

175 176 176 177 177 178 179

Page

Matters for information (continued) Report on meetings of expert committees and study groups (and report on appointments to expert advisory panels and committees)............................ Global Alliance for Vaccines and Immunization ... ... .. ...... .......... .... ... ... ... .. ........ ...... ... Eradication of poliomyelitis ........... .. .. ... ...... ... ........ ... ........ .......... .. .. ...... ........... ... ... ... .. Date and place of the I lOth session ofthe Executive Board....................................... Closure of the session............................................................................................................

182 183 184 185 185

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AGENDA 1

1. 2.

Opening of the session and adoption of the agenda Report by the Director-General • Discussion on issues raised

Health strategy matters 3.1 Intensifying the response to the conditions associated with poverty, including the Global Fund to Fight AIDS, Tuberculosis and Malaria Public-private interactions for health: WHO's involvement The role of contractual arrangements in improving health systems' performance Quality of care: patient safety Assessment of health systems' performance: report of the peer review WHO medicines strategy • Expanding access to essential drugs • Revised procedure for updating WHO's Model List of Essential Drugs

3.2 3.3 3.4 3.5 3.6

3. 7

The health of children and adolescents Infant and young child nutrition • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes • Global strategy for infant and young child feeding

3.8

3.9

Food safety and health

3 .I 0 Diet, physical activity and health 3.11 Violence and health

3.12 Dengue prevention and control

As adopted by the Board at its first meeting (14 January 2002).

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EXECUTIVE BOARD, 109TH SESSION

3.13 Deliberate use of biological and chemical agents to cause harm 3.14 Smallpox eradication: destruction of variola virus stocks 3.15 Global health sector strategy for HIVIAIDS 4. Programme and budget matters 4.1 4.2 4.3 5. Meeting of Interested Parties, 2001 Priorities for the biennium 2004-2005 Miscellaneous income

Financial matters 5.1 Assessed contributions • Status of collection • Assessments for 2003 5.2 Revolving and other long-term funds

Human resources 6.1 6.2 6.3 Reform of human resources management Statement by the representative of the WHO staff associations Amendments to the Staff Rules

Other management matters 7.1 7.2 Appointment of the Regional Director for the Eastern Mediterranean Reports of the Executive Board Committees • Programme Development Committee • Administration, Budget and Finance Committee • Audit Committee • Nongovemmental organizations • WHO/UNICEF!UN FPA Coordinating Committee on Health • Awards

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AGENDA

7.3 7.4

Reports of the Joint Inspection Unit Governing body matters • Review of working methods of the Executive Board • Future sessions

Matters for information 8.1 Report on meetings of expert committees and study groups (and report on appointments to expert advisory panels and committees) Global Alliance for Vaccines and Immunization Eradication of poliomyelitis Annual report on human resources

8.2 8.3 8.4 9.

Closure of the session

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LIST OF DOCUMENTS

EB109/1 Rev.1 EB109/2

Agenda 1 Statement by the Director-General to the Executive Board at its 109th session Intensifying the response to the health conditions associated with poverty, including the Global Fund to Fight AIDS, Tuberculosis and Malaria Public-private interactions for health: WHO's involvement The role of contractual arrangements in improving health systems performance Assessment of health systems' performance: report ofthe peer review WHO medicines strategy. Expanding access to essential drugs WHO medicines strategy. Revised procedure for updating WHO's Model List of Essential Drugs Quality of care: patient safety The health of children and adolescents Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes Infant and young child nutrition. Global strategy for infant and young child feeding Food safety and health Diet, physical activity and health Violence and health Dengue prevention and control Smallpox eradication: destruction of variola virus stocks Meeting of Interested Parties, 2001

EB109/3

EB109/4 EB109/5

EB109/6 EB109/7 EB109/8

EB109/9 EB109/10 EB109111

EB109/12

EB109/13 EB109/14 EB109/15 EB109/16 EB109/17 EB109/18

See page ix.

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EXECUTIVE BOARD, I 09TH SESSION

EBI09/19 EB I 09/20, Corr.l and Add. I EBI09/21 EBI09/22 EBI09/23 EBI09/24

Priorities for the biennium 2004-2005 Status of collection of assessed contributions including Members in arrears to an extent which would justify invoking Article 7 of the Constitition Assessments for 2003 Revolving and other long-term funds Miscellaneous Income Review of working methods of the Executive Board. Committees of the Executive Board Reform of human resources management The deliberate use of biological and chemical agents to cause harm: public health response Confirmation of amendments to the Staff Rules Amendments to the Staff Rules Appointment of the Regional Director for the Eastern Mediterranean Collaboration with nongovemmental organizations. Report of the Standing Committee on Nongovemmental Organizations Reports ofthe Joint Inspection Unit. Review of management and administration in the World Health Organization Reports of the Joint Inspection Unit Review of the working methods of the Executive Board Future sessions: provisional agenda for the Fifty-fifth World Health Assembly Report on meetings of expert committees and study groups Report on expert advisory panels and committees and their membership Global Alliance for Vaccines and Immunization Eradication of poliomyelitis Global health-sector strategy for HIVIAIDS Annual report on human resources

EBI09/25 EBI09/26

EB109/27 EB109/27 Add.l EBI09/28 EBI09/29

EBI09/30

EB109/30 Add.l EBI09/3I EBI09/32

EBI09/33 EBI09/33 Add.l EBI09/34 EB I 09/3 5 and Corr.l EBI09/36 EBI09/37

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LIST OF DOCUMENTS

EB109/38

Reports of the Executive Board Committees. Report WHOIUNICEFIUNFPA Coordinating Committee on Health

the

Information documents EB109/INF.DOC./l EB I 09/INF.DOC./2 Statement by the representative of the WHO staff associations Assessments for 2003

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LIST OF MEMBERS AND OTHER PARTICIPANTS

MEMBERS, ALTERNATES AND ADVISERS VANUATU Mrs M. ABEL, Director of Public Health, Ministry of Health, Port Vila (Chairman)

BELGIUM Dr G. TillERS, Directeur, Institut scientifique de la Sante publique- Louis Pasteur, Bruxelles Alternates Mme M. AEL VOET, Ministre de la Protection de la Consommation, de la Sante publique et de I'Environnement, Bruxelles M. J.-M. NOIRFALISSE, Ambassadeur, Representant permanent, Geneve M. B. COOLS, Conseiller, Cabinet de Madame la Ministre de la Protection de la Consommation, de la Sante publique et de l'Environnement, Bruxelles Mme J. ZIKMUNDOVA, Conseiller, Mission permanente, Geneve M. A. CREUSEN, Conseiller d' Ambassade, Ministere des Affaires etrangeres, Bruxelles M. A. BERW AERTS, Directeur general, Ministere de la Sante publique, Bruxelles Mme L. MEULENBERGS, Conseiller adjoint, Ministere de la Sante publique, Bruxelles M. P. NAYER, Delegue de la Communaute fran((aise et de la Region wallonne de Belgique, Geneve M. H. V AN OYEN, Chef de Section, Institut scientifique de la Sante publique- Louis Pasteur, Bruxelles M. M. GINTER, Attache principal de la Carriere exterieure aupres de la Delegation WallonieBruxelles, Geneve

BRAZIL Professor J. YUNES, Professor, Public Health Faculty, University ofSao Paulo, Sao Paulo Alternates Ms C.M.A. DO V ALLE PEREIRA, Deputy Permanent Representative, Geneva Mr F.S. DUQUE ESTRADA MEYER, Minister Counsellor, Permanent Mission, Geneva Mr C.L. SALM, Assistant to the Health Minister, Ministry of Health, Brasilia Ms D. COSTA COUTINHO, Coordinator ofthe Technical Area of Food and Nutrition, Secretariat of Health Policies, Ministry of Health, Bras ilia Mr J. BARBAROSA DA SILVA JUNIOR, Director, National Epidemiological Centre, National Health Foundation, Ministry of Health, Brasilia Mr J. BERMUDEZ, Director, National School of Public Health, Oswaldo Cruz Foundation, Ministry of Health, Brasilia Mr R. OLIVA, Director for Food and Toxicology, Office of the Surgeon General, Ministry of Health, Brasilia Mr J.M. NOGUEIRA VIANA, Head, International Affairs Division, Ministry of Health, Bras ilia

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EXECUTIVE BOARD, 109TH SESSION

Mr J. GON<;ALVES VALENTE, Researcher, National School of Public Health, Oswaldo Cruz Foundation, Ministry of Health, Bras ilia Ms C. LANDMAN, Researcher, National School of Public Health, Oswaldo Cruz Foundation, Ministry of Health, Bras ilia Mr F. COSTI SANTAROSA, Second Secretary, Permanent Mission, Geneva Ms R. MUNHOZ, Assistant for External Cooperation, National Coordination for Sexually Transmitted Diseases and AIDS, Ministry of Health, Bras ilia Mr R. BONIFACIO, Deputy Coordinator for Sexually Transmitted Diseases and AIDS, Ministry of Health, Bras ilia Mr J.A. DOURADO QUINTAES, First Secretary, International Affairs Division, Ministry of Health, Brasilia

CHAD Dr M.E. MBAIONG, Directeur general adjoint, Ministere de la Sante publique, N'Djamena

COLOMBIA Dr J. BOSHELL, Director General, Instituto Nacional de Salud, Santafe de Bogota Alternates Sr C. REYES RODRiGUEZ, Embajador, Representante Permanente, Ginebra Sra F.E. BENAVIDES COTES, Ministro Plenipotenciario, Misi6n Permanente, Ginebra

COMOROS Dr A. MSA MLIV A, Directeur general de la Sante, Ministere de la Sante publique, des Affaires sociales et de la Condition feminine, Moroni Alternate M. M. ABDOU MOUIGNI, Directeur general des Finances et du Budget, Moroni

CONGO Dr D. BODZONGO, Directeur general de la Sante, Ministere de la Sante, de la Solidarite et de 1'Action humanitaire, Brazzaville (Rapporteur) Alternates M. H. KENGOUY AT, Conseiller juridique, Ministere de la Sante, de la Solidarite et del' Action humanitaire, Brazzaville Mme D. BIKOUTA, Premier Conseiller, Mission permanente, Geneve

COTE D'IVOIRE Professeur R. ABOUO-N'DORI, Ministre de la Sante publique, Abidjan Alternates M. C. BEKE DASSYS, Ambassadeur, Representant permanent, Geneve Dr F .B. TOURE, Secretariat technique permanent du Plan national de Developpement du Secteur sanitaire, Abidjan

MEMBERS AND OTHER PARTICIPANTS

M. J.K. WEYA, Premier Conseiller, Mission permanente, Geneve Dr F. KOUNANDY, Directeur, Inspection de la Medecine du Travail, Abidjan

CUBA Dr C. DOTRES MARTINEZ, Ministro de Salud Publica, La Habana Alternates Sr C. AMAT FORES, Embajador, Representante Permanente, Ginebra Sr J.I. MORA GODOY, Representante Permanente Suplente, Ginebra Dr A. GONZALEZ FERNANDEZ, Director de Relaciones Intemacionales, Ministerio de Salud Publica, La Habana Dr R. BORROTO, Director, Escuela Nacional de Salud Publica, Ministerio de Salud Publica, La Habana Advisers Dr A. ALV AREZ PEREZ, Asesor del Ministro de Salud Publica, La Habana Sra A. RODRiGUEZ CAMEJO, Segundo Secretario, Misi6n Permanente, Ginebra Sr A. CASTILLO SANTANA, Tercer Secretario, Misi6n Permanente, Ginebra

DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA Mr JANG CHUN SIK, Counsellor, Permanent Mission, Geneva (alternate to Dr Kim Won Ho) Alternates Mr KIM SONG CHOL, Counsellor, Permanent Mission, Geneva Mr KIM YONG HO, Second Secretary, Permanent Mission, Geneva

EGYPT Dr I. SALLAM, Minister of Health and Population, Cairo Alternates Dr W. ANWAR, Adviser to the Minister of Health and Population, Ministry of Health and Population, Cairo Dr E. MAN SOUR, Director, Essential Care Department, Ministry of Health and Population, Cairo Mr H. SELIM LABIB, Counsellor, Permanent Mission, Geneva

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

ERITREA Dr Z. ALEMU, Director, Primary Health Care Division, Ministry of Health, Asmara

EXECUTIVE BOARD, 109TH SESSION

ETHIOPIA Dr GIRMA A., Head, Department ofPlanning and Programming, Ministry of Health, Addis Ababa (alternate to Dr Kebede T.)

GRENADA Dr C. MODESTE-CURWEN, Minister of Health and the Environment, St George's (Rapporteur)

GUATEMALA Dr I. LEMUS BOJORQUEZ, Director, Sistema Integral de Atenci6n en Salud, Ministerio de Salud Publica y Asistencia Social, Ciudad de Guatemala Alternates Sr A. ARENALES FORNO, Embajador, Representante Permanente, Ginebra SrI. ESPINOZA FARF AN, Ministro Consejero, Misi6n Permanente, Ginebra Srta S. HOCHSTETTER, Segundo Secretario, Misi6n Permanente, Ginebra

INDIA Mr J.A. CHOWDHURY, Secretary, Health and Family Welfare, New Delhi (Vice-Chairman) Alternates Ms S. KUNADI, Ambassador, Permanent Representative, Geneva Dr S.P. AGGARWAL, Director-General ofHealth Services, Ministry ofHealth and Family Welfare, New Delhi Mr S. SABHARW AL, 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, Tehran (Vice-Chairman) Alternate Mr P. SEADAT, First Se,cretary, Permanent Mission, Geneva Adviser Mr R. POURMAND-TEHRANI, First Secretary, Permanent Mission, Geneva

ITALY Dr M. DI GENNARO, Directeur general du Systeme de !'Information et de la Statistique, Direction du Systeme d'Information sanitaire et des Investissements structuraux et technologiques, Ministere de la Sante, Rome Alternates M. F. CICOGNA, Bureau des Relations intemationales, Ministere de la Sante, Rome M. G. MAJORI, Directeur, Laboratoire de Parasitologie, Ministere de la Sante, Rome Mme N. QUINTAVALLE, Conseiller, Mission permanente, Geneve

MEMBERS AND OTHER PARTICIPANTS

JAPAN Dr H. SHINOZAKI, Director-General, Health Policy Bureau, Ministry of Health, Labour and Welfare, Tokyo Alternates Mr 0. TASAKA, Director, International Affairs Planning Office, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo Mr M. W AT ANABE, Counsellor, Permanent Mission, Geneva Dr K. OKAMOTO, 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 Dr M. SAKOI, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo MrS. HEMMI, First Secretary, Permanent Mission, Geneva Mr I. TSUNOI, Deputy Director, International Affairs Planning Office, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo Dr A. SAKUMA, Deputy Director, Evaluation and Licensing Division, Pharmaceutical Medical Safety Bureau, Ministry of Health, Labour and Welfare, Tokyo Mr G. OTANI, International Affairs Planning Office, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, Tokyo

JORDAN Dr S. AL KHARABSEH, Director-General, Primary Health Care, Ministry of Health and Health Care, Amman (alternate to Dr F. El Nasser) Alternates Mr S.A. MADI, Ambassador, Permanent Representative, Geneva Mr M. QASEM, Head of International Health, Ministry of Health and Health Care, Amman Mr W. OBEIDAT, Second Secretary, Permanent Mission, Geneva

KAZAKHSTAN Professor M. KULZHANOV, Rector, Kazakhstan School of Public Health, Almaty

LEBANON Dr K. KARAM, Minister of Tourism and Alternate Minister of Health, Beirut

LITHUANIA Professor V.J. GRABAUSKAS, Rector, Kaunas University of Medicine, Kaunas Alternates Mr A. RIMKUNAS, Ambassador, Permanent Representative, Geneva Mr E. PETRIKAS, Minister Counsellor, Permanent Mission, Geneva

EXECUTIVE BOARD, 109TH SESSION

MYANMAR Mr KET SEIN, Minister of Health, Yangon Alternates Mr MYA THAN, Ambassador, Permanent Representative, Geneva Dr KYI SOE, Director-General, Department of Health Planning, Yangon Professor MAUNG MAlJNG WINT, Director-General, Department of Medical Sciences, Yangon Dr PE THET TUN, Director, International Health Division, Ministry of Health, Yangon Mr TIN MAUNG A YE Deputy Permanent Representative, Geneva Advisers Mr TUN OHN Counsellor, Permanent Mission, Geneva Mrs A YE A YE MU, Counsellor, Permanent Mission, Geneva Mrs El El TIN, First Secretary, Permanent Mission, Geneva Mr YE HTUT, First Secretary, Permanent Mission, Geneva Mr SOE AUNG, Third Secretary, Permanent Mission, Geneva

PHILIPPINES Dr A.G. ROMUALDEZ, Jr, President, Friendly Care Foundation Inc., Mandaluyong City, Alternate Ms M.E. CALLANGAN RUECA, First Secretary, Permanent Mission, Geneva

REPUBLIC OF KOREA Dr Y.-J. OM, Special Adviser, Ministry of Health and Welfare, Seoul Alternates Dr C.-J. MOON, Counsellor, Permanent Mission, Geneva Mr D.-I. SHIN, Counsellor, Permanent Mission, Geneva Mr H.-W. HAN, Deputy Director, International Cooperation Division, Ministry of Health and Welfare, Seoul Ms S.H. KIM, Deputy Director, Division of Human Rights and Social Affairs, Ministry of Foreign Affairs and Trade, Seoul Ms T.H. KIM, Special Officer, International Cooperation Division, Ministry of Health and Welfare, Seoul

SAUDI ARABIA Dr Y.Y. AL-MAZROU, Assistant Deputy Minister, Preventive Medicine Department, Ministry of Health, Riyadh

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, Counsellor, Ministry of Health and Social Affairs, Stockholm Ms B. SCHMIDT, Senior Adviser, National Board of Health and Welfare, Stockholm

MEMBERS AND OTHER PARTICIPANTS

Ms P. STAYAs, First Secretary, Permanent Mission, Geneva Ms K. RANGNITT, First Secretary, Permanent Mission, Geneva Dr A. MOLIN, Swedish International Development Cooperation Agency, Stockholm Mr I. SUNDQUIST, Counsellor, Ministry for Foreign Affairs, Stockholm

SWITZERLAND Professeur T. ZELTNER, Directeur de l'Office federal de la Sante publique, Berne (Vice-Chairman) Alternates Dr R. DURLER, Chef par interim, Section des Affaires internationales, Office federal de la Sante publique, Departement federal de l'Interieur, Berne Mme M. BERGER, Conseiller special (Sante publique et Developpement), Mission permanente, Geneve Advisers M. C. FAESSLER, Representant permanent adjoint, Geneve Dr F. DEL PONTE, Conseiller medical, Division de I' Aide humanitaire, Direction du Developpement et de la Cooperation, Departement federal des Affaires etrangeres, Berne M. R. VONOVIER, Premier Secretaire, Mission permanente, Geneve

UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND Sir Liam DONALDSON, Chief Medical Officer, Department of Health, London Alternates Dr P. TROOP, Deputy Chief Medical Officer, Department of Health, London Mr S. FULLER, Ambassador, Permanent Representative, Geneva Mr N. BOYD, Department of Health, London Ms H. NELLTHORP, First Secretary, Permanent Mission, Geneva Dr W. THORNE, Senior Public Health Adviser, Department of Health, London Mr J. BRADLEY, Second Secretary, Permanent Mission, Geneva MrS. SABEY, Public Health Specialist, Department for International Development, London Ms S. COTTON, Attache, Permanent Mission, Geneva Mr A. ROBB, Senior Public Health Specialist, Department for International Development, London Mr A. ROSS, Sexual and Reproductive Health Section, Department for International Development, London

VENEZUELA Dra N. LOPEZ, Directora de Epidemiologia y Amilisis Estrategico, Ministerio de Salud y Desarrollo Social, Caracas (alternate to Dr M.L. Urbaneja Durant) Alternates DraM. MORALES, Directora de Salud Poblacional, Ministerio de Salud y Desarrollo Social, Caracas Sra M. HERNANDEZ, Consejero, Misi6n Permanente, Ginebra

EXECUTIVE BOARD, 109TH SESSION

MEMBER STATES NOT REPRESENTED ON THE EXECUTIVE BOARD 1 ARGENTINA Sr E. V ARELA, Consejero, Misi6n Permanente, Ginebra

AUSTRALIA Ms J. BENNETT, Minister, Pennanent Mission, Geneva Mr B. ECKHARDT, Director, International Organisations Section, Department of Health and Ageing, Canberra Mr L. BRODRICK, First Secretary, Permanent Mission, Geneva Ms L. D'CRUZ, AusAID Assistant, Permanent Mission, Geneva

AUSTRIA Dr V. GREGORICH-SCHEGA, Head, International Health Relations, Department of Public Health, Federal Ministry for Social Security and Generations, Vienna Dr J.-P. KLEIN, Deputy Director, Department of Communicable Diseases, Federal Ministry for Social Security and Generations, Vienna Ms E. ATZLER, Minister, Permanent Mission, Geneva

BENIN M. S. AMEHOU, Representant permanent, Geneve Mme R.D. ADJANONHOUN, Attache, Mission permanente, Geneve

BOLIVIA Dr F. ANTEZANA ARANIBAR, Representante, Ministerio de Salud Publica y Previsi6n Social, LaPaz

BOTSWANA Mr G. PITSO, Second Secretary, Permanent Mission, Geneva

BULGARIA Ms B. DJONEV A, Attache, Permanent Mission, Geneva

Participating by virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

MEMBERS AND OTHER PARTICIPANTS

CANADA Mr C. WESTDAL, Ambassador, Alternate Permanent Representative, Geneva Dr J. LARIVIERE, Senior Medical Adviser, International Affairs Directorate, Health Canada, Ottawa Mr D.R. MACPHEE, Counsellor, Permanent Mission, Geneva Mr M. METHOT, Director, International Affairs Directorate, Health Canada, Ottawa Ms J. HUTT, Senior Programme Manager, United Nations and Commonwealth, Multilateral Programmes Branch, Canadian International Development Agency, Ottawa

CHILE Dra R. CHILD, Jefa, Relaciones Internacionales, Ministerio de Salud, Santiago Sr J.E. VEGA, Embajador, Representante Permanente, Ginebra Sr F. ERNST, Primer Secretario, Misi6n Permanente, Ginebra

CHINA Mr SHA Zukang, Ambassador, Permanent Representative, Geneva Mr LIU Peilong, Director-General, Department of International Cooperation, Ministry of Health, Beijing Mr QI Qingdong, Director, Department oflnternational Cooperation, Ministry of Health, Beijing Mr REN Yisheng, Director, Department of International Organizations and Conferences, Ministry of Foreign Affairs, Beijing Mr SHEN Yongxiang, Counsellor, Permanent Mission, Geneva Mr DIAO Mingsheng, Counsellor, Permanent Mission, Geneva Mr LONG Zhou, Second Secretary, Permanent Mission, Geneva

COSTA RICA Sra N. RUiZ DE ANGULO, Embajadora, Representante Permanente, Ginebra Sr S. CORELLA, Ministro Consejero, Misi6n Permanente, Ginebra Sr C. GUILLERMET, Ministro Consejero, Misi6n Permanente, Ginebra

CZECH REPUBLIC Mrs B. JANKASKOV A, Head of Section, Department oflnternational Relations, Ministry of Health, Prague Mr I. PINTER, Counsellor, Permanent Mission, Geneva Mrs E. SVIMBERSKA, Department of International Relations, Ministry of Health, Prague Mr J. SCHWIPPEL, Department of International Organizations, Ministry of Foreign Affairs, Prague

DENMARK Mr H.R. IVERSEN, Ambassador, Permanent Representative, Geneva Mrs L. GARV AL, Head of Section, Ministry ofF oreign Affairs, Copenhagen Mr M.B. JENSEN, Secretary of Embassy, Permanent Mission, Geneva MrS. THOMSEN, Head of Section, Ministry ofthe Interior and Health, Copenhagen

EXECUTIVE BOARD, 109TH SESSION

DOMINICAN REPUBLIC DraM. BELLO DE KEMPER, Consejero, Misi6n Permanente, Ginebra

ECUADOR Sr J.C. CASTRILLON, Primer :Secretario, Misi6n Permanente, Ginebra

FINLAND Ms A. VUORINEN, Minister Counsellor, Permanent Mission, Geneva Ms K. HAIKIO, Counsellor, Permanent Mission, Geneva Ms L. VALJENTO, Counsellor, Ministry for Foreign Affairs, Helsinki Ms A. RASSKASOV, Permanent Mission, Geneva

FRANCE M. B. KESSEDIJAN, Ambassadeur, Representant permanent, Geneve Professeur J.-F. GIRARD, President, Institut de Recherche pour le Developpement, Paris M. F. SAINT-PAUL, Representant permanent adjoint, Geneve M. J.-B. BRUNET, Direction g1~nerale de la Sante, Ministere de l'Emploi et de la Solidarite, Paris Mme F. AUER, Conseiller, Mis.sion permanente, Geneve Mme A. PINTEAUX, Delegation aux Affaires europeennes et intemationales, Ministere de l'Emploi et de la Solidarite, Paris

GABON Mme M. ANGONE ABENA, Conseiller, Mission permanente, Geneve

GERMANY Mr H. VOIGTLANDER, Ministerialdirigent, Federal Ministry of Health, Bonn Dr H. PEITSCH, Counsellor, Division United Nations Specialized Agencies, Federal Foreign Office, Berlin Mr K. BOTZET, Counsellor, Permanent Mission, Geneva Ms S. MICHEL, Attache, Permanent Mission, Geneva

GREECE Dr A. MILIOS, Counsellor, Permanent Mission, Geneva

GUINEA M. B.M. CAMARA, Representant permanent adjoint, Geneve

MEMBERS AND OTHER PARTICIPANTS

HUNGARY Mr A. NYIKOS, Second Secretary, Permanent Mission, Geneva

ICELAND Mr D.A. GUNNARSSON, Permanent Secretary, Ministry of Health and Social Security, Reykjavik Mr S.H. JOHANNESSON, Ambassador, Permanent Representative, Geneva Mr I. EINARSSON, Director, Ministry of Health and Social Security, Reykjavik Mrs I. DAVIDSDOTTIR, First Secretary, Permanent Mission, Geneva

IRELAND Or J. KIELY, Chief Medical Officer, Department of Health and Children, Dublin Ms M. A YL WARD, Assistant Principal Officer, Department of Health and Children, Dublin Mr E. MACAODHA, First Secretary, Permanent Mission, Geneva Mr B. ARDIFF, Attache, Permanent Mission, Geneva

ISRAEL Mr Y. LEVY, Ambassador, Permanent Representative, Geneva Or Y. SEVER, Director, General Medicine Division, Ministry of Health, Jerusalem Mr H. W AXMAN, Counsellor, Permanent Mission, Geneva Ms S. HERLIN, Adviser, Permanent Mission, Geneva

KENYA Mrs A.C. MOHAMED, Ambassador, Permanent Representative, Geneva Mr J.N. BUSIEGA, First Secretary, Permanent Mission, Geneva

LIBYAN ARAB JAMAHIRIYA Or S.S. A WENA T, Director of Health Services, General People's Committee for Health and Social Security, Sirt Or A. AMARA, National Pharmaceutical Company, Tripoli Ms N. AL SEGHAIR, Assistant Coordinator, Higher Committee for Children, Tripoli Ms Z. SAHLI, Counsellor, Permanent Mission, Geneva

LUXEMBOURG Mme M. PRANCHERE-TOMASSINI, Ambassadeur, Representant permanent, Geneve M. M.-H. GODEFROID, Premier Secretaire, Mission permanente, Geneve

EXECUTIVE BOARD, 109TH SESSION

MADAGASCAR Mme Y. PASEA, Conseiller, Mission permanente, Geneve

MEXICO Sr G. ALBIN, Embajador, Representante Permanente, Ginebra Sra L. SOSA MARQUEZ, Segundo Secretario, Misi6n Permanente, Ginebra

MONACO M. J.-P. BERTANI, Deuxieme Secretaire, Mission permanente, Geneve Mile A. MEDECIN, Mission permanente, Geneve

MOROCCO M. 0. HILALE, Ambassadeur, Representant permanent, Geneve Mme S. BOUASSA, Conseiller,, Mission permanente, Geneve

NETHERLANDS Mr H.J. HEINEMANN, Ambassador, Permanent Representative, Geneva Mr B.C.A.F. VAN DER HEIJDEN, Deputy Permanent Representative, Geneva Mr L. VAN DE HEIDEN, Senior Health Adviser, Ministry of Health, Welfare and Sports, The Hague Ms E.A.C. VAN GINNEKEN, Policy Officer, United Nations Department, Ministry of Foreign Affairs, The Hague Ms H. BOEX, Permanent Mission, Geneva Ms M.A.C.M. MIDDELHOFF, First Secretary, Permanent Mission, Geneva

NICARAGUA Srta C. SANCHEZ REYES, Ministro Consejero, Misi6n Permanente, Ginebra Sr S. URBINA GUERRERO, Primer Secretario, Misi6n Permanente, Ginebra Sr N. CRUZ TORuNO, Primer Secretario, Misi6n Permanent, Ginebra

NORWAY Ms H.C. SUNDREHAGEN, Director-General, Ministry of Health, Oslo Ms T. KONGSVIK, Adviser, Ministry of Foreign Affairs, Oslo Ms E. R0INE, Adviser, Ministry of Health, Oslo Dr P. WIUM, Directorate ofHe:alth and Social Affairs, Oslo Dr O.T. CHRISTIANSEN, Counsellor, Permanent Mission, Geneva

MEMBERS AND OTHER PARTICIPANTS

PAKISTAN Mr M. AKRAM, Ambassador, Permanent Representative, Geneva Mr I. HUSSAIN, First Secretary, Permanent Mission, Geneva Ms M.Z. BALOCH, Second Secretary, Permanent Mission, Geneva

POLAND Dr M. MANICKI, Director, Department for the European Integration and International Cooperation, Ministry of Health, Warsaw Mrs B. BITTNER, Department for the European Integration and International Cooperation, Ministry of Health, Warsaw Mr A. SADOS, Second Secretary, Permanent Mission, Geneva

RUSSIAN FEDERATION Mr A.V. PIROGOV, Deputy Permanent Representative, Geneva Dr Y.M. FEDOROV, Chief, Control of Emerging Infectious Diseases and Emergency Relief Operations Unit, Ministry ofHealth, Moscow Mr A.A. PANKIN, Senior Counsellor, Permanent Mission, Geneva Mr P.G. CHERNIKOV, Counsellor, Permanent Mission, Geneva Mr N .N. FETISOV, Counsellor, Permanent Mission, Geneva Mr V.P. KOVALENKO, Counsellor, Permanent Mission, Geneva MrN.N. SIKACHEV, Counsellor, Permanent Mission, Geneva Mr A.V. MARKOV, Second Secretary, Permanent Mission, Geneva Mr S.V. BYCHKOV, Attache, Permanent Mission, Geneva

SAN MARINO Mme F. BIGI, Ambassadeur, Representant permanent, Geneve M. R. INNOCENTINI, Mission permanente, Geneve

SENEGAL Mme A.C. DIALLO, Ambassadeur, Representant permanent, Geneve M. A. BASSE, Premier Secretaire, Mission permanente, Geneve

SLOVAKIA Mr S. HLA V ACKA, Director-General, Health Management Section, Ministry of Health, Bratislava Mrs Z. CERVENA, Ministry of Health, Bratislava Mrs J. BARTOSIEWICZOV A, Counsellor, Permanent Mission, Geneva

SOUTH AFRICA Ms D. MAFUBELU, Counsellor (Health Affairs), Permanent Mission, Geneva

EXECUTIVE BOARD, 109TH SESSION

SPAIN Sr R. MORENO PALANQUES, Secretario General de Gesti6n y Cooperaci6n Sanitaria, Ministerio de Sanidad y Consumo, Madrid Sr J. PEREZ-VILLANUEVA Y TOVAR, Embajador, Representante Permanente, Ginebra Sr 0. QUINTANA TRIAS, Subdirector General de Relaciones Intemacionales, Ministerio de Sanidad y Consumo, Madrid Sr M. PEREZ DEL ARCO, Secretaria General de Asuntos Exteriores, Ministerio de Asuntos Exteriores, Madrid Sra I. I. DE LA MATA BARRANCO, Subdirectora General de Programas Sanitarios y Sociosanitarios, Acreditaci6n, Calidad y Prestaci6n, Ministerio de Sanidad y Consumo, Madrid Sr J.L. CONSARNAU GUARDIOLA, Consejero, Misi6n Permanente, Ginebra Dra I. TORRES, Misi6n Permanente, Ginebra

UKRAINE Mrs S. HOMANOVSKA, Second Secretary, Permanent Mission, Geneva

UNITED STATES OF AMERICA Mr K.E. MOLEY, Ambassador, Permanent Representative, Geneva Mr W. STEIGER, Special Assistant to the Secretary of Health and Human Services, Department of Health and Human Services, Washington, DC Dr K. BERNARD, Assistant Surgeon General and Special Adviser for National Security, Intelligence and De fen se, Office of Public Health and Science, Department of Health and Human Services, Washington, DC Ms A. BLACKWOOD, Director for International Health Programs, Office of Technical Specialized Agencies, Bureau of International Organization Affairs, Department of State, Washington, DC Ms D. GIBB, Senior Technical Adviser, Office of Health and Nutrition, Bureau for Global Programs, Field Support and Research, Agency for International Development, Washington, DC Mr D.E. HOHMAN, Health Attache, Permanent Mission, Geneva Mr C.A. STONECIPHER, International Resource Management, Permanent Mission, Geneva Ms M.L. VALDEZ, Associate Director for Multilateral Affairs, Office oflnternational and Refugee Health, Department of Health and Human Services, Washington, DC

YUGOSLAVIA Mr M. SCEPANOVIC, Ambassador, Permanent Representative, Geneva Mr A. RADOV ANOVIC, Counsellor, Permanent Mission, Geneva Mrs S. BOSKOVIC-PRODANOVIC, Attache, Permanent Mission, Geneva

ZAMBIA Miss A. KAZHINGU, Second Secretary, Permanent Mission, Geneva

MEMBERS AND OTHER PARTICIPANTS

ZIMBABWE Mr B.G. CHIDY AUSIKU, Ambassador, Permanent Representative, Geneva Mrs B. MUTETW A, Deputy Permanent Representative, Geneva Dr S.T. MUKANDURI, Minister Counsellor, Permanent Mission, Geneva Mr B. MUGARISANW A, Counsellor, Permanent Mission, Geneva

OBSERVERS FOR A NON-MEMBER STATE HOLY SEE Mgr J.-M.M. MPENDA WATU, Conseil pontifical pour la Pastorale des Services de la Sante Dr A. LANDI, Expert Dr G. RIZZARDINI, Expert

REPRESENTATIVES OF THE UNITED NATIONS AND RELATED ORGANIZATIONS United Nations Mr A. SMITH SERRANO, External Relations and Inter-Agency Affairs Officer, United Nations Office, Geneva Ms L. OLDRING, Office ofthe High Commissioner for Human Rights, Geneva Mr E. PALSTRA, Senior External Relations Officer, UNFP A Office, Geneva Ms E. MA YRHOFER, Junior Professional Officer, UNFP A Office, Geneva Mr A. BUZURUKOV, Junior Professional Officer, Humanitarian Response Group, UNFP A Office, Geneva Ms C. SCHWALLER, UNFPA Office, Geneva

United Nations Children's Fund DrY. BERGEVIN, Chief, Health Section Dr A.W. EL ABASSI, Senior Project Officer for Health, UNICEF Office, Geneva

United Nations Relief and Works Agency for Palestine Refugees in the Near East Dr F. MOUSSA, Director of Health Mr R. AQUARONE, Chief, UNRWA Liaison Office, Geneva Ms R. TYLKA, Administrative Assistant, UNRWA Liaison Office, Geneva

United Nations Development Programme Mr E. BONEV, Senior Adviser, UNDP Office, Geneva

United Nations Environment Programme Mr J.B. WILLIS, Director, UNEP Chemicals, Geneva Mr S. MILAD, UNEP Chemicals, Geneva Mr H. F ADAEI, UNEP Chemicals, Geneva

Office of the United Nations High Commissioner for Refugees Mr M. BADURAUX, Medical Officer, Joint Medical Service Ms K. BURNS, Senior Public Health Officer, Health and Community Development Section Ms T. ASSEBE, Reproductive Health Officer, Health and Community Development Section

United Nations Population Fund Mr A.L. MACDONALD, Director, UNFPA Office, Geneva

EXECUTIVE BOARD, I 09TH SESSION

Ms S. O'DONOV AN, Nurse, Joint Medical Service, Ms M. KAJI, Head a.i., Secretariat and InterOrganization Service Mr M. LOFTUS, Senior Inter-Organization Officer, Secretariat and Inter-Organization Service Mr L. CURCI, Associate Inter-Organization Officer, Secretariat and Inter-Organization Service

UN AIDS Dr P. PlOT, Executive Director Ms K. CRA VERO, Deputy Executive Director Ms M.-0. EMOND, Executive Assistant to the Executive Director Mr M. BARTOS, Senior Adviser and Speech Writer, Policy Coordination Ms M. FAHLEN, Director, Country and Regional Support Department Mr M. SIDIBE, Director, Social Mobilization and Information Department Mr J. SHERRY, Director, Programme Development and Coordination Group

Mr E. HARMAN, Chief, Finance and Administration Ms J. GIRARD, Chief, Human Resources Management Mr J. FLEET, Senior Adviser, Policy Coordination Ms H. TRACEY, Policy Adviser, Policy Coordination Ms R. CHAHIL-GRAF, Chief, Governance, Donor and UN Relations Mr R. NOBLE, Senior Adviser, External Relations, Donor Relations Ms S. LILLESTOL, External' Relations Officer, Governance, Donor and UN Relations Mr J. TYSZKO, External Relations Officer, Governance, Donor and UN Relations

United Nations International Narcotics Control Board Professor H. GHODSE, President Mr H. SCHAEPE, Board Secretary

SPECIALIZED AGENCIES Food and Agriculture Organization of the United Nations Mr T.N. MASUKU, Director, FAO Liaison Office, Geneva

International Monetary Fund Mr G.B. TAPLIN, Special Representative to the WTO and Assistant Director, IMF Office, Geneva,

United Nations Educational, Scientific and Cultural Organization M. G. MALEMPRE, Directeur, Bureau de Liaison de I'UNESCO, Gene:ve Mile K. HOL TS, Chargee de Liaison, Bureau de Liaison de !'UNESCO, Geneva

World Meteorological Organization Mr C. WANG, External Relations Officer

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

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

MEMBERS AND OTHER PARTICIPANTS

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

European Commission Ms M.-A. CONINSX, Minister Counsellor, Permanent Delegation, Geneva Mr A. LANARAS, Directorate General for Health and Consumer Protection, Luxembourg Mr G. THINUS, Directorate General for Health and Consumer Protection, Luxembourg Mr C. DUFOUR, Permanent Delegation, Geneva

Organization of African Unity Mrs S.A. KALINDE, Permanent Observer, Geneva Dr A. EL HUSSEIN, Addis Ababa Mr 1.0. MENSA-BONSU, Minister Counsellor, Permanent Delegation, Geneva Dr G. KALIMUGOGO, Head, Population, Health, Labour and Social Affairs Division, Addis Ababa

International Organization for Migration Dr D. GRONDIN, Director, Migration Health Services

Organization of the Islamic Conference Mr A.T. HANE, Permanent Observer, Geneva Mr J. OLIA, Deputy Permanent Observer, Geneva

Commonwealth Secretariat Dr R. PAUL, Head, Health Department

REPRESENTATIVES OF NONGOVERNMENTAL ORGANIZATIONS IN OFFICIAL RELATIONS WITH WHO Commonwealth Association for Mental Handicap and Developmental Disabilities Dr G. SUPRAMANIAM

FDI World Dental Federation Dr A. RA TNANESAN Dr P.A. ZILLEN Dr J.T. BARNARD

Council for International Organizations of Medical Sciences Dr J.E. IDANPAAN-HEIKKILA Professor M. ABDUSSALAM MrS. FLUSS Dr J. GALLAGHER

Federation for International Cooperation of Health Services and Systems Research Centers Dr BUI DANG HA DOAN DrD. LEVY

Council on Health Research for Development MrP. MAKARA

German Pharma Health Fund e.V. Dr C. FINK-ANTHE

EXECUTIVE BOARD, 109TH SESSION

In fact MsK.MULVEY Ms L. WYKLE-ROSENBERG Mr R. GUEVERA Mr A. OLUFEMI

International Commission on Occupational Health Professor G. SCHACKE

International Confederation of Midwives Mrs R. BRAUEN Mrs J. BONNET

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

International Consultation on Urological Diseases ProfessorS. KHOURY

International Council of Nurses International Alliance of Women MrsM.PAL Dr J.A. OULTON Dr T. GHEBREHIWET

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

International Council of Women Mrs P. HERZOG

International Council on Alcohol and Addictions Dr J. SPIELDENNER

International Association for the Study of Obesity Professor P. JAMES MrN. RIGBY Ms K. BAILLIE

International Cystic Fibrosis (Mucoviscidosis) Association Mrs L. HEIDET

International Catholic Committee ofNurses and Medico-social Assistants Mile J. BARTLEY

International Epidemiological Association Dr R. SARACCI

International Clearinghouse for Birth Defects Monitoring Systems DrE.ROBERT

International Federation of Gynecology and Obstetrics DrR. KULIER

International College of Surgeons Professor P.B. HAHNLOSER

International Federation of Medical Students Associations Ms H. BENCEVIC

MEMBERS AND OTHER PARTICIPANTS

International Federation of Pharmaceutical Manufacturers Associations DrH.E. BALE Or E. NOEHRENBERG DrD. WEBBER DrO. MORIN Ms P. GOLDSCHMID Or P. CARLEV ARO MrP. HEDGER

International Federation of Surgical Colleges Professor S.W.A. GUNN

Ms B. BATIONO Or L. LHOTSKA Ms A. LINNECAR DrS.KANON Ms P. KISANGA MrR.MASEKO DrM. REA Ms P. RUNDALL Or J. SOBTI Ms E. STERKEN Ms M. TREJOS Ms YEONG 100 KEAN MrB. MISRA

International Pediatric Association Professor J. SCHMITZ

International Hospital Federation Or R. MASIRONI

International Pharmaceutical Federation Or P. KIELGAST MrT. HOEK MsD.GAL MrL. PLAIN Mr B. TODOROV Ms S. FARIA Ms L. McCLURE

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

International League of Dermatological Societies Professor J.H. SAURAT

International Physicians for the Prevention of Nuclear War Or H. SPANJAARD

International Occupational Hygiene Association Or A. STEINEGGER

International Special Dietary Foods Industries Or A. BRONNER Mr A. MICARDI Mr M. DE SKOWRONSKI MrK. DEJONG Ms J. KEITH Mr N. CHRISTIANSEN Ms H. MOUCHLY WEISS Ms K. BOLOGNESE MsN. SOOD Mr L.C. DELGADO Ms C. DROTZ-JONASSON Mr D. SPIEGEL Ms G. KOFFI Mr LUONG VAN MY THIEN

International Organization for Standardization Mr T.J. HANCOX

International Organization of Consumers Unions (Consumers International) MsM.EWEN Mr A. CASSELS Ms M. MORSINK MsN. METZ MsE. 'tHOEN MrD.BERMAN MsA. ALLAIN

EXECUTIVE BOARD, 109TH SESSION

International Union against Cancer Ms I. MORTARA

The International Association of Lions Clubs (Lions Club International) Mr G.E. CANTAFIO

International Union against SE:xually Transmitted Infections Dr G.M. ANTAL

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

International Union for Health Promotion and Education Mrs M.-C. LAMARRE

World Association of Girl Guides and Girl Scouts MrsM.ABA

La Leche League International Ms H. KUONEN-GOETZ

World Federation for Medical Education MrH.KARLE

Medical Women's International Association Dr C. BRETSCHER-DUTOIT DrS. CAPEK

World Federation for Mental Health Mrs P. LAHTI DrS. FLACHE MrA.OZAMIZ Mr CHUEH CHANG

Medicus Mundi lnternationalis (International Organization for Cooperation in Health Care) OrE. WIDMER DrT. PULS

World Federation of Public Health Associations DrT. ABELIN

World Heart Federation OXFAM MsJ. VOUTE Ms P. SAUNDERS

World Medical Association Rotary International DrD.HUMAN M. G. COUTAU

World Organization of Family Doctors Save the Children Fund (UK) Dr I. HELLEMANN Ms R. KEITH Ms E. FORTIER MsA. HEATON Ms H. CRABTREE

World Self-Medication Industry Dr J.A. REINSTEIN

Soroptimist International Ms I.S. NORDBACK

World Veterans Federation Mr M. HAGMAJER

COMMITTEES AND WORKING GROUPS 1

Programme Development Committee

Dr C. Dotres Martinez (Cuba), Dr Kebede T. (Ethiopia), Dr B. Sadrizadeh (Islamic Republic oflran, member ex officio), Mr Ket Sein (Myanmar), Dr A.G. Romualdez (Philippines), Dr Y.Y. Al-Mazrou (Saudi Arabia), Ms K. Wigzell (Sweden)

Eighth meeting, 11 January 2002: Ms K. Wigzell (Sweden, Chairman), Dr A. Gonzalez (Cuba, alternate to Dr C. Dotres Martinez), Dr Girma A. (alternate to Dr Kebede T., Ethiopia), Dr B. Sadrizadeh (Islamic Republic oflran, member ex officio), Mr Ket Sein (Myanmar), Dr A.G. Romualdez (Philippines), Dr Y.Y. Al-Mazrou (Saudi Arabia), Mrs M. Abel (Vanuatu, member ex officio)

Administration, Budget and Finance Committee

Dr Kim Won Ho (Democratic People's Republic of Korea), Dr S. Abia Nseng (Equatorial Guinea), Dr I. Lemus Bojorquez (Guatemala), Mr J.A. Chowdhury (India, member ex officio), Dr H. Shinozaki (Japan), Dr K. Karam (Lebanon), Sir Liam Donaldson (United Kingdom of Great Britain and Northern Ireland)

Sixteenth meeting, 10 and 11 January 2002: Dr K. Karam (Lebanon, Chairman), Mr Jang Chung Sik (Democratic People's Republic ofKorea, alternate to Dr Kim Won Ho), Dr S. Abia Nseng (Equatorial Guinea), Dr I. Lemus Bojorquez (Guatemala), Mr 0. Tasaka (Japan, alternate to Dr H. Shinozaki), Mr T. Kingham (United Kingdom of Great Britain and Northern Ireland, alternate to Sir Liam Donaldson), Mrs M. Abel (Vanuatu, member ex officio)

Audit Committee

Dra L. Silvani de Moreno (Colombia, alternate to Dr J. Boshell), Mr P.H. Kengouya (Congo, alternate to Dr D. Bodzongo), Professor I. Sallam (Egypt), Mr G.R. Patwardhan (India, alternate to Mr J.A. Chowdhury), Or Y.-J. Om (Republic of Korea), Ms A.-C. Filipsson (Sweden, alternate to Ms K. Wigzell), Professor T. Zeltner (Switzerland, member ex officio)

Fifth meeting, 9 and 10 January 2002: Dr Y.-J. Om (Republic of Korea, Chairman), OraL. Silvani de Moreno (Colombia, alternate to Dr J. Boshell), Mr P.H. Kengouya (Congo, alternate to Dr D. Bodzongo), Professor I. Sallam (Egypt), Mr G.R. Patwardhan (India, alternate to Mr J.A. Chowdhury), Ms A.-C. Filipsson (Sweden, alternate toMs K. Wigzell), Mrs M. Abel (Vanuatu, member ex officio)

Showing their current membership and listing the names of those members of the Executive Board who attended meetings held since the previous session of the Board.

- 21 -

EXECUTIVE BOARD, I 09TH SESSION

Standing Committee on Nongovernmental Organizations

Dr Z. Alemu (Eritrea), Dr B. Sadrizadeh (Islamic Republic oflran), Dr M. Di Gennaro (Italy), Mr Ket Sein (Myanmar), Dr M. Urbaneja Durant (Venezuela)

Meeting of 15 January 2002: Dr Z. Alemu (Eritrea), Dr B. Sadrizadeh (Islamic Republic of Iran), Dr M. Di Gennaro (Italy), Professor Maung Maung Wint (Myanmar, alternate to Mr Ket Sein), Dr L. L6pez (Venezuela, alternate to Dr M. Urbaneja Durant)

Jacques Parisot Foundation Fellowship Selection Panel

The Chairman of the Executive Board and member of the Foundation Selection Panel (Dr Y.-J. Om, Republic ofKorea)

Meeting of 16 January 2002: Mrs M. Abel (Vanuatu, Chairman), Dr Y.-J. Om (Republic of Korea)

Ihsan Dogramaci Family Health Foundation Selection Panel

The Chairman of the Executive Board, the President ofBilkent University, Turkey, or his or her appointee, and a representative of the International Children's Centre (Ankara)

Meeting of 16 January 2002: Mrs M. Abel (Vanuatu, Chairman), Professor P. Erdogan (appointee of Professor I. Dogramaci, President ofBilkent University), Professor M. Bertan (representative ofthe International Children's Centre)

Sasakawa Health Prize Selection Panel

The Chairman of the Executive Board, a representative of the founder and Dr A.G. Romualdez (Philippines)

Meeting of 17 January 2002: Mrs M. Abel (Vanuatu, Chairman), Professor K. Kiikuni (representative of the founder), Dr A.G. Romualdez (Philippines)

United Arab Emirates Health Foundation Selection Panel

The Chairman of the Executive Board and a representative of the founder, members ex officio, and Dr Y.Y. Al-Mazrou (Saudi Arabia)

Meeting of 17 January 2002: Mrs M. Abel (Vanuatu, Chairman), Mr N.S. Al-Aboodi (representative of the founder), Dr Y.Y. Al-Mazrou (Saudi Arabia)

SUMMARY RECORDS FJRST MEETING Monday, 14 January 2002, at 9:40 Chairman: Mrs M. ABEL (Vanuatu)

OPENING OF THE SESSION AND ADOPTION OF THE AGENDA: Item 1 of the Provisional Agenda (Document EB 109/1 Rev.1)

The CHAIRMAN declared open the 109th session of the Executive Board and welcomed all participants. Most members of the Executive Board, she recalled, had taken part in a retreat from 11 to 13 November 2001 in Florence (Italy), which had let members get to know one another and familiarize themselves with the workings of the Executive Board and some of the issues on the horizon. The Director-General had made presentations on the Global Fund to Fight AIDS, Tuberculosis and Malaria, perspectives on WHO's work with the private sector, health systems performance assessment, ethics and health, and bioterrorism. The Board member from Egypt had made a presentation on experiences and perspectives on access to medicines. The situation in Afghanistan and WHO's work there had also been discussed. The provisional agenda (document EB 10911) contained most of the items explored informally during the retreat, and Board members would be able to express their more considered views in public and on the record, with the benefit of that initial discussion. Referring to the provisional agenda, she proposed deletion of item 5.3, Amendments to Financial Regulations and Financial Rules, since no amendments were being proposed at the present session of the Board. In the light of a proposal from Sweden to submit a draft resolution, she suggested that the item on global health-sector strategy for HIV/AIDS, currently agenda item 8.4, be moved to item 3, where it would become item 3.15. It was so agreed. Mr MORA GODOY (alternate to Or Dotres Martinez, Cuba) said that he had no objection to the amendments proposed by the Chairman but sought clarification of the content of document EB 109/32, referred to under the second subitem, Future sessions, of item 7 .4, Governing body matters. Mr AITKEN (Senior Policy Adviser) said that document EB 109/32 would contain the provisional agenda proposed by the Director-General for the Fifty-fifth World Health Assembly, plus any other suggestions for that agenda received from Member States. In keeping with the past practice of the Board, the document would be issued on the third or fourth day of the current session, for consideration on the last day, so that relevant comments received from Board members during the session could be taken into account. Mr MORA GODOY (alternate to Or Dotres Martinez, Cuba) said that, while well acquainted with the established practices and working methods of the Board, he wished to know specifically which items were contained in the document, as some by their very nature might require the Board to

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EXECUTIVE BOARD, 109TH SESSION

take a decision in connection with adoption of the agenda. He failed to see why mentioning the items should present a problem, as the Board had no secret documents and its operations were open. Mr AITKEN (Senior Policy Adviser) surmised that the Board would not want him to read out the 20 items to be proposed by the Director-General and the two items requested by Member States. Mr TOPPING (Legal Counsel) pointed out that the agenda item in question related to the adoption of a provisional agenda for the Health Assembly, which was a prescribed activity of the Executive Board as set forth in Article 28(f) of the WHO Constitution and Rule 4 of the Rules of Procedure ofthe World Health Assembly. Mr MORA GODOY (alternate to Dr Dotres Martinez, Cuba), regretting the loss of time, said that his question had been perfectly clear. He was interested not in established practice but in the new items that had been proposed and which might result in adoption of an inappropriate agenda for the Board. He made an urgent plea to the Secretariat to provide the information he had requested. Mr AITKEN (Senior Policy Adviser) said that members of the Board were probably aware of the issue to which the representative of Cuba was referring. The Secretariat had received a request from a number of Member States for addition to the agenda of the Health Assembly on the issue of observer status for China (Province of Taiwan) at the Health Assembly. The Director-General had intended to report on that item in her introduction to document EB 109/32. Mr MORA GODOY (alternate to Dr Dotres Martinez, Cuba), thanking the Secretariat for the information, said his delegation was not currently in a position to agree to discussion of an issue which, in view of the background and procedural considerations, the Executive Board was not competent to consider. The request had been rejected year after year by the Health Assembly, most recently in 2001. How could the Board, an executive body of the Health Assembly, therefore take such a decision? Secondly, the request was entirely political. Both the General Assembly of the United Nations and the Health Assembly had adopted resolutions on the matter (resolution 2758 (XXVI) of 25 October 1971 and resolution WHA25.1, respectively). Moreover, it would be a gross violation of the procedures of the United Nations system if the Executive Board were to become involved in matters properly falling within the purview of the General Assembly. WHO's primary and vital objective was health. He urged that a decision be taken that the Board should not take up an issue it had no authority to consider. Dr MBAIONG (Chad), recalling that it was the Board's responsibility to prepare the agenda of the Health Assembly, noted that the issue was to be discussed later in the week. It was therefore inappropriate to embark on that debate at present. Taiwan's request for observer status at the Health Assembly was a health issue, not a political one. Members of the Board should consider the question from that point of view and place it on the agenda of the Health Assembly, where it could be discussed in detail. Mr MYA THAN (altemate to Mr Ket Sein, Myanmar) said that, as a country that had consistently observed a "one China" policy and had a tradition of close ties with China, Myanmar could not accept any move or initiative running counter to that position. The proposal by some members of the Executive Board to grant observer status to Taiwan was not a health-related but a political issue. The Health Assembly pursued the noble aim of improving health conditions throughout the world. The proposal by some countries to place the question of observer status for Taiwan on its agenda was inconsistent with that aim and would merely detract from the Organization's work. It would also be inconsistent witth the United Nations General Assembly resolution admitting the People's Republic of China to the United Nations and the Health Assembly resolution admitting that country to WHO. Taiwan's attempts to put similar proposals to the United Nations General Assembly

SUMMARY RECORDS: FIRST MEETING

had all failed. Myanmar maintained the positiOn it had adopted at the United Nations General Assembly and opposed the proposal by some Member States to include the item in the agenda of the Health Assembly. Further, it supported the remarks by Cuba and proposed under Rule 32 of the Rules of Procedure of the Executive Board that the question should not be considered at the current session of the Executive Board. Dr LEMUS BOJORQUEZ (Guatemala) said that his country was one of the signatories of a proposal to allow Taiwan to participate as an observer at the Health Assembly and in no way considered that to be a political matter. Guatemala wished not to go into the substance of the question but rather to look at the legal position. Rules 4 and 5(d) of the Rules of Procedure of the World Health Assembly provided that the Board should prepare the provisional agenda of each regular session of the Health Assembly and that it should include in that agenda any item proposed by a Member or an Associate Member. From a procedural point of view, therefore, there need be no further discussion on the content of document EB 109/32. Mr JANG Chun Sik (Democratic People's Republic of Korea) strongly supported Cuba's position. It was pointless to discuss a matter that had been resolved by United Nations General Assembly and Health Assembly resolutions. Observer status for Taiwan had consistently been rejected since 1997. Dr BODZONGO (Congo) said that members of the Board could either accept or reject a proposal to include an item in the agenda of the Health Assembly. Furthermore, discussion should not be postponed. The question of Taiwan had been discussed some six months before, and why it had come up again was unclear. The question concerned China's territorial integrity and was therefore highly political, despite the opinions of some previous speakers. Representatives of a region or province of a country could not be allowed to attend the Board or WHO as observers, as such status could be granted only to countries or nongovemmental organizations. Taiwan was neither. The subject had been rejected consistently over the past few years, and there was no reason why it should be discussed again at the present session. Professor ABOUO-N'DORI (Cote d'Ivoire) agreed that the status of Taiwan was not just a health problem. Cote d'Ivoire had adopted the policy of "one China", and considered Taiwan to be a province of China. No African would ever agree, for example, to Casamance being granted observer status at meetings of the African Union, still less at Health Assemblies. Dr GIRMA (Ethiopia) said that the Board should be in no doubt about the political motives behind the proposal: it was an attempt by the Taiwanese authorities to achieve their objective of two Chinas, or "one China, one Taiwan". Although its supporters might argue that Taiwan had been excluded from WHO's information-sharing practices, the fact was that Taiwan had full access to all WHO documentation and information. The Constitution of WHO stipulated that only sovereign states were entitled to be Members. Furthermore, the General Assembly and Health Assembly resolutions cited by previous speakers contained clear decisions that had resolved the question of the representation of China both in the United Nations and in WHO. Over the past five years, the Health Assembly had consistently rejected similar proposals. Any decision to include the proposal in the provisional agenda of the next Health Assembly would clearly violate both resolutions. Moreover, tabling of the Taiwan proposal by a few Member States would disrupt the normal activities of WHO and generate unwelcome political confrontation among its Members. Since adoption of the agenda without consensus on the Taiwan issue would set a bad precedent, Ethiopia supported Cuba's proposal.

EXECUTIVE BOARD, I 09TH SESSION

Mr TOPPING (Legal Counsel) said that the Board should be considering its agenda, which set forth the items for subsequent discussion, rather than entering into the substance of one of those items. The issue of whether to place a proposal by some Member States in the provisional agenda of the Health Assembly was a matter for discussion at the appropriate time. Although Cuba's proposal, seconded by several other countries, clearly challenged the Board's competence to take certain action, the Board's competence to prepare the agenda of the Health Assembly was determined by the Constitution of the Organization and was therefore not in doubt. In addition, the Board was required under the Rules of Procedure of the World Health Assembly to place in the provisional agenda of the Health Assembly any item proposed by a Member State. The United Nations General Assembly had a similarly worded rule. At the present stage, therefore, the Board should only be considering whether to adopt the agenda before it, including, by virtue of its constitutional obligations, the item "Future sessions", under which the provisional agenda of the Health Assembly would be considered. Dr SADRIZADEH (Islamic Republic of Iran) proposed that, to enable the Board to proceed with its heavy agenda, discussion of the issue be adjourned so that China and Taiwan could discuss it outside the Executive Board meeting and report the outcome to the Board two days later. Dr MSA MLIVA (Comoros) strongly supported Cuba's proposal. The Board should not be called upon to discuss purely political problems. As the representative of a country that had only recently experienced upheaval as a result of a separatist crisis, he firmly believed that the territorial integrity of China had to be respected. Dr MODESTE-CURWEN (Grenada) said that controversial issues had to be faced, even when political elements were involved. Failure to address the issue of Taiwan would merely be to postpone its resurgence, when discussion might prove less convenient. The issue involved a sizeable proportion of the world's population, and the Board had a duty to consider the request made by a number of Member States to consider according observer status to Taiwan at the Health Assembly. Mr MORA GODOY (altt!rnate to Dr Dotres Martinez, Cuba) agreed with previous speakers that time was being wasted as the matter was one the Board was not competent to discuss: the Board addressed health-related issues, whereas the topic under discussion was a contentious political matter. It could be dealt with in one of two ways: the simplest was not to consider it, if there was genuinely no consensus; the alternative, which he did not favour, was to vote on the proposal in accordance with Rule 32 of the Rules of Procedure of the Executive Board. The agenda could not be approved until it was known what items it would contain. Professor ZELTNER (Switzerland) agreed with the comment of the Legal Counsel that the issue was simply to adopt the agenda of the Board. The sub item "Future sessions" under item 7.4 of the provisional agenda would have to be included. Its content, with the important item on the status of Taiwan, would be discussed when that agenda item came up. The CHAIRMAN, noting that a Member State without a member on the Board was requesting the floor, pointed out that, under the established practice of Rule 3 of the Rules of Procedure of the Executive Board, Member States that were not members of the Board but had registered and were present should normally request the floor in writing before the start of discussion of an item of particular concern to that Statt!. She agreed nevertheless to give the floor on that occasion to the Member requesting it. Mr SHA Zukang (China), 1 speaking at the invitation of the CHAIRMAN, recalled that every year since 1997 the Health Assembly had considered, then rejected, proposals to invite Taiwan to 1

Participating by virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

SUMMARY RECORDS: FIRST MEETING

participate in the Health Assembly as an observer. He regretted that the proposal had been put to the Board and his Government was adamant in rejecting it. The underlying intention of the Taiwan authorities and their supporters was to split Taiwan from China in the international arena, rather than benefit the health of the people of Taiwan. Taiwan was a province of China and, as such, did not qualify for membership of WHO, which was reserved for sovereign states. To include the item under discussion in the provisional agenda would contravene both United Nations General Assembly resolution 2758 and World Health Assembly resolution WHA25.1. As the Board was obliged to abide by the decisions of the Health Assembly, it had no competence to consider the Taiwan-related proposal. He denied that Taiwan had no access to information from WHO, as claimed by the Taiwan authorities. China was concerned with the well-being of the people of Taiwan and actively promoted exchanges and cooperation in health-related matters. Although Taiwan had become a member of WTO on 1 January 2002, it had been admitted with the status of "Separate Customs Territory of Taiwan, Penghu, Kinmen and Matsu", not as a sovereign state. Furthermore, WTO was not a United Nations specialized agency. Respect for state sovereignty, territorial integrity and non-interference in internal affairs were fundamental principles enshrined in the United Nations Charter. Taiwan was an inalienable part of China, represented by the Government of the People's Republic of China. Consequently, to raise a proposal on the Taiwan question constituted an infringement of the sovereignty and territorial integrity of China. Indeed, the issue merely diverted the Board's attention from its proper work. He urged WHO to abide by the resolutions of the United Nations General Assembly and the Health Assembly, and not to include the Taiwan-based proposal in the agenda of the Executive Board or of the Health Assembly. Countries genuinely concerned with the well-being of the people of Taiwan ought to encourage rather than discourage the unification of China. The CHAIRMAN, referring to informal consultations during the coffee break, said that, if she had understood correctly, the Member States concerned had decided not to press the matter of Taiwan's request for observer status at the Health Assembly. Was that understanding correct? If so, the matter need not be discussed under proposed agenda item 7.4. Dr LEMUS BOJORQUEZ (Guatemala) said that, on the contrary, he wished to insist that the matter be taken up. It was for the Board to ensure that proposals by members were included in the provisional agenda, which did not imply that it was required to discuss them. The proposal by Switzerland and other Member States for the inclusion of an item in the provisional agenda, which he supported, fulfilled the conditions set forth in Rule 9 of the Board's Rules of Procedure, particularly sub paragraphs (c) and (d). Exclusion of the proposed item would therefore set a bad precedent. Mr MORA GODOY (alternate .to Dr Dotres Martinez, Cuba) said that the issue under discussion was not the right of Member States to make proposals, but rather the competence of the Executive Board to consider the question of Taiwan's request for observer status. It was his understanding that the Chairman had just made a ruling, which he endorsed, that Taiwan's request would not be considered under proposed agenda item 7.4. Or KARAM (Lebanon) said that the issue was more procedural than political. Member States had the right to propose the inclusion of any item in the provisional agenda. If the Executive Board indeed had the right to exclude such items, it should vote on the matter, as proposed by the representative of Cuba. If the vote favoured inclusion of the item, it could be then discussed at the allotted time. If it rejected inclusion, however, he wished to know from the Legal Counsel whether, through the Director-General, the Member States concerned would still be able to bring it before the Health Assembly without further reference to the Executive Board. Despite previous failures, Taiwan ought not to be debarred from making another attempt to acquire observer status at the Health Assembly.

EXECUTIVE BOARD, 109TH SESSION

Dr AL KHARABSEH (Jordan) agreed with Professor Zeltner that any discussion of Taiwan's request for observer status should be postponed until the scheduled meeting to discuss provisional agenda item 7.4, particularly since the agenda as it stood contained no explicit reference to Taiwan. In any event, adoption of the provisional agenda implied no obligation to discuss a particular item. Dr BODZONGO (Congo) endorsed the Chairman's conclusion. Members of the Board were responsible enough to appreciate that, in deciding whether to include items in the agenda, the basic principles and rules of the Organization should be observed. They were all aware that the question of Taiwan and China divided both governing bodies, and moreover that it had been accepted at previous Health Assemblies that WHO was not competent to rule on what was essentially a political issue. That issue had been raised again and had wasted a great deal of the Board's time. The Chairman's decision should, he urged, be upheld to allow the Board to move on to other matters. Dr MBAIONG (Chad) said that, if certain countries had requested that the problem of Taiwan and China be placed on the agenda of the Health Assembly, they must have done so with due reference to the rules in force. It would be better to keep the matter on the agenda and discuss it at the appropriate time. Professor ABOUO-N'DORI (Cote d'Ivoire) objected to the proposal that the debate be postponed until Wednesday of that week. The Board had already spent the morning debating the issue; it was time to take a decision since many other items awaited discussion. The Chairman's statement had indicated that agreement had been reached not to place the matter on the agenda. Mr MORA GODOY (altt!rnate to Dr Dotres Martinez, Cuba) suggested that any member of the Executive Board not accepting the Chairman's ruling should request that a vote be taken on the matter. As had been reiterated, valuable resources were being wasted and the item, being political, was not relevant to the Board's agenda. Dr LEMUS BOJORQUEZ (Guatemala) said that the issue was really one of procedure, as the item had been proposed for inclusion in the agenda by a Member State. Also regretting the waste of time, he proposed that the Legal Counsel be asked for his opinion on whether, from the procedural viewpoint, the matter should be placed on the agenda and the question put to the vote. Mr MORA GODOY (alte:rnate to Dr Dotres Martinez, Cuba), on a point of order, drew attention to Rule 29 of the Rules of Procedure of the Executive Board, which stated that during discussion of any matter a member could rise to a point of order, which should be immediately decided by the Chairman, and also that a member could appeal against the ruling of the Chairman, in which case the appeal should immediately be put to the vote. He sought clarification from the Legal Counsel as to whether the Chairman's statement had in fact been a ruling, and whether any member of the Board had challenged that ruling. Mr TOPPING (Legal Counsel) recalled that the Chairman had stated that it was her understanding that those Member States which had requested that the invitation to Taiwan to attend the Health Assembly as an observer be placed on the agenda of the Health Assembly had agreed not to pursue the request. She had th1~n asked if her understanding was correct, to which the member for Guatemala had replied that it was not. In short, the Chairman had asked a question but not made a ruling. The CHAIRMAN confirmed that such was the position. Dr AL-MAZROU (Saudi Arabia), commenting that much time had been spent on the issue, called for the discussion to be brought to a conclusion.

SUMMARY RECORDS: FIRST MEETING

Mr TOPPING (Legal Counsel) said that, in the light both of the Chairman's confirmation that she had not made a ruling and of the various statements, a decision would have to be taken on how to conclude the debate. It was his understanding that Cuba, supported by several Member States, had called for a vote based on Rule 32 concerning the competence of the Board to adopt a proposal submitted to it. The item before the Board was the adoption of its agenda, including item 7.4, which comprised a proposal by five Member States to place on the agenda of the Fifty-fifth World Health Assembly an item inviting Taiwan as an observer to the Health Assembly. A vote would therefore be appropriate. He would interpret a vote in the affirmative to be in support of the position that the Board did not have the competence to decide on that issue, and that accordingly the item would not be submitted to the Board for consideration. A negative vote would mean that the Board could consider that item in the course of its discussion of the Health Assembly's provisional agenda. As Legal Counsel, he had to draw the attention of the Board to the statement he had made earlier to the effect that, in that context, a "yes" vote would mean that the Board would be adopting a position inconsistent with the application of Rule 5( d) of the Rules of Procedure of the World Health Assembly, which stated that the Board should include in the Assembly's provisional agenda any item proposed by a Member or by an Associate Member. However, in the event of a decision not to consider the matter at the current session of the Executive Board, it could still be examined at the Health Assembly upon the request of a Member State or States that it be included as a supplementary agenda item. It could then be considered by the General Committee and subsequently by the Plenary. He advised, therefore, that the Board take a vote in accordance with the request made by Cuba, which had also, in accordance with Rule 45 of the Board's Rules of Procedure, requested a roll-call vote. Dr DI GENNARO (Italy), speaking on behalf of the European Union, requested a short break in order to have time to consult with European Union members on a common position. The meeting was suspended at noon and resumed at 12:30. Mr MORA GODOY (alternate to Dr Dotres Martinez, Cuba) said that he wished to clarify his earlier proposal, in order to obviate the need for a vote. His proposal was that the Executive Board should adopt the agenda as it stood, on the understanding that the issue of the invitation of Taiwan to attend the Health Assembly as an observer should not be included in item 7.4 of the agenda of the Board. Dr LEMUS BOJORQUEZ (Guatemala) emphasized that the Rules of Procedure of the Executive Board must be respected. He drew attention to Rule 9, which provided that except in the case of sessions convened under Rule 6, the provisional agenda of each session should include, inter alia, any item proposed by a State Member or Associate Member of the Organization, and any item proposed by a member of the Board. Both those requirements were applicable to the present case. The matter was one of procedure, not of substance. The substance of the issue would have to be addressed later by the Health Assembly. The CHAIRMAN invited the Board to vote on the proposal by Cuba as just formulated. Mr MORA GODOY (alternate to Dr Dotres Martinez, Cuba) requested a roll-call vote. A vote was taken by roll-call, the names of the Member States being called in the English alphabetical order, starting with Belgium, as determined by lot.

EXECUTIVE BOARD, 109TH SESSION

The result of the vote was as follows: In favour: Brazil, Colombia, Comoros, Congo, Cote d'Ivoire, Cuba, Democratic People's Republic of Korea, Egypt, Equatorial Guinea, Eritrea, Ethiopia, India, Islamic Republic of Iran, Jordan, Lebanon, Myanmar, Republic of Korea, Saudi Arabia, Switzerland, Vanuatu. Against: Chad, Grenada, Guatemala. Abstaining: Belgium, Italy, Japan, Lithuania, Philippines, Sweden, United Kingdom of Great Britain and Northern Irel1md, Venezuela. Absent: Kazakhstan. The proposal was therefore adopted by 20 votes to 3, with 8 abstentions. Mr TOPPING (Legal Counsel) explained that, according to Rule 42 of the Rules of Procedure, members considered to be present and voting were those casting a valid affirmative or negative vote. There had been 23 members pn:sent and voting; the required majority was 12; accordingly, the motion was carried. Dr DI GENNARO (Italy), speaking on behalf of the European Union in explanation of the vote, said that the Member States of the European Union which designated members of the Executive Board had abstained. They maintained their support for resolution WHA25.1, but at the same time considered that any Member State had the right to place any item on the agenda according to the Rules of Procedure, as clearly stated by the Legal Counsel. Dr ROMUALDEZ (Philippines), speaking in explanation of vote, said that, although the Philippines had endorsed all previous resolutions by the United Nations General Assembly and the Health Assembly on the matter, in the present case he said that he feared that certain complex procedural issues might arise as a result of such a vote, with possible consequences for the future operation of the Board and other WHO bodies. The Philippines had therefore abstained. Professor GRABAUSKAS (Lithuania), speaking in explanation of vote, said that Lithuania had abstained for the reasons given by Dr Di Gennaro, on behalf of the members of the Board from the European Union. Mr DUQUE ESTRADA MEYER (alternate to Professor Yunes, Brazil) said that Brazil had voted in favour of the proposal on the understanding that it would not set a precedent. Dr LEMUS BOJORQUEZ (Guatemala), speaking in explanation of vote, stated that Guatemala had voted against the proposal solely out of respect for the Rules of Procedure. The agenda, as amended, was adopted. 1

The meeting rose at 12:45.

See page ix.

SECOND MEETING Monday, 14 January 2002, at 14:15 Chairman: Mrs M. ABEL (Vanuatu)

OPENING OF THE SESSION AND ADOPTION OF THE AGENDA: Item I of the Agenda (Document EB I 09/ I Rev .I) (continued)

The CHAIRMAN, noting the length of the agenda for the Executive Board at its I09th session, recalled decision EBI08(10) whereby the Board had decided that the current session should close no later than Monday, 2I January 2002. The opening and closing times for meetings would have to be strictly observed and statements kept reasonably concise, to avoid recourse to Rule 28 of the Rules of Procedure of the Executive Board. She outlined the proposed working methods and timetable for discussion of the items on the agenda and said that she took it that they were acceptable. It was so agreed.

MEMBERSHIP OF THE JACQUES P ARISOT FOUNDATION SELECTION PANEL

The CHAIRMAN recalled that, at its 108th session, the Board had decided on the members of the Jacques Parisot Foundation Fellowship Committee. She informed the Board that it must also decide on the two members of the Selection Panel from among the members of the Committee. The practice had been for the Panel to consist of the Chairman of the Executive Board and a member of the Committee designated by the Board who was not a Vice-Chairman. In the present instance, that was Dr Y.-J. Om of the Republic of Korea. Decision: The Executive Board, in accordance with the Implementing Regulations of the Jacques Parisot Foundation, appointed Dr Y.-J. Om (Republic of Korea) a member of the Jacques Parisot Foundation Selection Panel for the duration of his term of office on the Executive Board, in addition to the Chairman of the Board, member ex officio. It was understood that should Dr Om be unable to attend, his successor or the alternate member of the Board designated by the Government concerned, in accordance with Rule 2 of the Rules of Procedure, would participate in the work of the Selection Panel. 1

REPORT BY THE DIRECTOR-GENERAL: Item 2 of the Agenda (Document EBI09/2)

The DIRECTOR-GENERAL, welcoming all participants, reflected on an extraordinary year when threats to the future of humanity had been starkly outlined. The destructive power of terrorism

Decision EB I 09(1 ).

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EXECUTIVE BOARD, I 09TH SESSION

had targeted innocent civilians. The world had also finally begun to grasp the immensely destructive effects of HIVIAIDS. But it had also been a year in which the world came together in a spirit of hope and cooperation, through alliances and partnerships, moving towards greater equity and firmer resolution to rout the scourge of poverty. She highlighted the Report of the Commission on Macroeconomics and Health, delivered in December 2001, with its demonstration that disease was a drain on development and that, conversely, investments in health were a concrete input into economic development. The Commission argued for a comprehensive, global approach, with clear goals, specific time frames and an emphasis on results. She indicated that WHO would, inter alia, encourage countries to conduct similar work within existing forums or to establish national commissions on economics and health. Stressing the importance of effective national health systems, she outlined three initiatives likely to prove helpful: the generation of locally relevant information for national decision-makers on the costs and consequences of crucial interventions; the World Health Survey, which would help Member States obtain important basic information for evaluating progress towards the Millennium Development Goals; and analysis of ways to improve health financing and human resources in health systems. She underlined the importance of new partners and the contribution of civil society, particularly in areas such as access to medicines. Turning to specific health strategy matters, she highlighted the political commitments to health, including a new strategy for tackling HIVI AIDS and the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria. She described the progress made towards eradicating poliomyelitis. She looked forward to the World Summit on Sustainable Development, to be held in Johannesburg (South Africa) in August-September 2002, an occasion when the central role of health in the development process and the links between health and poverty would be stressed. Work continued on the review of methods for heallth systems' performance assessment, and she stated that the detailed annexes to The world health report on those assessments of countries would be produced in 2003. She underlined WHO's contribution to dealing with unexpected health events and disease outbreaks. She recalled the establishment of task forces on the deliberate use of biological and chemical agents as weapons and the release of guidance on the public health response to such an event. With regard to smallpox, she reported that the WHO Advisory Committee on Variola Virus Research had recommended further research before the destruction of the virus. She proposed that the Committee continue to oversee that researc:h. The Health Assembly could review the progress of research in two to three years' time. She outlined preparations for the Global Consultation on Child and Adolescent Health and Development, to be held in Stockholm in March 2002, and emphasized WHO's commitment to halving the mortality due to measles by 2005. A draft global strategy for infant and young child feeding was being submitted to the Board, en route to the Health Assembly, and she noted other initiatives launched such as the mental health Global Action Programme and a programme to strengthen developing countrie:s' research capacity in genetics and genomics. Forthcoming reports included one on violence and health and The world health report 2002 on risks to health. She also described steps being taken in 2002 to separate sports and tobacco, and progress in the negotiating process for the WHO framework convention on tobacco control, noting actions already taken by several governments to curb tht:: use of tobacco. She recalled the strategic programme budget and the increased emphasis on monitoring performance regularly and evaluating impact. She outlined the "Country-Focus" Initiative designed to ensure that all parts of WHO's network gave maximal attention to what happened in countries: elaboration of country cooperation strategies, definition of core competences of country teams, strengthening country offices with, for instance, appropriate management and administrative systems. She observed that events relating to several items on the agenda had recently unfolded, contributing to later-than-expected dispatches of documents. Processes would be reviewed in order to improve them.

SUMMARY RECORDS: SECOND MEETING

• Discussion on issues raised Mrs AELVOET (alternate to Dr Thiers, Belgium) commended the report. Health had to be taken seriously in the highest political circles and it was therefore important to set the right priorities, draw up plans for implementation, take action and evaluate the results. The Report of the Commission on Macroeconomics and Health had shown that certain health conditions were contributing to the toll of preventable deaths in poor countries and therefore that a few well-targeted measures could save millions of lives. Belgium was particularly interested in how WHO would implement the report. Indeed, at the end of2001, during its presidency of the European Union, it had organized a meeting on health care for all, the results of which reflected the fundamental concern expressed in the work of the Commission on Macroeconomics and Health, namely, the issue of health and poverty. In that connection, the Director-General was quite right to refer to the World Summit on Sustainable Development to be held in Johannesburg, because the United Nations Conference on Environment and Development in Rio de Janeiro had chiefly stressed the link between what was supposed to be increasingly sustainable development and the environment, and health was a determining factor in that context. It was essential that commitment be shown at the highest levels, including in political circles, at the World Summit. The Laeken Declaration, issued at the European Union summit meeting held in Belgium, explicitly reiterated the invitation for heads of state to travel to Johannesburg, not simply to participate in the meeting, but to underscore the Summit's significance by their presence. She drew the Board's attention to the importance of agenda item 3.11 on violence and health: violence was a major problem in society and therefore had to be considered an important public health issue. The forthcoming World Report on Violence and Health was the first such world report on that issue. The causes of violence had to be better understood and possible action to prevent violence examined. The Board should go beyond taking note of the report and use it as a basis for future action. WHO's efforts to promote the issue of mental health were fundamental. All the initiatives developed the previous year, to a large extent on the basis of WHO's work, required tangible follow-up. The world health report 2001, Mental Health: New Understanding, New Hope, was a work of reference in the field of mental health. So that it should be put :nto force, Belgium had taken a number of initiatives nationally and, during its Presidency of the European Union, organized a meeting that had resulted in a number of resolutions and recommendations, subsequently approved by ministers of health of the European Union. Belgium would be submitting a draft resolution to the Board based on those resolutions, the main purpose of which was to organize continuation of the work started the previous year. It was essential that improved responses be found on the basis of experiences in each country. Mental health support structures in Europe, for example, could also be reoriented, as Europe had in the past experienced periods of institutionalization that had probably not promoted the integration ofthe mentally ill. Dr SALLAM (Egypt) stressed the crucial importance of health in the fight against poverty. That point of view had in the past been crowded out by those who considered poor health a result and not a cause of poverty, and the fact that it was now being heard represented a breakthrough. His experience as Minister of Health had taught him that there could be no development unless basic health needs were met. Health was also an important political and economic tool in the alleviation of disparities, whether gender-based, socioeconomic, geographical or arising from special needs. In fighting poverty, it must be stressed to the donors that at least 20% of funds should be directed to health strategies dealing with the alleviation of disparities. He welcomed the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria but pointed out that its targets could not be met in the absence of health systems, which were important vehicles for fighting all three diseases. Access to pharmaceuticals could not alone reduce the number of victims. Moreover, the issue of such access should not be simplified to apply to three or four diseases but should be addressed as an economic issue for countries requiring access to pharmaceuticals.

EXECUTIVE BOARD, 109TH SESSION

It had been a good idea to focus on mental health in 2001, and there had indeed been a regional breakthrough on the issue. However, WHO must tackle all aspects of violence, including stress and its effects. Dr SHINOZAKI (Japan) welcomed the launch of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the admirable outcome of the well-coordinated work of the transitional working group comprising national governments, United Nations agencies such as WHO, civil society and private organizations. He commended the work of the Organization in establishing that innovative public-private partnership. The Global Fund had been made possible by a series of major international initiatives, including the Kyushu-Okinawa Group of Eight Summit and the Infectious Diseases Initiative. Japan had pledged US$ 200 million to the Global Fund and would continue actively to support it. WHO and UNAIDS should play an active role in supporting country-level activities via existing mechanisms, especially WHO regional offices. WHO and UNAIDS were capable of bearing heavy responsibilities, and it was to be hoped that expectations of their leadership in those areas would be confirmed. From the Ministry of Health's point of view, he agreed with the Director-General and with the recent Report of the Commission on Macroeconomics and Health, that stepped-up investment in health would benefit other sectors of society, not only public health. Those responsible for national health policy were all aware that it was their responsibility to advocate that idea and make it clearer to the general public, including the financial authorities and private donors. At the same time, however, resources were limited. A number of countries, including Japan, were struggling with economic recession and their peoples were carrying out painful reform in every sector. It must be borne in mind, therefore, that financial requests from WHO would not be automatically granted. National decision-making processes required not just urgent requests for resources, but also evidence of the benefits of current and additional expenditure. Japan had to be confident that WHO was also seriously engaged in major reform to make the Organization efficient. While it was understood that WHO was making a major effort in that direction, more substantive and visible reform efforts would facilitate greater understanding among the general public and result in strengthened support for WHO. The tragic events of 11 September 2001 had occurred as health issues were being discussed at the Regional Committee for the: Western Pacific in Brunei Darassalam. Serious thought had since been given to the measures to be taken to prevent a reoccurrence. The most important contribution of the health community to preventing such tragedies was to remain focused on, and committed to, its work in the field of health. He reitc~rated Japan's support for WHO; his country was standing ready to support the Organization because it remained confident in WHO's mission. Dr OM (Republic of Korea) recalled that, in cooperation with Japan, the Republic of Korea had decided to hold the forthcoming FIFA World Cup as a tobacco-free event. Smoking and tobacco advertising would not be allowed at World Cup venues in the country- as proof of its support both for the Tobacco Free Initiative and the draft framework convention on tobacco control. Since the opening ceremony of the World Cup would coincide with World No Tobacco Day in 2002, it would also provide an opportunity to move on towards a tobacco-free world. In that connection, WHO should give special attention to the ev(mt and endeavour to develop policies associating international sporting events with its major projects on health for all. The Organization was also requested to inform all Member States that the 2002 World Cup would be a tobacco-free event to allow for coordination with national anti-tobacco policies, as appropriate. Ms WIGZELL (Sweden) said that, in the United Nations Millennium Declaration, Heads of State and governments had made a strong commitment to fighting poverty. The important initiative of the Global Fund to Fight AIDS, Tuberculosis and Malaria, combined with the findings of the Commission on Macroeconomics and Health, provided a unique opportunity to respond to that commitment by investing in health. She welcomed the Director-General's decision to establish the

SUMMARY RECORDS: SECOND MEETING

Commission and her determination to put health high on the global political agenda. Health and poverty reduction must go hand in hand. It was an indisputable fact that poverty could be considerably reduced by addressing a few health conditions responsible for a high proportion of excess, and avoidable, death and disability. The Report of the Commission on Macroeconomics and Health clearly showed that major investments in health were necessary and could only be achieved through solidarity and shared responsibility. However, national leadership was essential in coordinating the inputs of different global initiatives, bringing them into line with local needs and national priorities. WHO should provide support and guidance to countries in that respect. She was therefore encouraged by the Director-General's intention to improve WHO's work at country level further. Professor ZELTNER (Switzerland) said that the Director-General's comprehensive statement was evidence of how much had been achieved during the past year. The choice of mental health as the theme of The world health report 2001 and World Health Day 2001 had resulted in major progress being made in placing mental health on the political agenda. Far too often, mental and physical health were treated as two separate issues; further study was needed on how the two were interrelated. The Director-General had good reason to be proud of her efforts to establish a constructive dialogue on access to drugs and related international trade agreements and in successfully bridging the hitherto seemingly enormous gap between health and trade experts on such matters. All partners involved were starting to be convinced of the potential benefits of and the need for further negotiation. Although the Global Fund to Fight AIDS, Tuberculosis and Malaria was one of the positive results ofthe United Nations General Assembly special session on HIV/AIDS, it would not suffice on its own. More funds to combat the diseases were required. He nevertheless welcomed the commitment shown by the United Nations system as a whole to tackle HIV/AIDS as a global issue. He asked to what extent the other points raised at the special session had been followed up. The Report of the Commission on Macroeconomics and Health was of paramount importance. In its recommendations, however, greater emphasis should have been laid on the need to disseminate information on, and promote knowledge of, the close link between health and development. Although that link might be seen by health professionals, it might not be by partners from other sectors. He would welcome a similar report on the theme of global security and health. The health community knew that such matters were related but so far there was no hard collective evidence of the connection between health and peace. Perhaps a group along the lines of the Commission might follow that up. Dr GIRMA (Ethiopia) commended the achievements of the previous year. WHO had benefited from the Director-General's strong leadership in three important areas in particular. First, he welcomed the timely initiative on HIVIAIDS, tuberculosis and malaria and encouraged the Director-General to ensure equitable access to the Global Fund in order to make a real impact. Secondly, while considerable progress had been made regarding access to affordable drugs, further efforts were required to ensure greater availability and better quality of drugs, especially for poor countries. Thirdly, he welcomed the initiative to strengthen WHO country offices. He endorsed the proposal by Belgium relating to mental health and violence, where a holistic approach was indeed required. Dr SADRIZADEH (Islamic Republic of Iran) recalled that, since taking office, the Director-General had stressed the importance of placing health at the centre of development; with the United Nations and worldwide support being mobilized for the reconstruction of Afghanistan, she would have the opportunity to prove her theory. Health must be given the priority it deserved by all partners involved in the reconstruction process, in which WHO should play a prominent role. He welcomed the Report of the Commission on Macroeconomics and Health as a timely step towards raising the status of health matters on the development agenda, with a view to the forthcoming World Summit on Sustainable Development.

EXECUTIVE BOARD, 109TH SESSION

Dr DI GENNARO (Italy) commended the decision to establish the Commission on Macroeconomics and Health. Although the views on the link between health, poverty reduction and economic growth expressed in its Report had been put forward previously in other forums, their crystallization in a high-level, evidence-based study was a most timely and welcome development. One of the Report's conclusions warranting particular attention was that the disease burden slowed economic growth, and that ev1~n where economic growth existed it would not suffice to improve health. Hence the need for a concerted global strategy to increase access to essential health services. Also welcome was the concept of a new health pact between donors and recipient countries. Adequate follow-up to the Report was very important. One option would be to include consideration of the Report on the agenda of the forthcoming Health Assembly with a view to drafting recommendations on its main conclusions. Such recommendations should cover how the work of the Commission related to the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria. For instance, how did WHO intend to support Member States in setting up new mechanisms for absorbing resources and scaling-up key health outcomes? She welcomed WHO's t!mphasis on mental health during 2001 through World Health Day, relevant round tables and The world health report 2001. The next important step was to move from advocacy to commitment at national and international levels. Such was the intent of the draft resolution to be submitted by Belgium, which she would support. She also looked forward to the five-year Global Action Programme aimed at devising policies and generating resource mobilization for mental health. Dr MBAIONG (Chad) welcomed the Director-General's report with its emphasis on the correlation between health and development and the disruption of development through terrorism, armed conflict and violence, much of which stemmed from poverty. He commended the initiatives in favour of the least developed countries, such as those aimed at a tobacco-free world, the eradication of malaria, the campaign against tuberculosis, macroeconomics and health, and access to quality drugs in general and antiretroviral therapy in particular. Dr MSA MLIVA (Comoros), welcoming the report, expressed appreciation to WHO for the support given to the Comoros in respect of a recent immunization campaign, the launching of a national filariasis eradication programme and initiatives in developing and evaluating reform of the health system. The reorganizatilon of the health system necessitated by his country's move towards decentralization would require further WHO support. His Government was currently drawing up a national health policy and an investment plan. The Comoros would express its views on the question of variola virus stocks through the representative of the African Group later in the session. He commended the move to make limited funds available to WHO Representatives to deal with emergencies, particularly in view of a cholera epidemic that had threatened the Comoros since December 2001, and expressed the hope that WHO country offices would be able to assist in strengthening national human resources. Professor ABOUO-N'DORI (Cote d'Ivoire), speaking on behalf of the African Region members of the Executive Board, welcomed the report, and the particular attention given to the African continent. Africa needed much financial and other assistance in the face of its many problems, and the countries of the African Region greatly appreciated the regular budgetary and extrabudgetary resources provided through WHO and various donors. The African Group supported the publication of the next health system performance evaluation in 2003. He thanked WHO for the support provided in his country's efforts to combat the recent yellow fever epidemic, and its leading role in the mass immunization campaign conducted at a time of world shortage of yellow fever vaccint:. Dr KARAM (Lebanon), expressing appreciation of the Director-General's report, said that it remained important to look into the causes of disease, since that was where action could be most

SUMMARY RECORDS: SECOND MEETING

effective and economical. The same went for the fight against the pathogens that caused malaria and tuberculosis, as much as for the changing of the sexual practices and attitudes that led to the spread of HIV and for combating the social causes of violence and terrorism. While WHO's tobacco-free initiative was especially commendable, policy-makers had hitherto been slow to act in a field in which cause and effect were so obviously linked. He endorsed the Director-General's view of health as a mitigator of poverty, and that ill-health was a major cause of it. The peace of body, mind and soul provided by good health was invaluable in combating disease, violence and poverty. Mr JAN Chun Sik (Democratic People's Republic of Korea) welcomed the Director-General's report, which reflected achievements as well as challenges to be faced in the global health sector. He also agreed with the Commission on Macroeconomics and Health that health was the main factor in sustainable development and that it was therefore important to strengthen national health systems. The Director-General, referring to her visit to his country in November 2001, had remarked that an emergency programme alone would not solve sustainable development and health issues. His Government agreed, and was seeking to convert the current emergency programme into one of sustainable development. His country had been proud of its high standard of medical care, which had provided free high-quality care for all, before the recent series of natural disasters had affected all sectors of the economy. It was hoped that the previous levels of care would be restored and even surpassed. Professor GRABAUSKAS (Lithuania), commending the report, welcomed the recognition that health was central to sustainable development globally. It had been noted at the fifth Global Forum for Health Research, held in Geneva in October 2001, that an increase of one year in life expectancy resulted in an increase in global gross national product of up to 0.4%. Due attention must go to noncommunicable diseases, however, which caused some 60% of all deaths worldwide and accounted for 43% of the global disease burden; nearly 80% of the deaths, mostly preventable, occurred in the developing countries. In that connection, Lithuania congratulated WHO on its initiatives in regard to the framework convention on tobacco control, physical activity and healthy nutrition, and organizing a Research Partners Meeting on noncommunicable diseases in December 2001. Since children would be the focus of attention during 2002, the opportunity must not be missed of drawing attention to the need to stress that habits and practices which led to disease or health were acquired early in life, and to emphasize the importance of infant feeding, physical exercise and health hazards. He looked forward to The world health report 2002, on health risks, to which Lithuania would be pleased to contribute its own research data and experience. Mr CHOWDHURY (India), commending the Director-General's report, said that among the significant achievements of WHO in 2001 was its impact on policy-making in other forums. The strong initiative on trade-related aspects of intellectual property rights (TRIPS) had had a welcome outcome in the form of the Declaration on the TRIPS Agreement and Public Health adopted by the fourth WTO Ministerial Conference in Doha in November 2001, and the observer status obtained by WHO in WTO was bound to infuse deliberations with a much-needed concern for access to medicines for all and upholding the right of Member States to protect public health. He welcomed the establishment ofthe Global Fund to Fight AIDS, Tuberculosis and Malaria, which should prove to be an effective public-private partnership to improve access to health services. It was unfortunate, however, that WHO was not represented on the management Board of the Fund, where it could promote respect for its policies and objectives of ensuring access to health services for all. It was also imperative to ensure that access to funds was determined by rational criteria, especially the burden of disease borne by Member States. The Report of the Commission on Macroeconomics and Health was timely. The integrated global economy sought by WTO could only become a reality if worldwide access to services in the

EXECUTIVE BOARD, I 09TH SESSION

social sector was secured on an equitable basis. WHO had an essential role to play in ensuring such access as a basic human right. To bring that about, the international funds available for health must be allocated according to the needs of the various countries. Dr ABIA NSENG (Equatorial Guinea) said that the Director-General's excellent report reflected the efforts made by the Organization in 2001 in achieving the highest total for collection of contributions in the past 10 years, which at 83% far exceeded the 67% reached in 2000. He wished her continuing success. Professor YUNES (Brazil) welcomed the Director-General's announcement that she would be present at the event to be held in Sao Paulo to launch the World Health Day for 2002, which would also be attended by the President of Brazil. His country was eager to support the negotiating process for the framework convention on tobacco control, and he looked forward to further progress in March 2002. He supported the Director-General's suggestion that publication of the next health system performance assessment be postponed until 2003. Brazil intended to introduce a draft resolution on the subject. Dr ALEMU (Eritrea), expressing his appreciation to the Director-General and the Regional Director for Africa, said that his country had experienced a significant improvement in public health, despite years of drought and armed conflict, the HNI AIDS pandemic and the burden of poverty suffered by the African Region. With the support of WHO, poliomyelitis had almost been eradicated in Africa. Much nevertheless n:mained to be done, especially in poverty reduction. He welcomed the efforts of WHO to build national capacities and public-private interactions to provide affordable and accessible health services and drugs. African countries would give those efforts their fullest support. Mr WESTDAL (Canada),' speaking at the invitation of the CHAIRMAN, applauded the work of the Commission on Macroeconomics and Health. Its highly numerate Report displayed a clear and compassionate vision which duly respected national health systems and solutions and reflected, with unsparing candour, the need for hard choices in setting priorities. At the same time, it argued persuasively that health was a prerequisite for and not merely a product of development, and showed that those in need would receiv(: more help than at present. He endorsed WHO's continuing emphasis on the link between poverty and ill-health. Poverty alleviation was at the heart of Canada's own aid policies and programmes, and had inspired its contribution to the WHO campaign to eradicate poliomyelitis. In 2002, Canada would be chairing the summit meeting of the Group of Eight, which was expected to yield substantial extra resources for the Global Fund to Fight AIDS, Tuberculosis and Malaria. He welcomed the decision to make available the report entitled "Public health response to biological and chemical agents: WHO guidance". The anthrax attacks in the United States of America had killed few people but caused widespread disruption. The information in the WHO report was extremely valuable. WHO had a unique role to play in coordinating information drawn from national surveillance programmes, and in issuing appropriate technical guidance in that area. The international ministerial consultation on the subject organized in Ottawa in November 2001 by Canada's Minister of Health had concluded that the best and only way to prepare for deliberately caused disease was to strengthen public health surveillance and responses to naturally occurring disease, which was the policy adopted by Canada. He supported the proposal to include health and the environment as a priority in WHO's programme of work for 2004-2005. WHO should contribute to and benefit from the forthcoming World Summit on Sustainable Development in Johannesburg. In cooperation with PAHO and UNEP,

Participating by virtue ofRult: 3 of the Rules of Procedure of the Executive Board.

SUMMARY RECORDS: SECOND MEETING

Canada would be hosting a joint meeting of health and environment ministers in March 2002, and a meeting of environment ministers of the Group of Eight would also be held in Banff, Alberta, in April. Mr MORENO PALANQUES (Spain)/ speaking at the invitation of the CHAIRMAN, welcomed the mention in the Director-General's report of genomics and world health, an area that would undoubtedly affect health in Member countries in the years to come. As the European Union country holding the Presidency of the Union during the first half of 2002, Spain wished to pay tribute to WHO's efforts in the field of mental health, and to support the draft resolution on strengthening mental health to be introduced by Belgium later in the session. The world health report 2001 highlighted the continuing need for special policies and programmes on mental health, and for information-gathering to assess their effectiveness. There was no real distinction between physical and mental health, since the absence of either amounted to illness, and they must be tackled together. Dr EL HUSSEIN (OAU), 1 speaking at the invitation of the CHAIRMAN, said that the African continent as a whole benefited from the various WHO programmes. For the past two years, African Heads of State had undertaken to reduce the incidence of HIVIAIDS, malaria and tuberculosis, an endeavour strongly boosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the pledges of the Group of Eight. The African Heads of State had, over the same period, made an equally significant commitment to eradicating the tsetse fly and trypanosomiasis, which represented a daily threat to more than 60 million people in 37 countries of sub-Saharan Africa, 22 of which were among the least developed countries. With their devastating effects on land use and livestock, trypanosomiasis and the tsetse fly were responsible for annual losses amounting to US$ 4500 million, and were perpetuating poverty in many African communities. Two landmark resolutions on the subject had been adopted by African Heads of State and Government at their summit meetings in Lome and Lusaka in July 2000 and July 2001 respectively, and a pan-African campaign for the eradication of trypanosomiasis and the tsetse fly had been launched on 30 September 2001. Resolutions in support of the campaign had been adopted by the Economic and Social Council of the United Nations, IAEA and FAO. He urged WHO, as the leading organization for disease prevention and control, to take appropriate action by adding trypanosomiasis control to the ongoing efforts to eradicate HIV IAIDS, tuberculosis and malaria in Africa. The DIRECTOR-GENERAL thanked participants for their comments, support and suggestions. Not surprisingly, many speakers had commented on the Report of the Commission on Macroeconomics and Health; it was an important document addressing issues that had long been of concern to Board members. She drew attention to the fact that the Report's Executive Summary was available in the six official languages. Several members had commented on the importance of follow-up to the Report, and it had been suggested that consideration of the subject should be included in the agenda of the forthcoming Health Assembly. The Global Fund to Fight AIDS, Tuberculosis and Malaria would be concerned not just with commodities and medicines, but also with implementing existing, and hopefully improved, health systems in a number of poor countries, since commodities or medicines could not be used without a basic infrastructure and access to a health system. WHO therefore saw its role as one of support for countries in using those increased opportunities to move forward on key public health issues. Replying to Dr Di Gennaro, she said that WHO would respond to requests from countries regarding the Global Fund and their national commissions on macroeconomics and health, whether existing or prospective, within the context of the "Country-Focus" Initiative. Evidence-based analysis and strong links with national governments, development partners and civil society were needed to prepare for the work of the Fund; work at country level was a key aspect.

Participating by virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

EXECUTIVE BOARD, 109TH SESSION

Responding to Mr Chowdhury's comment about WHO's representation in the management structure of the Fund, she observed that WHO, the World Bank, UNAIDS and one nongovemmental organization would enjoy, ex olficio, non-voting membership of the management Board. That was the outcome of a long debate about the balance in representation of developing and developed countries, civil society and foundations, and represented the role assigned to the United Nations family. The main point was not the right to vote but the ability of key institutions to present their views, knowledge and experience. Mr Chowdhury had also referred to the allocation of the resources of the Fund. Its Board would decide on all such issues; the indications, however, were that allocations would be on the basis first of needs and then of capacity to use the resources made available. She agreed with Dr Sadrizadeh that health must be given due priority in reconstruction efforts in Afghanistan. Welcoming the comment by Dr Om about support for making the forthcoming football World Cup tobacco-free, she said that information about the events was already available on the WHO web site and additional material! would shortly be made available to all Member States. WHO, Japan, the Republic of Korea, the World Cup organizing committee and the Federation Intemationale de Football Association were completing plans to display a smoke-free logo on World No Tobacco Day and throughout the World Cup. Regarding the question from Professor Zeltner on follow-up to the United Nations General Assembly special session on HIVI AIDS, it had already been decided that the Secretary-General would report to the General Assembly twice in 2002 and then annually, presumably until substantial progress was noted. WHO had established a public health programme that focused on integrating evidence-based HIV interventions in existing health systems. Progress had been made on voluntary counselling and testing, on mother-to-child transmission and on surveillance and care. The global health-sector strategy was being elaborated with wide participation of regions and countries. The Board would have the opportunity to consider a draft resolution on the contribution of WHO to the follow-up of the special session under agenda item 3.15. Professor Zeltner had also highlighted the importance of demonstrating the links between health, peace and development. The work of the Commission on Macroeconomics and Health, the planned WHO report on violence and health and ongoing work showing how infectious diseases could undermine security all contributed to an emerging vision of health's role in improved security. WHO would continue to study the links between health and human security and the role of health and security in the context of sustainable development. The WTO Ministerial Conference in Do ha in 2001 had covered questions regarding equity in health illustrated by the prices of, and access to, medicines and vaccines, and the earlier statement of OAU on African trypanosomiasis was another example both of a commitment by Heads of State and of a tropical disease that needed active work with partners to find solutions that the market alone was incapable of providing. WTO and WHO were under an obligation to strengthen the existing collaboration between the two institutions in order to fulfil the mandate to follow up the Doha Declaration. Health systems development and improving human resources had been addressed in her report; Dr Msa Mliva had emphasized the urgency and importance of that issue. She gratefully took note of several expressions of approval for WHO's intention to take account of new mechanisms and new needs in order to contribute at country level to support national processes. The CHAIRMAN said that she proposed to leave the item open for the time being and return to it to consider the draft resolution on strengthening mental health to be submitted by Belgium. It was so agreed.

(For continuation of discussion on the Report by the Director-General, see summary record of the eighth meeting, section 3.)

SUMMARY RECORDS: SECOND MEETING

HEALTH STRATEGY MATTERS: Item 3 of the Agenda

Public-private interactions for health: WHO's involvement: Item 3.2 of the Agenda (Document EB109/4)

Dr BOSHELL (Colombia) said that interactions between the public and private sectors were a matter of special interest in Latin America, but he submitted that there were some noteworthy shortcomings concerning the relationship with the private sector, the pharmaceutical industry and diseases of high social impact. WHO should seek support from the private sector for mass media promotion of public health programmes. Countries in the Region of the Americas could, for instance, be supported in controlling vector-transmitted diseases, such as dengue haemorrhagic fever, yellow fever, and equine encephalitis, which had a major impact that transcended the health sector and required an intersectoral approach, in both the public and the private sector. WHO support was also needed in associated initiatives concerning hydrographic studies and combating water and soil pollution. WHO should establish appropriate guidelines or models governing interaction between the public and private sectors to avoid conflicts of interest and to ensure proper analysis of private sector proposals without external interference. Dr ANWAR (alternate to Dr Sallam, Egypt) emphasized the importance of public-private interactions in the provision of health services, health insurance and medical supplies. WHO should establish models to regulate partnerships with the private sector that included accreditation and quality assurance requirements. Private-public relationships could enhance programmes such as those concerned with family planning, health education to combat specific diseases, or the solution of other health problems, especially in remote areas needing community participation. Dr AL-MAZROU (Saudi Arabia) agreed that, to avoid any conflict of interests between the public and private sectors, guidelines and the principle of transparency should be established. Due consideration should be given to the relations between the regional offices and the private sector, and the proper limits to them. Positive interactions should be strengthened to ensure benefits at country level. Dr DI GENNARO (Italy) recalled that, in the informal exchange of ideas on WHO's work with the private sector during the retreat for members of the Board in November 2001, emphasis had been placed on the importance of obtaining the maximum benefit from all possible actors, and it had been agreed that public-private interactions had great potential to improve health outcomes and to combat poverty. At previous sessions of the Board, Italy had raised concerns regarding the collaboration of WHO with the private sector, stressing that WHO should not be just one of the partners, but the leader and constituent body. She welcomed efforts to establish a clear policy on the collaboration of WHO with governments in the field of public-private interactions and to train staff accordingly. WHO indeed had a unique role to play in the accreditation process for partners, both from the private sector and from civil society organizations. Accreditation of potential partners and evaluation of the results of interactions required sound expertise and deep knowledge of the many aspects of the delicate issues involved, including ethical aspects. She would welcome information on the development of the planned system of checks and balances, and was confident that its application would increasingly guarantee transparency and productive interaction. Dr SHINOZAKI (Japan) endorsed the measures proposed in the Director-General's note (document EB109/4), including the requirement for clear statements of purpose, regular updates of staff guidelines, and the development of staff training modules. Ms COSTA COUTINHO (alternate to Professor Yunes, Brazil) mentioned the substantial reductions in the price of anti-HIV drugs and the revised Brazilian code of marketing of breast-milk

EXECUTIVE BOARD, 109TH SESSION

substitutes, resulting from negotiations between the Government and industry, as good examples of public-private interactions. Indeed, there was constant interaction between all the social forces in a country and the challenge was to maximize the potential of that while avoiding conflicts of interest. Commercial enterprises were becoming increasingly aware of the importance of fulfilling their social responsibilities and of their public image in that regard. Results of a survey of the level of private investment in social affairs in Brazil, conducted in 2001 by the Ministry of Planning, had shown that investment was increasing, and marketing considerations were giving way to strategic, high-level decisions. The main areas of investment were health, nutrition, education and culture. She commended the steps being taken by WHO and proposed that the Organization should initiate discussions on a code of conduct or code of ethics to complement the work being done by the Office of the Legal Counsel and the Committee on Private Sector Collaboration. In Brazil, the discussion process had been launched by the Ministry of Health, with the support of the President, its aim being to establish the parameters for managing donations of commodities, the cosponsorship of health education or information campaigns, health research funding, and activities by companies in the workplace or in the community. Implementation was scheduled for the end of 2002. A similar effort at international level would support those countries which were striving to improve the levels and transparency of interactions between the public and private sectors. Mr CHOWDHURY (India) said that some public-private initiatives, such as the Sasakawa Foundation's donations of drugs to the leprosy eradication programme in India, had been extremely useful. However, the principles followed in other initiatives, for example the Global Alliance on Vaccines and Immunization and the Global TB Drug Facility, appeared to depart from those used by WHO in allocating its own resources. Support did not always go to the countries with the highest disease burden, and therefore did not ensure disease elimination. Whatever the form of partnership, WHO allocation priorities should be respected. Dr SADRIZADEH (Islamic Republic of Iran) commented that public-private partnerships were of the utmost importance to both health and socioeconomic development and should be carefully planned and implemented. In such partnerships, WHO should give priority to the development of effective diagnostic tools and vaccines, and of affordable drugs against the diseases associated with poverty. Conflicts of interest must be avoided through appropriate measures such as the development of proper guidelines, training for WHO staff, and regular and transparent reports to the WHO governing bodies. Dr ROMUALDEZ (Philippines) said that reforms in the health sector in many countries were leading to the increasing involv1ement ofthe private sector in areas formerly the preserve of the public sector, necessitating a fresh definition of public-private interactions. In some cases the local political situation had prevented or impeded government action, for example in the fields of reproductive health or family planning, and the private sector had stepped into the breach. WHO should provide guidance for countries in their dealings with the private sector, in order to achieve an effective mix of publicprivate provision without compromising ethical principles. Dr THIERS (Belgium), noting that collaboration with the private sector had increased considerably under the current Director-General, particularly with regard to vaccines and drugs, nonetheless sounded a note of caution: WHO might become over-reliant on the pharmaceutical industry. There were important ethical aspects to consider and donations might appear generous until the figures were analysed. The partnership concerning Internet access to scientific journals, mentioned in paragraph 4 ofthe Annex to document EB109/4, was undoubtedly a success story. Other instances would need to be scrutinized in a few years' time, with the benefit of hindsight since it was known that providing something free of charge often had a perverse effect, interfering with the way in which normal systems operated. Without wishing to challenge existing partnerships, he insisted that they must be pursued prudently.

SUMMARY RECORDS: SECOND MEETING

Mr AITKEN (Senior Policy Adviser), replying to Dr Al-Mazrou, said that full consideration would indeed be given to training programmes and advice for all the regions. The debate had been a generally thoughtful one and the Organization would take due note of the points raised, in terms both of support for Member States and of its own practices. Ms HEATON (Save the Children), speaking at the invitation of the CHAIRMAN, said that Save the Children had already raised concerns, at the Fifty-fourth World Health Assembly, regarding the impact of public-private interactions on health systems, the health of vulnerable groups and the integrity of WHO. She welcomed WHO's structured approach to public-private interactions, and particularly supported measures designed to avoid possible risks. She was saddened, however, that consultation on such matters had not been as inclusive and open as had been understood at the previous session of the Executive Board. Based on its own experience, particularly its research on the Global Alliance on Vaccines and Immunization, Save the Children offered the following suggestions, building on the proposals contained in document EB 109/4. Proposals for public-private interactions should contain not only a clear statement of purpose, but specific outcomes with defined benefits to the health of vulnerable groups, and indicators to evaluate them. Guidelines for staff on handling public-private interactions specific to commodity donations and lower prices for commodities should incorporate principles of good practice based on critical research and transparent consultation with relevant stakeholders. Guidelines on conflict of interest should emphasize the need for transparency in documenting the nature and interests of all relevant parties and they should seek to separate the functions of partnership and governance, ring-fencing the governance function to keep it independent from commercial interests. In working to bring about behavioural change in companies with a negative impact on health, it was important for WHO to consult relevant civil society organizations. Further, WHO should establish a mechanism for public hearings in relation to WHO's work themes that examined good and bad practice regarding company impact on health. For the integrity of WHO, it was vital that the tool under development to assess the good standing of companies with which interaction was envisaged be independent and sufficiently robust to serve as an incentive to companies to improve their standards of practice, and that it therefore require companies' compliance with existing WHO standards. Lastly, she noted that document EB109/4 made no mention of any external evaluation ofthe impact of public-private interactions on the independence of WHO. Ms MORSINK (Consumers International), speaking at the invitation of the CHAIRMAN on behalf of Consumers International, Health Action International (HAI) and the International Baby Food Action Network (IBF AN), said that those organizations had previously expressed concerns about WHO's promotion of public-private interactions. For example, at the International Seminar on Global Public-Private Partnerships for Health and Equity, held in Rome in November 2000, WHO had been urged to examine the advantages and disadvantages of public-private partnerships, consider when they were and were not appropriate and define an open process of decision for or against such partnerships, using a broad range of inputs. She shared the concerns expressed by Board members, in particular regarding some of the practices involved in public-private partnerships, and emphasized the need for adequate reporting. Several suggestions to focus WHO's work in the area had emerged from the retreat for Board members in November 2001. The Director-General had highlighted the success stories without, however, providing a thorough, critical analysis of the known risks. Where were the revised guidelines that Board members had clearly called for in January 2001? The issue deserved more serious attention and she therefore urged WHO: to sponsor a full, open, transparent and inclusive debate on the concept of public-private interactions as an appropriate means of securing the human right to health care; to conduct a comprehensive risk-benefit analysis, examining how public-private interactions might conflict with WHO's functions as the highest health standard-setting and regulatory authority; and to analyse public-private interactions with a view to classifying them by acceptability or unacceptability in terms of public health.

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She urged the development, by an independent body, of broadly based criteria for the proposed WHO tool to assess the good study and practices of companies with which interaction was expected. She further referred to a recent critical look at the Global Alliance for Vaccines and Immunization. Who was going to direct major efforts in the field of health and to make sure that they reached the people most in need? Who would ensure that public health needs were addressed before the private sector agenda? Could private corporations be held accountable as could governments and United Nations bodies? Was there not an inherent conflict of interest where private-sector companies were major players in developing health-care policy and provision? National governments were clearly responsible for the development of equitable health policies as a long-term, transparent commitment for which they could be held accountable. The CHAIRMAN said that she took it that the Board wished to take note of the Director-General's note contained in document EB109/4, and to request that WHO should continue its work in the area of public-private interactions in the light of the points therein. It was so agreed.

The meeting rose at 17:50.

THIRD MEETING Tuesday, 15 January 2002, at 9:00 Chairman: Mrs M. ABEL (Vanuatu)

HEALTH STRATEGY MATTERS: Item 3 of the Agenda (continued) The role of contractual arrangements in improving health systems' performance: Item 3.3 of the Agenda (Document EB 109/5) The CHAIRMAN drew attention to the draft resolution in paragraph 8 of the report. Dr MBAIONG (Chad) said that the difficulties in improving health systems' performance could only be overcome by developing and applying new policies and strategies and using new tools. Among the latter were contractual arrangements not involving privatization or the abandonment by the State of its responsibilities: rather, they would redefine the relationships between all actors in the health sector. Diversification and more actors would in turn mean new types of relationships, which should be used as effectively as possible in different national situations and contexts. He congratulated the Director-General for having created a new department, Health financing and stewardship, which would enable contractual arrangements to be dealt with in all their aspects, given that they affected all clusters, regional offices and country offices in daily contact with the situation at grassroots level. During the debate on the draft resolution he had submitted in January 200 l, several speakers had rightly observed that the role of the State had not been highlighted sufficiently: in fact, the State's role would be essential in ensuring that contractual arrangements were clearly defined in national health policy, since only in that way could a lasting improvement in health systems' performance be achieved. On several occasions in the course of the past year, including at the previous Health Assembly, progress had been reported on the amendment of the draft resolution, as requested by the Board, particularly in respect to the role of the State. While the title of the amended resolution, "The role of contractual arrangements in improving health systems' performance", was satisfactory, the text contained neither sufficient background information nor sufficient indication of why such a resolution should be needed. It also over-emphasized the private sector and nongovemmental organizations, despite the growing use of contractual arrangements within the public sector to regulate the relationship between ministries of health and local authorities and to allocate public resources on the basis of performance criteria. Furthermore, while the stewardship aspect had been highlighted in The world health report 2000, it was not adequately reflected in the draft resolution. He urged members of the Board to propose amendments for the sake of a more substantial text for adoption at the next Health Assembly. Dr AL-MAZROU (Saudi Arabia) proposed that at the end of paragraph 2 support should also be requested for the establishment of a system for supervising the implementation of contractual arrangements, in order to guarantee the quality of the services provided. Ms WIGZELL (Sweden) said that, although WHO could undoubtedly provide Member States with good technical advice for evaluating the impact of different types of contractual arrangements, the means whereby health for all and an equitable, well-run health care system were attained was a matter for choice at the national level. She therefore proposed that paragraph 3 be amended to read: -45-

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"FURTHER REQUESTS the Director-General to provide support m response to requests from Member States in developing ... " etc. Dr SHINOZAKI (Japan) said that the role of the private sector and of nongovemmental organizations in health care was becoming increasingly important in view of the high priority being given to developing a more effective and efficient health care system with limited resources. It would therefore be useful for Member States to share their experiences of contractual arrangements, and for research to be carried out to identify best practices in health care systems. However, in applying the results of such research, due regard should be given to the situation and sociocultural background of each Member State. Issues such as the role of for-profit entities in providing health care services, which was limited and restricted in many Member States, including Japan, would require particular consideration. He suggested that paragraph 2 of the draft resolution should be amended to reflect the need to take into account the sociocultural differences between Member States. Mr CHOWDHURY (India) said that his country had few private agencies or nongovemmental organizations with the capacity to undertake a comprehensive major disease control programme on any appreciable geographical scale. In addition, the lean budgets of health programmes would not provide a profit element, and would therefore discourage private agencies from developing the necessary skills. India was nevertheless looking for non-profit entities with the capacity, or potential capacity, to undertake major programme components such as information, education and communication, or drug distribution for simple treatment regimens. With reference to the request in paragraph 3 of the draft resolution that the Director-General should support Member States in developing capacities and expertise, he questioned whether full account had been taken of the additional workload that such support would impose, bearing in mind that similar initiatives in other areas had been turned down in the past. Sweden's proposed amendment to the effect that support should be provided in response to requests would to some extent reduce the burden. Professor ABOUO-N'DORI (Cote d'Ivoire), speaking on behalf of the African Group, read out a draft resolution in French prepared by Chad and Cote d'Ivoire: Le Conseil executif, Ayant examine le rapport sur le role de la contractualisation dans }'amelioration de la performance des systemes de sante ; RECOMMANDE a la Cinquante-Cinquieme Assemblee mondiale de la Sante d'adopter la resolution suivante : La Cinquante-Cinquieme Assemblee mondiale de la Sante, Prenant actt:: que la performance des systemes de sante doit etre renforcee afin d'ameliorer davantage la sante des populations, d'assurer un financement equitable de la sante et de repondre aux attentes legitimes de la population ; Considerant que les reformes des systemes de sante ant generalement entralne des recompositions institutionnelles qui se sont traduites par une diversification des acteurs dans le domaine de la sante (tant au sein du secteur public que des secteurs prive et associatif) ; Reconnaissant le role important de !'administration generale dans la regulation de la contractualisation dans le secteur de la sante ; 1. INVITE INSTAMMENT les Etats Membres : 1) a s'assurer que la contractualisation dans le secteur de la sante adopte des regles et des principes qui soient en harmonie avec la politique nationale de sante;

SUMMARY RECORDS: THIRD MEETING

2) a developper des politiques contractuelles qui maximisent !'impact sur la performance des systemes de sante et harmonisent les pratiques de chaque acteur de maniere transparente pour eviter les effets negatifs ; a echanger leurs experiences sur les arrangements contractuels impliquant 3) les secteurs public et prive et les organisations non gouvernementales ; 2. PRIE le Directeur general : 1) de creer une base de donnees factuelles afin de permettre l' evaluation de !'impact de differents types d'arrangements contractuels sur la performance des systemes de sante et de determiner les meilleures pratiques, et ceci en prenant en consideration les differences socioculturelles ; 2) d'apporter, a leur demande, un appui technique aux Etats Membres en vue de renforcer leurs capacites et leurs competences dans le developpement des arrangements contractuels ; 3) de developper des methodes et des outils a l' appui des Etats Membres en matiere d'accreditation, d'homologation et d'octroi de licences pour les secteurs public et prive et les organisations non gouvernementales. Une attention particuliere devra etre portee pour permettre un meilleur processus de surveillance afin de fournir des services de sante de grande qualite ; 4) de faire rapport au Conseil executif et a l' Assemblee mondiale de la Sante sur les effets positifs de la contractualisation dans !'amelioration de la performance des systemes de sante des pays Membres de !'Organisation en 2005.

Mrs BERGER (alternate to Professor Zeltner, Switzerland) recalled that at its 108th session the Board had concluded that, in view of the complexity of the subject of contractual arrangements, more information was needed on experience gained and on potential benefits and risks. She had therefore expected more substantial information in the draft resolution and, like Chad, would have liked more details concerning the many new agents and new forms of collaboration involved. Roles and responsibilities should in particular be clarified, including the role of stewardship. Member States needed to be able to count on WHO's support in developing their stewardship capacities, since it was for them to do that in the context of their own health systems. Switzerland therefore supported the proposals by Sweden and Cote d'Ivoire. Professor GRABAUSKAS (Lithuania) agreed that links with the private sector should be strengthened and initiatives to develop private medical practice supported. However, countries in transition, such as his own, were particularly concerned about the development of private initiatives at the expense of the State and about quality. In that connection the suggestion that the Director-General should support Member States in building capacities and expertise in the accreditation, licensing and regulation of the private sector was welcome, and he supported the draft resolution as amended by Sweden. Dr THIERS (Belgium) suggested that, in order to avoid confusion, terms such as "public-private interactions" should be defined. He regretted that the text put forward by the Secretariat for the sake of a more acceptable wording had considerably weakened the original draft resolution. However, the text proposed by Cote d'Ivoire redressed the balance and constituted a good compromise. He also endorsed the amendments proposed by Sweden and Japan. Dr SALLAM (Egypt), noting that the health situation in the developing world differed from that in the developed world, called for different solutions. He outlined five principles deserving consideration: a system of separation between the provision and financing of health care should be adopted, but introduced gradually and on a cost-benefit basis; there should be clear regulations

EXECUTIVE BOARD, 109TH SESSION

regarding accreditation, and incentive programmes; solutions offering a positive economic impact should be applied; health programmes should take account of the needs of underprivileged groups; and South/South cooperation should be encouraged. He would endorse the resolution resulting from the discussion. Dr GIRMA (Ethiopia) said that Ethiopia attached great importance to the matter under consideration, on which it had hosted an inter-country workshop. The capacities of governments needed to be strengthened if they were to enter into, monitor and enforce useful contractual arrangements. Such arrangements did not amount to privatization, but were simply a means of providing health care through collaboration where the public sector was not in a position to do so costeffectively on its own. He supported the text put forward by Chad and Cote d'Ivoire as well as the amendment proposed by Saudi Arabia. Dr KARAM (Lebanon) said that private sector health care in many countries, including his own, was more advanced than that of the public sector, and one consequence of contractual arrangements was better care. However, government stewardship of such arrangements was essential in order to provide a cost-effective, transparent service. There was a need to ensure that private provision was based on identified needs and solutions, minimizing total health costs; contractual arrangements for outpatient services could have benefits in the long run. Such arrangements should include a third-party auditing system to oversee and regulate patient care, hospital admissions and hospital costs, as well as a system to prevent the possible over-use or abuse of medicines. Mr KET SEIN (Myanmar), observing that different countries had different health needs, said that the private sector was deve:loping rapidly in his country, and it was his Government's policy to encourage it. However, the Government also had a duty to regulate the quality of health care, improve professional standards and protect vulnerable groups. Developing countries could learn from pooling their experiences, and in that respect WHO had a useful role to play. Dr ROMUALDEZ (Philippines) agreed with the views expressed by previous speakers, in particular with regard to the need to define terms. In his country private health care groups were starting to provide services forn1erly provided by local government, and any guidance from countries with similar experience as well as from WHO, would be most welcome. Private health care providers needed to be encouraged to take account of public health concerns. Dr MSA MLIVA (Comoros) recalled that the member for Switzerland had drawn attention to the need for more information on the risks involved in contractual arrangements. He quoted the example of a case in his own country where considerable sums had been paid directly by the donor, the European Union, to a certain nongovernmental organization without the Government's knowledge. As a result, a large part of the funds had disappeared and only a small portion had been available for their intended purpose, the immunization of children. Greater transparency was therefore needed and he urged developed countries, notably donor countries, to support the draft resolution. Dr AL KHARABSEH (J9rdan) said that the number of private hospitals had mushroomed, owing to such factors as the inability of public hospitals to meet the increasing demand for treatment other than primary health care. In Jordan, for example, private hospitals were so numerous that they had an overall occupancy rate of under 50%, prompting the Ministry of Health to enter into contractual arrangements with them for the treatment of non-private patients and so ease the burden on public hospitals. As a consequence, however, nothing had been done to provide more public hospitals. In such situations, it was essential to ensure that the poor received treatment free of charge at public hospitals or were referred to private hospitals for treatment at the State's expense. It was also essential to monitor the entire process strictly and accurately, in order to prevent health ministries from spending their entire budgets on services by the private sector.

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Dr DI GENNARO (Italy) expressed support for the draft resolution, together with the amendment proposed by Sweden. It was important to strike a balance between the autonomy of providers and their accountability, to put in place systems of accreditation, and to analyse the health outcomes achieved through contractual arrangements. Professor KULZHANOV (Kazakhstan) joined in supporting the draft resolution, but observed that a distinction should be made between the private sector and nongovernmental organizations. Account should be taken of the need to enter into contracts with specific government sectors, such as agriculture and education, which often had their own medical facilities, and with international organizations. The private sector in Kazakhstan was developing quickly, and would need to be coordinated. If it took those comments into account, he believed the draft resolution could be adopted. Dr MURRA Y (Executive Director) commented on the growing interest in contractual relations in terms of effective stewardship. He had noted the comments and suggestion made regarding the crucial role governments could play in implementing, monitoring and evaluating contractual arrangements, and would endeavour to follow them up. In response to questions raised, he said that he did not expect the extra workload involved in implementing the resolution to be too heavy, given that it would in any event form part of the ongoing work on stewardship. He had noted the request made by several speakers for more precise language and definitions of terminology. Lastly, he acknowledged the lack of experience of contractual arrangements and the desire of members to learn from the experience of others in using such arrangements, notably within the public sector. Mr AITKEN (Senior Policy Adviser) suggested that, if the Board agreed, a revised version of the draft resolution would be produced, taking account of suggestions made, which would be put before the Board at a later session. The CHAIRMAN enquired whether such a course of action would be acceptable. It was so agreed.

(For continuation of discussion on the role of contractual arrangements in improving health systems' performance, see summary record of the eighth meeting, section 4.) Assessment of health systems' performance: report of the peer review: Item 3.5 of the Agenda (Document EB 109/6) The CHAIRMAN, introducing document EB109/6, pointed out that the interim report of the Scientific Peer Group on Health System's Performance Assessment was annexed in the document. She drew attention to the following draft resolution entitled "Assessment of health systems' performance", which had been proposed by Brazil: The Executive Board, Taking note of resolution EB107.R8, on health systems' performance assessment; Having analysed the report "Assessment of health systems' performance: report of the peer review"; 1 Appreciating the suggestions of the advisory group on assessment of health systems' performance regarding the timetable for completion of the next report, namely that the Secretariat could produce a different type of report in October 2002 that would summarize the

Document EB I 09/6.

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work undertaken in relation to resolution EB107.R8, and that the next reporting on the performance of countries' health systems would follow in 2003; Noting with satisfaction the measures already taken by the Director-General in accordance with resolution EB107.R8; Bearing in mind, none the less, that because of the radical methodological changes already proposed and yet to be implemented in the framework of the new report, much further work needs to be accomplished, REQUESTS the Director-General: ( 1) to produce an interim report to be submitted to the Executive Board at its Ill th session that shall summarize the work undertaken in relation to resolution EB107.R8, and to present the next statistical annex reporting on the performance of countries' health systems for publication, after consultation, later in 2003; (2) to provide the report to the health authorities of Member States 15 days before the intended date of publication. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil) proposed that the date of October 2002 set for publication of the next draft report on assessment of health systems' performance, in accordance with resolution EB 107 .RS, should be changed to late 2003 for a variety of reasons. First, given the volume of material and lack of time, the members of the Scientific Peer Review Group had been able to review only parts of the summary documents. Secondly, the Group's interim report made it clear that some important issues, such as those covered in paragraphs 5, 7, 10, 12 and 17, still required further development and/or review. Thirdly, the Group had not discussed the transverse dimension of equity which needed highlighting in any health system performance assessment. Postponement of the report would therefore be beneficial, given the importance of the subject and the need to address the scientific recommendations made. He expressed Brazil's wish to participate in the World Health Survey, and concluded by asking whether the Executive Board could convene before September 2003 in order to analyse the next draft report before its publication in late 2003. Or OM (Republic of Korea) said that all future work on the assessment of health systems' performance should take into account three essential factors: reliability of data, reliability of the evaluation process, and transparency. Given the role of technical consultation in improving the assessment procedure, experts from a wider selection of Member States should be allowed to participate in the Scientific Peer Review Group. Or SADRIZADEH (Islamic Republic of Iran) said that The world health report 2000: Health systems: improving performance had stimulated competition to develop efficient mechanisms for the collection of statistical data and other relevant health information, with a view to improving the ability to monitor the performance of health systems. As a result of subsequent efforts to revise assessment methods, monitor WHO support and update methodology, he was confident that The world health report 2003 would arouse more appreciation than concern. As it was important that both the public and decision-makers understood the main messages of the assessment of health systems' performance, a concise summary should be annexed to the report, highlighting the main policy issues and the lessons learned, with a view to further improvement of health systems' performance in the countries concerned. Or SALLAM (Egypt) said that a novel solution should be found to problems associated with health systems' performance assessment. In connection with the assessment of improvement rates, the particular situation in countries should be taken into account as it was difficult to compare progress between countries at widely differing stages of development. In his view, countries should be divided into categories to minimize differences when it came to rating their health status. Such a system

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should be considered without delay, since results under the current system would undoubtedly be criticized when they appeared in the next report. Dr SHINOZAKI (Japan) said that the intention behind health systems' performance assessment was to fashion a critical tool for analysis and policy dialogue for the sake of effective health systems. Global use of that tool would provide information about the allocation of resources, the priority areas and measures to be adopted by governments. He consequently favoured the notion of developing the procedure on the basis of scientific and evidence-based approaches. It was still too early, however, to conclude that the process of reviewing the framework of the assessment was complete. In that connection, efforts should be made to establish a consensus in full consultation with Member States. He therefore supported the second option proposed in paragraph 5 of the report, namely to produce a different type of report in October 2002 that would summarize the work undertaken in relation to resolution EB107.R8 and indicate that the next reporting on country health systems' performance would follow in 2003. Dr KARAM (Lebanon) expressed his appreciation of current efforts by WHO to assess health systems' performance. Supporting the suggestion by Brazil, he said that, should more time be allowed for the next draft report, the parameters used to assess health systems could be improved in terms of both status and progress made towards more equitable and efficient health care. Professor ABOUO-N'DORI (Cote d'Ivoire), speaking on behalf of the African Group, supported the proposal to postpone publication of the report until late 2003. Above all, Member States should be informed of the content of the report prior to its publication in order to avoid any subsequent queries concerning the performance of some countries, as had occurred in 2000 in view of the assessment criteria used. In that connection, he agreed with the member for Egypt that the classification of countries into groups was a more acceptable and reasonable approach. Dr DI GENNARO (Italy) said that she agreed with much of the interim report of the Scientific Peer Review Group but observed that, despite the latter's hard work and constructive approaches, much remained to be done. The interim report devoted more attention to the review of the scientific methods proposed for the next round of health systems' performance assessment than to revision of the methods used. Concerning the current timetable for completion of the next draft report, she too supported the second option set forth in paragraph 5 of the report. She further supported the proposal that publication of the next draft report be postponed to late 2003, but was receptive to other views on the subject. Professor GRABAUSKAS (Lithuania) said that his country was eager to implement changes to its health system in order to improve its efficiency and cost-effectiveness, to which end it was applying some of the features of previous health system performance assessments, together with some being used to produce The world health report 2003. In that connection, the measurement of health research in a country, especially the efficiency of investment, referred to in paragraph 11 ofthe interim report, was particularly relevant to the value system widely accepted in Baltic societies, where such research had done much to assist politicians and decision-makers. The academic community had also been responsible for continued implementation of the health policy formulated and developed on the basis of WHO's health-for-all principles. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) welcomed the proposal to delay publication of the next detailed report until 2003 in orderto draw on the findings of the Scientific Peer Review Group. While favouring the performance assessment initiative as a whole, he commented on what he perceived to be major outstanding problems with the methodology, some of which had been highlighted in the interim report of the Group. As many of the data used to

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compile the report were imputed, he wondered what the prospects were for gathering more complete data for the next report, given that significant problem and the limited time. There was discordance between the broad health systems goals implied by the use of the disability-adjusted life expectancy measure to assess attainment, and the much narrower goals implied in the assessment of fairness of financing and responsiveness. The alternative was to try, where data existed, to extract more specific indicators of health care outcomes. There were also difficulties with estimating the attainment threshold on the narrow basis of years of education. It should be ensured that no major diversion of effort was caused by locking all countries into one approach to assessing performance, given that many other statistical measures needed to be developed within countries. The United Kingdom therefore fully supported further work on the assessment methodology. He had four specific requests in regard to that work: first, that the points he had raised in regard to methodology be taken into account; secondly, that the outcomes of regional consultations also be taken into account; thirdly, that the peer review group's report, if possible, be published in the scientific press, to allow external experts and others the opportunity to comment; and fourthly, that in the draft resolution proposed by Brazil specific mention be made of the need to give Member States a further opportunity to comment on the next version ofthe methodology before its final publication. Dr LOPEZ (Venezuela) welcomed the activities to improve the assessment of health systems' performance and the establishment of a group of experts for the task. She had read the interim report of the Scientific Peer Review Group and was conscious of its excellent work. Nevertheless, there were some aspects of that work as yet undeveloped. There was a need for the proposed methodology to be disseminated within countries, thus facilitating improvement in technical capacities and better monitoring and assessment of health policies and better focused cooperation by agencies. She believed that the proposed methodology could go beyond the mere ranking of performance and become a genuine means of improving health conditions. She supported the proposal by Brazil to defer the next presentation of statistical data to 2003, for the reasons outlined by previous speakers, and the proposal that Member States be consulted before publication. Ms WIGZELL (Sweden), noting that improvement of health systems was a core issue, strongly supported that new focus of WHO. Referring to the report on the performance of health systems, she recalled that there had been much debate on methodology and transparency. Although the work of experts, the Scientific Peer Review Group and the advisory group was appreciable, greater transparency with regard to the process was needed. For example, Member States needed to know in advance when and how they would be requested to participate. The assessment would be both complex and long, but a well-functioning process would guarantee the production of a scientifically based report of great use to Member States and to WHO's strategy to develop strong national health systems. Like many other Member States, Sweden supported postponement of presentation of the detailed report until 2003. Dr BOSHELL (Colombia) considered that measurement of the performance of health systems was one of the more difficult tasks undertaken by WHO, and, perhaps for that reason, the attempt had drawn a good deal of criticism. Such criticism should, however, lead to improvement of the methods used. He asked for clarification of how the measurement would be carried out. He fully supported the proposal by Brazil to postpone the final report until 2003, on the understanding that, should a preliminary report be presented to the Executive Board in January 2003, a meeting would be held between its presentation and publication of the final report later in 2003, so avoiding unpleasant surprises from its conclusions. Dr MODESTE-CURWEN (Grenada) said that assessment of health systems' performance was a new, highly significant undertaking of particular relevance to Caribbean countries. The assessment would give Member States the opportunity to evaluate their own systems and to improve performance, although WHO assistance would be required. She supported the draft resolution proposed by Brazil.

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Or MSA MLIV A (Comoros) commented that assessment of the performance of health systems was a difficult exercise for Member States. Given the diversity of health systems, it would be difficult to assess, in the same context, those from developed, developing and least developed countries. He recalled that he had not been convinced by the ranking of the Comoros as 146th in The world health report 2000, and further work was required by the Organization on the matter. With the assistance of WHO, UNICEF, UNFPA, China and France, his country had begun a reform of its health system in 1994 and had assessed the system in July 2001, according to the WHO method. It was difficult to say whether that method had been appropriate. Given the complexity of the work ahead, he supported the proposal that publication of the report be delayed until 2003. The Director-General and the Regional Director for Africa should take note of the institutional changes that had taken place in the Comoros, which would necessarily affect the performance of its health system. The Union of Comoros, formerly known as the Islamic Federal Republic of the Comoros, was in a most decisive phase in regard to the development and performance of its health system. A national health system based on regional or district services and in the context of a policy of decentralization and autonomy for regions would be implemented in 2002 in accordance with WHO and UNICEF action plans, with the assistance of development partners. His Government considered that devolving responsibility to the regions would make for a more effective, accurate assessment of health system performance. Mr STEIGER (United States of America)/ speaking at the invitation of the CHAIRMAN, supported the proposal of Brazil to postpone publication of the report until the end of 2003. Like the United Kingdom, his country had some concern about the method and process by which health systems' performance had been assessed in the previous two years. Member States should be given more time than in the past to review the report and the statistical annexes before they were published. Concern remained about the reliability of much of the data used, the gaps in data collection and how WHO had gathered the data. In future, WHO should use official, credible data in its analysis, rather than imputing data or using consultants to collect data. WHO should provide countries with complete information on the method of analysis and the data collected. He supported the wish of members of the Board from developing countries that WHO should make every effort to include scientists from each region in its analytical activities. Ms BALOCH (Pakistan)/ speaking at the invitation of the CHAIRMAN, said that analysis of health systems was a prerequisite for future health policy making. At the Fifty-third World Health Assembly, the delegate of her country had stated that analysis of health systems' performance should take into account the problems confronting developing countries struggling to provide health care to their people with extremely limited resources, lack of modem technology, competing domestic demands, inadequate financial flow, a heavy debt burden, unequal trading systems and difficult security environments. He had expressed his concern about the development of arbitrary health indicators which did not take into account those factors. Pakistan had been concerned at the previous year's discussions in the Executive Board and the non-transparent and non-participatory manner in which the Board had adopted resolution EB107.R8. While putting in place the so-called "consultation" process, the resolution had failed to take into account the recommendations of the United Nations Economic and Social Council on the use of indicators. Further, the Board had not referred it to the Health Assembly for information or endorsement. That behaviour suggested that, instead of performing its functions as the executive organ of the Health Assembly, the Board was becoming a parallel decision-making body. While scientific peer review of the method used to assess health systems was essential, any decision about how that method would best be used was a policy decision, which should rest with the Health Assembly and not with its executive organ.

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

EXECUTIVE BOARD, 109TH SESSION

In regard to the interim report of the Scientific Peer Review Group annexed to document EB 109/6, paragraph 6 stated that the database had been improved since publication of The world health report 2000, but the basis for that statement was not given. Had the Group had access to the database, in order to assess its "quality and quantity", or had the conclusion been simply based on a briefing? More importantly, how could Member States gain access to the database? Even though the Scientific Peer Review Group had improved the sampling method, for instance by including refugees in population surveys, it should also consider the financial and economic burden shared by host countries in developing indicators for financing of health systems. The models used in identifying indicators related to financing and service provision were interesting, but it was not clear how qualitative or quantitative assessments would be made in developing the stewardship function. Pakistan considered that evaluation of governance issues was not within the mandate of WHO. Furthermore, statisticians had been unable to develop a satisfactory method for accurate measurement of governance indicators. WHO should not venture to analyse health systems at the sub-national level. Comparisons of different federal units within the same country could have political consequences, as the Organization might, in following such an approach, inadvertently contribute to domestic politics. While sub-national comparisons were important, it should be recalled that States, and not their federal units, were Members of WHO, and decisions on the best method for particular national circumstances and conditions and on the right indicators for evaluating sub-national health systems should be policy decisions of the country concerned. One solution might be to develop flexible models which could be used at sub-national level, but only upon request from the Member State concerned. The method proposed for measurement of effective coverage had been termed "promising" by the Review Group, although it had recognized it was still experimental. No matter how promising they might appear, the Group should suggest only methods that had proved their worth. It was surprising that no survey had been made of existing indicators and methods in use in other organizations of the United Nations system. The Board should inform the Review Group that its terms of reference did not include any policy guidance for Member States, despite the comments in paragraph 19 of the report. The Group had been established to assist the Director-General in proposing a viable, reliable method for assessing health systems. Formulation of health policies was a sovereign right of Member States. Refinement of the assessment method and the background research should be made transparent to Member States. Mr LIU Peilong (China), 1 speaking at the invitation of the CHAIRMAN, noted the significant progress made by WHO in its work on health systems' performance assessment during the previous year. The introduction of innovative ideas and new techniques for measurement of health systems would require WHO to examine what support Member States needed in order to improve their ability to monitor the performance of their health systems. Paragraph 21 of the report acknowledged that, at headquarters, WHO lacked the capacity to meet all the demands for direct country support. If neither headquarters nor the regions could meet the demand for assistance, how was the assessment work carried out by Member States to be supported? It was his understanding that WHO was cooperating with a number of countries; however, cooperation should not be confined to providing funding to conduct investigations and collect data in some countries. The question was how WHO could provide support for capacity-building in all countries. China supported the request put forward by previous speakers that more developing countries be included in the review process. Referring to the principle that equal weighting should be given to all the Organization's languages, he asked the reason for the delay in publishing the annual world health report in Chinese. It should be published simultaneously in all six languages. Although the 200 l report had been officially launched globally in October 2001, China was still awaiting publication of the document in Chinese.

Participating by virtue of Rule 3 ofthe Rules of Procedure of the Executive Board.

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That had delayed the publication ceremony in the Western Pacific Region. He therefore requested that the problem be addressed. Dr MURRA Y (Executive Director), responding to the question from Brazil regarding consultations with Member States, said that the intention in postponing the final report on country health systems' performance to 2003 was to allow time for consultations with every Member State about the content, which process would last several months. The member from the Republic of Korea had stressed the importance of transparency in bringing together the input from the current year's regional consultations, which had involved experts from more than 90 Member States and several technical consultations. All the material from those consultations had been made available to the Scientific Peer Review Group. In addition, the proposals of the Secretariat had been collated in a synthesis document, which was available to the entire public health community on the WHO web site. Thus, the materials forming the basis for the expert deliberations of the Scientific Peer Review Group were available to all. Those materials included information relevant to some of the issues raised by the member for the United Kingdom, namely, the strategy for improved data collection and issues relating to imputation of the value of specific interventions. In that context, emphasis had been laid on including the notion of effective coverage with critical interventions in performance assessment. Detailed technical discussions had been held on production frontiers and strategies for data collection. The member for Egypt had stressed the importance of having alternative ways of presenting information on performance assessment. He wholeheartedly agreed on the need to focus attention on change in, rather than simply measurement of, performance. In that regard, experience of other social indicators within the United Nations system was highly informative: for example, the focus of work on national income accounts was increasingly on the percentage growth rate, rather than on per capita income. Given that a consensus-based approach to performance assessment had gained wider acceptance, that evolution was normal. The member for Italy, while agreeing with the proposal to delay publication of the detailed annexes on performance assessment to 2003, had asked for a report on work undertaken in response to resolution EB107.R8. That appeared to be in accordance with the proposal by Brazil. The member for Lithuania had referred to the importance of measuring health research in assessing the performance of health systems overall. A programme was under way to consider how funding and implementing health research for health systems' performance could be facilitated and how related experiences could be shared among countries. The next consultative meeting on the theme was to be held the following week. The outcome of the regional consultations and the methodological points raised by the member for the United Kingdom would be taken into account by the Scientific Peer Review Group, and the report of that body would be available to all, not only through WHO, but also in the scientific literature. All the inputs to the review should also be in the public domain, to ensure that the deliberations were transparent. Two further meetings of the Group were considered, and it was envisaged that the Group's final report would be available in time for the 11 Oth session of the Executive Board in May 2002. In the interim, any comments by Member States would be welcome. Regarding the comment of Pakistan about subnational performance assessment, he said that WHO had no intention of forcing countries to engage in such an exercise. The only work undertaken in that area had been driven by requests from Indonesia, Mexico, Spain and Thailand to evaluate the components of their systems. As to effective coverage and the evaluation of stewardship, the Scientific Peer Review Group had only recently begun to reflect on how the method might be improved and whether it met the crucial criteria of scientific credibility and reliability. Those issues would be on the agenda of the Group's next meeting. With regard to the comments by China, WHO was trying to strengthen capacity for performance assessment by Member States so wishing. An international training workshop on the development of methods had been well attended. The World Health Survey would provide a further vehicle for capacity strengthening and exchange of methods. Specific efforts in place included retreats held with

EXECUTIVE BOARD, 109TH SESSION

regional office counterparts to the headquarters group working on performance assessment, aimed at strengthening the ability of the Organization as a whole to support Member States in that area. In conclusion, the Secretariat would be pleased to discuss the problems associated with translation of The world health report with the representative of the Chinese Government, with a view to facilitating the process. Mr AITKEN (Senior Policy Adviser), responding to a question by the representative for Brazil about the timing of Executive Board sessions, said that at each session the Board determined the arrangements for its next session. The practice was to hold sessions in January and May. A meeting in the early autumn would be difficult to organize because the regional committees met between late August and early October. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil), on a point of clarification, said that his question concerned the guidance to be given by the Board to the Director-General. Paragraph 1 of the draft resolution included the words "after consultation", indicating that the report should not be distributed before the Board had had an opportunity to scrutinize it. One option would be to convene a two-day session of the Board, at the request of 10 members, in late September or early October 2003. If a meeting in Geneva posed problems, Brazil would be pleased to host it. Ms WIGZELL (Sweden) asked for confirmation that Brazil was proposing an extraordinary session of the Board, at which it would check the report before publication. If so, the proposal was, in her view, misguided. The report was an expert report and, as such, the responsibility of the DirectorGeneral. The Board had a role to play in ascertaining that Member States had been consulted on data and methods but was not entitled to issue an imprimatur. The CHAIRMAN invited the Board to adopt the draft resolution proposed by Brazil. The resolution was adopted. 1

WHO medicines strategy: Item 3.6 ofthe Agenda • Expanding access to essential drugs (Document EB 109/7) Dr SALLAM (Egypt) said that document EB109/7 was mistitled: few countries had problems with regard to "essential" drugs, and definitions of what constituted an essential drug differed. Furthermore, by running together the issue of access to essential drugs and the very different issue of accessibility of pharmaceuticals through the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), the report vitiated much of the work done by Member States and WHO. Dr ROMUALDEZ (Philippines) endorsed the previous speaker's comments. Broadly speaking, document EB 10917 was to be commended and gave reason to hope for an improvement in access by poor individuals, families and communities to state-of-the-art remedies for their health problems. However, the critical roles played by the TRIPS agreement and other such trade-related instruments in modifYing that access required separate attention. While the Director-General had correctly interpreted the declaration issued after the fourth session of the WTO Ministerial Conference in Do ha as broadly supportive of health, a more intensive effort by the health sector was needed to ensure that such would indeed be the outcome. The present situation still allowed the pharmaceutical industry to use the TRIPS agreement and similar instruments to delay, if not deny, access to modem medicines for the poor. The Board might wish at some point to commit Member States not only to refraining from using

Resolution EB109.Rl.

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provisions of those instruments to prevent or delay access to important remedies, but also actively to facilitating access to those remedies for the poor. Mr BERMUDEZ (alternate to Professor Yunes, Brazil) said that, following extensive debate in his country on the challenges arising from trade agreements, universal access to antiretroviral drugs for people living with HIV/AIDS had been identified as a successful model for middle-income countries. The Ministry of Health had recently implemented certain economic and health regulations, including decentralization of financial resources for medicines within basic health care and central procurement of medicines for strategic programmes. Negotiation and domestic production had led to lower prices for Government procurement, while economic regulation and the generic drug law had made medicines more affordable in the private sector. He welcomed the report, in particular the priority for drug pricing; new partnerships and initiatives such as international reference price information, sources and prices of drugs related to HIV I AIDS and regional price information services in Africa, Latin America and Europe; the discussion on trade agreements, particularly the TRIPS agreement, and access to drugs; and the citation by the Director-General from the Doha Declaration that the TRIPS agreement "can and should be interpreted and implemented in a manner supportive of WTO Members' right to protect public health and, in particular, to promote access to medicines for all". Stressing the importance of resolution WHA54.11, he favoured inclusion of the WHO medicines strategy in the agenda of the Fifty-fifth World Health Assembly, pursuant to paragraph 2(8) of the resolution. Furthermore, he would request, under the relevant agenda item, the inclusion of access to medicines as a priority for the next biennium. Dr BODZONGO (Congo) congratulated the Director-General on WHO's contribution to the resolutions passed at the WTO Ministerial Conference in Doha. It was regrettable, however, that the report before the Board mentioned no ancillary measures relating to the four factors crucial to securing and expanding access to essential drugs, namely rational selection and use of essential drugs, affordable prices, adequate and sustainable financing, and reliable health and supply systems, as part of the follow-up to that Conference in order to ensure that countries had access to essential medicines. Geographical access presupposed that the necessary health structures were in place, which in turn came down to financing. On prices, he was surprised that the report made no mention of generic medicines, since they were such an important part of access to medicines for people in developing countries. He suggested that the national and international courses mentioned in paragraph 7 of the report should be extended to all WHO regions, so as to improve rational use of medicines among those prescribing and using them. In view of the problems experienced by countries such as his own in ensuring the quality of donated medicines not passing through WHO, he suggested that countries be assisted in building up quality control systems. Since access to medicines was part of access to health care generally, he expressed the hope that WHO would help countries to adopt proper health financing policies, including health insurance and social security systems. Dr SADRIZADEH (Islamic Republic of Iran) said that, in the two decades since the first WHO Model List of Essential Drugs had been issued, the health situation in most developing countries had changed significantly. Many of them bore a double burden of communicable and noncommunicable diseases, with emerging diseases and multidrug-resistant pathogens compounding the problem. Those developments called for drug policies and management programmes relevant to the health needs ofthe population and aimed at ensuring access for the whole population to essential drugs at a cost the country could afford. He welcomed the report and fully supported the revised procedure for updating the Model List. He expressed his appreciation for the creation of an essential medicines library, which would certainly do much to disseminate information worldwide. As the TRIPS agreement had significant implications, not only for access to essential drugs, but also for local drug industries, drug research and development and traditional medicine, he agreed with Dr Sallam that a separate section of the report should have been devoted to it.

EXECUTIVE BOARD, I 09TH SESSION

Dr DI GENNARO (Italy), speaking on behalf of the Member States of the European Union, said that the undoubted success of WHO's essential drugs strategy since its inception in the 1970s fully justified the support it had enjoyed from Member States. Nevertheless, with one-third of the world's population still without regular access to the most basic drugs, universal access was still a long way off; all States must pursue that goal, not just in the case of natural disasters or war, but by becoming involved in development programmes at regional and local level conducive to national medicines policies for ensuring the access of the entire population to safe, effective, high-quality drugs. She welcomed the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which would help to expand coverage of tried and tested interventions, in particular through strengthening access to primary health services. Seeing how hard it was to ensure affordable access to drugs in an increasingly globalized economy, she particularly welcomed the adoption of a comprehensive declaration on the TRIPS agreement and public health at the WTO Ministerial Conference in Doha. The Declaration provided urgently needed clarification concerning the flexibility inherent in the TRIPS agreement, which was expected to facilitate the adoption of measures to protect public health in the future. It struck a better balance between the need of developing countries for efficient drugs to combat HIVIAIDS and other epidemics, and the need to maintain the appropriate incentives for further investment in research and development of life-saving drugs. WHO should make full use of its expertise in health matters, so ensuring that Member States could take due account of health aspects in the sphere of trade negotiations. In that regard, she particularly welcomed the contacts established between the relevant international organizations and encouraged WHO to contribute to meaningful application of trade agreements that supported public health concerns. As noted in the recent report of the Commission of Macroeconomics and Health, access to affordable medicines in all countries could best be promoted by cooperation between all parties - governments, international organizations, civil society and the private sector, including the pharmaceutical industry. She supported WHO's efforts to promote wide application of tiered pricing, a strategy taken into account by the European Union in formulating a programme for action on communicable diseases in the context of poverty reduction. Medicines alone, even free of charge, were not the whole answer to preventable or curable diseases in the absence of viable health systems to protect the vulnerable. That involved, on the one hand, a political commitment by governments to set up sustainable infrastructures and, on the other, assistance in the form of training, transfer of technology and research. The European Union was strengthening its own health-related assistance. Welcoming WHO's involvement in emergency situations, she stressed the importance of continued close coordination of WHO's humanitarian assistance activities with international humanitarian organizations and of WHO's full participation in the United Nations Inter-Agency Consolidated Appeal Process. She emphasized the importance of publications such as the recommendations on drug donations and the New Emergency Health Kit, which included opioid analgesics. It seemed reasonable to ease controls on the import and export of those drugs, in so far as they formed part of humanitarian aid for emergency situations. She urged WHO to continue along the route indicated by successive Health Assembly resolutions, in conjunction with the medicines strategy. Over the years, its predecessor, the revised drugs strategy, had proved to be an outstandingly effective means of improving access to high-quality drugs and providing initiatives and information for more rational drug use. Dr SHINOZAKI (Japan), while gratified by the rise in the number of countries with a public essential drugs list, from I 00 in 1990 to 156 in 1999, stressed that the crucial factor in better access to essential drugs was the strengthening of infrastructures, including human resources and drug quality assurance systems. In that regard, he welcomed WHO's intention to focus on reliable supply systems during 2002 and 2003. In the discussion on differential pricing, private sector initiative should be given priority over public intervention. Furthermore, it should be made clear that the drugs listed in the WHO Model List were not automatically subject to differential pricing or compulsory licensing. With reference to paragraphs 13 and 14 of the report, he said that innovations covered by patent protection

SUMMARY RECORDS: THIRD MEETING

were important to improve access to better medicines in the long run and a balanced approach should be sought there. WHO should act in collaboration with WTO concerning the TRIPS agreement and access to drugs. On financing, WHO should consult Member States before conducting an analysis of options for public financing for drugs and publishing the results. Similarly, consultation would be required before expansion of the indicator-based system for monitoring access, quality and rational use. The Government of Japan had supported the three-step pain relief system advocated by WHO and had sought to promote better understanding and knowledge of opiate use for medical purposes. It would continue to enhance proper use and management of drugs, while strictly controlling abuse of dependence-forming drugs, especially amphetamine-type stimulants and cannabis. Dr AL-MAZROU (Saudi Arabia) said that international trade agreements should have been discussed at greater length in the report, and greater emphasis should have been placed on the success achieved at the WTO Ministerial Conference in Doha, the declaration from which supported the right of WTO Member States to protect public health and promote access to medicines. The Member States of the Gulf Cooperation Council had achieved various successes of their own during their 20 years of experience in the supply and purchase of drugs, such as price reductions and better conditions of supply. Furthermore, the methods of clinical treatments used in the six States were at present more similar than before. He hoped that efforts to expand access to essential drugs would be coordinated in the interests of inter-State trade. Dr THIERS (Belgium) highly praised WHO's essential drugs strategy, which he said had brought about revolutionary changes he would not have thought possible three years earlier. He paid tribute to all those who had taken part, especially the Director-General, for having had the courage to launch the strategy, to Brazil for the resolutions it had initiated, and to the excellent cooperation between WHO and UNAIDS.

The meeting rose at 12:30.

FOURTH MEETING Tuesday, 15 January 2002, at 14:00 Chairman: Mrs M. ABEL (Vanuatu)

HEALTH STRATEGY MATTERS: Item 3 of the Agenda (continued) WHO medicines strategy: Item 3.6 of the Agenda (continued) • Expanding access to essential drugs (Document EB 109/7) (continued) Dr KARAM (Lebanon) commended the WHO contribution to the WTO Ministerial Conference in Doha. Endorsing the position taken by Dr Sallam, he said that WHO must ensure the sustained availability of reliable and affordable medicines. Protection of intellectual property rights was also important inasmuch as it stimulated innovation, ensured drug safety and protected the interests of manufacturers and consumers. However, it was essential to safeguard the right to medicines as an integral component of the right to health for all. Dr DOTRES MARTINEZ (Cuba) agreed that greater attention should be focused on financing medicines and ensuring reliable supply systems. Document EB 109/7 indicated that WHO was actively promoting the concept of differential pricing to increase access to essential drugs by people in poor countries or among vulnerable groups for whom such drugs were sometimes prohibitively expensive. He welcomed the Director-General's affirmation on the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), to the effect that it could and should be interpreted in such a way as to support the right of WHO Members to protect public health and, in particular, to promote access to medicines for all. Cuba also endorsed the WHO medicines strategy, provided it was applied creatively and continued to be improved, in accordance with the proposal by Dr Sallam. Dr LOPEZ (Venezuela) affirmed her belief that everybody should have equal access to treatment, including access to medicines. Venezuela's new law on drugs reflected the main points contained in document EB 109/7, a factor that would assist in the implementation of that law. However, WHO should continue to consolidate its work in all the areas indicated in the document, particularly in relation to prices. Access to essential drugs should be included among the priorities for the 2004-2005 biennium as it was an important issue for all countries. Mr CHOWDHURY (India) stated that India was committed to discharging its responsibilities in providing essential drugs for its people in accordance with the Doha Declaration on the TRIPS Agreement and Public Health. In line with the Director-General's statement that the agreement should be interpreted and implemented in a manner supportive of WTO Members' right to protect public health and, in particular, promote access to medicines for all, India intended to restructure its patent laws in a manner consistent with that agreement. In future, it would have the right to grant compulsory licences, the freedom to determine the grounds on which it would do so, and the right to determine what constituted a national emergency or circumstances of extreme urgency, which might include public health crises. The definition of "working a patent" would include domestic manufacture, as such a provision ensured drug availability and security for developing countries without undermining the rights ofthe original developer of the product concerned.

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Dr MOON (alternate to Dr Om, Republic of Korea) suggested that WHO should initiate international programmes designed to help developing countries to improve their capacity to manufacture cost-effective, high-quality generic drugs, as a way of broadening access to essential drugs. Ms BENAVIDES COTES (alternate to Dr Boshell, Colombia), referring to paragraph 13 of document EB109/7, stressed the need for WHO to continue to provide technical support to Member States through regional briefings on international trade agreements and their impact on access to drugs. Following the granting of observer status to WHO at the WTO Ministerial Conference in Doha, Member States would be looking to WHO for guidance on implementing the Doha Declaration. The debate would intensifY as the number of patents on drugs increased, making it more difficult to guarantee access to essential drugs for all those in need of them. She endorsed the statement made by Dr Thiers at the previous meeting and commended the excellent work undertaken on follow-up to the TRIPS agreement. She concurred with Brazil that essential drugs should be included in agenda item 4.2, Priorities for the biennium 2004-2005. Dr SALLAM (Egypt) observed that, despite the considerable effort of all concerned in expanding access to essential drugs, an international strategy was still lacking. In devising such a strategy, a balance needed to be struck between commercial interests and public health goals. As a first step, WHO should take the lead in clarifYing the implications of the TRIPS agreement and in supporting countries that were encountering problems. Multinational companies might be encouraged to form partnerships with local companies; once they became aware of the trade benefits to be gained, they would be more sympathetic towards expanding access to essential drugs. Although the Doha Declaration was important in itself, it needed translating into concrete rules and regulations. The issue should therefore be discussed further at the next Health Assembly. Mr STEIGER (United States of America), 1 speaking at the invitation of the CHAIRMAN, said that his country supported fully the goals of expanding access in the developing world to essential medicines. The primary evidence of that support was its founding donation and continued leadership in the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The United States would continue to work to promote lower prices for critical medicines to be used in pandemics. Nevertheless, it disagreed profoundly with the way in which document EB109/7 had been developed and with WHO's pursuit of certain goals under the rubric of access to essential medicines. It disagreed first with a number of premises in documents EB 109/7 and EB 109/8, elements of which made clear that there remained in certain sectors of WHO and its Membership a profound bias against the private sector. There was an inherent assumption that generic drugs were always preferable to those produced by the research-based pharmaceutical industry, an assumption that ignored quality control problems and the commercial interests of the generic drug sector. Conflict of interest was not confined to the research-based pharmaceuticals sector but could also be found in nongovernmental organizations and generic drug producers. Document EB I 09/7 had an overriding and inappropriate focus on drug pricing, costeffectiveness and intellectual property questions, and a lack of focus on the normative functions of WHO, such as strengthening the technical and other aspects of national health infrastructures, including quality assurance issues relating to drug access. Contrary to the thrust of the report and to many of the statements made at the current session, the TRIPS agreement was not part of the problem of expanding drug access, but part of the solution. For example, a recent Harvard study had suggested that intellectual property was not a barrier to access to essential medicines to treat HIVI AIDS and related conditions in much of sub-Saharan Africa. More than 95% of the drugs currently included in the WHO Model List of Essential Drugs were free of patent protection anywhere in the world, yet that

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

EXECUTIVE BOARD, I 09TH SESSION

had not increased access to most of those medicines in many nations. The Doha Declaration sent a strong message of support for the TRIPS agreement and confirmed that it was an essential part of the wider national and international response to the public health crises afflicting many developing and least developed Members of WHO and WTO, in particular those suffering from the pandemics of tuberculosis, HIVI AIDS and malaria. Some procedural and methodological issues needed further work. The United States had questions about the relationship between the WHO Model List and the WHO clinical guidelines; more research was needed to identify optimal treatment options in resource-poor settings. A focus on differential pricing meant different things to different people: his country could not and would not support any effort to establish an international or multinational mechanism to regulate drug prices. It would, however, continue to support efforts to provide market-based, voluntary ways of reducing prices across the world. Any attempt by WHO or other organizations to establish price guidelines or pricing schemes would be inappropriate. Paragraph 14 of document EB 109/7 referred to draft model indicators formulated for use in studies of the impact of globalization and the TRIPS agreement on the access to essential drugs. What were those indicators, how could they be obtained, how had they been validated and had WTO and WIPO been involved in their formulation? Intellectual property questions could not be neglected in the current discussion, and he urged the Board and the Organization to exercise caution. After all, without intellectual property protection, there would be no second-generation life-saving medications. Dr ANTEZANA ARANIBAR (Bolivia),' speaking at the invitation of the CHAIRMAN, commended WHO's commitment and courage in tackling expanded access to essential drugs. In the light of the concept's 25-year existence, the Doha Declaration represented a breakthrough equivalent to that of the 1978 Declaration of Alma-Ata in relation to primary health care. The challenge of globalization was to strike a balance between commercial, technological and economic interests on the one hand, and public health interests on the other. Full health could not be disassociated from access to medicines, and gaps between the haves and the have-nots could no longer be tolerated. Study, dialogue and cooperation were needed to ensure access to essential medicines for all who needed them. Professor GIRARD (France),' speaking at the invitation of the CHAIRMAN, expressed satisfaction at the achievements of the past several years. Those who had spent many long hours negotiating resolution WHA52.19 on the revised drug strategy had had the patience to seek common ground when no one thought it possible. They could take justified pride in having given the initial impetus to the developments of the past three years. Certain technical aspects remained to be dealt with, however. For example, many poor countries lacked the technical capacity to produce medicines. How were they to obtain supplies if other countries did not have the right to export them? The answer to that question would be found jointly by WTO and WHO, which should collaborate more closely. There was a risk of further injustice and inequality. The issue would only have been definitively dealt with when all countries had access to medicines. It was vital for the pharmaceutical industry to maintain its level of investment in research and development, in particular for medicines to treat neglected diseases, first and foremost malaria. Finally, progress in treatment had brought with it shortfalls in prevention. The point was not to choose between treatment and prevention, but rather not to forget prevention on the pretext that all the world's countries were finally able to obtain treatment. Professor GHODSE (United Nations International Narcotics Control Board) recalled that under the provisions of the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances, WHO was responsible for assessing the therapeutic usefulness of particular

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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substances, their dependence liability and the seriousness of public health and social problems related to their misuse. The Organization thereby played an important role in determining whether those substances should be placed under international control. WHO had long advised the International Narcotics Control Board (INCB) and its predecessor bodies on medical questions related to certain drugs, while INCB had brought developments of concern to the attention of WHO. The international drug control treaties not only recognized the dangers associated with drugs, but also acknowledged that such drugs were indispensable in medicine. Ensuring the availability of narcotic drugs for legitimate medical and scientific purposes was as important as preventing their use for non-medical purposes. Under Article 9 of the 1961 Convention, INCB had been entrusted with ensuring that narcotic drugs were available for medical and scientific purposes, and had been working with governments to achieve the dual objectives of the treaties. In its 1995 report, 1 INCB had noted significant imbalances in the global availability of opiates, particularly those used in the treatment of serious and/or severe pain. It had recommended that governments critically examine their methods of assessing the domestic medical need for opiates and of collecting and analysing that data. At the end of the twentieth century, however, the overall objective of adequate availability of opiates to treat pain and human suffering remained elusive, and many countries suffered dramatic shortfalls of morphine and other pain-relieving medicines with serious consequences for treatment, for example, of cancer patients. One reason for the shortage was the inadequacy of national drug control systems. Establishing a reliable method of assessing medical need was the first step towards ensuring that narcotic drugs were available so that patients did not suffer unnecessarily. Governments should be assisted in establishing more reliable baseline estimates and assessments of medical need. Over-restrictive regulations, difficult administrative procedures, and concerns about diversion and unintended dependence could also impede the availability of opiates. INCB called on governments and the medical profession to review procedures and to facilitate patients' access to essential pain-relieving medicines without jeopardizing the proper functioning of safeguard mechanisms to minimize misuse and leaks to the illicit market. Other major obstacles, particularly in developing countries, were the lack of financial and human resources and insufficient health training of health care professionals. Other life-threatening social and health problems, such as malnutrition and infectious diseases, could take priority over pain relief, and there might be too few and insufficiently trained health personnel to administer comprehensive pain-management programmes. INCB proposed that developing country access to essential narcotic drugs be improved by encouraging preferential conditions from international suppliers and by developing non-profit mechanisms for the use of narcotic products. Moreover, organizers of international aid programmes should consider donations of analgesic drugs to countries unable to obtain them from the international pharmaceutical market. A joint strategy was required to improve the availability of opiates in the countries concerned, with WHO playing a crucial role. In 2000, he and the Administrator of UNDP had written to all resident coordinators of the United Nations system at country level to raise awareness of the issues and to encourage more action at national level and within United Nations assistance programmes. In addition, the United Nations Secretary-General had urged close cooperation between WHO and INCB to ensure more equitable global access to analgesics and had been assured that INCB welcomed and cooperated closely in the development by WHO of guidelines for national health authorities on the establishment of a balanced national opioid control policy. He asked the Executive Board to give serious consideration to INCB's practical recommendations for further action and reiterated his organization's willingness to discharge its treaty-based duty to assist governments in that regard.

International Narcotics Control Board, Availability of opiates for medical needs, New York, United Nations, 1996,

27 pp.

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Dr SUZUKI (Executive Director), replying to comments, assured Dr Sallam that the question of expansion of access to essential drugs did not relate exclusively to those drugs currently on the WHO Model List. Many speakers had enquired about WHO's work in connection with the TRIPS agreement. In pursuance of resolution WHA52.19, the Secretariat would submit a report to the Fifty-fifth World Health Assembly on the results of its cooperation with Member States and other international organizations in assessing the potential public health implications of international trade agreements and in providing assistance to Member States in developing appropriate pharmaceutical and health policies. That report would also include information on the follow-up to the WTO Ministerial Conference in Doha. He agreed with Dr Bodzongo on the need to stress the importance of health financing policies and noted that greater emphasis would be laid on such matters in the current biennium, as well as support for Member States, inter alia, in strengthening national drug regulatory authorities. In response to Or Di Gennaro's comment on the use of opioid analgesics in humanitarian crises, he said that WHO was working with Member States to simplifY drug regulations so that imports of essential drugs to areas affected by humanitarian or emergency situations would not be blocked. Replying to Professor Ghodse, he pointed out that under its programme on cancer control WHO was currently reviewing the use of opioid analgesics. Turning to Dr Shinozaki's remarks, he said that WHO did not consider it appropriate to link the Model List of Essential Drugs systematically to differential price arrangements. The list was intended as a model for Member States and would not be uniformly adopted. Moreover, essential drugs should be selected on the scientific grounds of efficacy and safety, and where necessary comparative cost-effectiveness. He confirmed that Member States would be involved in consultations in the public funding ofthe pharmaceutical sector. In reply to Dr Al-Mazrou, he said that group procurement was a key strategy in lowering the price of essential drugs; further work was needed on WHO support to Member States in that regard. He took the opportunity to thank all Member States, international organizations, academia and civil society as well as the private sector for enabling WHO to continue its important efforts on improving access to essential drugs. Intellectual property rights were indeed important in ensuring future investments in research and development and protecting public health. The Doha Declaration had shed some light on the balance between such issues and access to medicines, which, as Dr Sallam had suggested, could be further discussed at the forthcoming Health Assembly. The CHAIRMAN said she took it that the Executive Board wished to note the report contained in document EB 109/7. The Secretariat was requested to pursue its work on expanding access to essential drugs in the light of the comments made and to report further to the Fifty-fifth World Health Assembly. It was so agreed.

(For further discussion of WHO's medicines strategy and adoption of a resolution, see summary record of the ninth meeting, section 4.) • Revised procedure for updating WHO's Model List of Essential Drugs (Document EB109/8) The CHAIRMAN, introducing the item, drew attention to a draft resolution on the subject submitted by Brazil, which read:

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The Executive Board, Having analysed the report on the Revised procedure for updating WHO's Model List of Essential Drugs, 1 RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Recalling discussions and proposals of Member States in their regional meetings before the Fifty-fifth World Health Assembly, mainly at the Fifty-third session of the Regional Committee for the Americas 2 (September 2001) and the Forty-eighth session of the Regional Committee for the Eastern Mediterranean (October 2001 and additionally the thorough discussion of the Executive Board at its 109th session; Reaffirming resolution WHA54.11, emphasizing the WHO medicines strategy and its requests to Member States and the Director-General; Aware of the urgent need to assure continuity of the proposed revised procedures for updating the WHO Model List of Essential Drugs in the light of scientific information, clinical trials, meta-analysis and other science-based proofs of evidence in order to include, substitute or exclude any medicine in the list; Conscious of the responsibilities that Member States have to support solid scientific evidence, excluding any biased information or external pressures that may arise and that may benefit exclusively industrial or commercial interests, to the detriment of public health approaches,

URGES Member States: ( 1) to reaffirm their commitment to increasing access to medicines and to translate such commitment in specific regulation within countries, especially enactment of national drug policies, establishment of lists of essential medicines based on evidence and supported by WHO's Model List, and implementation of actions to promote policy for access to, and quality and rational use of medicines within the national health systems; (2) to set up national revision committees for the essential medicines list that are science-based, independent of industry, and with a broad scope of expertise, and are updated at the most every two years; (3) in addition to health policies and actions, to implement additional measures to ensure that national lists of essential medicines are supported by standard clinical guidelines, preferably in the form of national therapeutic formularies, with the aim of achieving rational prescription, mainly within the public sector; (4) to reaffirm, within the national drug policies, WHO's concept of essential medicines as those that satisfy the priority health-care needs of the population, emphasizing the evidence base required for national discussion; (5) to undertake country action to introduce nationwide the concept and list of essential medicines for the entire public sector, and gradually also to introduce it within the private sector and schemes that reimburse medicine costs; (6) to continue to initiate the necessary monitoring of information in order to assess the implications of recent patent protection laws and the compliance with the Agreement on Trade-Related Aspects of Intellectual Property Rights on access to

1 2

Document EBI09/8. See document CD43/5. See resolution EM/RC48/R.2.

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essential medicines and other mechanisms of accessing health systems and services, especially in middle- and low-income countries; 2. REQUESTS the Director-General: (1) to reaffirm the concept of essential medicines as a tool for the development and implementing of equitable health systems and services; (2) to strengthen the Expert Committee on the Use of Essential Drugs, ensuring its independence of industry pressures at all times, and scientific criteria for permanent revision and updating, receiving, as appropriate and required, the necessary inputs from the pharmaceutical industry; (3) to include where necessary the impact of cost variations and costeffectiveness estimates in order to compare medicines for the treatment of relevant diseases; (4) to undertake necessary action in order effectively to promote differential pricing for essential medicines between high-, middle- and low-income countries; (5) to advocate, mainly within developing countries, the concept and policies of essential medicines, not restricted to poor populations, but intended as a tool for implementing rational prescription of medicines; (6) to continue leading the way to establish computerized databases on reference prices of essential medicines worldwide, as a matter of urgency, including cost per unit, per treatment, and per month of treatment; (7) to exhaust diplomatic and political arrangements aiming to discuss the mechanisms necessary to ensure that patent protection will not be a barrier for access to essential medicines, allowing Member States to make these medicines accessible and affordable to the people who need them; (8) to work with public interest nongovemmental organizations when they are implementing initiatives that are compatible with public health priorities, and to promote regional or local meetings.

Dr DI GENNARO (Italy), speaking on behalf of Member States of the European Union, said that essential drugs were one of the most effective elements of modem health care, with considerable potential impact on public health. One quarter of the 40 million deaths each year in developing countries were attributable to acute respiratory infections, diarrhoea, tuberculosis and malaria illnesses for which safe, effective and cheap medicines were available. While the WHO Model List of Essential Drugs had stood the test of time, and had been regularly updated since 1977, the changes to it had been relatively minor, with new medicines having been included and others no longer considered adequate removed. The value of the concept of essential drugs as one of the main tools for promoting better health had been acknowledged early on through its inclusion in the 1978 Declaration of Alma-Ata. Notwithstanding the success of the Model List, there had been delays in incorporating innovative treatments, including many designed to combat previously untreated illnesses. It therefore seemed advisable to make the inclusion procedure more systematic and to incorporate an evidence-based approach, which reflected availability and prices, to underpin the selection criteria, irrespective of patent status, thereby separating the scientific and public health aspects from commercial considerations. The European Union supported the proposal to establish a WHO essential medicines library, to provide access not only to the Model List but also to all the technical data used in defining a medicine as essential, for the sake of greater transparency. For all those reasons the proposed revision ofthe updating procedure seemed justified. Speaking on behalf of Italy, she said that the concept of essential drugs, one of the most important developed and promoted by WHO, had been adopted in a wide range of Member States, by governments and the private sector. WHO should continue to support the concept and to stress that the Model List had served its purpose well in the previous 25 years. Although Italy supported the European Union's position, it was concerned about some of the proposed changes in the revised

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procedure. For instance, stressing the importance of evidence over expert opinion and experience led to the possibility that older drugs, for which recently published clinical studies were rare, or lacking, might be phased out in favour of newer more expensive alternatives for which interested parties had built up considerable clinical documentation. Moreover, compiling evidence to show comparative effectiveness and safety was no easy task at national level, let alone globally, with the huge variety in human resources and clinical settings. Mr BERMUDEZ (alternate to Professor Yunes, Brazil) said that since 1977 the WHO Model List had been regularly updated and was widely used by Member States. Discussions on revision of the Model List, in particular during the 1999 meeting of the WHO Expert Committee on the Use of Essential Drugs, had highlighted the fact that evidence-based decision-making was fast becoming the norm; the high cost of many new and effective medicines covered by reimbursement schemes had resulted in the rapid development and use of comparative cost-effectiveness analysis; decisions on essential drugs lists were increasingly linked to clinical guidelines; and the number of patented drugs on the Model List was likely to increase. Discussions at the WHO Meeting of Interested Parties in June 2001 had indicated that evidence-based guidelines followed a systematic and transparent process which covered: guideline development with wide professional participation; careful consideration of conflicts of interest; systematic computer searches for evidence and an evaluation of such evidence; systematic comparative cost-effectiveness analysis; the evaluation of public health considerations; and external review and consensus expert opinion, where evidence was insufficient. In Brazil's own experience, updating the national essential medicines list could be conflictual unless correctly enforced by a strong technical group; evidence-based revision of such lists must rely heavily on clinical trials and meta-analysis of different therapeutic groups of medicines. Strong industrial capacity in developed and developing countries alike would draw attention to economic interests and put pressure on those responsible for the revision. That could place the least developed countries, which received drug donations from international pharmaceutical companies, in a very delicate situation. At the other extreme, developed countries where many transnational pharmaceutical companies were based might be regarded as supporting or even representing the interests of those enterprises. Times had changed. Promotion of access to medicines through the essential drugs list and patents issues were being given increasing attention, as in the case of antiretrovirals in Brazil and ciprofloxacin in Canada and the United States of America during the recent anthrax scare. Essential drugs lists were not important exclusively in connection with primary health care. They applied both to public and to private health-care systems and were tools for promoting rational medicine use and prescription as well as for market regulation, especially in the developing countries. In view of the important issues at stake, and recalling the Brazilian Ministry of Health position paper submitted to WHO in October 2001, he requested the Executive Board to recommend to the Fifty-fifth World Health Assembly the adoption of the draft resolution on the revised procedure for updating WHO's Model List of Essential Drugs submitted by Brazil. Professor ZELTNER (Switzerland), noting the importance of ensuring access to essential medicines, asked whether WHO had considered establishing a similar list for essential medical devices and test kits, access to which was to become increasingly important. Welcoming the proposal to revise the procedure for updating the WHO Model List, he said that he understood the major changes to be the introduction of a standard application form for candidate medicines and a more formal process of consultation with Member States. He was uncertain as to the changes proposed in relation to prices and cost-effectiveness analysis and requested further information in that regard and on any other changes proposed. He asked whether the revision process would be coordinated with follow-up by WHO and WTO to the Doha Declaration. While he appreciated the need for a resolution on the revised procedure for updating the Model List, he had some difficulty with the wording of the draft resolution proposed by Brazil. He suggested

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that informal consultations, guided by the Brazilian delegation, should be held to refine the proposal before it was considered in detail by the Board. Dr SHINOZAKI (Japan), referring to paragraph 6 of document EB 109/8, commented that the updating procedure should not be revised just in order to lower drug prices. The Expert Committee should be accountable to all interested parties, and all collective comments should be made public; it was important that the work of the Committee and WHO be transparent. The feasibility of global comparisons of cost-effectiveness was open to question. Evaluation could not be based on spot checks of retail prices alone but should take account of such factors as political situations and supply practice regulations. Moreover, selection should be made through an analysis of efficient input of resources and maximum benefit to public health rather than identification of the most cost-effective drug for a particular indication. Dr ROMUALDEZ (Philippines) commended the report. The revised procedure was important not only for updating the Model List but as a tool for countries to use in developing their own programmes, especially through the use of evidence-based methods of selection, and possibly even deselection, which were vital for promoting equity in health. He agreed with Switzerland that ways in which the revision process could be linked to follow-up to the Doha Declaration and access to medical devices improved should be considered. He supported the draft resolution in principle but endorsed the suggestion that informal consultations should be held to refine the text before its discussion by the Board. Dr SALLAM (Egypt) welcomed the proposals set out in the report, which reflected a scientific approach. Egypt, too, had submitted a draft resolution for consideration. Mr STEIGER (United States of America), 1 speaking at the invitation of the CHAIRMAN, said that his country regarded the essential drugs programme as one of WHO's most important and successful programmes. For that reason, it had taken steps to assess and consult with others on the proposed revisions and had submitted comments on them before the session. The current version of the revised procedures was not ripe for adoption by WHO's governing bodies. He echoed the concerns voiced by Dr Shinozaki, and invited WHO to issue a public written statement that drugs on the essential list should not automatically be subject to tier-pricing or compulsory licensing, and should not be exempted or excluded from patent protection. WHO should not enter into any major programme to help countries produce generic drugs- a task more appropriate to UNIDO. It was regrettable that Member States had not been fully consulted on the updating procedure and it was unfortunate that a nongovernmental organization had been privileged to participate in closed consultations during the drafting process. There was no consensus on the definition of certain terms crucial to ensuring transparency and accountability- such as "priority disease", "evidence-based" and "cost-effectiveness". Moreover, too much emphasis was on cost and cost-effectiveness, especially in view of the major problems in collecting and appraising drug prices for the same products worldwide, a problem recognized by WHO, whereas there was no focus on the importance for selection of substantial scientific evidence of the efficacy and safety of a particular drug for use against a specific disease in the patient population under consideration or on the problems relating to changes in drug sensitivity or resistance patterns at the national or regional level. Detail was also lacking on data collection and review. He proposed that the Board should request further consultation with experts and officials in Member States so that their experience of current procedures could be made available during the preparation of a revised document. Member States and governmental organizations were, after all, the major customers rather than nongovernmental organizations. The membership of the Expert

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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Committee on Essential Drugs must be publicized and the procedure for that selection should be transparent. Further discussion of the revision should be in a forum open to Member States. The Expert Committee should perhaps meet as planned, in April 2002, under WHO rules for such committees, but using only the current procedures for adding or removing listed drugs; the meeting could thereafter become a forum open to Member States and invited experts, including nongovernmental organizations. It was also important for WHO to place the subject of list revision on the agenda of the Tenth International Conference of Drug Regulatory Authorities rescheduled for June 2002, since WHO must consult with national regulatory authorities before adopting any new procedures. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) strongly supported the statement made on behalf of Member States of the European Union. He too regarded the Model List of Essential Drugs as one of WHO's prime achievements. The methodology must be kept up to date on the best scientific evidence available. Although affordability and cost-effectiveness were important, WHO should not be trying to create a global price index without being sure that such a task was feasible; it could be time-consuming and difficult, distracting the Expert Committee from its core task. Alongside the work on the Model List, efforts to secure improved access to medicines were essential, and he welcomed WHO's work in that area during the past year in collaboration with Member States and other partners. He expressed his appreciation of WHO's participation in his Government's initiative to examine the feasibility of differential pricing options, and encouraged WHO to conclude its work in that area as quickly as possible. He broadly supported the draft resolution proposed by Brazil, but had some detailed comments. He therefore agreed with Professor Zeltner that, to save time, it should first be studied through informal drafting consultations. Dr LOPEZ (Venezuela) said that the report under discussion clearly explained the procedure for updating and disseminating the WHO Model List of Essential Drugs, and also showed why the accessibility of medicines was a priority for WHO. Venezuela supported the inclusion of the draft resolution in the agenda of the Fifty-fifth World Health Assembly as it was a timely proposal relevant to many countries. Dr REINSTEIN (World Self-Medication Industry), speaking at the invitation of the CHAIRMAN, said that he was also representing the views of the International Federation of Pharmaceutical Manufacturers Associations. He expressed appreciation of the open and transparent nature of the procedure for updating the Model List, and of the more evidence-based approach to its revision. However, he did not support the proposal that sessions of the Expert Committee should be held in the presence of only its members and the Secretariat. Nongovernmental organizations maintained an official relationship with WHO, and it was therefore reasonable that they should be able to hear the discussion and make technical comments. Such participation would also help to widen the impact of the essential drugs policy, sustaining the commitment of all concerned through broad and significant collaboration. There were many well-established ways of ensuring that no undue influence was brought to bear on the Committee's deliberations, without excluding interested parties. To exclude public interest and industry nongovernmental organizations, and patient groups from the meetings would suggest that the Committee had something to hide. If the proposed transparent procedure for reviewing applications to the Model List was so effective that there was no need for observers to attend the meetings, it would seem that the meetings were themselves unnecessary. That was not so, however, because experience showed that discussions at the meetings could significantly influence their outcome, which in turn warranted their being opened to interested parties. Their exclusion would be a reversal of WHO policy, and would also conflict with the new Guidelines for the Expert Committee on Drug Dependence, which had had to be revised at the request of the Executive Board to ensure greater transparency.

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Ms HOEN (Consumers International), speaking at the invitation of the CHAIRMAN, explained that she was also representing the views of Health Action International, Medecins sans frontieres and Oxfam. The Model List was an important public health tool that provided guidance for States and nongovernmental organizations in selecting drugs and in making decisions on procurement, pricing policy and rational drug use. She welcomed the proposed procedure for updating the Model List, which would ensure an independent, transparent and evidence-based process. She emphasized the importance of ensuring the independence of the Expert Committee compiling the Model List. She also welcomed the fact that expensive essential drugs were no longer excluded from the List purely on price grounds. However, the extension of the Model List and the revised procedure for updating it were not enough in themselves; they must be accompanied by measures to ensure that the medicines listed were affordable for the individuals and communities needing them. WHO should continue and expand its work on achieving equity pricing systems, which should include measures to encourage generic competition, differential pricing, global and regional procurement and distribution, local production through either compulsory or voluntary licensing, and technology transfer. A combined strategy was required because there was no single way to achieve equity pricing. She cautioned against undue optimism about the willingness of the pharmaceutical industries to bring drug prices down. Equity pricing would not be achieved through voluntary actions by pharmaceutical companies alone. Several nongovernmental organizations which were working with WHO on drug pricing activities, including Medecins sans frontieres, would be continuing to work as well with UNICEF and UNAIDS on providing information on drug prices. The nongovernmental organizations were happy to collaborate in the development of a price monitoring methodology, coordinated by WHO and Health Action International. Another significant area of work to be continued was the pre-qualification of low-cost medicines, which was important for procurement by Member States and nongovernmental organizations and also for procurement activities in connection with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Doha Declaration showed that enormous progress had been made in public health issues in the context of trade regulation. She encouraged WHO to make sure that the Declaration was implemented at country level, possibly by providing model legislation and regulations showing the potential use of the options in the Declaration at national level. WHO should play an active role on the WTO Council for Trade-Related Aspects of Intellectual Property Rights in advancing proposals for low-cost medicines for procurement by countries that lacked manufacturing capacity. Problems in the area of production for export were due to be resolved by that Council during 2002, and the nongovernmental organizations active in the field would continue working with WHO on those issues. Commenting on the effectiveness of the TRIPS agreement for access to medicines, she remarked that the protection of intellectual property interests could do little to encourage research and development relating to the most neglected diseases, such as leishmaniasis, trypanosomiasis and Chagas disease, because there was no market for the medicines. Approaches based on public-private partnerships alone could not provide a solution; radical new approaches were needed to kick-start such research and development, including new funding mechanisms and not-for-profit initiatives. WHO must play a major role in that area, together with governments and donors, in setting the agenda and stimulating research and development. She reiterated the commitment of the nongovernmental organizations to working with WHO on those issues. Dr BOSHELL (Colombia) re-emphasized his country's comments on WHO's medicines strategy. Given the importance of the Model List in Latin America, he would prefer the draft resolution submitted by Brazil to be adopted as it stood. Two speakers had suggested that the draft was not yet ready for adoption and that consultations would improve it. Should such action be needed, however, he would suggest that such a consultative group comprise no more than three members of the Board.

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Mr JANG Chun Sik (Democratic People's Republic of Korea) suggested that WHO consider expanding its support to developing countries that were capable of producing essential drugs but at present lacked raw materials for unavoidable reasons like natural disasters. Such support would help to strengthen national capacity in public health and meet local needs for medicines effectively. Access to life-saving essential drugs should not be restricted by patents. Dr SUZUKI (Executive Director) thanked members of the Board for their comments. Professor Zeltner, in raising key questions on the exact difference between the current and proposed procedures, was correct in that one of the major issues involved was consultation. The current procedure did not include any consultation with Member States. A limited number of nongovemmental organizations in official relations with WHO and United Nations bodies had participated in the process, as observers. Since the next meeting of the WHO Expert Committee on the Use of Essential Drugs would be discussing important issues such as the use of antiretroviral agents for HIV treatment, it had been thought appropriate to offer an opportunity for Member States and other stakeholders to provide comments and guidance. Two formal consultations would be held, open to all, on the application of the Model List, and on the draft recommendations. However, only members of the Committee and the Secretariat would be present for the decision-making portion of those meetings. The second difference between the current and proposed procedures was in the application and review of the Model List. At present, anyone could apply for the addition, deletion or substitution of pharmaceuticals by simply writing a note. That placed a heavy burden on the Secretariat to collect all the evidence required to review the application. It was accordingly preferable for a standard application form to be filled in and sent through the relevant WHO technical programme, thereby ensuring sufficient linkage between the work on the clinical guidelines and on WHO's Model List. With regard to the handling of cost information in the selection of essential medicines, it unfortunately appeared that there had been a misunderstanding. Since 1977, information on cost-effectiveness had been used only when there were two or more pharmaceuticals in the same therapeutic group. The cost issue came in when a choice had to be made among a number of pharmaceuticals. In the consultation process, it had been suggested that a threshold of cost-effectiveness be set and that only pharmaceuticals above that threshold be listed. That would mean comparing different types of pharmaceuticals, such as antimalarials with antitubercular drugs, which did not seem feasible at present. The current and the suggested uses of cost information were identical except in respect of the principle, suggested by the Expert Committee and agreed upon in the consultation process, that cost itself would not be a criterion for exclusion if other conditions were met by a given pharmaceutical. Referring to Professor Zeltner's enquiry about the linkage between intellectual property right protection and the selection of essential drugs for the Model List, he recalled his earlier remarks in reply to Dr Shinozaki on the same subject and reiterated that systematic linkage was felt to be inappropriate for many reasons, including undue politicization of the whole process. Professor Zeltner had also asked about medical devices and test kits. Test kits, several of which were currently included in the Model List, and tools for HIV diagnosis were being studied, but more time and human resources were required. For medical devices, the process would be slightly different but quality assurance would also be required. A summary of work in that area could be provided to the Board at its 11 Oth or Ill th sessions. Referring to Dr Di Gennaro's concerns that if strict requirements for evidence were applied, only recent pharmaceuticals would be listed, he said that the risk was fully recognized and a complete set of evidence would not be requested for all pharmaceuticals. Expert advice would also be taken into account. Dr Shinozaki had observed that the pharmaceuticals listed as essential medicines should not be limited to low-cost ones, and he agreed. Cost per se would not be an excluding factor in the selection process. All comments received by WHO would be made public in the selection process to ensure transparency.

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As agreed, the next meeting of the WHO Expert Committee would be held in April 2002, when the Board's comments on document EB109/8 would be taken into account. Mr AITKEN (Senior Policy Adviser) pointed out that the Board had before it a proposed draft resolution from Brazil and a draft resolution on the same subject from Egypt with several cosponsors. The CHAIRMAN suggested that informal consultations be held on those texts pending further discussion. It was so agreed. (For adoption of the resolution, see summary record of the ninth meeting, section 4.) The health of children and adolescents: Item 3. 7 of the Agenda (Document EB 109/1 0) Ms WIGZELL (Sweden), recalling the Director-General's indication in her report that 2002 would see a focus on children, said that an exciting chain of events had been set in motion and should lead to better opportunities for health and development for all children. A gender perspective had to be included: prevalence levels and fatality rates for many major health problems and diseases differed between boys and girls. She was therefore glad that document EB 109/10 covered that aspect. The Commission on Macroeconomics and Health had pointed to the benefits of investing in control of childhood infections, perinatal illnesses and micronutrient deficiencies. Over the years, WHO and other organizations had developed a good set of interventions in those areas. They knew what worked and needed to scale up activities in those fields. Reducing the toll taken by measles was one important task ahead. The United Nations General Assembly special session on children in May 2002 would take stock of progress over the past decade and set out directions for future work. Action on the proposals in the various reports before the Board would make a difference to many children. The millennium development goal to reduce child mortality would also be addressed. The progress report underlined two areas needing higher priority: improvements in the health of newborn infants and adolescent health. She agreed with both. Drawing the Board's attention to the global consultation on child and adolescent health and development to be hosted by Sweden in March 2002, she expressed her appreciation of the invitation to the meeting extended by the Director-General and the Executive Director of UNICEF to political leaders and technical experts, whose presence would contribute to the pledge to make a difference for children. It was timely that the strategy on child and adolescent health and development would be presented to the Fifty-fifth World Health Assembly and to the Executive Board at its 111 th session. Dr DOTRES MARTiNEZ (Cuba) said that the report before the Board was of the utmost importance to Member States since it concerned a vulnerable group that had received little or inadequate attention. The health and well-being of children and adolescents was vital to minimizing health problems in adulthood and old age and to ensuring that people could maintain their quality of life. He considered that, without a solution to the present health problems of that group, future adult populations and old people would suffer health problems detrimental to economic and social development. The future scenario for such development would depend on the achievements of a country's children and adolescents as they developed. Serious health problems mentioned in the report, namely consequences of lifestyle including tobacco and alcohol consumption, drug addiction, sexually transmissible diseases and malnutrition, showed that, although there was enough knowledge and experience to address the problems, that had not yet been done. IdentifYing the most suitable interventions required systematic attention and research. Effective interventions for health for newborn infants and throughout life should have a community and intersectoral approach. Children and adolescents should have more information about

SUMMARY RECORDS: FOURTH MEETING

sexuality, eating habits, physical activities and the damage caused by the consumption of toxic substances. They should take an active part in making health decisions for the sake of harmonious biological and social development. He supported the initiative of a strategy on child and adolescent health and development. The group preparing the document could, he suggested, avail itself of information and undertake debate with adolescents in several countries, since they would be the main beneficiaries of the strategy. Its implementation in Member States would thereby be greatly improved. He fully concurred with the views in the report. Dr ANWAR (alternate to Dr Sallam, Egypt) commended the report; the topic was one of the greatest challenges faced throughout the world where children and adolescents together represented 40% of the population. Much care and attention was required to change their behaviour and help them to resist the lure of alcohol and tobacco. Considerable progress had already been made in protecting the health of those groups and in avoiding problems due to malnutrition and respiratory diseases. Health problems such as sexually transmitted diseases and tobacco and alcohol addictions remained, however, particularly among children and adolescents. Programmes dealing with those issues should be included in overall primary health programmes, and integrated into proper publicity campaigns for the benefit of children and adolescents. Dr AL-MAZROU (Saudi Arabia) referred to the health of deformed newborn children and the need to detect possible malformations during pregnancy. Because of the importance of avoiding such malformation and hereditary diseases, the question of premarital consultation was considered of great importance in Saudi Arabia and many other countries in the region. Dr MORALES (alternate to Dr L6pez, Venezuela) commended the report as an integral vision of the health situation of children and adolescents, forming the basis of an intensified programme. She suggested that the Board should submit a resolution to the Fifty-fifth World Health Assembly to the effect that Member States would renew their efforts to improve the health of children and adolescents, instead of the limited goal of just reducing mortality. Professor ZEL TNER (Switzerland), commending a precise and interesting report, observed that the period of adolescence had been extending from about four years to as long as I 0 to 15 years in highly developed countries since young people stayed at home much longer without marrying and becoming parents. The phenomenon was even becoming a social problem in some developed countries, such as Italy, and was related to health behaviours that might be hazardous. It was not known whether such behaviours over a longer period had major implications for health in adult life. With regard to the development of the strategy for child and adolescent health, he sought emphasis on monitoring the long-term effects of the prolongation of adolescence, as unwelcome surprises might well be in store. Dr BERGEVIN (UNICEF), speaking at the invitation of the CHAIRMAN, welcomed the report; he considered it critical to highlight the importance of the health of children and adolescents. UNICEF and WHO had a longstanding collaboration, particularly in the areas of immunization and child and adolescent health. That collaboration should be strengthened in the area of safe motherhood, where little progress had been made, and in respect of HIVIAIDS, where the challenge was daunting. As already pointed out, a global consultation was being convened by the Director-General and the Executive Director of UNICEF, for which he thanked the Government of Sweden, the host. That meeting would be a key step in developing the health agenda for the United Nations General Assembly special session on children to be held in May 2002, immediately preceding the Health Assembly, which would be able to examine its deliberations and results. Member States should then be in a position to move forward with clear, time-bound goals to improve the health of children and

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adolescents. He looked forward to working with WHO on formulating a strategy and reinforcing a programme of work to improve the health of children and adolescents. Dr TURMEN (Executive Director) called attention to the fact that the report was the first to look at the health of children and adolescents together, a further indication that the consequences of growth and development, whether compromised or not, were cumulative throughout an individual's lifespan and could pass to the next generation. She confirmed that gender perspectives had been an integral part of the work undertaken and would be also part of the strategy. The active participation of adolescents in the development of the strategy was indeed an important point, as raised by Dr Dotres Martinez, and was being worked on with UNICEF. Further significant concerns were the health of deformed newborn children and prenatal consultations. It was difficult to talk about newborn infants and adolescents without considering the parents, particularly the role of the mother, and the link between her and the newborn baby, in addition to their diet. Since the period of adolescence was indeed extending, with uncertain effects on adulthood and society, she agreed with Professor Zeltner that it would be useful to monitor the long-term effects of the phenomenon. The CHAIRMAN said that, as there were no further comments, she took it that the Board wished to take note ofthe report on the health of children and adolescents. It was so agreed.

Food safety and health: Item 3.9 of the Agenda (Document EB109/13) Dr DI GENNARO (Italy) supported the draft global food safety strategy as presented in its summary version in document EB109/13 and in the full text circulated. She particularly supported some points in the document such as the need for more data on food intake and on the concentration of contaminants in food. Assessment of risks potentially associated with new safe technologies should be based on internationally agreed principles and integrated with consideration of other factors, such as ethics and environment, the importance of surveillance of food borne diseases and the appropriate risk communication. Dr SADRIZADEH (Islamic Republic of Iran) said that foodborne diseases were an increasingly important health problem in many countries for a variety of reasons such as industrialization, rapid urbanization and globalization of the food trade. The problem was compounded in developing countries, where data on foodborne diseases were either non-existent or unreliable and resources were scarce and strictly limited. He welcomed the drafting of the global food safety strategy and looked forward to its wide dissemination as soon as it was finalized. WHO should support countries in formulating their national strategies for food safety with particular emphasis on strengthening laboratory capacities for identification of foodborne pathogens. It should also play a catalytic role in mobilizing adequate resources for proper implementation of national food safety policies and plans. Dr AL-MAZROU (Saudi Arabia), commending the strategy presented, stressed the importance of helping developing countries to identifY dangerous foodstuffs. That was particularly important when they were imported into developing countries, since many countries lacked detection capabilities. Dr TRIERS (Belgium), referring to paragraph 9, said that safety along the entire food production chain was of paramount importance. Better risk assessment was also very significant; in that area there was a need for more international standards and guidelines, which would be an important task for WHO. The safety of new technologies, including genetic engineering, was a further

SUMMARY RECORDS: FOURTH MEETING

important feature much in the news, and it was not always simple to discern the best scientific advice. He concluded that major input from WHO was needed in that regard. Or SHINOZAKI (Japan) said that various food poisoning cases from different causes had been identified in his country. Series of such incidents might undermine consumer trust in food safety. He recalled that resolution WHA53.15 included valuable suggestions that Member States should implement. He commended WHO's activities in the area of food safety and looked forward to the advancement of the food safety programme. As a major food-importing country, Japan attached particular importance to global food safety assurance. It would actively continue to be involved in and support WHO's activities, particularly the Codex Alimentarius Commission. Mr OLIVA (alternate to Professor Yunes, Brazil), commending the report, recognized the efforts of WHO to reinforce food safety as a priority in public health policies. Brazil strongly supported the strategy proposed in the document, but wanted WHO's role in the decision-making process of the Codex Alimentarius Commission to be reinforced. WHO must take strong positions in defending or implementing Health Assembly resolutions in order to promote public health. For example, it was a prime necessity to implement resolution WHA54.2 on infant and young child nutrition in the Codex Alimentarius, reaffirming the global public health recommendation of exclusive breastfeeding for six months in order to promote the optimum growth, development and health of infants. Mr MASUKU (FAO), speaking at the invitation of the CHAIRMAN, said that FAO had given the highest priority to food safety and quality in its programme of work and budget for the current biennium. It emphasized the importance of cooperation with WHO on those issues, both nationally and internationally, and would continue to work with WHO on food safety operations. FAO agreed with the thrust of the document under discussion. Microbiological hazards, including chemical hazards, and the foodborne diseases they caused were an increasing public health concern. New technologies had to be rigorously and objectively tested before they were introduced. Developing countries particularly needed support to build capacity in food safety, an area with which the agriculture and food processing sectors, including animal husbandry and fisheries, had an intimate connection. FAO supported the overall goal and the methods identified in paragraphs 8 and 9 of the document. With regard to surveillance, mentioned in paragraphs 10 and 11, there was a need for more epidemiological information on trends in foodborne diseases and their impact on human health, including information on emerging foodborne diseases. In that area, WHO was expected to take the lead. FAO would continue to work actively with WHO on safety evaluations, risk assessment and the safety of new technologies, especially with regard to the development and provision of adequate tools, methods, guidelines and information to permit the effective transfer of evaluation technologies and data between countries, including developing countries. FAO welcomed the commitment by WHO to seek greater involvement of the health sector in the work of the Codex Alimentarius Commission, and he expressed the hope that that would be reflected in WHO's allocation of resources, both financial and human, to the Commission's operations and secretariat. He drew attention to the decision of FAO's Programme Committee, endorsed by the FAO Conference, to undertake a thematic evaluation of the joint FAO/WHO Food Standards Programme. The results of the evaluation would be reported to the respective governing bodies and to the Codex Alimentarius Commission. Mr CASSELS (Consumers International), speaking at the invitation of the CHAIRMAN, strongly supported WHO's initiative to improve and strengthen partnerships between international organizations involved in food safety and observed that the draft global food safety strategy incorporated many of the suggestions already advocated by Consumers International. The management of genetic engineering continued to present major new challenges. Despite a clear

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intention to move away from the traditional "top-down" approach, he believed that even greater inclusion of civil society, particularly nongovernmental organizations and consumer groups, needed to be enshrined in all aspects of the strategy. It was essential to build the capacity of consumers and their communities to participate and contribute effectively, for example through market surveillance, helping to set food safety standards, and public education. It was not enough simply to recognize the need to consult consumer groups: such groups needed to be invested in, to ensure that food safety initiatives reached all consumers, especially the most vulnerable. Moreover, the experiences of individuals living in communities constantly affected by foodborne diseases were a vital source of knowledge. Consumers International looked forward to pursuing its successful collaboration with WHO in the development of the long-term work plan for the implementation of WHO's new food strategy. Dr BOSHELL (Colombia) said that the Region of the Americas contained two of the leading centres in the field, namely the Pan American Foot-and-Mouth Disease and Zoonoses Center and the Pan American Institute for Food Protection and Zoonoses. Colombia's National Institute for Drug and Food Surveillance, which had been modelled on those two centres, had also produced magnificent results and could serve as a reference body. Dr SCHLUNDT (Coordinator, Food safety), replying to comments that food control systems needed to be reinforced, said that WHO was working with FAO on the issue, and that a new document on the subject would be produced within two months. Furthermore, a new WHO/FAO expert body was looking at the assessment of microbiological risks. On the issue of new technologies, WHO had commissioned a fresh risk-benefit study on biotechnology foods and related areas and the results could be expected by the end of 2002. As to the Codex Alimentarius, WHO had agreed with FAO that the time had come to review it. That would be a major venture lasting some 18 months. Lastly, he welcomed the comments made by the spokesman for Consumers International, and said that WHO would set up a long-term plan for implementation of food safety based on the draft strategy and on the comments made at the meeting. The CHAIRMAN said that she took it that the Board wished to endorse the draft global food safety strategy set out in summary in document EB109/13. It was so agreed.

Diet, physical activity and health: Item 3.10 of the Agenda (Document EB 109/14) Professor GRABAUSKAS (Lithuania), while praising the document, suggested replacing the words "is a key determinant" by "should be taken as a key determinant" in the introductory sentence of paragraph 1, since budgets often sidelined noncommunicable diseases. Noncommunicable diseases were silent for a long pre-clinical period, making it difficult to motivate people to change unhealthy behaviours. At the Fifth-fourth World Health Assembly many delegations had asked for evidencebased health promotion advice. Document EB 109114 tackled an important area of health promotion, emphasizing two approaches, namely the need to create an environment favourable to healthy choices, which was a matter for politicians, and the need to motivate individuals to change their behaviour. Behaviour could indeed be changed, as had been illustrated by the FINBALT Health Monitor, a survey which had monitored health-related behaviour at national level in Estonia, Finland, Latvia and Lithuania every two years since 1992. The survey had recorded major, sustained improvements in dietary habits, for example a halving of the consumption of animal fat among both men and women alongside a twofold increase in the. consumption of vegetable oil, fresh fruit and vegetables. That change seemed to be sustainable, according to the data gathered. Lithuania welcomed and endorsed WHO's efforts to frame a strategy. Might it also be possible to prepare a draft resolution on the subject?

SUMMARY RECORDS: FOURTH MEETING

Dr DI GENNARO (Italy), noting that the concise, interesting document highlighted the role of primary prevention, said there was strong evidence of the benefits of diet and physical activity. It was alarming to note that 79% of deaths from noncommunicable diseases occurred in developing countries. Since renewed effort was needed to counter that trend, she welcomed both the draft strategy and WHO's commitment to updating the scientific evidence on the links between diet and health outcomes. Italy was playing an active role in the latter process. In March 2002, the WHO Collaborating Centre, the Centre for Nutrition, would jointly host a workshop organized by the Regional Office for Europe in order to develop a national nutrition action plan. Dr SADRIZADEH (Islamic Republic of Iran) noted that health patterns were changing rapidly in many countries, as the prevalent communicable diseases were brought under control and noncommunicable diseases moved to the top of the list of causes of mortality. The common preventable risk factors were tobacco use, an unhealthy diet and lack of physical activity. Noncommunicable diseases were largely preventable and he was delighted to see WHO giving prevention and control high priority globally. Unprecedented socioeconomic change had seriously affected diet and levels of physical activity in many countries and WHO should continue to provide up-to-date evidence on the relation between risk factors and noncommunicable diseases, as well as providing guidelines for appropriate action by individuals and by the population as a whole. It should also seek to collaborate with industry in tackling the issues of advertising, mass communication, world trade agreements, food labelling, new foods, urban planning and transport. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba), noting that noncommunicable diseases were also being found in developing countries, partly as a result of increased longevity, said that it was important for WHO to analyse the links between diet or physical activity and such chronic diseases. Lifestyles were closely linked to the cultural, culinary and social values of a country, so that it was difficult to identify appropriate approaches. WHO's strategy, including educational activities, must target children and teenagers, in order to bring about cumulative change, without forgetting the needs of the older generation. The strategy should take account of each country's eating habits and possibilities of action to change lifestyles. Endorsing the report, he suggested that WHO could disseminate information on positive experiences in some countries, as well as focusing on promoting scientific research in the field.

The meeting rose at 17:30.

FIFTH MEETING Wednesday, 16 January 2002, at 9:00 Chairman: Mrs M. ABEL (Vanuatu)

HEALTH STRATEGY MATTERS: Item 3 of the Agenda (continued)

Diet, physical activity and health: Item 3.10 of the Agenda (Document EB109114) (continued) Dr THIERS (Belgium) highlighted the considerable differences in cardiovascular mortality rates between the two distinct linguistic groups in Belgium, which epidemiological studies attributed to diet and associated cultural factors. Attempts to change people's behaviour had met with little success, and a new type of research was needed into human behaviour and means of influencing it. While recognizing the importance of the subject of the draft resolution proposed by Brazil and Lithuania, he considered that WHO should confine its efforts to areas in which it could achieve real results. Dr SHINOZAKI (Japan) supported WHO's priority for primary prevention of noncommunicable diseases. Rapid population ageing was a significant problem in Japan, and a national campaign to promote healthy lifestyles by 2010 was being implemented. It covered five main areas - food and nutrition, physical exercise, rest and mental health, smoking and alcohol drinking and was designed to reduce mortality, morbidity and disability associated with lifestyle-related diseases. Ms COSTA COUTINHO (alternate to Professor Yunes, Brazil) referred to the sharp increase in the number of deaths in her country attributable to noncommunicable diseases, which at that time accounted for 70% of all deaths. The trend, which was echoed all over the world, had to be stopped. She welcomed the fact that the theme of World Health Day 2002, to be launched in Brazil, was to be physical activity. She drew the attention of the Board to the following draft resolution, proposed by Brazil and Lithuania. The Executive Board, Noting the report on diet, physical activity and health; 1 Encouraged, in the context of global prevention of noncommunicable diseases, by the potential of diet and physical activity to reduce premature mortality, human suffering and economic cost, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Having considered the report on diet, physical activity and health; Recalling resolution WHA53 .17 on prevention and control of noncommunicable diseases that reaffirmed that the global strategy for the prevention and control of

Document EB109/14.

- 78-

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noncommunicable diseases and the ensuing implementation plan were directed at reducing premature mortality and improving the quality of life; Recalling The world health report 2001, which indicates that mortality, morbidity and disability attributed to the major noncommunicable diseases, currently account for approximately 60% of all deaths and 43% of the global burden of disease, and are expected to rise to 73% of all deaths and 60% of the global burden of disease by 2020; Noting that already 79% of the deaths attributed to noncommunicable diseases occur in the developing countries; Alarmed by these rising trends as a consequence of the demographic and epidemiological transition, including those in diet and physical activity, and the globalization of economic processes; Recognizing, however, the vast body of knowledge and experience that exists in this domain, and the need to reduce the level of exposure to the major risk factors of unhealthy diets, physical inactivity and tobacco use; Mindful also that these major behavioural and environmental risk factors are more amenable to modification through implementation of concerted essential public health action, as has been demonstrated in several Member States; Recognizing the importance of the proposed framework for action on diet and physical activity within the integrated prevention and control of noncommunicable diseases, including the support ofhealthy lifestyles, facilitation of healthier environments, provision of public health services, and the major involvement of the health, nutrition and other relevant professions in improving the lifestyles and health of individuals and communities, I. URGES Member States to collaborate with WHO in developing a global strategy on diet, physical activity and health for the prevention and control of noncommunicable diseases based on evidence and best practices, with special emphasis on an integrated approach to improving diets, and increasing physical activity, in order: (I) to promote health and reduce the common risks of chronic noncommunicable diseases that stem from poor diet and physical inactivity through essential public health action and integration of preventive measures in the functions of health services; (2) to encourage, as part of health sector reform, incorporation in national plans of action for nutrition as they are updated, strategies for diet, physical activity and health involving all sectors, including civil society and the food industry; (3) to monitor scientific data and to support research in a broad spectrum of related areas, including human genetics, nutrition and diet, matters of particular concern to women, and development of human resources for health; 2. REQUESTS the Director-General: (I) to develop a global strategy on diet, physical activity and health within the framework of the renewed WHO strategy for the prevention and control of noncommunicable diseases and, in consultation with Member States, and with the bodies of the United Nations system and professional organizations concerned, to give priority to providing support to Member States for establishing corresponding national policies and programmes; (2) to ensure, while developing the strategy, an effective managerial mechanism for collaboration and technical support involving all programmes concerned at different levels of the Organization and WHO collaborating centres, emphasizing the introduction and strengthening of global and regional demonstration projects; (3) to strengthen collaboration with other organizations of the United Nations system, and other partners, including the World Bank, international

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nongovemmental organizations, and the private sector for implementation of plans at global and interregional levels and to promote capacity-building at national level; (4) to submit a progress report on integrated prevention of noncommunicable diseases to the Executive Board at its lllth session and the Fifty-sixth World Health Assembly in 2003. Dr LEMUS BOJORQUEZ (Guatemala) said that food safety was a serious problem in Central America, in terms of both microbiological contamination and chemical risks due to the misuse of pesticides. Although inappropriate diets were not a principal cause of noncommunicable diseases in Central America, young people, in particular, were bombarded with advertisements for "junk" food, consumption of which could be merely storing up problems for the future. He agreed that it was appropriate to ask WHO and Member States to implement measures on food safety in terms of the availability of good food, which was closely related to purchasing power. A good diet could also be ensured by promoting healthy lifestyles. He endorsed the draft resolution. Mr KET SEIN (Myanmar), recognizing not only the importance but also the difficulties of promoting lifestyles conducive to good health, suggested a multisectoral approach to the problem. Dr SALLAM (Egypt) observed that lifestyle changes were becoming an important issue, in which connection health education was vital. In the interests of the most effective health education, he advocated establishment of a health education laboratory. Different target groups required different approaches, and such a laboratory would carry out research into the most effective approach for each group. Countries in the Eastern Mediterranean Region intended to set up such research. The United States of America had been successful in changing lifestyles over the past 30 years, and his country was collaborating with it on a programme to promote a healthy lifestyle in Egypt. In view of the increasing importance of lifestyle changes globally, he considered that wider cooperation could only be beneficial. Dr AL KHARABSEH (Jordan), while not objecting to any part of the document under consideration, considered that it did not go far enough since it gave only the epidemiological basis of the problem. He suggested that WHO, through its regional offices, should support countries in implementing pioneer projects promoting a healthy lifestyle, such as the North Karelia Project in Finland. Where successful, such models could be extended to other areas or even other countries. Ms GIBB (United States of America), 1 speaking at the invitation of the CHAIRMAN, said that her country strongly supported the idea of a WHO global strategy on diet, physical activity and health. The Secretary of Health and Human Services in the United States was setting an example in promoting healthy lifestyle by committing himself to losing weight and had encouraged his staff to follow suit in terms of exercise and diet. Dr KARAM (Lebanon) raised two considerations: awareness and the application of such awareness. Awareness could be increased through the media, influential social and religious leaders, and medical practitioners. The issue should be most importantly incorporated in the medical curriculum. The application of awareness, however, required cooperation between health providers and legislators and repeated propagation of health information. Ms VOUTE (World Heart Federation), speaking at the invitation of the CHAIRMAN, said that her organization was a global nongovemmental organization with 147 member societies committed to 1

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

SUMMARY RECORDS: FIFTH MEETING

the prevention and control of heart disease and stroke, with a focus on low- and middle-income countries. Its programme included reduction of risk among the public, and internationally applicable principles of prevention were being developed. WHO had already assumed leadership with regard to tobacco, and should take the lead in the areas of diet and physical activity, in which the World Heart Federation would be pleased to collaborate at national and community levels. Dr RATNANESAN (FDI World Dental Federation), speaking at the invitation of the CHAIRMAN, said that oral diseases were the most prevalent conditions throughout the world and were closely linked to diet and nutrition. His Federation, which comprised 152 associations in 140 countries, was the authoritative, independent voice of dentistry worldwide, representing all the specialities. Having recently relocated its head office close to Geneva, his organization wished to cooperate, collaborate and complement WHO and other international health organizations, not only with regard to oral health but also in relation to HIVIAIDS, cancer, tobacco and ageing, as oral health was an integral part of health in general. The aim of his organization was to serve the disadvantaged in particular. Mr MISRA (Consumers International), speaking at the invitation of the CHAIRMAN, considered that all health strategies should include consumer participation, and the performance and benefits should be evaluated by consumer organizations. Diet and physical activity were critical risk factors in chronic disease, but increased prevention efforts were also important in respect of tobacco. His organization was concerned at the efforts of the tobacco industry to derail the third round of negotiations on the framework convention on tobacco control by attempting to demonstrate to policy-makers the economic benefits of tobacco-related deaths and by proposing voluntary marketing standards. It also misled consumers through deceptive advertising and promotion. He urged the Board to remain alert to such misinformation efforts and to be aware of the affiliations between the tobacco industry and members of delegations in all such global negotiations. He also urged WHO to pursue its efforts for transparency and to continue to inform Member States about any tobacco industry activities with a negative impact on WHO-initiated tobacco control efforts. He asked Board members to suggest mechanisms for building confidence and accountability to consumers, particularly the poor and disadvantaged, bearing in mind that public health issues should always prevail over trade and industry considerations. To that end, a consumer-friendly framework convention on tobacco control would be an important step towards global cooperation to safeguard consumer health and lives. Professor JAMES (International Association for the Study of Obesity), speaking at the invitation of the CHAIRMAN, said that the consequences of the escalating epidemic of obesity that was increasingly affecting both children and adults were extremely wide-ranging and included diseases and conditions that were central to the health strategies under consideration. Unhealthy weight gain was precipitated by inappropriate diets, compounded by a reduction in overall physical activity. He therefore strongly supported the emphasis on a coherent approach to the prevention and management of chronic diseases, since the burden of ill health and premature death in developed and developing societies alike would otherwise increase markedly over the next 20 years. In formulating that approach, particular attention should go to the global impact of the private sector with a view to achieving effective prevention. His organization would maintain and reinforce its contribution to WHO's endeavours and fully endorsed its efforts to improve patterns of diet and physical activity. Mrs LAMARRE (International Union for Health Promotion and Education), speaking at the invitation of the CHAIRMAN, supported document EB109/14. Concerted action by many different players was required to ensure the success of health promotion strategies based on a wide range of factors. Noting WHO's intention to strengthen evidence on the links between diet, nutrition, physical activity and noncommunicable diseases, she drew attention to a global project on providing evidence for the effectiveness of health promotion, conducted by her organization in partnership with WHO, the European Commission and other agencies. The first part of the project, which sought to make a

EXECUTIVE BOARD, 109TH SESSION

substantial case for increasing both policy and resource support for health promotion, had brought together high-level experts in health promotion and public health to compile an accessible reference work on the impact and effectiveness of health promotion. WHO health promotion priorities, such as tobacco and diet, were included, and physical activity would be made a priority. The project aimed to act as a catalyst for debate in which political audiences and health promoters regarded each other as natural allies in coping with health challenges; expanding globally, it would involve review and dissemination of evidence, include evidence from non-English literature, and address agreed priorities worldwide. After drawing attention to some of the key conclusions of the project that were of immediate relevance to diet, physical activity and health, she gave her assurance that her organization had both the will and the capacity to act as a partner in global, regional and national initiatives to be undertaken following the discussions of the Board. Or BOSHELL (Colombia), referring to the incontrovertible link between physical activity and health, said that the main problem in developing countries was the lack of exercise facilities for the overwhelming majority of the population, who had no access to private health clubs. Some 15 years earlier, as an experimental solution to that problem, the main thoroughfares in Bogota had been closed to all traffic other than bicycles during weekends and holidays. The practice had so successfully transformed the lives of its citizens that it had ultimately extended to include other areas of Bogota, other cities and other forms of physical activity. It could therefore serve as a useful example fo~ other regions of the world affected by that particular problem. Dr YACH (Executive Director), responding to the comments made during the discussion, confirmed the importance of addressing the social, cultural and economic determinants of diet and physical activity in influencing individual behavioural change. He also agreed that it was critically important for health professionals to demonstrate leadership through their own behaviour in terms of diet and physical activity, although efforts should be made to ensure that fiscal, economic and regulatory actions complemented and supplemented individual behavioural change, which otherwise tended to fail. In view of the limitations of national efforts carried out alone, global advocacy and global standards were vital components of the overall response. On that score, World Health Day and its related activities were a powerful example of global advocacy leading to changes in both policy and individual behaviour. Community-based approaches of the type mentioned by Dr Boshell, and also practised in other cities such as Sao Paulo (Brazil) and Isfahan (Islamic Republic of Iran), were extremely important, in so far as the call for physical activities on World Health Day should not be confused with attempts to promote only the use of private health clubs. The Director-General would be joining in efforts at the level of the International Olympic Committee to urge top athletes to show more leadership in encouraging young people to participate in physical activities. Emphasis had been placed on the "life course approach", starting with children and adolescents. Healthy ageing had also been strongly emphasized and would receive high priority at the forthcoming Second World Assembly on Ageing to be held in Madrid, at which WHO would be represented by the Director-General. In addition, WHO would be giving explicit attention to the question of advertising and marketing which influenced the diets of children, by strengthening the science base and finding practical means of promoting healthy messages and reducing harmful ones. To that end, it would be essential to continue dialogue with the food and nutrition industry, consumer groups and health professional bodies. The concern of some Member States about the availability of evidence to policymakers should be met by the important project of the International Union for Health Promotion and Education on strengthening the evidence base to demonstrate the effectiveness of health promotion. Finally, he recognized the crucial importance of demonstrating success at the country level. Projects focusing on the prevention of noncommunicable diseases and implemented by networks of countries were already under way, and further initiatives were at an advanced stage of planning. Representatives of those networks would convene later in 2002 in Shanghai (China) with a view to enhancing their work.

SUMMARY RECORDS: FIFTH MEETING

The CHAIRMAN invited the Board to consider the draft resolution proposed by Brazil and Lithuania. The resolution was adopted. 1

OTHER MANAGEMENT MATTERS: Item 7 of the Agenda

Governing body matters: Item 7.4 of the Agenda • Review ofworking methods ofthe Executive Board (Documents EB109/24 and EB109/31) The CHAIRMAN drew attention to a draft resolution proposed by Brazil, reading: The Executive Board, Taking account of resolution WHA54.22 that requests the Executive Board to conduct a review of its working methods and those of its subsidiary bodies in order to ensure that they are effective, efficient and transparent, and to improve participation of Member States in its proceedings, including working groups and drafting committees; Stressing that the timely distribution of documents would contribute to a more effective participation by Member States in sessions of the Executive Board; Taking note of resolution WHA51.30 which requests the Director-General to ensure that the governing body documents for forthcoming sessions are dispatched and made available on the Internet in the six official languages not less. than 30 days before the date fixed for the opening of the session; Recognizing that end-of-year festivities create difficulties for the Secretariat to make these documents available and for Member States to prepare adequately for sessions of the Executive Board; Recalling that Rule 5 of the Rules of Procedure of the Executive Board establishes that the Executive Board shall hold at least two sessions a year, DECIDES that sessions of the Executive Board shall always be convened at the beginning of February each year, and immediately after the Health Assembly. Or OM (Republic of Korea) said that the Executive Board should carefully review any proposed working methods to ensure that they did not interfere with the effectiveness of the Board, even though open-ended membership would improve the participation of Member States that were not entitled to designate members. He suggested that Member States without Board members should be given the opportunity to state their views, subject to limits on how long and often they spoke. It was essential to bear in mind, however, the role of the Board as defined in the Constitution and to find an appropriate balance between efficiency and transparency. Ms WIGZELL (Sweden) agreed that the review of working methods of the Board should focus on efficiency and transparency, including the number of meetings and the timing of both meetings and background documentation. The interesting draft resolution proposed by Brazil should be discussed in the working group provided for in resolution WHA54.22, which should be set up as soon as a chairman had been appointed and whose first task should be to recommend its terms of reference to the Board, for approval during the current session. The terms of reference should permit the working

Resolution EB109.R2.

EXECUTIVE BOARD, 109TH SESSION

group to work intersessionally and report on its progress at the following Board session. She therefore requested the Chairman to propose a chairman for the working group as soon as possible. Mr CHOWDHURY (India) said that documents for items on the agenda were often not circulated 48 hours in advance, as stipulated in Rule 11 of the Rules of Procedure of the Executive Board. He therefore supported the Brazilian proposal with its reminder that such documents needed to be made available at least 30 days in advance. Not only would that give members time to study them but it would avoid any perception that documents dealing with sensitive issues were deliberately circulated at the last minute. The only logical exceptions to such a rule would be reports containing the proceedings of the Board's committees, as their meetings were usually scheduled to take place shortly before the Board session. All draft resolutions should be included with the documents relevant to the discussion of agenda items, and substantive draft resolutions should not be proposed during Board meetings as small delegations did not have access to the advice available in their countries and could not attend concurrent sessions of drafting groups. Working procedures should therefore be modified to ensure that smaller delegations were not at a disadvantage. Dr LOPEZ (Venezuela) supported the views expressed by the member from India. She commended the documents produced on the review of working methods of the Board and considered that the review would lead to an improvement in its efficiency. She supported the draft resolution proposed by Brazil, as her country had experienced difficulties in preparing for the session. Dr DI GENNARO (Italy) said that the report contained in document EB109/31 gave useful background information on the existing rules and practices of the Executive Board of WHO and those of other organizations of the United Nations system. Equitable participation in the work of the Organization, as found at the Health Assembly, was a fundamental principle and a prerequisite for transparency and consensus. The Board was committed to continue conducting its business in an effective, efficient and transparent manner. Of course, improvements could always be made. Clear, objective and constructive rules of procedure were needed for efficiency and transparency. She recalled that election of members ensured fair geographical representation. Nevertheless, the Board's workload and time constraints affected the possibility of in-depth discussions, although more extensive debate and improvement of draft resolutions took place during the Health Assembly. She fully supported the establishment of a working group, as requested in resolution WHA54.22, and looked forward to the appointment of a chairman to guide the group in fixing its terms of reference. Dr SHINOZAKI (Japan) said that it was important to reflect the diversity of the Organization's membership in the Board's discussions while, at the same time, respecting the character of the Board. For example, its members were not representatives of Member States, but rather persons technically qualified in the field of health who were simply designated by them. Board members were responsible for the rules governing that organ's affairs. Each member was responsible for making appropriate, transparent and fair contributions to the meeting. The Board and the Health Assembly needed to collaborate as constituent parts of the same Organization. Review of the methods of work of the Board was thus important for WHO as a whole. Japan wished to contribute to the deliberations of the working group. Professor ZELTNER (Switzerland) agreed that, although the methods of work of the Board had improved in recent years, it was timely to review its procedures and seek further improvements. Greater clarity was required in interpreting the Rules of Procedure. He shared the view that the role of Board members required redefinition, as did the rights of Member States without members of the Board and the relationship between the two groups. He also agreed that the most urgent task was to set up a working group and agree its terms of reference.

SUMMARY RECORDS: FIFTH MEETING

Dr ROMUALDEZ (Philippines) supported Dr Om's comment that a balance should be struck between the efficiency of the working methods and the need for transparency. Article 24 of the WHO Constitution, which stated that not less than three Members from each of the regional mganizations should be elected to designate persons to the Board, permitted representation of regional views on the Board, and use of that mechanism should foster the necessary spirit of collegiality among WHO Member States. Professor ABOUO-N'DORI (Cote d'Ivoire), speaking on behalf of the African Region, identified himself with the preceding speakers who considered that the Board already worked in a transparent manner, while acknowledging room for improvement. The review should specifically aim to identify the separate competences of the United Nations General Assembly, the Health Assembly and the Executive Board. The Board should remain WHO's executive organ, applying the decisions taken by the Health Assembly. It would not be appropriate to transform the Board into a second Health Assembly, allowing observers to intervene at will. The Board was composed of representatives of Member States serving on a rotating basis, thus providing transparency. To make the Board's work more effective and give members enough time to prepare thoroughly, documents should be received in good time, as mentioned in the draft resolution. He supported the establishment of a working group to draw up its terms of reference. Certain Rules of Procedure of the Board (particularly Rules 3, 4 and 9) required clarification for the sake of uniform interpretation. Dr THIERS (Belgium) supported the proposals for improving the efficiency and transparency of the Board. Responding to the previous speaker, he said that the term "Executive Board" could be misleading, as it gave the impression that the Board executed decisions in its own right. However, executive authority lay with the Director-General and with Member States. In Belgium, the term Conseil exlX;utifwould be rendered as Conseil d'Administration, indicating that the Board prepared work for consideration by the Health Assembly. He did not propose that the name be changed but wished to specify that it was not an organ that executed but rather one that prepared and submitted work to the Health Assembly. Professor ABOUO-N'DORI (Cote d'Ivoire) replied that the Executive Board was indeed an executive organ, as stipulated in Article 28 of WHO's Constitution: "The functions of the Board shall be: (a) to give effect to the decisions and policies of the Health Assembly; (b) to act as the executive organ ofthe Health Assembly; ... ". Dr THIERS (Belgium), acknowledging that to be correct, observed that there was nevertheless often a difference between the spirit and the letter of instruments and between theory and practice. The matter should perhaps be taken up by the working group. Mr JANG Chun Sik (Democratic People's Republic of Korea) voiced his concern at the continued delay in distributing documents to Member States. WHO should bear in mind that a number of countries did not have Internet connections. The delay in receiving documents hampered the effective participation of Member States in Board sessions. He supported the statement of the member from India and the draft resolution proposed by Brazil. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) recalled that the item had been prompted by a request from the Fifty-fourth World Health Assembly to the Board to review its working methods. As previous speakers had indicated, the review should be carried out with great care, to ensure that the Board's methods of work were really improved and to allow the Organization to operate more effectively.

EXECUTIVE BOARD, I 09TH SESSION

Dr AL-MAZROU (Saudi Arabia) noted that two of the committees of the Board had met on the Friday before the current session, thereby necessitating payment of per diem to their members over the intervening weekend, at significant cost to the Organization. He therefore proposed a further amendment to the timetable, to be considered in conjunction with the proposal by Brazil, to allow the Board to begin its deliberations on a Tuesday, setting aside the preceding Monday for committee meetings and thus obviating the need for payment of per diem over two weekends for members participating in those committees. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil) said that the draft resolution proposed by Brazil concerned a relatively minor matter in comparison with other aspects of the review of the working methods of the Board, which remained to be discussed. He noted the support given to the draft resolution and suggested that, in view of the consensus reached, it be considered in the Executive Board meeting itself and not referred to the working group. To allow more time for documents to reach Member countries, and taking into consideration the seasonal break, Brazil had proposed that the Board meeting be held at the beginning of February or the last week in January. Dr OM (Republic of Korea) drew attention to the regulations governing reimbursement of air fares for members of the Board travelling to official meetings. While WHO provided the full economy class fare, regardless of the distance travelled, it was his belief that United Nations policy, the practice in other organizations and WHO practice for the Secretariat was to provide business class tickets for persons travelling for more than eight hours. On the definition of full economy class fare, he noted that, in his case, the cost of a ticket at US$ 2400 was two-thirds that of a business class ticket and double the market price of an economy ticket. He found it difficult to decide whether to travel for more than 12 hours in discomfort or pay out of his own pocket to upgrade to business class. He proposed that the WHO policy on air travel for Board members be adjusted and amendments made to the relevant resolutions, so that business class travel could be provided for those with longer flight distances or travel times. There would be no need to change the policy in regard to the provision of fares for the chief delegates of least developed countries attending the Health Assembly, as the two issues were unrelated. Dr GIRMA (Ethiopia) endorsed the comments of the previous speaker. Ministers travelling to Geneva from distant countries such as his own were obliged to upgrade their tickets. Less fortunate participants arrived very tired after a journey of 12 hours or more in economy class. In the interests of fairness, members faced with air journeys of eight hours or more should be entitled to business class travel. Such a measure need not entail additional costs for the Organization, as business class tickets could be bought at cut prices. Mr CHOWDHURY (India) said that Dr Om had had the courage to raise a sensitive but nonetheless valid point, which he had no hesitation in supporting. The requirement to undertake 12- or 14-hour flights in economy class was in fact a false economy, as participants arrived too tired to contribute to the proceedings. In the interests of their health, Indian officials on government business were allowed to travel in business class - an entitlement that WHO should extend to members of the Board faced with long flights. Mr AITKEN (Senior Policy Adviser) said that the requirement for members of the Board to travel in economy class stemmed from resolution WHA30.10 of the Health Assembly, adopted in 1977. If the Board considered that a change was needed, it was free to make a suggestion to that effect, either at its current session or through the mechanism of the working group as part of the recommendations that would go forward to the Health Assembly. Any change would have to be authorized by that body.

SUMMARY RECORDS: FIFTH MEETING

Dr BOSHELL (Colombia) said that he regretted having supported the proposal, made at the I 07th session of the Executive Board, that members of the Board should travel in economy class as a cost-saving measure. Instead, he supported the proposal by the Republic of Korea. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil) also endorsed the proposal from the Republic ofKorea. The requirements of Brazil's domestic legislation led to an anomalous situation in which alternates were entitled to business class travel, whereas the Board member himself was obliged to travel in economy class. The matter fell within the competence of the Health Assembly, and the Board should prepare a resolution for discussion by that body. Dr BODZONGO (Congo) endorsed the previous speaker's comments: it was regrettable that the same treatment could not be extended to members of an international body as was extended to senior officials of national administrations. Furthermore, the requirement that members travel in economy class made it difficult for them to alter their flight arrangements in the event of a change in the dates of meetings. Mr REN Yisheng (China), 1 speaking at the invitation of the CHAIRMAN, said that it was important to ensure that all countries were able to participate fully and on an equal footing in the work of the Board and the Health Assembly, in accordance with the United Nations principles of equality and democracy, thereby enabling the ideas and suggestions of all countries on world health issues to be reflected. Accordingly, China supported the proposal to establish an intergovernmental working group to review the working methods of the Executive Board. As an executive organ of the Health Assembly, the Board had a duty to strengthen its functions in implementing and reviewing the resolutions and policies of the Health Assembly. It should improve its working methods and define its role, in order to avoid making decisions clearly at odds with the policies, resolutions and decisions ofthe Health Assembly. Members and Associate Members should comply with the organizational rules of WHO and the resolutions and decisions of the Health Assembly. They should not put forward political proposals irrelevant to health issues. The Secretariat should be efficient in distributing documents and providing conference services, so that all could participate fully in the discussions. It should adhere strictly to the Charter of the United Nations and to the relevant resolutions and rules of the United Nations General Assembly. In particular, it should be neutral and objective, as a prerequisite for the effectiveness and the nonpolitical character of meetings of the governing bodies. Ms BALOCH (Pakistan), 1 speaking at the invitation of the CHAIRMAN, said that the reform of the Board and the review of its working methods were issues that far transcended such matters as distribution of documentation and provision of air tickets. The Board's discussions should be guided by resolution WHA54.22, adopted in May 2001, which provided clear guidelines as to how the Board should proceed. Unfortunately, the debate at the current session had failed to conform to them. No Member State wished to turn the Board into a miniature Health Assembly - quite the contrary. However, the recent, and growing, impression was that the Board was becoming too independent of the Health Assembly, and was working not as an executive organ of the latter but as an independent decision-making body, sometimes in parallel with it. Earlier in the session the Board had witnessed an attempt to override a previous decision of the Health Assembly with regard to its own agenda. As to the participation of observers in the Board's proceedings, Rule 3 of the Rules of Procedure of the Executive Board allowed some scope for participation by Associate Members and non-Member States. Rule 4, however, which concerned representatives of the United Nations and other intergovernmental organizations, appeared to go further and to provide for participation by such

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

EXECUTIVE BOARD, 109TH SESSION

representatives in committees and subcommittees. By contrast, paragraph 2 of the resolution concerning rights and obligations of Associate Members adopted by the First World Health Assembly (resolution WHA 1.80) provided for the right of Associate Members, equally with Members, to submit proposals to the Executive Board and to participate, in accordance with regulations established by the Board, in committees established by it. There were consequently some flaws in the Rules of Procedure that it was the duty of the Board to rectifY. The CHAIRMAN recalled that in resolution WHA54.22 the Health Assembly had requested the Board to establish an ad hoc open-ended intergovernmental working group that would make recommendations to the Board. She suggested that the working group should be set up immediately and should meet that evening in order to consider its terms of reference, with a view to reporting back to the Board the next day on its progress. She further suggested that Professor Zeltner (Switzerland) should chair the working group. Dr SADRIZADEH (Islamic Republic of Iran) and Professor ABOUO-N'DORI (Cote d'lvoire) supported that suggestion. It was so agreed. Professor ZELTNER (Switzerland) thanked the Board for the confidence it had shown in him, which was an honour to his country. He looked forward to acting as steward of the working group's deliberations; the work itself could, however, be accomplished only by Member States themselves. (For further discussion, see eighth meeting, section 2.)

HEALTH STRATEGY MATTERS: Item 3 ofthe Agenda (resumed)

Intensifying the response to the conditions associated with poverty, including the Global Fund to fight AIDS, Tuberculosis and Malaria: Item 3.1 of the Agenda (Document EB109/3) The CHAIRMAN drew attention to a draft resolution on WHO's contribution to achievement of the millennium development goals proposed by Egypt, Ethiopia, Islamic Republic oflran and Sweden, which read: The Executive Board, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Recalling the commitments made in the United Nations Millennium Declaration adopted by the United Nations General Assembly in September 2000 1 and the United Nations Secretary-General's road map towards its implementation; 2 Recalling in particular the goal set out in the Millennium Declaration, to reduce maternal mortality by three-quarters, and under-five mortality by two-thirds, of their current levels by the year 2015;

1 2

United Nations General Assembly Resolution 55/2. General Assembly document A/56/326.

SUMMARY RECORDS: FIFTH MEETING

Recognizing that increased access to good-quality reproductive-health information and services is critical for attainment of several millennium development goals; Recalling and recognizing the Programme of Action adopted at the International Conference on Population and Development, and the Beijing Declaration and Platform for Action, as well as their recommendations and five-year follow-ups; Mindful of WHO's function, as set out in its Constitution, to promote the health and welfare of women and children; Recognizing the equal right of men and women to the highest attainable standard of health and, in that regard, the importance of access to good-quality reproductive-health care, including family planning services that are effective, affordable and acceptable; Recognizing also the importance of the Convention on the Rights of the Child as a framework for addressing child and adolescent health and development; Recognizing that maternal, child and adolescent health and development have a major impact on socioeconomic development, and that achievement of the global targets for the coming decades will require renewed political commitment and action; Concerned that, because of poverty and lack of access to basic health and social services, close to 11 million children under five years of age, nearly four million of them within the first month of life, die every year of preventable diseases and malnutrition, and that complications related to pregnancy and childbirth kill more than half a million women and adolescent girls every year, and injure and disable many more; Concerned also by global inequities which lead to women dying during pregnancy and childbirth from conditions that are readily preventable and treatable, such as severe bleeding, infections, obstructed labour, hypertensive disorders, as well as from unsafe abortions; Convinced that concerted action to make pregnancies and childbirth safer will have a beneficial impact on the survival of women and neonates, and will contribute to the health and development of children and adolescents and to the well-being of families; Recognizing, as concluded by the Commission on Macroeconomics and Health, that improvements in maternal and neonatal health and survival are vital contributions to poverty reduction; Reaffirming resolution WHA48.10 on reproductive health: WHO's role in the global strategy, 1. URGES Member States: ( 1) to strengthen and scale up efforts to achieve the millennium development goals and other internationally agreed goals and targets; (2) to strengthen and expand efforts to meet, in particular, international development goals and targets related to reduction of maternal and child mortality and malnutrition and to improve access to reproductive-health services, with special attention to the needs of the poor and other underserved populations; (3) to continue to advocate as public health priorities, for safe pregnancy and childbirth and neonate, child and adolescent health and development; (4) to include in efforts to develop health systems, plans of action for making pregnancy safer, based on cost-effective interventions for good-quality maternal and neonatal care; (5) to ensure that primary health care facilities provide information and services related to reproductive health and strive for full coverage of their neonate, child and adolescent populations with interventions known to be effective, including those that help families and communities care for their children and young people; REQUESTS the Director-General:

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(1) to report to the Executive Board at its 11lth session and to the Fifty-sixth World Health Assembly on measures taken by WHO to contribute to the attainment of the millennium development goals; (2) to report to the Executive Board at its 111 th session and to the Fifty-sixth World Health Assembly on WHO's strategy for child and adolescent health and development, together with WHO's planned follow-up to the United Nations General Assembly special session on children; (3) to develop a strategy for accelerating progress towards attainment of international development goals and targets related to reproductive health, and to submit a progress report to the Executive Board at its 111 th session and to the Fifty-sixth World Health Assembly; (4) to promote reporting on progress towards internationally agreed goals and targets in the area of reproductive health as part of WHO's contribution to the Secretary-General's report to the United Nations General Assembly on progress towards attainment of the millennium development goals.

Dr AL KHARABSEH (Jordan) said that the Organization's role in the Global Fund remained ambiguous and would require further clarification if it was to continue to play a part in fighting diseases in poor countries. In particular, he would welcome more precise details regarding the mechanism used to select those developing countries that were to benefit from the Fund, the role played by WHO in that process, and the criteria governing decisions. He also wanted to know what was to be the fate of ongoing programmes such as UNAIDS, and whether conflicts between programmes might arise. Would the Fund's role be technical or confined to provision of financing? Would WHO oversee the administration of the Fund single-handed or jointly with other agencies? Did the establishment of the new Fund mean an end to other WHO support for tuberculosis and malaria programmes? Would the lessons ofUNAIDS be better learned than those of the Global Programme on AIDS? Lastly, was there any definition of what constituted a "donor country" in terms of the level of contributions made? Dr DOTRES MARTiNEZ (Cuba) said that while Member States recognized that poverty was a fundamental health hazard, how to combat it had been one of the most intractable problems of the final years ofthe twentieth century. Improving levels of health meant, first and foremost, working to reduce poverty, while demonstrating the benefits of economic and social equality. He endorsed WHO's choice of AIDS, tuberculosis and malaria as the three most important poverty-related diseases, but reminded the Board that other communicable diseases were a cause of serious health problems in many countries. The elements of the proposed framework for combating AIDS seemed to him appropriate. With regard to the Global Fund to Fight AIDS, Tuberculosis and Malaria, he noted that an additional effort would be required to raise the current total commitment of US$ 1.5 thousand million per annum to the required level of between US$ 7 and I 0 thousand million. In his view a secretariat of 43 persons to administer the Fund seemed rather large, and clearer regulations would be required to establish how and where the resources available should be deployed. WHO and UNAIDS had a key role to play in ensuring their efficient and effective use. As a response to the gravity of the AIDS pandemic in Africa, he reiterated the offer of assistance made by Cuba at the United Nations General Assembly special session on HIV/AIDS. Endorsing the strategies proposed for tackling tuberculosis and malaria, he pointed out that the funds required to implement them remained to be mobilized. In conclusion, he stressed the need to pursue efforts to find a vaccine against malaria. Ms WIGZELL (Sweden), welcoming the excellent report, said she was gratified to learn that work to establish the Global Fund had proceeded rapidly and that several difficult matters had been satisfactorily resolved. WHO had been an active partner in the process, and the location of the Fund in Geneva and WHO's representation as a non-voting member of the Board of the Fund rightly gave the

SUMMARY RECORDS: FIFTH MEETING

Organization an important role in its future functioning. She wished to highlight two aspects. First, the funds were truly additional to existing development assistance and did not merely represent alternative channels for donor countries. Secondly, national ownership in the planning and implementation of programmes financed by the Fund was crucial, especially as a number of global initiatives had to be coordinated at country level. Although the Report of the Commission on Macroeconomics and Health had already been discussed, she reiterated its importance by pointing to the fundamental need to scale up health investment, especially if the millennium development goals were to be achieved. It was vital not to limit the discussion on the health conditions associated with poverty to three diseases, however important. She had chosen to focus specifically on the reduction of maternal mortality and on reproductive health, as the Commission on Macroeconomics and Health had included maternal conditions among conditions responsible for a high proportion of the health deficit. That was because maternal mortality reduction was one of the millennium development goals, and because reproductive health services, including family planning and access to contraceptives, were crucial elements of disease control and indispensable to efforts to combat the HIVIAIDS pandemic. Referring to the draft resolution on WHO's contribution to the achievement of the millennium development goals, she said the sponsors believed that WHO's work should relate to those goals, and the commitments made at United Nations conferences during the 1990s were fundamental to their achievement. Among other things, the sponsors had proposed that WHO develop a strategy for accelerating progress towards attainment of the international development goals and targets related to reproductive health. The Report of the Commission on Macroeconomics and Health would, she noted, be an important input into the forthcoming International Conference on Financing for Development, and drew attention to the Report's conclusion that increased development assistance was a prerequisite for attaining the commitment of the Millennium Declaration to fight poverty. Dr ABIA NSENG (Equatorial Guinea) congratulated the Director-General on both her excellent report and her appeal to African countries to participate actively in a global fund to fight three major communicable diseases. The approach advocated by the Director-General required that developed and developing countries exchange experience on appropriate technologies and their cost, but also that affected countries possess the necessary diagnostic facilities, medicines and new vaccines at affordable cost, and that they demonstrate the will to mount joint efforts and mechanisms to mobilize the financial and material resources they needed to strengthen their health care services. He thanked WHO for its active participation in the development of the strategic framework and emergency plan to fight HIVIAIDS in his country, to which his Government had contributed substantial funds under the 2000 budget. Dr OM (Republic of Korea) said that AIDS, tuberculosis and malaria were directly related to poverty and that it would be impossible to overcome poverty, particularly in the developing countries, if they were not controlled. The establishment of the Global Fund was therefore appropriate and timely. The Republic of Korea would actively participate in and contribute to the Fund, in the interests of sustainable socioeconomic development and the promotion of health in Member States. Dr MODESTE-CURWEN (Grenada) observed that only two years earlier, when few in the Caribbean had thought of treating HIV IAIDS with antiretroviral agents, the emphasis had been on prevention, and the future looked bleak. The idea of a global fund to fight HIVIAIDS, tuberculosis and malaria was an admirable one and had reversed the approach to those diseases. She applauded WHO for its hard work towards establishing the Fund, and donor countries for generously contributing to it. To be successful, the Fund had to operate with as little as possible of the bureaucracy and transaction costs that in the past had prolonged suffering and swallowed up resources. The eligibility criteria, technical review process and guidelines for application, which were crucial to the process, were still unclear and she was concerned about the Fund's implementation. The Caribbean countries had the highest incidence of HIVIAIDS in the Americas and ranked second in the world after sub-Saharan Africa. Unfortunately, human and other resources were scarce

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and if disbursement of the Fund was to start in April 2002, little time was left for preparation. Many Caribbean countries were formulating strategic plans for HIV/AIDS, which required certain levels of technical expertise that would not be readily available in the months ahead, especially as all countries would be rushing to meet the deadline and qualify. Although PAHO and the Caribbean Epidemiology Centre had been extremely supportive in providing guidance and technical assistance, it was uncertain whether there would be enough human resources, and she asked how WHO could assist in that respect. Work on the Fund had been intense and WHO had played a highly commendable role. Information on the guidelines for accessing the Fund's resources was nevertheless urgently required. Professor YUNES (Brazil) commended WHO's participation in the design and development of the Global Fund. He urged Member States to participate actively in the Board of the Fund by influencing the regional states represented on it. The Fund's financing mechanisms should be sufficiently flexible and effective to allow streamlined access for beneficiary States. Brazil had contributed to the process since its inception, and a Brazilian expert had participated in the transitional working group set up to develop an operational mechanism for the Board of the Fund. He noted that there were already seven donor countries on the Board and so far only two developing countries, Brazil and Uganda, and he urged other regions to designate representatives as soon as possible. Brazil supported the Fund as an independent entity which had resulted from public-private partnerships and was made up of nongovernmental organizations, the private sector and public foundations. Brazil, he reaffirmed, had decided not to make use of the Fund's resources for itself, but to participate as a donor country by contributing generic medicines, technology and expertise and offering its experience of prevention, care and free universal antiretroviral therapy. He expressed the hope that countries would be able to use the Fund's resources to develop vaccines in accordance with the principles and criteria already established and with the guidelines that would soon be available. He commented that experience in Brazil had shown that the use of condoms, not mentioned in the report, was very important in preventing the sexual transmission of HIV. Dr SHINOZAKI (Japan) said that, among the important issues the report raised, he wished to focus his comments on the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Fund was an admirable result of well-coordinated work by the transitional working group, in which critical partners such as national governments, United Nations agencies like WHO, civil society and private organizations had participated. He welcomed the Fund's innovative framework for public-private partnership, made possible by a series of significant initiatives and efforts, which he believed would be a model for new types of international cooperation in addressing major problems in the twenty-first century. The Fund should be operated simply, efficiently and unbureaucratically on the basis of the new concept of public-private partnership. Once it had been launched, country-level coordination mechanisms would be one of the keys to successful implementation of the projects supported. WHO should take an active and important role in supporting country-level activities, relying fully on existing mechanisms, especially the regional offices. More specifically, critical technical issues had to be dealt with, such as the emergence of drug-resistant viruses. WHO's expert guidance on science-based and technically sound projects was vitally needed across the globe. He was confident that WHO was capable of meeting those challenges and providing the necessary leadership. The Fund must address the needs of regions in a balanced manner. The major burden of tuberculosis, for example, lay in the Asian and Pacific areas. Dr AL-MAZROU (Saudi Arabia) observed that, regarding the International Conference on Financing for Development, WHO clearly had a major role to play where health was concerned. Inputs for preparation of the conference should be forthcoming from regional and country levels, in particular as to how WHO's role could be strengthened and how health could be placed at the top of the agenda. Similarly, early preparation for the World Summit on Sustainable Development would be vital in ensuring that health, including the aspects mentioned in the report, were higher on the agenda

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than at the 1992 United Nations Conference on Environment and Development in Rio de Janeiro (Brazil). Mother and child health should also be accorded the priority it deserved, as it continued to be a considerable problem in the developing world generally. The report of the Commission on Macroeconomics and Health would, he was confident, make a significant contribution to preparations for the World Summit on Sustainable Development. Mr CHOWDHURY (India) said that the establishment of the Fund was a very favourable outcome of the trend towards greater integration of the efforts of all the countries of the globe in the health sector. The rapid progress achieved in making the Fund operational was commendable, and he looked forward to seeing it operate as a transparent, even-handed dispenser of funds enabling poor countries to meet basic health needs. He was confident that the Fund would be used to combat all diseases representing a particularly heavy burden on Member States. The impression was that the Fund would be principally used for HIVIAIDS and to a lesser extent for malaria and tuberculosis. While HIVIAIDS was particularly dangerous in terms of morbidity and mortality, in some parts of the world the age-old diseases malaria and tuberculosis had also taken a very heavy toll of human life over the years. He therefore urged that mortality and morbidity should be the yardstick for dividing funds among the various diseases. The approach proposed by the transitional working group, whereby grants would be awarded to institutions in countries such as civil society organizations and government agencies, was highly commendable. Experience showed, however, the need for all proposals to be routed via the country coordinating mechanism rather than made directly by institutions, to ensure that national governments assumed control over all initiatives under the Fund. Or THIERS (Belgium) said that, following the great interest the Fund had aroused in Belgium, his Government had decided to contribute six million euro per year to it over three consecutive years. Although Brussels had initially been a candidate for hosting the Fund, a better location, for operational reasons, would undoubtedly be Geneva. There was concern in Belgium among those working with developing countries that too vertical an approach to disease control might harm or even destroy basic health services in those countries. In October 2001, the matter had been discussed at a ministerial working party in Antwerp at which WHO had been represented. A report on the very important recommendations made at that meeting would be made available to WHO. Or ROMUALDEZ (Philippines) endorsed Ms Wigzell's view that maternal and child health and reproductive health were closely linked to poverty. The relationship between diseases of poverty such as tuberculosis, AIDS and malaria, and poor access to reproductive health information and services was well recognized. Family planning services and access to contraception were vital components of reproductive health. He therefore strongly supported the draft resolution, with its specific reference to family planning services as a part of reproductive health care. Or DI GENNARO (Italy) welcomed the report and supported the draft resolution on WHO's contribution to achievement of the millennium development goals. Italy attached great importance to the establishment of the Global Fund, and was confident that in the near future it would succeed in mobilizing additional resources from both the public and the private sectors. Her Government had already made a contribution of US$ 200 million. Professor GRABAUSKAS (Lithuania) joined in commending the report, which dealt with problems - notably HIVI AIDS and tuberculosis - that were of tremendous concern not only to developing countries but also to middle-income countries. He too supported the draft resolution. Professor KULZHANOV (Kazakhstan) said that the creation of the Fund had been welcomed, particularly by countries in transition, which lacked the resources to combat such scourges as

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HIVIAIDS and tuberculosis on their own. Sweden's proposal that the Fund be used to deal with reproductive health problems was a good one, bearing in mind the increased mortality among children and the poor health of women of reproductive age in such countries. Recent research in Kazakhstan had shown that 15% of women of reproductive age were in poor health, and that 85% had little or no access to health care. In addition, there were increasing numbers of people with strains of tuberculosis not responding to standard treatment. It was therefore to be hoped that such problems could be addressed through the Fund. Dr GIRMA (Ethiopia) said that the relationship between AIDS, tuberculosis and malaria and poverty could not be overemphasized, and the establishment of the Fund was therefore welcome. WHO should lead strongly in helping countries gain access to the Fund. He called on members of the Board to support the draft resolution, which would help foster reproductive health, safer pregnancy, better child and adolescent health and lower maternal and infant mortality, all issues of crucial importance to developing countries. Dr LOPEZ (Venezuela) commended the work that had gone into the establishment of the Fund and the efforts made to ensure its flexibility and transparency. On the question of governance, and notably the allocation of four seats on the Board of the Fund to nongovernmental organizations or private sector foundations, care should be taken to ensure that those suffering from tuberculosis and malaria were represented, as they were the least well organized in terms of participation in society. With regard to eligibility, and the suggestion in paragraph 14 of the report that grants might be awarded to government agencies, civil society organizations, universities and academic institutions, it was important that the Board of the Fund consult ministries of health responsible for policy issues and allow them to participate in the award process, in order to ensure that any action taken was in line with . programmes financed by the countries themselves. Dr MSA MLIVA (Comoros) welcomed the report and the establishment of the Fund. On the question of governance, several speakers had urged WHO to play an important role in the Fund. However, neither WHO nor UNAIDS, the organizations with the greatest technical expertise, had voting rights on the Board, and he wondered whether that meant they had no decision-making power in the Fund. He also wondered what would be the "mechanisms acceptable to Member States", referred to in paragraph 11 of the report. HIVI AIDS and malaria were accorded high priority in the Comoros and for the first time in the country's history the Government had opened a budget line for health programmes, which included 40 million Comorian francs for HIVI AIDS alone. Despite having one of the lowest rates of prevalence, the country's population of500 000 was vulnerable because ofthe large number of foreign visitors. Small countries such as his lacked the resources to establish an AIDS programme by themselves, and the assistance of WHO experts was badly needed. His Government intended to contribute to the Fund through a national AIDS control committee set up the previous year. The fight against AIDS, tuberculosis and malaria was to be intensified by strengthening programmes aimed to ensure mother and child survival. Efforts were needed to promote health education and raise awareness of health issues, and there too the expertise of WHO would be welcome. The actual or potential disease burden in respect of HIVI AIDS should not be the major criterion of eligibility. Instead, countries should be assessed on the basis of all the health problems they faced, so that in small countries where the incidence of AIDS was too low for selection, the focus could be on slowing its progression. The experience so acquired could then be used to do more elsewhere. Professor ZELTNER (Switzerland) endorsed the views expressed by the member from Belgium. It was essential that the question of sustainability be kept in mind in all efforts made. Too much emphasis had already been placed on vertical programmes such as those relating to AIDS and

SUMMARY RECORDS: FIFTH MEETING

malaria, and in the interests of sustainability there needed to be greater emphasis on horizontal investment in health systems. He would appreciate some clarification of the links between the Fund and the Commission on Macroeconomics and Health, in the light of the statement in paragraph 13 of the report that the Fund would work with existing programmes at national and multicountry levels. Referring to the International Conference on Financing for Development, he wondered whether the donors would in fact take a global approach to supporting poverty-reduction efforts, as recommended by the Report of the Commission on Macroeconomics and Health, by financing other areas of economic development such as water and sanitation. Like Italy, Switzerland welcomed the establishment of the Fund in Geneva.

The meeting rose at 12:35.

SIXTH MEETING Wednesday, 16 January 2002, at 14:15 Chairman: Mrs M. ABEL (Vanuatu)

HEALTH STRATEGY MATTERS: Item 3 of the Agenda (continued) Intensifying the response to the conditions associated with poverty, including the Global Fund to fight AIDS, Tuberculosis and Malaria: Item 3.1 of the Agenda (Document EB 10913) (continued) Dr MBAIONG (Chad), welcoming the clarity of document EB 10913, said that, although Africa had always been poor, its plight had been exacerbated in recent years by armed conflicts, epidemics and population displacements. The deleterious effects of HIVI AIDS, malaria and tuberculosis in particular had prompted the Government of Chad, with WHO support, to take specific steps to fight HIVI AIDS with its neighbouring countries, notably the Initiative of the Lake Chad Basin Countries, undertaken with the Central African Republic, Niger and Nigeria, and the Initiative of Countries in the Congo River Basin - Oubangui-Chari, launched with the Central African Republic and the Congo. Chad had also undertaken to participate in the Global Fund and had already established a national AIDS programme for which budget funds had been securely allocated. The countries of the region would continue their efforts to fight HIVIAIDS, tuberculosis and malaria, but they were continually hampered by the acute lack of means. He applauded the Director-General's readiness to ensure that African countries received the resources they needed to fight illness in general, and requested her renewed support in ensuring that they were given priority, through the Regional Office for Africa, in the allocation of grants by the Fund, to fight poverty-related diseases. He joined previous speakers in endorsing the draft resolution. Dr BODZONGO (Congo), referring to paragraph 8 of the document, expressed the hope that the unchanging level of commitments to the Fund did not mean that donor interest was stagnating. He shared Professor Zeltner's concern about the emphasis on vertical programmes. Paragraph 13 gave the impression that the Fund worked independently, associating directly with the various programmes, and needed to be clarified, as did the mechanisms and procedures by which money would reach those programmes. He was also concerned that no mention was made of followup. Given the Fund's specific nature, contributions to it needed to be tracked so as to ascertain where those monies went, how they were used and what impact they had. Mr STEIGER (United States of America)/ speaking at the invitation of the CHAIRMAN, commended the Secretariat's outstanding support for the transitional working group and thanked the Government of Switzerland for its generous assistance both in finding a location for the Fund's Secretariat and in providing a rental subsidy for the first several years of the Fund's existence. When the President of the United States of America, accompanied by the United Nations Secretary-General, had announced the initial contribution of the United States to the Fund, there had been widespread scepticism about the Fund concept. He congratulated the members of the transitional

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working group for their hard work in bringing the Fund as far as it had come. While much remained to be done, his country was confident that the Fund would begin operations shortly. He said that he was pleased that the Fund's architecture and operations reflected the principles outlined in May 2001: a focus on HIVIAIDS, tuberculosis and malaria, a balanced approach that supported prevention and care for all three diseases; an innovative public-private partnership that included the full participation of civil society in the design and implementation of projects; rigorous, independent technical review of all proposals; an independent governance structure and legal status, including a Board to make policy and grant-making decisions; and respect for intellectual property rights within the context of the Do ha Declaration. In the light of comments made by previous speakers, he asked for an explanation of the roles of the United Nations and WHO vis-a-vis the Fund and why the Secretary-General and the other agencies had supported an independent status for the Fund with ex officio status on the Board for United Nations agencies. He expected that there would be considerable technical input from WHO and UNAIDS. While the United States supported the intent of the proposed draft resolution he wished to clarify that references in the text to reproductive health and family planning services did not and should not include abortion. He expressed the hope that that view was shared by the members of the Board and the sponsors of the resolution. Mrs SOSA MARQUEZ (Mexico)/ speaking at the invitation of the CHAIRMAN, stated that her Government's decision to participate even more actively in United Nations' efforts to eliminate poverty and create the conditions for sustainable development through international cooperation for development was reflected in its hosting of the International Conference on Financing for Development in Monterrey, Mexico, from 18 to 22 March 2002. Mexico hoped that that Conference would take the commitments made in the Millennium Declaration a step closer to reality. Given the importance of investing in health to promote economic development and reduce poverty, WHO's contribution to the Monterrey Conference was highly relevant and important. As the Director-General had stated in December 200 1, part of that contribution would be to promote the innovative recommendations made by the Commission on Macroeconomics and Health. As the world was experiencing a serious economic slowdown, it was possible that pressure would grow to cut back resources for health. The Commission's work would help to convince the international community that those resources were necessary, not only to meet the health-related aspects of the millennium development goals but also to reduce poverty, stimulate economic development and promote global security. Mexico was confident that the Conference would serve to consolidate a new world alliance for development that would be ratified by the political leaders attending the conference, with the active participation of the leaders of the multilateral system. She expressed the hope that the DirectorGeneral would be able to make a personal contribution in Monterrey in two months' time. Mr LIU Peilong (China), 1 speaking at the invitation of the CHAIRMAN, recalled that the Fund was an entirely new and independent entity whose normative practices and mechanisms for dealing with specific issues had not yet taken shape. It was therefore extremely important for WHO to provide active support. Further clarification was required of WHO's role in the Fund and in particular the role of the six regional offices in helping Member States to participate in the Fund's activities. WHO should first help Member States take a swift decision on the developing country members of the Board. Although seven of the 18 Board seats were to be for developing countries drawn from all six WHO regions, the mechanism for deciding which country would sit on that Board had not yet been specified. A decision had already been reached on all seven donor country members but only on two developing country members. The first Board meeting would be held on 28 and 29 January 2002, and China therefore requested that the six WHO regional offices use existing mechanisms and act as

Participating by virtue of Rule 3 ofthe Rules ofProcedure of the Executive Board.

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facilitators to help the countries in each region to decide on their Board members and thereby support their attendance at the first meeting of the Board. WHO should also help the Member States to prepare project proposals quickly. It was stated in paragraph 15 that the independence of the technical review of proposals submitted to the Fund was considered of critical importance and that the United Nations system had a role to play in the organization of an independent review process. However, there was no mention of the potential role of the United Nations system, in particular that of WHO, in helping Member States to submit project applications. Present commitments to the Fund totalled US$ 1500 million, with the first grants to be approved by April 2002. That left little time for countries to prepare project proposals. Since most countries were not familiar with how the Fund would operate, they required urgent guidance and support. China hoped that WHO would respond positively to Member States' requests for such support. Dr PlOT (UNAIDS), speaking at the invitation of the CHAIRMAN, fully endorsed document EB 109/3, on which UNAIDS had been consulted. The United Nations Secretary-General and the United Nations system, in particular UNAIDS' cosponsors, had strongly supported the establishment of the Global Fund. UNAIDS had favoured an independent mechanism as the best means of mobilizing additional funds, particularly from non-traditional sources. Never before had so much money been pledged to support activities such as those to be conducted by the Fund. An independent mechanism would ensure a clear focus on the United Nations system's core business, namely to respond to countries' needs for support in planning and implementing programmes and to provide policy and technical guidance. The United Nations system had been involved in the Fund's establishment from the outset and had acted as a team. In reply to Dr AI Kharabseh's question about UNAIDS' future, he recalled that the Fund was a financial mechanism that would be fully complementary to existing funding and international technical support mechanisms, in other words an additional means of raising and receiving funds. UNAIDS was a cosponsored agency whose collective investment of the past years was beginning to pay off as most countries were moving from planning to action. The Fund's establishment was therefore most timely. Several factors would have to be borne in mind if the Fund was to attract additional resources and not divert contributions from existing development funds. First, an innovative mechanism would have to be established to receive and forward funds. Secondly, as the Fund would not be able to fill the entire funding gap for AIDS and other issues, funding to existing mechanisms would have to continue in a complementary manner. Thirdly, rather than imposing new and complicated planning and evaluation instruments the Fund should use existing procedures as the most cost-effective way forward. UNAIDS stood ready to help the Member States prepare their proposals for submission during any of several rounds. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) acknowledged WHO's significant contribution to the development of the Global Fund and its important role in the future in ensuring that the Fund managed health and poverty outcomes effectively. He endorsed Ms Wigzell's request that maternal and child health should also be taken into account. The information provided by the Commission on Macroeconomics and Health facilitated targeting of those issues. Dr NABARRO (Executive Director), responding to queries and comments made during the discussion, recalled that many speakers had referred to the importance of the Millennium Development Goals as well as the need to recognize the broad range of diseases and other conditions associated with poverty, including maternal and child health. Others had stressed the importance of social mobilization and effective health systems in tackling such conditions and the need to achieve results, but not necessarily through vertical programmes. It had also been noted that, although the

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Report of the Commission on Macroeconomics and Health was extremely valuable, its call for a significant increase in resources had resulted in widespread discussion. He recognized that in order to achieve effective and sustained results, greater account would need to be taken of specific national requirements. Many speakers had focused on the Fund; he reminded the Board that it was merely one mechanism to mobilize additional but necessary resources. The Fund was the innovative outcome of an intensive international process among many partners and was intended to be an independent entity. Many of the countries represented at the current session of the Board had been involved in that development process, including the recent activities of the transitional working group. However, a number of issues remained unresolved and would be taken up at the first meeting of the Fund's Board scheduled for 28 and 29 January 2002. As Professor Yunes and Mr Liu Peilong had pointed out, some of the seats on that Board had still to be decided. The handling of applications from interested countries was being facilitated by the Regional Directors and the results would shortly be made known. WHO, the United Nations system as a whole, and in particular UNAIDS, would be closely involved in the work of the Fund and its Board and the Director-General would represent WHO at that first Board meeting. The frustration caused by the time taken to finalize guidelines for proposals was understandable: the problem was due to the need to agree such guidelines before the first Board meeting. Preparations had nevertheless reached an advanced stage. Following their approval, WHO would do its utmost to support countries in drawing up cost-effective proposals that were likely to achieve success, and would continue to provide appropriate normative guidance and technical support. He reassured Dr AI Kharabseh that WHO's existing activities would be intensified, not delayed, by the Fund. Responding to Dr Modeste-Curwen's concern about possible bureaucracy he emphasized that the transitional working group intended the Fund to be prompt and effective and to deliver sustained results. The group had also paid heed to the concerns expressed by India and Venezuela about the importance of involving national governments in the country coordination process. Appropriate procedures were being developed and would no doubt be approved by the Fund's Board. He confirmed the expectation that the criteria for eligibility would indeed be those outlined in paragraph 14 of the report. WHO, other United Nations partners and some Member States were responsible for planning the technical review process, and a meeting had already been held to advance that work. How exactly the process would unfold would become clearer at the end of the first Board meeting. In reply to Dr Bodzongo, he explained that no mention had been made of follow-up activities in the report owing to lack of space, but the Board would establish relevant and standardized evaluation procedures. On the subject of administration raised by Dr AI Kharabseh, he said that WHO and UNAIDS would be working with the Fund in many areas including administration. The World Bank would also be in charge of overseeing the proper management of funds. He reiterated Mr Steiger' s appreciative comments about the Government of Switzerland. It was expected that some initial grant allocations would be made in April 2002, and it was important to ensure that the Fund continued to work effectively thereafter. Replying to Professor Zeltner, he said that the Director-General would prepare a detailed response to the Report of the Commission on Macroeconomics and Health within the next three months, including ways in which the Organization would coordinate with national governments in that connection. The essential point was that there should be no duplication of efforts: new committees would be supported if governments already had mechanisms to deal with macroeconomic and health issues. He viewed positively the concept that existing programmes should be boosted in ways that would increase effectiveness and, at the same time, encouraged new thinking on health and economics, especially with regard to poverty reduction at national level. In conclusion, he agreed that it was an exciting time. There had already been an extraordinarily high level of pledging to the Fund, and other potential donors were awaiting the outcome of the Fund's first Board meeting and the initial allocation of grants. Good results and sustained achievements were the keys to attracting more money.

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The CHAIRMAN said that she took it that the Executive Board wished to take note of the report and endorse WHO's actions as described in the document. It was so agreed. Dr MOLIN (alternate to Ms Wigzell, Sweden) proposed that the draft resolution proposed by Egypt, Ethiopia, the Islamic Republic oflran and Sweden, 1 on WHO's contribution to achievement of the Millennium Development Goals be amended as follows: first, the title should read: "WHO's contribution to achievement of the goals of the Millennium Declaration". The second preambular paragraph should read: "Recalling in particular the goals set out in the Millennium Declaration, by the year 2015, to have reduced maternal mortality by three-quarters, and under-five mortality by twothirds, oftheir 1990 levels;". The third preambular paragraph should read: "Recognizing that increased access to good-quality primary health care information and services, including reproductive health, is critical for attainment of several development goals of the Millennium Declaration". In paragraph 1(2) the phrase "reproductive health services" should be replaced by "primary health care services, including reproductive health". In paragraph 1(5), the phrase "provide information and services related to reproductive health and" should be deleted. In paragraphs 2(1) and (4), the words "millennium development goals" should be replaced by "development goals of the Millennium Declaration". Dr SALLAM (Egypt) supported the amendments proposed by Dr Molin, which would ensure broader consensus on the draft resolution. The CHAIRMAN said that she took it the Executive Board wished to adopt the draft resolution as amended. The resolution was adopted. 2 Quality of care: patient safety: Item 3.4 of the Agenda (Document EB 109/9) Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) commended the report, noting that the subject was possibly the most important element of health care quality and was being discussed by the Board for the first time. All health care systems undoubtedly had patient safety problems, and there was no systematic way of learning how to reduce the risk of recurrence or of collecting information on "near misses", which evidence suggested were 300 times more common than serious events such as avoidable deaths. Little effort had been made to tackle the problem of medication error, which accounted for one quarter of all avoidable adverse outcomes worldwide. Patient safety could be improved through greater awareness-raising and the promotion of a safety culture in hospitals. Human error could not be eliminated but safer health care systems could reduce error and minimize its impact. More reporting should be encouraged and information systems on "near misses" and adverse events should be established. A positive organizational culture in which blame was not apportioned to those who admitted their errors, good information systems as a basis for learning lessons on risk reduction, and active rather than passive learning from adverse events were the hallmarks of safe and resilient practice in other sectors. Regrettably the health sector had been slow to realize that such lessons applied to it as well. WHO was well placed to raise awareness about safety as a fundamental element of health care quality, to promote good practice in the design of suitable information systems and to facilitate standardization regarding definitions for reporting purposes.

See summary record of the fifth meeting, section 3. Resolution EBI09.R3.

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The previous year, as a member of an international panel on patient safety, he had been particularly impressed by a presentation made by the mother of a child who had suffered brain damage as a result of a serious lapse in her care during pregnancy. Her difficulties not only in bringing up her child but also in establishing the truth about the lapse had led her to say that to err was human but to cover up was inexcusable. To that should be added the further guiding principle that to fail to learn was unforgivable. Health care systems the world over must rise to the major challenge of creating open and inquiring health services that learned from their mistakes and improved patient safety. The United Kingdom intended to table a draft resolution on the subject. Dr MODESTE-CURWEN (Grenada), observing that whereas it was easy to share information on best practices, the same did not hold true for bad practices, drew attention to the statement in paragraph 16 of the report that many threats to patients had similar causes and often similar solutions and that there was great scope for designing and implementing systems for patient safety. She commended the member from the United Kingdom for sharing his negative experiences at the presentation the previous day which had proved to be a most constructive exercise. The recommendation in paragraph 18 of the report that a framework should be drawn up for WHO support to countries in a wide range of activities relating to patient safety was welcome. As criticism was more readily accepted from peers than from superiors, the importance of team work and peer review in ensuring good practice for patient safety could not be overemphasized. Dr AL KHARABSEH (Jordan) welcomed the detailed information on patient safety. The proposed action by WHO would be an important step forward in tackling a problem that went unrecognized in many parts of the world. The statistics relating to cases in some developed countries, alarming as they were, probably reflected but a fraction of the problem's true dimensions, bearing in mind the lack of data for developing countries. Unawareness or neglect of the problem stemmed largely from the lack of information; as a result, mistakes continued to be made without being recognized and corrected. He therefore requested the Director-General to initiate measures to survey the situation, and develop plans and programmes, particularly in developing countries, relating to health care quality. Dr SHINOZAKI (Japan) said that his Government was intensifying activities to prevent medical accidents, including malpractice, having recognized that such problems, particularly in big hospitals, were leading to growing public concern. WHO should support Member States in strengthening their activities in that area through measures such as defining terminology related to medical accidents and developing model methodologies for surveys. It should provide strong leadership in that field. Dr DI GENNARO (Italy) welcomed the report and the inclusion in the Board's current agenda of a subject which, although not new, was often neglected and underestimated. The task was to reduce not only preventable harm to patients but also losses in finance and, especially, public confidence. Patient safety improvement called for action in areas such as staff training, risk management, clinical practice and safe use of drugs and medical devices. She was grateful to the member from the United Kingdom for the information he had provided, including striking examples and figures, and looked forward to supporting a draft resolution on the subject. She supported the proposals for action contained in the report and hoped that WHO would carry out its expressed intention to provide leadership in the reduction of adverse outcomes. She stressed the importance of establishing an information network embracing hospitals, general practitioners, industry and health centre administrations, to monitor adverse reactions and disseminate information on recently marketed drugs and medical devices. Dr SALLAM (Egypt) emphasized the need for balanced investment in and enforcement of quality of patient care to improve the situation in developing countries. WHO might usefully develop software relating to standards of care similar to the system introduced in Egypt the previous year for

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pharmaceutical products; that would be useful to all countries but give added weight to developing country problems. Particular difficulties in those countries stemmed from a lack of facilities. More attention might be given, through WHO, to raising standards through training of personnel of all grades, from medical to technical staff. In addition, WHO, in collaboration with the United Kingdom and other countries, should develop accreditation and certification standards applicable to the developing countries. It would also be important to monitor the quality and utilization of equipment in those countries. Since assuming the office of Minister of Health in his country, he had negotiated performance guarantees for all new equipment and had required all hospitals to abide by a form of regulation, originally established in the United Kingdom, on standards for equipment and its use. Efforts should be made to achieve worldwide standardization in that regard. Moreover, attention should not be confined to hospitals but should embrace the primary health care system too. The task should not be left to WHO alone. Rather, committees should be established in which representatives of both developed and developing countries would participate, as a means to promote the establishment of suitable standards of care. With regard to harm stemming from pharmaceutical use in the developing world, he stressed that the lack of resources made the problem difficult to overcome. Further investment was required if pharmaceutical practices were to be adequately monitored and improved. Dr LEMUS BOJORQUEZ (Guatemala), while commending the report, was not in full agreement with the way in which paragraph 5 seemed to justify the shortcomings in care in the developing countries. Although he was certainly not denying their existence, it would be more useful to identify those situations as a prelude to recommendations or action to improve them and so ensure quality of care. The guaranteeing of quality was a current concern in Central America and hospital accreditation was being undertaken with resolve both to guarantee the quality of care that patients deserved and to identify, by means of pre-established standards, the shortcomings or needs that existed in hospitals in order to remedy them. After such internal accreditation analysis, the intention was to conduct user-satisfaction studies that would yield better information on how to achieve quality of care with a human touch. Dr THIERS (Belgium) also welcomed the inclusion ofthe subject of patient care on the Board's current agenda. It was perhaps surprising that it had never been discussed before, since through collaboration within the European Region the subject had been considered and acted upon in Belgium since 1982 when the first workshop on hospital-related infection had been organized. In 1984 Belgium had conducted a preliminary study of illness related to surgical treatment, revealing a prevalence of some 13%, and had developed software, currently used throughout Europe and probably in other countries, to pinpoint sources of recurrent infection. The question of quality covered a broad field, involving aspects such as the training of medical and nursing staff, the overuse of drugs, X-rays and other tests, and the safety of products and equipment. One example in his own country was a problem that had stemmed from faulty sterilizing of endoscopy equipment, affecting some 50 000 persons, who had had to be traced, and leading to several cases of hepatitis. Belgium had also faced the problem of drug-resistant strains of staphylococci, linked to over-consumption of antibiotics; however, a threeyear campaign had resulted in a drop in the use of antibiotics, with a corresponding fall in resistance to them. Expectations of support from WHO were very high, as each country could only work within limited parameters. In an institute in Belgium a special department had been established to deal particularly with the issue of quality of patient care. Moreover, the country had long experience of using a network of "sentinel" general practitioners to provide valuable research data, since, as Dr Sallam had pointed out, the problem did not relate only to hospitals. Paragraph 18 of the report was excellent in drawing attention to the need for a broader system perspective, but the programme was ambitious, and a great deal of follow-up work would be required by WHO both at headquarters and at the regional level.

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Dr MOON (alternate to Dr Om, Republic of Korea) said that the safety of patients was a key factor both for health standards and for the protection of human rights. In the main, he supported the activities listed in paragraphs 16-18. The development of an international information system, would be a valuable starting point for effective policy. A special workshop to collect national experiences and establish a collaborative information exchange was also needed. Dr AL-MAZROU (Saudi Arabia) said that one aspect not reflected in the report was the health risk to medical professionals themselves arising from the poor or unskilled use of equipment, or faulty procedures. The risk was not confined to them but could also involve, for example, persons in contact with an infected physician. Since the action advocated in paragraph 18 included support for regional activities, provision should be envisaged for implementing regional training programmes to support practitioners. Professor GRABAUSKAS (Lithuania) welcomed the initiative taken by WHO in tackling patient safety as an indispensable aspect of quality of care. The subject was especially important in countries where intensive health reforms were under way. Those reforms could be undermined by repeated mistakes in patient care. While no country actually tolerated mistakes or malpractice, in many cases there was no system in place for monitoring adverse events. Such a system should be incorporated into general monitoring and evaluation procedures, to make it possible to learn from adverse events and improve the quality of health care, while creating an environmental culture conducive to patient safety. He was encouraged by the excellent informal presentation outside the meetings by the member from the United Kingdom to ask WHO to pursue its initiative, and to report on it from time to time to the Board and the Health Assembly. Professor KULZHANOV (Kazakhstan) endorsed the views expressed by the United Kingdom. Health system reforms and strategies must incorporate procedures for improving patient safety and standards of patient care. Such procedures were too often omitted from reform programmes. It was also necessary to develop quality norms and standards for medical treatment. The process of accreditation should be strengthened especially in countries such as the Newly Independent States where it was only at an early stage of development. Furthermore, there was an obvious link between the accessibility of health care treatment and its quality. The less accessible the treatment, the more frequent adverse events became, with predictable effects on the outcome of treatments. It was also important to focus on the link between the quality and the cost of medicines and medical equipment. The purchase of cheap medicines and equipment of inferior quality could not be justified. Finally, manuals should be developed on techniques of instruction in patient safety, and the attention of teaching institutions drawn to the problem. He welcomed the establishment in Belgium of a unit to deal with the problem. Kazakhstan would be willing to participate in its work. Dr MORALES (alternate to Dr L6pez, Venezuela) said that the report dealt with a serious issue often neglected because of the interests and the complexity of the interventions involved. Patient safety must be tackled if the quality of health care was to be improved. She supported the action proposed in the document, which should go hand in hand with the establishment by WHO of health care standards and the monitoring of those standards in all Member States. Mr KET SEIN (Myanmar) said that, although the data presented in the report were drawn from developed countries, the scale of the problem was probably greater in developing countries. The key to tackling it successfully lay in general awareness of the issue and its handling by individual countries. The entire medical profession and ministries of health should join forces to establish a comprehensive system to ensure the safety and quality of health care. WHO guidance in taking the matter forward would be much appreciated.

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Dr KARAM (Lebanon) pointed out that the human factor always played the chief role in error. Although human error could not be completely eliminated, its harmful effects could be reduced and health professionals made less imperfect. The member from the United Kingdom had emphasized systems and teamwork; however, both relied on individuals. Mistakes should be acknowledged and efforts made to avoid repeating them. Checking mechanisms should be multiplied and improved. Without minimizing the important role of the individual health professional, it was important to ensure that more than one person was involved in each separate action. Some health professionals were highly regarded and highly rewarded members of society; however, it was reasonable to ask whether more stringent criteria should apply to their selection. Dr SADRIZADEH (Islamic Republic of Iran) commended the member from the United Kingdom for his frankness in the informal presentation. Mistakes could be made by the medical profession, but in every country there should be a culture in which they could be reported without embarrassment. The discussion so far had focused on medical institutions and medical professionals, but the community aspect was equally important. There were many cases in which patients, once discharged from hospital, had taken the wrong medicines and died. Strategies to promote patient safety must therefore also include health education for the general public. He agreed with Dr Sallam that the role of primary health care services was also crucial. Mistakes could be made there too: for example, in one case, 10 infants had died as a result of being injected with insulin instead of diphtheria-tetanuspertussis vaccine during routine immunization at a health post, because the two products were stored together in the same refrigerator. Lastly, in some countries problems were emerging as a result of the over-use of medical services and medicines, which could itself endanger patients. Mr OLIVA (alternate to Professor Yunes, Brazil), welcoming the fact that the Board's attention had been drawn to a very important problem, mentioned two matters of concern to developing countries which called for study and guidance by WHO. First, health authorities must be alert to the risks of misleading information being given to the public about adverse events occurring during immunization programmes. Most developing countries had achieved high levels of control of infectious diseases through mass vaccination programmes, with very few adverse events. Those that did occur should be fully reported to the public, in order to preserve public confidence in the programmes. Secondly, the high cost of medical insurance to protect physicians and hospitals in relation to errors or adverse events could raise the costs of medical services to insupportable levels, restricting access to those services by many of the population. Ms VALDEZ (United States of America)/ speaking at the invitation of the CHAIRMAN, said that patient safety was a high priority in 2002 for the United States Secretary of Health and Human Services, who, through the Agency for Health Care Research and Quality, had launched an initiative the previous year with the United States Institute of Medicine to develop data standards for patient safety. In February 2002 he would be hosting a research meeting on the subject in Washington, with international participation, with a view to identifying the research and collaboration needed worldwide in order to improve the quality of patient care. The appropriate role for WHO in that area was as a convenor. The Organization should not seek to build new capacity, but rather to draw upon existing professional associations and medical networks in areas such as injection and vaccine safety. She agreed with Dr Sallam on the need to develop common data standards. WHO could do much to help countries which lacked such standards, and that role fitted well with its ongoing efforts in health systems performance assessment and collaboration in support of research findings.

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Dr ALLEYNE (Regional Director for the Americas), endorsed the basic thesis of the member from the United Kingdom on the importance of systems. He himselfhad been privileged to address the 2001 Conference of the International Society for Quality in Health Care Inc. in Buenos Aires on that issue. The data presented in document EB 109/9 indicated that the adverse event rate was inversely related to the level of litigation in a country. He endorsed Dr Sallam's call for efforts to include services for the population in general as well as those for individuals and drew attention to the need for data from health care settings other than hospitals as mentioned in paragraph 6 of the document. From a public health perspective, all health care services warranted equal attention as regards quality of care. Lastly, referring to paragraph 5 and echoing the comments made by Dr Lemus Bojorquez, he said that the infrastructure of a country and the capacity of its services must be taken into account when judging the quality of care provided in that country. Dr KIELGAST (World Health Professions Alliance), speaking at the invitation of the CHAIRMAN, commended WHO on its commitment to quality of care and patient safety and for its continued efforts to strengthen the health professions. He was taking the floor on behalf of the International Council of Nurses, the International Pharmaceutical Federation and the World Medical Association, which represented three professions forming the fundamental unit for delivering quality care to individuals, families and communities. The World Health Professions Alliance (WHPA) had been established by those organizations as part of the move towards continuous improvements in quality of care and patient safety, to promote partnerships between the members of the health team. With continuous investments in their recruitment, training, retention and involvement in health policy, health professionals constituted powerful partners for quality and safety of care. WHP A supported measures that improved the performance of health systems and reduced cost, but believed that cost-saving should not be to the detriment of quality and safety of patient care. It was concerned at the present global shortage of health professionals, the dilution of skilled workforces with less qualified personnel, and the reduction in overall staffing levels. There was growing evidence that inadequate institutional staffing levels were correlated with an increase in a variety of adverse events that could lead to longer hospital stays and higher hospital mortality rates. In short, inadequate human resources presented a serious threat to patient safety and quality of care. WHPA urged WHO, governments and others to examine how to attract and retain properly qualified health workers through such means as appropriate remuneration and working conditions, and the provision of support services, economic and social incentives, peer review and professional development. The role of national nursing, medical and pharmacy associations deserved continued support. Such associations could mobilize their many members in improving the quality and safety of patient care. WHP A reiterated its commitment to quality of care and patient safety and would continue to scale up its efforts in collaboration with member national medical, nursing and pharmacist associations and with WHO and other partners to strengthen its mandate and that of health professionals in those areas. Dr MURRAY (Executive Director) said that he had taken note of the wide interest in patient safety and the concerns expressed regarding the scope of activities in that area, including the need to include primary health care and population level services. Consideration should be given as to whether or not patient safety encompassed inappropriate care. As members of the Board had pointed out, patient safety was a key indicator for quality of care, and there were clear links between patient safety and the regulatory mechanisms available to national authorities, as well as general interventions to foster a culture of safety. He had further taken note of the recommendations to secure clearer definitions and standards of data collection that would lay the foundations for an evidence-based approach. More detailed evidence would also allow proper examination of any links between litigation and frequency of adverse events. He shared the concern expressed by the member from Brazil regarding costs, noting that it was important to establish realistic costs for the strategies available. As the representative of WHP A had said, human resources and the culture in which health providers

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worked were crucial. Moreover, as Dr Al-Mazrou had noted, there were several dimensions to patient safety, including inappropriate interventions, human error and transmission of infections among patients and carers. Clearly, patient safety was a core indicator, that should be seen in the broader context of quality of care, provider performance and health system performance. The CHAIRMAN said that she took it that the Board wished to take note of the report and announced that the item would be left open pending consideration of the draft resolution on quality of care: patient safety, to be submitted. It was so agreed. (For adoption of the resolution, see summary record of the ninth meeting, section 4.) Infant and young child nutrition: Item 3.8 of the Agenda • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes (Document EB109/ll) • Global strategy for infant and young child feeding (Document EB109/12) Ms COSTA COUTINHO (alternate to Professor Yunes, Brazil) commended the setting in motion of the consultative, science-based process that had led to the formulation of the draft global strategy for infant and young child feeding which she supported. Brazil had played a constructive part in that process by organizing discussions at national level. Referring to the resolution within the draft resolution set out in paragraph 7 of document EB109112, she proposed that paragraph 4 should be amended by replacing the words "consistent with the policy of WHO" by "in conformity with the International Code of Marketing of Breast-milk Substitutes and subsequent, relevant, World Health Assembly resolutions". The reason for the proposed amendment was that the Brazilian delegation to the Twenty-third session of the Codex Committee on Nutrition and Foods for Special Dietary Uses had noted continued resistance by some countries to the implementation of resolution WHA54.2 in respect of the optimum duration of exclusive breastfeeding. That resolution had represented a great step forwards, and it was desirable that the Codex Alimentarius Commission should heed it and other relevant Health Assembly resolutions. Referring to document EB 109111, she recalled that Brazil had had its own code of marketing of breast-milk substitutes since 1988, which had been reviewed in 1992 and again in 2001 by a committee in which all interested parties participated. Consequently Brazil had a wealth of experience arising from a broad spectrum of input. The object ofthe revised code was to protect exclusive breastfeeding for six months and the continuation of partial breastfeeding until at least the second year of life. The scope of the code had been clarified by defining terms and the responsibilities for monitoring compliance, and broadened to include, inter alia, the regulation of the marketing of breast-milk substitutes and the prohibition of new forms of advertising. Partnership had produced positive results. Ms WIGZELL (Sweden) expressed support for the draft global strategy for infant and young child feeding and the draft resolution contained in document EB109/12. She proposed that paragraph 3 of the resolution within that draft resolution should be amended to include UNFPA among the international organizations mentioned; and that in paragraph 4, "by clear labelling in line with resolution WHA54.2" should be inserted after "at an appropriate age". Dr SADRlZADEH (Islamic Republic of Iran) fully agreed with Ms Costa Coutinho that the agreed optimum duration of exclusive breastfeeding of six months should be emphasized on all possible occasions, including in draft resolutions. Referring to paragraph 3 of the resolution contained in the draft resolution in document EB I 09/12, he proposed that "independent" and "with no conflict of interest" should be inserted before and after the word "donors", respectively.

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Dr AL-MAZROU (Saudi Arabia) said that his country was in the final stages of translating into legislation a governmental decision to encourage breastfeeding. Two other member countries of the Gulf Cooperation Council had already adopted such measures. Several activities in that area were being carried out on a regular basis and a week-long training seminar in which 45 health professionals had received instruction with the support of the International Baby Food Action Network had recently been held. The International Code was an important weapon for protecting infants and young children from malnutrition. Any moves by the producers of breast-milk substitutes to discourage breastfeeding should be vigorously opposed. Dr DI GENNARO (Italy) said that the draft global strategy contained in the annex to document EB109112 was valid, well-structured and provided a guide for action. She supported the two guiding principles for the development of the global strategy as set out in paragraph 4 of the report. The strategy should be tailored to the specific needs of countries and build on past achievements and international commitments. She welcomed the integrated and comprehensive approach, and the reference in the policy framework to the need to consider mothers and babies as an inseparable biological and social unit. She asked whether there was any scientific evidence for the statement in paragraph 18 of the draft global strategy that it was safer to feed breast-milk substitutes using a cup rather than a feeding bottle and teat, and requested clarification of the term "imaginative legislation" at the end of the last bullet point in paragraph 28. If the global strategy were to be a guide for action, then proposing the appointment of national breastfeeding coordinators and the establishment of multisectoral breastfeeding committees, mentioned in the first bullet point in paragraph 28, should be presented as suggested options for implementation, leaving it to Member States to decide on the measures to be taken, as appropriate to their national circumstances. Referring to paragraph 31, she said that the request that governments develop, implement, monitor and evaluate a comprehensive policy on infant and young child feeding called for many initiatives, some of which would require considerable human and financial resources. The draft strategy must be refined to the best possible extent before its adoption in view of the crucial importance ofthe issue. Dr BODZONGO (Congo) welcomed the consideration of document EB109/12, which was the result of extensive discussions by the governing bodies of WHO and of studies done on, inter alia, duration of breastfeeding. Although the global strategy referred to breastfeeding, the draft resolution contained in paragraph 7 of the document did not. There were references in the preamble to the resolution contained in that draft resolution to inappropriate feeding practices (sixth paragraph) and appropriate feeding practices and related questions (ninth paragraph), the nature of which should be spelled out more clearly. Breastfeeding, an entirely natural function, was treated in the strategy in a way that was problematic for the developing countries. For example, the provisions proposed in paragraph 12 to enable women in paid employment to continue breastfeeding were complex and financially onerous. Dr MODESTE-CURWEN (Grenada) said that her country was convinced that the best form of nutrition for infants was breastfeeding, with exclusive breastfeeding for the first six months. The documents before the Board referred to persons with HIV or in extreme situations and who were unable to breastfeed, but some healthy people who had been given the facts about the importance of breastfeeding refused to breastfeed. How could ministries of health fulfil their responsibility to promote proper infant nutrition while giving out information on alternative forms of feeding which might send out the wrong signals to mothers? Professor ZELTNER (Switzerland), commending documents EB109/11 and EB109/12, said that the draft global strategy aptly reflected the lengthy debates held on the subject and was likely to prove generally acceptable. It was not highly innovative, but then it could not be, given the difficult nature of the issue and the fact that consensus was so slim.

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Dr MANSOUR (alternate to Dr Sallam, Egypt) considered the report on childhood nutrition (document EB109/11) to be a good starting point for improving children's health in the future. Personnel in children's hospitals should offer appropriate counselling to mothers on the benefits of breastfeeding. She endorsed the report contained in document EB109/12. It was time to give practical effect to the International Code of Marketing of Breast-milk Substitutes and to enlist the support of the media in promoting optimal infant feeding practices. Dr ROMUALDEZ (Philippines), recalling that the Philippines had adopted its own national code for marketing breast-milk substitutes as far back as 1987, pointed out that breastfeeding rates could not be improved simply by restricting marketing of breast-milk substitutes. The draft global strategy was therefore welcome as a guide for developing more positive country-specific mechanisms for improving infant feeding practices. However, he endorsed the reservations expressed by the members from Italy and Congo and agreed that the wording should be revised in light of comments received from Board members and Member States. Dr AL-MAZROU (Saudi Arabia), referring to the draft resolution contained in document EB 109/12, proposed the insertion of "taking into consideration local traditions and values," after "programmes," in paragraph 2(1) ofthe resolution contained therein. Ms VALDEZ (United States of America), 1 speaking at the invitation of the CHAIRMAN, wholeheartedly concurred with the over-arching principles of the draft global strategy, namely that it should be grounded on the best available scientific evidence and be as participatory as possible. Sustainable success in implementing the global strategy would ultimately depend on ownership and support by Member States. Given the late availability of the draft document, she welcomed the invitation to provide feedback after the present session of the Board for possible inclusion in a revised version to be submitted to the forthcoming Health Assembly. The United States would be providing comments in writing in due course. A critical area for inclusion was that of public-private partnerships. Although clear criteria would be needed to provide the necessary guidance, the private sector was a vital stakeholder in the research challenges that would be part of any implementation plan. Another area that could be strengthened was that of breastfeeding in the context of reducing the risk of maternal transmission of HIV. A primary concern was the interaction between nutritional status and the use of antiretroviral drugs in resource-poor settings. Knowledge regarding the severe metabolic effects of those drugs when used in the developed world should be used in planning action in the developing countries. Of particular significance was the total lack of evidence of the impact of antiretroviral drugs on the lipid composition of human milk. Further research was needed on mother-to-child transmission of HIV and the effects of antiretrovirals on the growth and immunocompetence of mothers and children. Dr BOSHELL (Colombia) agreed with previous speakers that the text of the draft global strategy should be revised in the light of comments and proposals received. Dr BERGEVIN (UNICEF), speaking at the invitation of the CHAIRMAN, endorsed document EB109/12 and the draft global strategy and assured the Board that UNICEF would work closely with WHO to support governments in implementing the global strategy and achieving its objective of fostering respect for the International Code of Marketing of Breast-milk Substitutes. Mr MASUKU (FAO), speaking at the invitation of the CHAIRMAN, said that FAO was particularly concerned about complementary feeding and fully supported the draft global strategy for

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infant and young child feeding, despite some minor reservations. He suggested that the Board might wish to consider the deletion of "for the majority" at the end of the first bullet point in paragraph 5 of document EB 109112. He pointed out that paragraphs 3 and 4 of the resolution contained in the draft resolution set out in paragraph 7 of the document referring to FAO and the Codex Alimentarius Commission had been endorsed by FAO. The Board might also wish to consider replacing "be required" with "help" in paragraph 17 of the draft global strategy. Since the consumption of appropriate amounts ofunfortified foods by older infants and young children in addition to breast-milk was adequate for good nutrition, the global strategy should not give the impression that fortified foods were "required" in any circumstances. More specific mention might be made in the draft global strategy of the role of the agricultural sector in ensuring that the type of foods appropriate for use in complementary feeding were produced, processed and made available. The Board might also wish to consider placing further emphasis on strengthening complementary feeding guidelines at household and community level to supplement existing breastfeeding initiatives. The Codex Alimentarius Commission was seeking to complete its work on quality standards for processed foods for infants and young children, taking into account WHO policies on childhood nutrition. Those standards would serve to promote the proper and safe use of such foods at the appropriate ages. Dr TORMEN (Executive Director) thanked Board Members for their wide-ranging and supportive remarks and reminded them that comments on the draft global strategy could be submitted up to 1 March 2002. She had taken note of the proposed amendments to the draft resolution contained in document EB 109/12. In reply to Dr Di Gennaro, she said that the main purpose of the global strategy was to provide a framework which countries could adapt to their individual requirements. "Imaginative legislation" was a concept that had originated in the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. Its aim was to protect the breastfeeding rights of working women, thereby improving the nutritional status of infants and young children. A recent example of "imaginative legislation" was the revised Maternity Protection Convention and Recommendation adopted by the ILO Conference at its eighty-eighth session. She confirmed that various studies had shown that the main advantage of feeding by cup rather than using bottles and teats was that cups were easier to clean. Responding to the comments made by Dr Bodzongo, she said that the main message was the promotion of better infant and young child feeding. Professor Zeltner had referred to a lack of innovation in the draft global strategy. Nevertheless consensus on reinforcing political commitment to improving infant and young child nutrition was important for future action. The inclusion of"civil society" in the document signalled the intention to involve all stakeholders with an interest in improving the nutrition of infants and young children. With regard to the comments from the United States of America, she said that WHO's new programme on HIV/AIDS included a substantial research component that would be investigating the links between nutritional status and the use of antiretroviral drugs. Member States would be kept informed of new developments in that field. She thanked the representatives of UNICEF and FAO for their comments and support in the preparation of the global strategy. All the comments made by Board members would be taken into account in revising the draft global strategy before its submission to the Fifty-fifth World Health Assembly.

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The CHAIRMAN proposed that informal consultations should be held to prepare a revised version of the draft resolution set out in paragraph 7 of document EB 109112 that took into account the comments made during the discussion. It was so agreed.

The meeting rose at 17:30.

SEVENTH MEETING Thursday, 17 January 2002, at 9:00 Chairman: Mrs M. ABEL (Vanuatu)

HEALTH STRATEGY MATTERS: Item 3 of the Agenda (continued) Infant and young child nutrition: Item 3.8 of the Agenda (continued) • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes (Document EB109/ll) (continued) • Global strategy for infant and young child feeding (Document EB109/12) (continued) Ms LEHMANN-BURI (International Lactation Consultant Association), speaking at the invitation of the CHAIRMAN, said that the aims and objectives of the draft global strategy for infant and young child feeding were fully consistent with those of her Association, which was ready to offer any practical help needed to implement that new strategy after its endorsement by the Health Assembly. The Association's clinical experts and breastfeeding specialists were also ready to provide professional, practical, clinical and evidence-based support in order to optimize good health through breastfeeding. It fully supported a science-based approach to any discussion of infant feeding, and therefore urged members of the Board to adopt the draft global strategy in the best interests of mothers and babies, who had a right to the best available nutrition. Mrs KUONEN (La Leche League International), speaking at the invitation of the CHAIRMAN and on behalf of the International Clearinghouse for Birth Defects Monitoring Systems, said that the annual number of pregnancies affected by neural tube defects amounted to some 300 000 worldwide, thus equalling the annual number of maternal deaths. Research had demonstrated that about half such cases could be prevented if women consumed adequate amounts of folic acid before conception and during early pregnancy. Consequently, various national health authorities sought to encourage women to take that important and worthwhile prevention measure, although better results would be achieved if it were to form a prominent part of the global health agenda. In countries with centralized food-processing capabilities, the fortification of staple foodstuffs was technically simple and inexpensive, particularly when flour was being fortified with other micronutrients. In other situations, it was potentially feasible to follow China's successful lead in promoting increased consumption of folic acid through the use of dietary supplements. She therefore urged WHO to consider ways of incorporating such measures into its maternal and child health programmes, thereby placing the prevention of neural tube defects on the global health agenda. Ms YEONG Joo Kean (International Organization of Consumers Unions (Consumers International)), speaking at the invitation of the CHAIRMAN, said that the International Baby Food Action Network (IBF AN), which was a member of Consumers International, regretted that its inputs in response to WHO's invitation to participate in the consultation process on the draft global strategy had not been reflected in the current draft, which bore an earlier date than the deadline specified to IBF AN for the submission of its comments. She therefore wished to highlight a number of concerns, the first of which was that the draft strategy should reiterate the recommendation contained in resolution WHA54.2 by clearly defining optimal infant and young child feeding practices to mean exclusive breastfeeding for the first six months of life and continued breastfeeding, with safe and - 111 -

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appropriate complementary foods, up to the age of two years and beyond. The draft strategy also failed to emphasize the continued unethical marketing of commercially prepared foods at the expense of breastfeeding and complementary foods prepared at home. Nor did it clearly acknowledge the failure of baby food manufacturers to fulfil their responsibilities under the International Code of Marketing of Breast-milk Substitutes. Moreover, document EB 109/12 failed to reflect the positive impact of the popular legal training courses that IBF AN had held over the past 10 years for a total of 550 government officials from 114 countries. Other activities such as sponsorship, staff secondment and funding for research and conferences were not identified as problems in the draft strategy, which should also reaffirm the concern raised in resolution WHA49.15 regarding conflict of interest and recognize that conflict as a recurring threat to the provision of full support for breastfeeding. After reiterating the need for independent funding of research, particularly in regard to HIVI AIDS and infant feeding, she stressed the responsibility of the United Nations system to ensure that its research programmes and policies were not funded by those with a vested interest in the outcomes. Paragraph 16 of the draft global strategy should again give effect to resolution WHA54.2, which set forth specific measures intended to improve complementary feeding practices. In that regard, she was concerned that, instead of reaffirming the health and nutritional benefits of exclusive breastfeeding, the preamble to the draft resolution contained in paragraph 7 of document EB109/12 emphasized nutritional deficiencies that would be offset by improving breastfeeding and optimal infant feeding practices, support for which should not be replaced or undermined by the use of micronutrient interventions. The draft strategy should also stress that the marketing of nutritional supplements should be subject to the protective provisions of the International Code of Marketing of Breast-milk Substitutes, with a view to ensuring that a mother's confidence to breastfeed was not undermined. Lastly, the definition of civil society given in the footnote to paragraph 7 of the draft strategy required revision in order to spell out clearly the roles of individual groups and actors, particularly those with commercial interests, whose aims and objectives were often entirely different from those of nongovernmental and community-based organizations. For the same reasons, she was also concerned by the wording in paragraphs 2(4), and 5(4) of the draft resolution, in that commercial groups and associations were included as equal actors in the implementation of the strategy. She was gratified, however, that the draft resolution contained provisions for monitoring the implementation of the global strategy, which her organization would be supporting. Mr DE SKOWRONSKI (International Special Dietary Food Industries), speaking at the invitation of the CHAIRMAN, welcomed the all-inclusive approach adopted in the draft resolution towards implementation of the global strategy, and the emphasis placed on the constructive role played by infant food manufacturers in feeding infants and young children and addressing the vital issues in that connection. He looked forward to working with Member States, both individually and collectively, through WHO, with a view to furthering the aims and objectives of the strategy by, inter alia, contributing to proactive programmes to improve such feeding and ensure implementation of the International Code of Marketing of Breast-milk Substitutes. His organization was committed to improving the health and well-being of infants and young children through proper nutrition, to which end it devoted considerable resources to research and development in the field of nutritionally balanced processed foods. He therefore applauded the scientific process advocated in the draft global strategy, and expressed his support for the development of strong public-private partnerships in matters of nutrition and health. Mrs KUONEN (La Leche League International), speaking at the invitation of the CHAIRMAN, welcomed the draft global strategy, which should provide impetus and direction to efforts to support breastfeeding and build on the work already accomplished as a result of the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, the Baby-friendly Hospital Initiative and the World Declaration and Plan of Action for Nutrition. Through its network of volunteer leaders and trained peer counsellors, La Leche League International would endeavour to implement the global strategy by a variety of means, such as helping mothers with breastfeeding, developing and publishing

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relevant literature, organizing conferences and other events, and disseminating information on the International Code of Marketing of Breast-milk Substitutes. She called on WHO to monitor the situation in regard to breastfeeding and HIVI AIDS so as to ensure that no action taken led to an unnecessary decrease in breastfeeding. The League was prepared to provide assistance for strengthening and accelerating the progress of the global strategy, which she challenged the international community to adopt in order to eliminate barriers to breastfeeding once and for all. The CHAIRMAN suggested that further consideration of the item should be deferred to permit further consultations on the draft resolution contained in paragraph 7 of document EB 109/12. It was so agreed.

(For adoption of the resolution, see summary record of the ninth meeting, section 4.) Violence and health: Item 3.11 of the Agenda (Document EB 109/15) Dr AL KHARABSEH (Jordan) said that the worst and most dangerous forms of violence consisted in unjustified wars and acts of State terrorism against innocent and defenceless civilians, whether by targeting them with lethal weapons or by depriving them of their livelihood and their most basic human rights. Worse still, the victims of such violence were most often the poor, who lacked access to the means needed for a decent lifestyle. Such armed conflict should be the subject of international condemnation, since without serious efforts to bring them to an end, the world would continue to close its eyes to the obvious. Any definition of violence should take cultural attitudes into consideration, as what might be regarded as an act of violence in one region or society could be viewed in an entirely different light elsewhere. Professor YUNES (Brazil) said that violence had now reached epidemic proportions in Brazil, particularly among young people, for whom homicide was the main cause of death. Since they were also the most economically productive group, the costs of violence in the form of health care and lost productivity were enormous. He consequently welcomed the creation of a framework to facilitate activities against violence, as well as the forthcoming world report on violence and health, which would be instrumental in increasing the involvement of Member States in strengthening primary prevention. He commended the transparent method used to produce the report and the steps taken to ensure a broad input. Scheduled for release in September 2002, the document would be highly relevant to the whole world and hence too important simply to be "noted" by the Executive Board. He therefore proposed that the report and its recommendations should be discussed at the Fifty-sixth World Health Assembly in 2003. Dr SALLAM (Egypt) said that a holistic approach was required when examining the very important subject of violence and health. Although the report stated that 1.7 million deaths in the world were due to violence, perhaps 100 times as many people suffered its ill effects every day. In the past, a healthy world had meant a world free of epidemics and physical illness. However, mental health within the family and the community was becoming an issue requiring increasing focus. Violence could be described as currently endemic: it disrupted the normal course of human life and was a source of injustice for the many who suffered it. Violence within families, in the street, at country and at global level was evidence of an inability to cope with stressful situations. The inability of human beings to contain such behaviour contrasted starkly with the progress made in global growth and improvements in technology. Inequality and injustice were undoubtedly major causes of violence. However, punishing the offenders was not a satisfactory solution. The focus should be on prevention: priority measures should include action to end gender and socioeconomic disparities. It was his experience that programmes for the advancement of women in rural areas led to a reduction in violence. Prerequisites for health were

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democracy, freedom of speech and institutions to support dialogue at the country, community and family levels. The answer lay in better education for the world's children, which would equip them with skills, and training for communities on how to prevent violence. Dr DI GENNARO (Italy) said that violence was a worldwide problem causing death, injury and psychological and physical suffering for victims and their families. The data were alarming and, as Professor Yunes had indicated, the number of violent deaths due to suicide and homicide was immense. The phenomenon was related to factors that were directly within the public health domain such as mental health problems, behavioural disorders, reproductive and sexual problems, and alcohol and substance abuse. The complex combination of factors that might contribute to violence called for diverse interventions and multisectoral involvement. Research into the effectiveness of violence-prevention measures was needed, as well as improved collection and analysis of data on all types of violence and its consequences. She attached great importance to the prevention of violence against women, especially vulnerable groups such as young mothers with children, which could be achieved through changes in cultural perceptions, and eliminating complacency and denial from the mindset of the aggressor. She was confident that the world report on violence and health would focus particularly on that issue, as it would form a good basis for the development of the plan of action for the prevention of violence requested and endorsed by previous Health Assemblies. Dr SADRIZADEH (Islamic Republic of Iran) said that violence was caused by a variety of social, economic, political, environmental and biological factors. The magnitude of the problem and its public health implications had not been properly appreciated. Some 50% of all violent deaths were suicides which, owing to prevailing social, cultural and religious norms, went largely unreported in many parts of the world. As suicide was both a social and a public health problem, its prevention required the commitment of many different sectors at the international, national and local levels. WHO could play a crucial role in raising global awareness, promoting commitment, strengthening interagency collaboration and placing the problem of violence, including suicide, high on the agenda of the world's decision-makers. Dr MBAIONG (Chad) said that poverty was one of the main causes of violence in all countries. At the domestic level, poverty fomented violence against vulnerable groups such as women and children, and at the community level led to armed conflict and terrorism. He congratulated the Director-General on the timely report, which highlighted measures for the monitoring, research and prevention of violence as well as for the treatment of its victims. Dr BOSHELL (Colombia) said that work on violence and health in the Region of the Americas had been undertaken with the assistance of PAHO for a number of years, and some of the results of that work were highlighted in document EB109/15. Colombia was all too familiar with violence. For many years, rural communities had been violently attacked by various groups acting outside the law and forced to leave their homes on an unparalleled scale. The unprecedented number of 27 000 persons displaced by violence in 1985 had risen to 720 000 by 1994 and 1 123 000 by 1999, with 308 000 forcibly displaced in 1998 alone. Statistics showed that 34% of such displacements were caused by guerrillas and 49% by paramilitary groups. Peasants forced to abandon the villages where they had been born had no option but to seek refuge in the cities, where they had no access to the most basic of services, and fell prey to chronic and communicable diseases as well as psychosocial difficulties. Faced with the difficulties of documenting the health status of the uprooted population, the National Health Institute of Colombia had set up an epidemiological surveillance system that was currently at the experimental stage of training community leaders to report on any diseases resulting from displacement.

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Colombia's painful experiences and especially of those of its people displaced through violence, deserved consideration by the Executive Board and inclusion in the world report. Dr GIRMA (Ethiopia) said that, although violence came in many different forms, he would confine his comments to rape, domestic violence and armed conflict. Rape was a major health problem in developing countries inducing mental trauma and with it the life-threatening risk of sexuallytransmitted diseases, including HIV/AIDS. Domestic violence against women was another problem recognized by the Government and by civil society, and action had been taken to turn the tide against the perpetrators. The consequences of armed conflict, both direct and indirect, were a serious problem. In countries such as Ethiopia, even after the conclusion of hostilities, anti-personnel mines continued to pose a threat to innocent people, many of whom lost their lives or suffered severe long-term injury. Ethiopia much appreciated the support provided by WHO in providing counselling services for the war-traumatized people of northern Ethiopia and helping to develop national guidelines to prevent violence. He called on the Executive Board to reject violence in all its forms and to reaffirm its support for the United Nations Millennium Declaration, adopted by the General Assembly at the Millennium Summit in September 2000, which stated that men, women and children had the right to live their lives in freedom and without fear of violence, oppression or injustice. Ms WIGZELL (Sweden) fully endorsed the proposed approach for tackling violence, in view of the resulting burden of ill health and its impact on individuals and families, on society as a whole, and on health services. WHO should examine the health dimension of violence and its links to environmental, economic, social and behavioural factors. Dr AL-MAZROU (Saudi Arabia) said that the problems of violence were wide-ranging and little was known. Not all cases came to the attention of doctors. Inequity and the lack of social justice were undoubtedly contributory factors, that might be remedied by the creation of fairer societies. Alcohol and drug abuse also increased the risk of violence, and should be discouraged. The subject was important and should be on the agendas of all international organizations. Dr THIERS (Belgium) said that his Government was currently drawing conclusions from the national public health survey for 2001, which had contained specific questions on the frequency of violent confrontations and in the course of the year, the Ministry of Health would be reviewing the data collected by a network of doctors on the frequency of violent incidents experienced by their patients. Belgium had one of the highest suicide rates in Europe. Suicide represented a particular type of self-inflicted violence, which, like other types of violence, was linked to mental health. The observations made by Professor Yunes and Dr Boshell, that demonstrated the extent to which a society could be destabilized by violence had been particularly impressive. He looked forward to the publication of the world report and in particular to the summary of recommendations for political decision-makers. Whether or not the report was to be referred again to the Executive Board or submitted directly to the Health Assembly was still to be decided. Dr KARAM (Lebanon) said that violence was one of the most serious problems facing WHO and the international community, and gave rise to several questions. How was violence to be defined? Could it be categorized only as bodily harm, or did other forms exist? Could violence be identified as being committed by organizations, movements or states as distinct from individuals? Was homicide the only form deserving attention, or should suicide and genocide also be addressed? Was it to be measured by the number of people upon whom violent acts had been inflicted, or should those suffering long-term mental and spiritual effects also be taken into consideration? Did the blame for violence lie with the individuals, groups or states that practised it, or with the institutions, authorities and nations that condoned it and closed their eyes to its causes, notably by

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promoting the sale of weapons? Should doctors confine themselves to treating the victims of violence, or should they also focus on the causes? Could WHO establish programmes to eradicate violence as it had for malaria and tuberculosis or, as for measles and smallpox, could a preventive vaccine be invented? If it were agreed that violence was a public health problem, then WHO should join the international community in a concerted effort to eradicate its social, economic and political causes. Professor GRABAUSKAS (Lithuania) welcomed the inclusion of the item on the Board's agenda. Violence inflicted untold suffering on families, communities and nations, causing countless deaths, a large proportion of which were preventable. Deaths by external causes ranked third within the overall structure of mortality in Lithuania, particularly among the younger sections of the population, and a large proportion of those deaths were caused by violence. Lithuania's suicide rate was among the highest in the world. Research conducted nationally showed a strong correlation between violent deaths and social factors such as low levels of educational attainment, low income, unemployment, social isolation, and alcohol and drug abuse. Accordingly, action to combat violence nationally and globally should be based primarily on socioeconomic strategies. International cooperation was thus essential, and Lithuania commended the leading role played by WHO in that regard. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) said that the report rightly pointed to the multisectoral nature of violence, and highlighted some of the deep-seated social factors involved. The contribution of those causal factors would differ from country to country, so public health programmes would need to be flexible enough to allow for different emphases in different settings. From a United Kingdom perspective, three points should be emphasized: first, the importance of alcohol misuse as a common factor in violence perpetrated in many settings; secondly, the insufficient emphasis hitherto placed on domestic violence in public health programmes; and thirdly, the paramount importance of preventing violence against children. In that regard, the abundance of good practice worldwide needed to be promulgated. Thus, the United Kingdom welcomed the initiative by WHO, but underlined the importance of ensuring strong links between strategies to reduce violence and complementary strategies and policies in fields such as alcohol misuse, domestic violence and child protection. Dr ROMUALDEZ (Philippines) endorsed the interventions by Dr Sallam and other speakers suggesting a holistic approach to the issue of health and violence. In the Philippines, and in some other countries, nutrition programmes were linked to early child education activities labelled as "mental feeding". Perhaps at some point health authorities would recognize the usefulness of approaches based upon acknowledging the spiritual aspects of the human condition. It might then be possible to consider "spiritual feeding" as an approach to the prevention of violence. Professor KULZHANOV (Kazakhstan) said that violence had become an urgent problem in countries that had experienced dramatic and stressful economic and social transformations over the past decade, and statistics bore witness to its seriousness in the Newly Independent States. Violence was a multisectoral problem, permeating the armed forces and schools as well as families in the most disadvantaged sectors of society. More epidemiological surveillance and scientific research into violence and health were needed, and it was to be hoped that WHO would accord fuller attention to that area, collaborating with other international bodies with relevant experience. WHO could play an important coordinating role in that regard. Lastly, local as well as global action was needed, since such problems were best resolved at grassroots level. Accordingly, local health authorities and organs must be involved in any initiative. Dr BODZONGO (Congo) said that, while the immeasurable repercussions of violence in the field of public health justified its place on the Board's agenda, it was important to address the causes

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as well as the effects. Violence was a multifaceted phenomenon, not all aspects of which were acknowledged in the report. Furthermore, the figures for causes of violent death given in paragraph I of the report were not true of Africa. In Congo, and in war-tom countries of Africa generally, wars, not suicide, were the main cause of violent deaths. In African society, unlike European society, suicide was a rare phenomenon. Thus, different causes called for different solutions, and while WHO might be in a position to make its own contribution to resolving the problem, it seemed overambitious to call upon it to play a leading role in that process, which must also take account of the human dimension, sociological issues and the prevailing world economic order. He doubted whether WHO had the capacity to address all those aspects of the issue. Dr MODESTE-CURWEN (Grenada) said that even when violence was viewed as a public health issue, the considerations were mostly physical, with little emphasis placed on managing the psychological and emotional aspects of violence. In her region, for example, an individual who had served a sentence for a crime of violence was very likely to re-offend, since no support system existed to assist such offenders in conflict resolution or anger management. Likewise, victims were treated for their physical injuries, but given no assistance in dealing with their psychological effects. Since that state of affairs was to a large extent attributable to lack of expertise, WHO should give serious thought to ways of developing human resources to deal with the emotional aspects of violence. Nor should the role of the film industry in promoting violence be overlooked. Dr BOSHELL (Colombia), in response to the question raised by the member from Lebanon, said that the Colombian paediatric community had indeed developed a vaccine against violence, and had been using it, with the assistance of a multinational pharmaceutical corporation, for the past year. It had been proposed for inclusion in Colombia's Expanded Programme on Immunization, and was offered to potentially violent parents on the recommendation of doctors and the children affected. Ways were being developed of measuring its impact, and full information on its effectiveness should be available in time for the forthcoming session of the Health Assembly. Dr SPANJAARD (International Physicians for the Prevention of Nuclear War), speaking at the invitation of the CHAIRMAN, said that his organization was a Nobel Peace Prize-winning federation of doctors and medical students in 65 countries working to eliminate the threats of weapons of mass destruction and to protect health and life from the effects of militarism and war. It also addressed other issues adversely affecting health, including land mines, small arms and light weapons and the current culture of violence, through research, education and advocacy. The current proliferation of arms represented a massive threat to human health and survival. Conventional wars caused human suffering and death on a pandemic scale. The twentieth century had been the most violent in history, killing over 110 million people, many of them civilians. Global military spending was on the increase, exceeding US$ 800 thousand million in 2000. That figure was all the more tragic when it was borne in mind that half the world struggled to survive on less than US$ 2 per day. Doctors and politicians must ask themselves how health professionals could promote peace and health education to counter the media's glorification of violence, and how they could contribute to a reordering of global priorities and a re-channelling of resources away from militarism and towards unmet human needs. His organization fully endorsed the role of WHO and civil society in the prevention of violence, as outlined in document EB109/l5. It applauded the efforts of WHO to address the crisis of violence and its root causes, and eagerly awaited the release of the world report on violence and health. It also sought closer cooperation with WHO, notably with the Department of Injuries and violence prevention, in order to further common aims in addressing both the consequences of conflict and violence and their prevention. Dr YACH (Executive Director) said that the Board's comments would help in finalizing the first world report on violence and health and in focusing the work. Many speakers had stressed that the causes of violence were complex and varied from country to country, and that the impact was

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widespread, extending well beyond physical aspects. There had been many important comments about the linkages between violence and mental health; in that regard, he assured the Board of the extremely close working relationship between the groups in WHO focusing on the prevention of violence and those on mental health and substance dependence. The report would include a chapter and explicit focus on collective violence and war, and Colombia, Ethiopia and Jordan in particular could rest assured that that focus would be very clear. The task of peace-building and violence prevention was a key function of the United Nations system and of the Security Council, as well as of governments and bodies such as International Physicians for the Prevention ofNuclear War. As pointed out by the member from Congo, WHO's specific role had to be circumscribed if it was to be effective, and an attempt had been made to define that role in paragraph 9 of document EB 109/15. The roles identified and functions specified therein were considered realistic and public health-oriented and were supported by United Nations agencies as being appropriate to WHO's mandate. The latter point had been discussed at the interagency meeting convened and coordinated by WHO and outlined in paragraph 11 ofthe document. Egypt, Ethiopia and the Philippines had emphasized the critical importance of primary prevention and, in so doing, had stressed that prevention of violence was a collective responsibility that started by giving the highest value to the sanctity of every life as powerfully described by Dr Karam and Or Spanjaard. Lastly, the suggestions by Belgium and Brazil that the first world report on violence and health be discussed at future governing body meetings would be carefully considered. The CHAIRMAN said that, if she heard no further comment, she would take it that the Board wished to take note ofthe report contained in document EB109/15. It was so agreed.

Dengue prevention and control: Item 3.12 of the Agenda (Document EB I 09116) Dr LOPEZ (Venezuela) said that, in addition to its social and economic implications, the sharp rise in the incidence of dengue fever and dengue haemorrhagic fever in the Americas, South-east Asia, the Eastern Mediterranean and the Western Pacific was having a serious political impact. Immediate and intensive vertical action by health services was required, as well as other measures relating to the control of mosquito vectors and their breeding grounds, domestic water supplies, effective solid waste management, and personal and community hygiene. Those measures should be implemented m parallel to achieve their full impact. She welcomed the draft resolution contained in paragraph 8 of document EB109/16, in particular the appeal to other specialized agencies, bodies and programmes of the United Nations system, bilateral development agencies, nongovernmental organizations and other concerned groups to step up their support for health development. Member States should be called upon, in addition, to place dengue fever on the political agenda and to create strategic alliances for intersectoral action on public health. Local government bodies were particularly important in that regard since they normally had responsibility for ensuring a healthy environment and were able to pass by-laws and adopt legal instruments to achieve specific aims. Mr BARBAROSA DA SILVA (alternate to Professor Yunes, Brazil) expressed his support for the draft resolution. As the report rightly pointed out, socioeconomic and environmental changes over recent decades had created conditions favouring the quick spread of dengue fever, and the threat of a major pandemic of dengue haemorrhagic fever with serious social impacts, including the collapse of health care systems, was real. Traditional tools to prevent and control vector-borne diseases were of limited effectiveness against dengue; the best results could be achieved with sustainable surveillance, prevention and control programmes, active community participation and intersectoral partnerships.

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Dr AGGARWAL (alternate to Mr Chowdhury, India) commended the preparation of a report on dengue prevention and control at a time when over 50 million cases were estimated to occur each year. A multi-pronged strategy, including proper clinical management, control of the main mosquito vector, Aedes aegypti, and attention to larval habitats, had kept the disease under control since its outbreak in India more than five years previously and should help in the prevention of yellow fever in tropical countries, since the conditions for the occurrence of yellow fever and dengue fever were nearly the same. He was in favour of the draft resolution. Dr DOTRES MARTiNEZ (Cuba) welcomed the fact that the issue of dengue fever and dengue haemorrhagic fever had been placed on the Board's agenda, as they had turned into a major public health problem in many parts of the world. The reality was that economic crises and social problems were hampering sustainable vector prevention and control at the domestic, community and institutional level, and the situation was further compounded by weak intersectoral and intrasectoral collaboration on programme implementation, low standards of hygiene and poor waste management. As an appropriate course of action for the future, Member States should undertake to ensure the sustainability of vector prevention and control programmes; step up resource mobilization for vector control and research into an effective vaccine; promote active intersectoral alliances; and increase social and community participation in vector control efforts. WHO should help to devise and build up a global surveillance system to which all Member States would have access, and set up a vector control fund to assist Member States in greatest need, thus ensuring effective vector control at the regional and/or subregionallevel. He, too, supported the draft resolution. Dr DI GENNARO (Italy) observed that dengue fever and dengue haemorrhagic fever remained very difficult to control, despite high levels of expenditure by governments in many endemic countries. WHO's efforts towards improving prevention and control, particularly its review of the global strategy and available tools were greatly appreciated. Urbanization, growing population movements and the proliferation of mosquito vector breeding sites were well-known causes of the deterioration in the public health situation; indeed, Aedes albopictus had been an uninvited guest in Italy since 1990, having been brought over from the United States of America via the used tyre trade. The difficulties of vector control could be overcome by effective community participation, and an intensified input by WHO into that strategy would be welcome. With the prospect of a major threat from dengue infection action was essential, and she wholeheartedly supported the draft resolution. Dr BOSHELL (Colombia), welcoming the sound and comprehensive report, noted, however, that due consideration had not been given to the importance of differential laboratory diagnosis. He asked that the omission be rectified in the draft resolution contained in document EB 109/16, possibly as subparagraph 1(5). Furthermore, in view of the pressing need to discover more about the pathogen, he suggested adding research to the areas of increased commitment by Member States in subparagraph I (I). A passage in paragraph 4 of the report, which read "... with the most rapid acceleration taking place in developing countries in the tropics and subtropics where dengue viruses are spread by mosquitoes", implied that in other parts of the world dengue viruses were spread by other means, which was not the case. Dr ROMUALDEZ (Philippines) said that outbreaks of dengue fever and dengue haemorrhagic fever were annual events in countries like his own. Although use of WHO guidelines had minimized the number of fatalities, the search for new methods of dengue prevention and control should continue because of the persistent and recurrent nature of the problem. He supported Or Boshell's suggestion to give more attention to early diagnosis and verification of cases. Dr AL-MAZROU (Saudi Arabia) said that, although dengue fever was not endemic in his country, its emergence some years previously was the natural outcome of large-scale international

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trade in used car tyres and their presence in an environment favourable to the evolution of the vector mosquito. Emphasis should be placed on preventive measures to control transmission. Mr KET SEIN (Myanmar) said that an outbreak of dengue fever in his country in 200I had been rapidly brought under control. The main factors in that success had been a good surveillance system and improved capacity for a rapid response, dissemination of clinical guidelines for diagnosis and treatment at all levels of health care, greater public awareness of when to seek medical assistance and advice, and intensified vector control by simple measures involving active community participation. The WHO guidelines and national and regional workshops had also proved helpful. He supported the draft resolution. Dr HEYMANN (Executive Director), responding to comments and suggestions, said that in view of the worldwide increase in the incidence of dengue, and the simultaneous decrease in vector control because of the difficulty of sustaining it, the report had emphasized three main areas of work: increased social mobilization and guidance to communities on sustainable multisectoral vector control; broadening the mandate of the WHO Special Programme for Research and Training in Tropical Diseases to include research on dengue, especially on vaccines, diagnostic tests and the pathogenesis of dengue, which was so important in vaccine development; and strengthening global monitoring and surveillance, including DengueNet, a monitoring and response system for dengue and dengue haemorrhagic fever on the Internet. DengueNet also permitted the exchange of standardized information so important to research. It was difficult to mobilize resources for diseases such as dengue, and countries that were affected should increase their own resource allocations to vector control. At the same time, WHO would impress upon bilateral partners the importance of the disease. The ultimate solution was a vaccine. WHO had recently cosponsored a meeting with the International Vaccine Institute to review all dengue vaccines that were being developed. WHO would continue to emphasize research, so that vaccines could be tested in clinical settings, leading eventually to development of the necessary vaccine. The CHAIRMAN asked the Board whether it was prepared to adopt the draft resolution contained in document EB I 09/I6, with the amendments proposed. The resolution, as amended, was adopted. 1 Deliberate use of biological and chemical agents to cause harm: Item 3.13 of the Agenda (Document EB I 09/26) The CHAIRMAN drew attention to the report contained in document EB 109/26 and to a draft resolution proposed by Switzerland and the United Kingdom of Great Britain and Northern Ireland, which read: The Executive Board, Having considered the report entitled "The deliberate use of biological and chemical agents to cause harm: public health response"; 2 Recognizing the need to counter the increasing public health concerns of threats against civilian populations; Acknowledging that the possible deliberate use of biological and chemical agents and radio-nuclear attacks can cause illness and death in targeted populations;

Resolution EBI09.R4. Document EB109/26.

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Aware that the local release of biological or chemical agents could have global public health implications and that working together is of global importance, as recognized at a ministerial meeting on health security and bioterrorism (Ottawa, Canada, 7 November 2001), RECOMMENDS to the Fifty-fifth World Health Assembly the adoption ofthe following resolution: The Fifty-fifth World Health Assembly, Having reviewed the report on the deliberate use of biological and chemical agents to cause harm: public health response; Seriously concerned about threats against civilian populations, including the possible deliberate use of biological and chemical agents to cause illness and death in targeted populations; Noting that such agents can be disseminated through a range of mechanisms, including the food- and water-supply chains, thereby threatening the integrity of public health systems; Acknowledging that the local release of biological or chemical agents designed to cause harm could have serious global public health implications and jeopardize the public health achievements of the past decades; Recalling resolution WHA54.14 on global health security: epidemic alert and response, which stresses the need for all Member States to work together, with WHO and with other technical partners, in addressing health emergencies of international concern, and resolution WHA45.32 on the International Programme on Chemical Safety, which emphasized the need to establish or strengthen national and local capacities to respond to chemical incidents; Recognizing that one of the most effective methods of preparing for deliberately caused disease is to strengthen public health surveillance and response activities for naturally or accidentally occurring diseases, 1. URGES Member States: (1) to ensure they have in place national disease-surveillance plans which are complementary to regional and global disease-surveillance mechanisms, and to collaborate in the rapid verification and sharing of surveillance data of international concern; (2) to collaborate and provide mutual support in order to enhance national capacity in field epidemiology, laboratory diagnoses, toxicology and case management; (3) to treat a local deliberate use of biological and chemical agents to cause harm as a global public health threat, and to respond to such a threat in other countries by sharing expertise, supplies and resources in order to rapidly contain the event and mitigate its effects; REQUESTS the Director-General: (1) to continue, in consultation with relevant intergovernmental agencies and other international organizations, to strengthen global surveillance of infectious diseases, water quality, and food safety, and related activities such as revision of the International Health Regulations and development of WHO's food safety strategy, by coordinating information gathering on potential health risks and disease outbreaks, data verification, analysis and dissemination, by providing support to laboratory networks, and by making a strong contribution to any international response, as required;

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(2) to provide tools and support for Member States, particularly developing countries, in strengthening their national health systems, notably with regard to emergency preparedness and response plans, including disease surveillance and toxicology, risk communication, and psychosocial consequences of emergencies; (3) to continue to issue international guidance and technical information on recommended public health measures to deal with the deliberate use of biological and chemical agents to cause harm, and to make this information available on WHO's web site; (4) to examine the possible development of new tools, including modelling of possible scenarios of deliberate use, and collective mechanisms to prevent, contain or mitigate the deliberate use of biological and chemical agents to cause harm. Dr DI GENNARO (Italy), speaking on behalf of the Member States of the European Union, with reference to agenda items 3.13 and 3.14 (Smallpox eradication: destruction of variola virus stocks) said that the Union reaffirmed its unequivocal condemnation of all acts and practices of terrorism as criminal and unjustifiable, regardless of their motivation, in all their forms and manifestations wherever and by whomever committed. It was currently reviewing its plans against the health-related threats associated with terrorist attacks, and the European Commission had brought together the various services and networks responsible for civil and health protection and for research in the area. Following a call by heads of state and government at the informal European Council in Ghent, Belgium, in October 2001, the Commission had issued a communication on 28 November 2001 (COM(2001) 707 final) on the state of preventive alert against possible emergencies, outlining the steps it was taking to strengthen cooperation in preparedness and response in the European Union. The communication had put forward four objectives which were based on guidelines agreed by the health ministers of the Member States of the European Union: to set up a mechanism for information exchange, consultation and coordination for the handling of health-related issues due to attacks in which biological or chemical agents might have or had been used; to create capability for timely detection and identification of biological and chemical agents that might be used in attacks and for rapid, reliable identification and diagnosis of relevant cases; to build up stocks of antidotes, a database of health services and a facility in which medicine and health care would be available in the case of a suspected or actual attack; and to draw up rules and disseminate guidance on responding to attacks and coordinating the European Union's response with those of third countries and international organizations. Those objectives would be accomplished in a programme drawn up by the Member States and the Commission which would build on and improve existing arrangements, measures and legislation. The European Union therefore supported the content of both reports, including the recommendation to retain variola stocks for research and continuation of systematic inspection of storage and research facilities. Speaking on behalf of her country, she welcomed the proposed emphasis in document EB 109/26 on surveillance of outbreaks, communication between responsible agencies and actors, communication of risks to professionals and the public, and risk management and contingency plans for enhanced response capacity. As requested in resolution WHA54.14, Global health security: epidemic alert and response, WHO should continue to facilitate a forum for discussion and joint action in the case of events that might constitute a public health risk. The publication Public health response to biological and chemical weapons 1 was of great assistance to countries in strengthening national preparedness and response programmes. As the health sector would be in the front line of the response in the event of any intentional dissemination of biological or chemical weapons, the lack of such programmes could have disastrous public health consequences. Among the principal challenges to be faced in responding to intentionally caused illness were the potentially large scale of the event in terms of the number of deaths, the psychological effects

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and the effects of panic, and the need for interaction among various sectors that had little or no experience of collaboration with the health sector. WHO should therefore strengthen its capacity in relation to international preparedness and response, particularly at the regional level, to enable it to address the challenge posed by the deliberate release of biological, chemical or radioactive agents, in close coordination with other sectors and organizations. It also had an important role to play in developing guidelines and standards and providing technical assistance to Member States with national preparedness and response plans. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) endorsed the statement made on behalf of the Member States of the European Union. Although many countries had developed contingency plans over the years to protect the health of their populations against the possibility of deliberate release of biological or chemical agents or radioactive materials, governments and public health services had, over the past five months, been forced to review their plans and intensify their range of health protection measures. Furthermore, it had become evident that an international dimension was needed. Three issues not necessarily uppermost in past planning considerations had now come to the fore. First, public health services might be the first to detect a threat, and specialist skills might be required for recognizing and investigating a covert source. Secondly, deliberate releases might occur in several different geographical locations at the same time; and thirdly, the diversity of potential agents and the ease of their use might be much greater than previously realized. With those issues in mind, a comprehensive programme of action should encompass strong contingency and emergency response plans to reduce vulnerability to deliberate releases, and regular review and updating of those plans; good coordination with other contingency and emergency plans at the international, national, regional and local levels; good clinical awareness and professional education with regard to symptoms and signs that might indicate a deliberate release; establishment of the appropriate stores and supplies of drugs, vaccines and equipment to respond to an emergency; good scenario planning and research; good surveillance, which was at the heart of health protection programmes, and forward thinking and innovation in identifying and protecting vulnerable populations in the future. The importance of international collaboration had been recognized, and bilateral, multilateral and global plans had been advanced. The issue had been discussed in Ottawa, Canada, at a meeting of ministers and secretaries of health from several countries and the Commissioner of Health and Consumer Protection of the European Union and in many other forums over the past three months. WHO, as the world's leading public health agency, had a key role in facilitating collaboration between developed and developing countries in meeting the public health challenges, by supporting Member States' efforts to strengthen their own infrastructures and strengthen global surveillance of infectious diseases, water quality and food safety. Following informal discussions, the sponsors proposed a number of amendments to the draft resolution. The fourth preambular paragraph should read: " ... working together is of global importance, noting the ministerial initiative on health security and bioterrorism as discussed in Ottawa, Canada, on 7 November 2001;". The words "and also a nuclear attack" should be inserted into the second preambular paragraph after the words "chemical agents". In subparagraph 1(1), the word "verification" should be replaced by "analysis", and subparagraph 1(3) should begin, "to treat any deliberate use including local, of biological and chemical agents and radionuclear attack to cause harm also as a global public health threat ... ". Subparagraph 2(4) should be amended to read: "(4) to examine the possible development of new tools within the mandate of WHO, including modelling of possible scenarios of deliberate use, and collective mechanisms concerning the global public health response to prevent, contain or mitigate the effects of deliberate use of biological and chemical or radiological agents to cause harm." Although further refinements were always possible, given that the aim was to promote measures to protect the health of populations around the world from serious emergencies, it was to be hoped that the draft resolution, as amended, would be fully supported so that the new protective measures could be put in place as soon as possible.

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Dr MBAIONG (Chad) said that the deliberate use of biological and chemical agents to cause harm had such serious public health consequences that it might be considered as a crime against humanity. Chad consequently endorsed the basic activity of WHO to strengthen disease alert and response systems at all levels, and supported the draft resolution. Dr SHINOZAKI (Japan) fully endorsed the contents of the report. Strengthening preparedness and responsiveness to the deliberate use of biological and chemical agents was an important public health activity in each Member State, and collaboration between them was critical. WHO should support such efforts and facilitate assessments of the risks of the most likely deliberate uses of biological and chemical weapons and the sharing of such information among Member States. Dr SADRIZADEH (Islamic Republic of Iran) said that prevention, preparedness and response to natural and accidental releases of biological and chemical agents required close intersectoral coordination and cooperation at both national and international levels, and the need to strengthen such efforts in responding to epidemic diseases could not be overemphasized. Rapid response to outbreaks posed a challenge for Member States and WHO, and the establishment of a global outbreak and response network had been crucial in strengthening countries' capacities. WHO's contributions in providing humanitarian assistance in disease outbreaks were extremely valuable; however, its involvement in verification and inspection of biological weapons, which had political connotations, could detract from its humanitarian mandate and jeopardize the mutual trust between the Organization and Member States and might reduce the number of requests for assistance and submission of voluntary reports of outbreaks. He considered that the proposed amendments to the draft resolution should be discussed in greater detail before a final decision was taken. Professor GRABAUSKAS (Lithuania) said that the chain of events in 2001 had clearly demonstrated the fragility of the world and had been a constant reminder of the interdependence of the world's populations. Lithuania welcomed the prompt reaction of WHO to the requests of a number of Member States, and of the Executive Board at its retreat in Florence, to place the issue of biological terrorism high on the agenda. Increased states of alert, preparedness and response at the national and international level, to the natural, accidental or deliberate release of biological, chemical or radiological agents were the only realistic way of tackling the problems that might arise. In that connection, Lithuania endorsed the views of the European Union and United Kingdom and supported the draft resolution. Dr THIERS (Belgium), adding to the statement made on behalf of the European Union, said that the rapid reaction of WHO and the information it had provided had met all his Government's expectations. In Belgium, heightened awareness of the threat of bioterrorism had led to more than 1000 samples suspected of containing anthrax organisms being received, highlighting all too clearly the inadequacy of the country's plans for rapid reaction, despite their constant enhancement since the accident at Chernobyl. In the wake of the crisis, as was all too often the case, the necessary budgets had been made available for a permanent system of surveillance, as outbreaks would always occur and, whether they were natural or deliberate, the method of identification would be the same. Belgium consequently supported the draft resolution, particularly as its recommendations to Member States would be of great help in setting up the necessary plans for rapid, effective action. Mr DUQUE ESTRADA MEYER (alternate to Professor Yunes, Brazil) said that the possibility of deliberate use of biological and chemical agents to harm populations was a matter of concern to the Brazilian Government, as demonstrated by its active participation in negotiation of a protocol to the Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on their Destruction of 1972 and in the Fifth Review Conference. It consequently welcomed the information provided in paragraphs 5 and 6 of the report.

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It was particularly important that the concept of verification in respect of WHO activities should

be properly defined. For WHO, verification should relate to the public health consequences of the release of biological, chemical or radiological agents and not to the nature of such an incident. Turning to paragraph 11 of the report, he sought clarification on the role of the United Nations, the Secretary-General, the Security Council, WHO and other specialized agencies. Dr LOPEZ (Venezuela) welcomed the timely discussion of the health response to the deliberate use of biological and chemical agents. The psychological impact of such incidents extended far beyond their location until it was eventually felt worldwide. From the epidemiological point of view, therefore, it could be regarded as a world panic attack, owing to the immediate reporting by the world's media of all suspect incidents. Two weeks after the first report of possible anthrax contamination, 600 similar reports had been received from various locations throughout the country, and the authorities had been faced with the task of responding in fields in which they had no experience, implementing specific measures to control both the panic and the biological problem and coordinating work between sectors that had not previously worked together. WHO should therefore continue its efforts in that area, placing special emphasis on emergency response measures, including coordination with bodies such as civil defence, the fire and rescue services and other state agencies, and define the areas of competence in each case and the emergency protection measures for groups at risk. WHO and PAHO were to be commended for their assistance at the time. Venezuela supported the draft resolution. Professor ABOUO-N'DORl (Cote d'Ivoire) said that, along with the rest of the world, Africa was under threat from the deliberate use of biological and chemical agents, as witnessed by the anthrax scare in Kenya. He supported the draft resolution. Cote d'Ivoire had already set up a team to collect and analyse information on suspected agents and to organize the necessary responses to protect the population. It had been decided that the current headquarters of the Onchocerciasis Control Programme in West Africa would house a disease monitoring centre, to serve not only West Africa but East and Central Africa too. Dr BERNARD (United States of America)/ speaking at the invitation of the CHAIRMAN, said that the events of 11 September 2001 had shown the entire international community that private persons and their state sponsors were willing to cause mass civilian casualties in order to advance their political agendas. The anthrax attacks against American civilians the following month had broken a second barrier, namely the use of deadly organisms as a weapon of war. Many countries represented on the Board had long suffered deliberate attacks on their civilian populations, and many had lost citizens in the attacks on the World Trade Center. Whether terrorism was of domestic or foreign origin, its impact was the same, and it had to be stopped. WHO had long maintained expertise to monitor and respond to emerging and re-emerging infectious diseases and its committed approach was to be commended. The newly revised publication Public health response to biological and chemical weaponi was further evidence of the useful work of WHO in that area. The United States unreservedly supported the draft resolution. The global public health threat of intentional uses of biological and chemical agents was real. The leadership of the Board and WHO would help provide increased security for all. Dr FEDOROV (Russian Federation), 1 speaking at the invitation of the CHAIRMAN, said that the matter under discussion was very important for the health of the international community, and he

1 2

Participating by virtue ofRule 3 of the Rules ofProcedure of the Executive Board. WHO, Public health response to biological and chemical weapons, Geneva, WHO, 2nd edition, in press.

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gave an assurance that the Russian Federation would always support forces to combat terrorism. He endorsed the draft resolution, although he considered that some of its terms called for closer study. Dr STEINEGGER (International Occupational Hygiene Association), speaking at the invitation of the CHAIRMAN, said that his organization represented over 20 000 occupational and industrial hygienists throughout the world. Protecting workers' health against biological and chemical agents was a prime aim, and, in working to achieve that, the Association had gained essential knowledge not only in addressing the deliberate misuse of such agents, but also in recognizing and evaluating associated hazards. Preventive action included control at source, control in the transmission path, control at user level and other actions of a more general nature, including storage and labelling. His organization would continue to collaborate with WHO on planning, implementing and maintaining preventive measures relating to the use of biological and chemical agents. Dr HEYMANN (Executive Director) thanked the Board for its support of the report and the draft resolution. A number of important Health Assembly resolutions provided a basis for addressing infectious diseases and had enabled WHO to focus on four main activities: revision of the International Health Regulations; establishing the Global Outbreak Alert and Response Network; creating a new centre devoted to strengthening laboratory and epidemiological capacity in developing countries; and updating the 1970 WHO guidelines, Public health response to biological and chemical weapons. As a result of cooperation with experts in updating the publication, WHO had come to appreciate that great care was needed to standardize terminology. "Verification" and "surveillance" were two cases in point. Another lesson learned had been the importance of WHO's neutrality in the detection of infectious diseases. However, the most important means of defence against biological or chemical agents was good public health systems. WHO tried to maintain its neutrality as part of the United Nations system and understood the difficulties experienced at national level when the public health community had to learn to collaborate with security and criminal authorities, a collaboration WHO was keen to encourage. He welcomed the draft resolution, both as a means of offering guidance in an international public health emergency and as a means of forging partnerships to strengthen public health, especially in developing countries. The CHAIRMAN enquired whether the Board was prepared to adopt the draft resolution, as amended. The resolution, as amended, was adopted. 1 Smallpox eradication: destruction of variola virus stocks: Item 3.14 of the Agenda (Document EB109/17) Dr AL KHARABSEH (Jordan) said that he fully understood the need to extend retention of existing stocks of smallpox virus beyond 2002 in order that the necessary research could be done. He expressed his thanks to the institutions and researchers who were carrying out such work. He agreed with the statement in paragraph 20 of the report that all approved research should remain outcomefocused and time-limited. At the end of the agreed time, which should be provisional, the WHO Advisory Committee on Variola Virus Research should submit a report to the Board describing the results of research and, if necessary, recommending an extension. That approach would have the advantage of stimulating rapid research and maintaining WHO's involvement. He expressed concern about the possibility that variola virus stocks might be held by countries other than the two that were officially recognized and requested WHO to call upon all countries to reaffirm their declarations that they had no virus stocks.

Resolution EBI09.R5.

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Dr OM (Republic of Korea) thanked WHO for its concern in relation to viruses with potential to cause global harm. Total destruction of virus stocks, at a time when the virus might be used as a deadly weapon of war, would be extremely unwise, and he agreed with the recommendation to propose a new date for their destruction when research outcomes made it possible to reach a consensus on such a date. He fully supported the recommendations contained in the report. Professor ABOUO-N'DORI (Cote d'lvoire), while acknowledging the reasons for delaying destruction of virus stocks, nevertheless expressed concern that, as long as such stocks existed, they constituted a potential terrorist risk. He agreed fully with the recommendation for regular, thorough inspections (paragraph 21 of the report). Mr ESPINOZA FARFAN (alternate to Dr Lemus Bojorquez, Guatemala) said that, after the events of 11 September 2001, systematic inspection of virus storage facilities was essential, as was continuation of research programmes, the results of which would allow consensus on a date for destruction of the virus stocks. The best protection against smallpox would be an improved vaccine for the protection of all sectors of the population. Dr SADRIZADEH (Islamic Republic of Iran) agreed that, while further research was necessary, it should be completed as soon as possible. He endorsed the suggestion that a report be submitted to the governing bodies within two to three years. Dr SHINOZAKI (Japan), while recalling that resolution WHA52.1 0 called for destruction of the remaining variola virus stocks, nevertheless recognized that the potential use of biological agents posed a real threat and agreed that research on smallpox virus should be continued. The Advisory Committee should continue to monitor such research and to assess periodically the need to retain the stocks, while maintaining its neutrality and independence. He asked that the results of the research be made available to Member States. Dr DI GENNARO (Italy), speaking on behalf of the European Union, endorsed the conclusions and recommendations of the Advisory Committee and the recommendations of the Director-General listed in the report. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) said that, although the Health Assembly had set 2002 as the date for destruction of remaining stocks of variola virus, the world situation had changed. Research on the virus had produced some interesting results, and an extension of the proposed date would allow those investigations to be completed, to the benefit of mankind. Nevertheless, he considered it important that a new date be set at the next Health Assembly. Dr KARAM (Lebanon) recalled that, although smallpox had been eradicated, the virus still existed, leading to fear that it might be used to cause harm and not for research for tools to combat it more effectively. He supported the recommendations and the proposed research programmes, but the question of time limits remained. There was a risk that time limits set one day might, as a result of world events, be rendered inapplicable the next.

The meeting rose at 12:30.

EIGHTH MEETING Thursday, 17 January 2002, at 14:10 Chairman: Mrs M. ABEL (Vanuatu)

HEALTH STRATEGY MATTERS: Item 3 ofthe Agenda (continued)

Smallpox eradication: destruction of variola virus stocks: Item 3.14 of the Agenda (Document EB 109/17) (continued) Dr BERNARD (United States of America),' speaking at the invitation of the CHAIRMAN, said that the United States viewed the potential risk of smallpox as a critical national and international security issue. Such an event would have a devastating impact worldwide, particularly given the considerable efforts made over the years to eradicate the disease. Recent events confirmed that the intentional release of variola virus was no longer a remote possibility. A case of smallpox anywhere in the world would have global consequences. The United States intended to work bilaterally and through WHO to support nations and regional groups in building up international stockpiles of vaccine against smallpox. Given the speed with which smallpox could spread and become pandemic, his country also stood ready to provide support to other countries in dealing with such disease outbreaks, resulting either from the re-emergence of the natural disease or the intentional use of the virus as a biological weapon. In the United States great strides were being made in the development of tools to combat the disease in the event of its recurrence. Such research was open to international scientific review and deemed essential for the world's population. It was only through the development and deployment of antiviral drugs and modem vaccines that nations could be protected against the risk of undeclared virus stocks being released by terrorists. The need for new drugs and vaccines was particularly acute in areas with large immunosuppressed or immunocompromised populations, for instance people with HIV infection or AIDS, for whom the current vaccinia vaccine would be potentially lethal. He supported the recommendations contained in the report, for the WHO Advisory Committee on Variola Virus Research to continue its research programme in an open and transparent manner, with inspections, and to submit periodic progress reports to the Executive Board and Health Assembly. Dr FEDOROV (Russian Federation), 1 speaking at the invitation of the CHAIRMAN, recalled that the programme for the study of the smallpox virus in 1999-2001 had been examined at the Fifty-fourth World Health Assembly in May 2001, and at the third meeting of the WHO Advisory Committee on Variola Virus Research, at which scientists from the Russian Federation and the United States of America had reported on the results of the WHO-sponsored research programme on the variola virus, and demonstrated major progress in all areas of research recommended by the Advisory Committee. There was every reason to suppose that the task of creating modem therapeutic, prophylactic and diagnostic preparations could be carried out through international efforts. It was nevertheless clear that the time limits set at the Fifty-second World Health Assembly for destruction of variola virus stocks in the Russian Federation and the United States would prevent the completion of much valuable research using live virus. Furthermore, the programme for the study of the variola virus had taken no account of the possible creation of genetically altered variants of the

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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virus in illegal laboratories, which would require fresh efforts to prevent further threats to national and global health and security. He consequently concurred with the position expressed by the United States and considered that the Board and Health Assembly should change their approach to the destruction of officially existing stocks of variola virus and, rather than set time limits, should take into consideration the demands of global health and security, the requisite level of knowledge and the provision of essential resources. The possible use of smallpox as a terrorist weapon called for increased international cooperation under the auspices of WHO. The position of the Russian Federation regarding the need to extend research beyond 2002 fully accorded with the recommendations of the third meeting of the Advisory Committee and with the position of a number of countries, including the United States. He therefore requested the Board to take account of his country's position when preparing its proposals for the Fifty-fifth World Health Assembly. Mr LIU Peilong (China) 1 said that, as the most populous country in the world, China was greatly concerned about the destruction of the variola virus. Since the global eradication of smallpox had been declared and vaccination against smallpox had ceased, the susceptible population in China had increased substantially. His country therefore attached great importance to the security of all variola stocks and believed that their early destruction was the only way to guarantee total eradication of the disease and to protect human life, especially as the genetic sequence of the virus had been clearly established and new technology allowed for vaccine to be manufactured artificially. Although research into the virus was important, it carried certain risks such as potential release of the virus from research laboratories as had already happened. If that happened mankind would face a biological catastrophe with children and adolescents being particularly vulnerable. The Chinese Government had been opposed from the very outset to postponing the destruction of the variola virus and wanted a date for the destruction of stocks to be finalized. Any pretext for further delays would be unacceptable. Dr HEYMANN (Executive Director) said that it had emerged from the discussion that the Board wished the Advisory Committee on Variola Virus Research to continue its work as an independent and neutral body. However, as several Board members had pointed out, it was also necessary to continue to monitor research into the virus and to submit a progress report to the Board within the next two or three years on the development and registration of antiviral drugs as well as on improved vaccines and diagnostic tests. Findings and practical knowledge arising from the research would be made available to all Member States. WHO would continue to monitor rumours of cases of smallpox through the global alert and response network. Since January 2000 there had been 11 such rumours: six had been cases of human monkeypox, others had been varicella (chickenpox); there had also been one instance of vaccinia related to contact with the vaccine against vaccinia virus. In response to the concern raised by Professor Abouo-N'Dori, he said that WHO would continue its regular biosafety examinations of laboratories and would update the WHO web site with information on smallpox research and the public health response to smallpox. A series of digitalized films on smallpox eradication were available to Member States upon request. Efforts would be pursued on the global inventory of vaccines stocks - so far 80 Member States had replied to requests for information regarding national stocks. Likewise an inventory of vaccine and bifurcated needle manufacturers was being compiled. Due account would be taken of other matters raised by the Board, such as necessary support to Member States in the event of the intentional use of the smallpox virus. Through its reference laboratories WHO would ensure the availability of diagnostic capacity for any Member State requiring confirmation of the occurrence of the disease.

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The CHAIRMAN said she took it that the Board wished to note the report and to endorse the Director-General's recommendations contained therein, which would be forwarded to the Fifty-fifth World Health Assembly. It was so agreed.

Global health sector strategy for HIV/AIDS: Item 3.15 of the Agenda (Document EB109136) The CHAIRMAN drew attention to a draft resolution proposed by Brazil and Sweden on the contribution of WHO to the follow-up of the United Nations General Assembly special session on HIVIAIDS, which read: The Executive Board, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Deeply concerned that the global HIVI AIDS pandemic, through its devastating scale and impact, constitutes a global emergency and one of the most formidable challenges both to human life and dignity and to the effective enjoyment of human rights, and undermines social and economic development throughout the world which affects all levels of society: national, community, family and individual; Noting with profound concern that HIV continues to spread unabated around the world and that in many countries, in particular in Eastern Europe and Asia, infection rates have risen dramatically during 200 I, so that by the end of 200 I, 40 million people worldwide were living with HIV/AIDS, 90% of them in developing countries, and 75% in Africa; Recalling and reaffirming the previous commitments on HIVI AIDS made through the Declaration of Commitment on HIVI AIDS adopted at the special session of the United Nations General Assembly on HIV/AIDS (27 June 2001), the United Nations Millennium Declaration (8 September 2000), and the United Nations Secretary-General's 1 road map towards its implementation as well as resolution WHA54.1 0 on scaling up the response to HIVI AIDS; Acknowledging WHO's special role within the United Nations system to combat and mitigate the effects of HIVIAIDS, and its responsibility in the follow-up of the Declaration of Commitment on HIVIAIDS and as a cosponsor ofUNAIDS; Recognizing the essential role of the health sector in the response to HIVI AIDS and the need to strengthen health systems and make them more effective so that countries and communities may contribute maximally to the fulfilment of the global targets set out in the Declaration of Commitment on HIVI AIDS; Recognizing that the full realization of human rights and fundamental freedoms for all is an essential element in a global response to the HIVI AIDS pandemic that includes prevention, care, support and treatment, reducing vulnerability to HIV I AIDS, and preventing stigmatization and related discrimination against people living with, or at risk of, HIVIAIDS;

General Assembly document A/56/326.

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Commending the efforts of the Director-General to enhance and strengthen WHO's response to the HIV I AIDS pandemic and further to develop and extend the role of WHO as a key cosponsor ofUNAIDS, 1. URGES Member States: ( 1) to act upon the political commitment expressed at the special session on HIV I AIDS, by operationalizing the Declaration of Commitment on HIV I AIDS and by allocating significantly increased resources to the health sector so that it may play an effective role in prevention, care, support and treatment ofHIVIAIDS; (2) to foster mechanisms to increase global resources for the response to HIVIAIDS; (3) to establish and strengthen monitoring and evaluation systems, including epidemiological and behavioural surveillance and assessment of the response of health systems to the epidemics of HIVI AIDS and sexually transmitted infections, to enhance programming of interventions by learning from success and failure and to optimize the allocation of resources; (4) to establish or expand counselling services and voluntary, confidential HIVtesting in order to encourage health-seeking behaviour and to act as an entry point for prevention and care; (5) to increase access to care, including by making prophylactic and therapeutic drugs affordable and assuring that they are safely and effectively used; (6) to build and strengthen partnerships between health-care providers, both public and private, and communities, including nongovemmental organizations, in order to mobilize and empower communities in the response to HIVIAIDS; (7) to scale up significantly programmes to increase coverage of interventions intended to reduce the spread of HIV and increase the quality and length of life of those living with HIV IAIDS, on the basis of scientific evidence and lessons learned, REQUESTS the Director-General: ( 1) to continue to play a key role in providing technical leadership, direction and support to the health system's response to HIV, within the United Nations systemwide response, as a cosponsor ofUNAIDS; (2) to provide support to countries in order to maximize opportunities for the delivery of interventions for prevention, care, support and treatment of HIVI AIDS, including reproductive health and family planning services; (3) to provide support to countries in order to strengthen the health sector so that it may play a more effective and catalytic role in relation to other relevant sectors with a view to achieving a well-coordinated, multisectoral and sustainable response to the epidemic; (4) within the framework of strengthening the health system's response to HIVI AIDS, to provide support to countries, as part of their national strategies, in the areas of prevention, care, support and treatment in order to meet the commitments and goals agreed at the special session on AIDS, in particular as they: (i) take effective measures, within a supportive environment, to ensure that people everywhere, particularly young people, have access to the information and services necessary to enable them to protect themselves from HIV; (ii) intensify and expand action to achieve the goal of the special session of lowering the proportion of infants infected with HIV through reduction of HIV transmission in women of reproductive age, avoidance of unwanted

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pregnancies in HIV -infected women, and the provision of interventions that reduce transmission of HIV from mother to child; (iii) develop national strategies and actions on care and support for people living with HIVI AIDS, including prevention and treatment of opportunistic infections and provision of palliative care and psychosocial support; (5) to continue broad-based consultations with countries and partners on the global health-sector strategy, which will comprise tools and approaches for scaling up effective, feasible and sustainable interventions; (6) to provide support for research on new technologies and approaches to prevent and treat HIVI AIDS, such as vaccines, microbicides, standard and simplified regimens for antiretroviral treatment and monitoring, and operational research on service delivery; (7) to submit a report on WHO's work on HIVIAIDS, including the global health-sector strategy to the Executive Board at its Ill th session and the Fifty-sixth World Health Assembly. Dr TORMEN (Executive Director) said that document EB109136 was not a strategy paper as such, but rather a progress report on regional consultations held and preparations under way to finalize the global health-sector strategy for HIVI AIDS which was to be submitted to the Executive Board at its lllth session in January 2003. In the countries most affected by the pandemic, health systems were not functioning well, and action was needed to provide them with the necessary human and financial resources and simple evidence-based interventions that would make a real impact, with a view to meeting the targets of the Declaration of Commitment on HIVIAIDS adopted by the United Nations General Assembly at its special session in June 2001. Although some small-scale activities were being carried out in those countries, many were not sustainable, nor was their impact always clear. The challenge was how to support health ministries in organizing sound but simple health strategies tailored to national needs. Through careful planning in key areas and drawing on the experience of the past decade it should be possible to generate momentum for change in the way both the health sector and society responded to HIVIAIDS. Consultations already held in the African, Eastern Mediterranean and European regions of WHO had been successful; consultations in the other regions were also planned. Several elements of the strategy were already emerging. Clear, measurable goals within deadlines must be identified for the health sector. Those goals should take account of specific regional needs and the United Nations General Assembly Declaration commitments. More effective use must be made of existing services and action on HIVI AIDS needed to be integrated - for instance, reproductive, maternal and child health services could be used as a starting point for the delivery of HIVI AIDS prevention and care. It was also necessary to seize strategic opportunities for change, to train specialized HIVI AIDS staff, to strengthen stewardship, to look into private-sector delivery and to forge useful community partnerships. Innovative evidence-based guidance on how to provide a minimum package of prevention and care interventions at grass-roots level, based on scientific knowledge and lessons learned was called for. Efforts should be focused downstream on the practical implementation of realistic, sustainable, cost-effective and evidence-based projects. No real impact on the pandemic could be made independently without constructive partnerships with relevant nongovernmental organizations and people living with HIVI AIDS. The global health-sector strategy would be elaborated within the framework of the United Nations system's strategic plan for HIVIAIDS drawn up by UNAIDS. Given that progress in devising the global strategy had been slow, Member States were clearly looking to WHO for guidance on minimum interventions that could be swiftly implemented; hence the establishment by the DirectorGeneral of the new HIV I AIDS programme to spearhead a stronger response to the HIVI AIDS challenge.

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Professor YUNES (Brazil) expressed his full support for the establishment of a global health-sector strategy to respond to the epidemics of HIV I AIDS and other sexually transmitted diseases. He described the considerable improvements achieved in Brazil's health system and the contribution of surveillance and good-quality epidemiological data to progress in combating the AIDS epidemic. Data up to June 2001 showed that, in some places, incidence rates were decreasing. Prevention focused on specific subgroups such as injecting drug users had resulted in reduced incidence. Support through intervention programmes for that group had increased by 55% compared to 1999. Overall, whereas 20 000 new cases of HIV infection per year had been reported from 1996 to 1999, the figure had fallen to 15 000 since the year 2000. The epidemic in Brazil was currently characterized mostly by heterosexual transmission (with a male/female ratio of about 1) expanding towards the most socially vulnerable population and in places outside the major urban areas not previously affected. Studies had shown that HIV prevalence had not increased, and that there was increased use of condoms and recourse to programmes of harm reduction. The Government was purchasing 300 million condoms for free distribution in 2002. Brazil was striving to achieve the goal of no mother-to-child transmission of HIV by HIV -positive pregnant women. Its expenditure on medicines was less each year, although the number of patients was increasing. Had Brazil imported all the antiretroviral medicines it provided, the cost would have amounted to US$ 530 million, around twice the actual governmental expenditure on Brazilian production of generics. AIDS mortality had been reduced by 50%, and expenditure on treatment of opportunistic infections brought down by 80%. Brazil's efforts were in line with the global strategy for HIV/AIDS outlined in the report. Ms STAY AS (alternate to Ms Wigzell, Sweden), introducing the draft resolution, said that the strategy was an important response to the epidemic. She fully supported the outcome of the consultations and the suggestions put forward and looked forward to discussing the next draft of the strategy when it was presented the following year. The fight against HIV/AIDS must take place primarily at the country level, with a crucial role for the health sector. The international community had a responsibility to support the countries wishing to intensify the capacity of their health systems for that purpose. The newly-established Global Fund to Fight AIDS, Tuberculosis and Malaria was one way to do so, but health sectors needed to have the capacity to absorb the new resources thus made available. WHO could play an important role in that regard, but it also had a wider responsibility and part in the global response to the pandemic. It was gratifying, therefore, that WHO had begun to strengthen its work in that field, including its role within UNAIDS. Member States, acting on the Declaration of Commitment on HIVIAIDS adopted by the United Nations General Assembly at its special session in June 2001, needed the support of the United Nations system, and it was therefore important for the Board and the Health Assembly to give guidance on WHO's role and contribution. For that reason, Brazil and Sweden had proposed the draft resolution. She drew attention to two amendments to the text of the proposed draft resolution. In paragraph 2(2) the words "all relevant" should be added before "interventions" and the words "including reproductive health and family planning services" deleted. Paragraph 4(ii) should end with the words "infants infected with HIV" and the rest of the phrase should be deleted. Dr SADRIZADEH (Islamic Republic of Iran) said that WHO had made welcome efforts to develop a global health-sector strategy for HIVI AIDS and should give high priority to strengthening the capacity of national health care systems, paying special attention to the development of primary health care services in the countries most severely affected by HIVIAIDS and sexually transmitted infections. In particular, WHO should provide technical support and guidance on best practice for HIV prevention, optimal care for people affected by HIV, as well as appropriate monitoring and evaluation of national control programmes. It should also continue with its efforts to improve access to essential drugs for those who needed them most.

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Dr DI GENNARO (Italy) welcomed the information provided on the global health-sector strategy for HIVI AIDS and the responses given by the Executive Director. She looked forward to information on the restructuring of the Department of HIVI AIDS, which would serve as a focal point for work in that field throughout the Organization. She emphasized the importance of WHO's work with communities, countries, and regions to support and strengthen national health systems, and fully agreed with Ms Stavas on the need to concentrate activities at country level and to strengthen health infrastructures in the campaign against HIVIAIDS. She would support the draft resolution, as amended, proposed by Brazil and Sweden. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) said that the issue was outstandingly important, since there were some 40 million people living with HIVI AIDS in sub-Saharan Africa, the worst affected region, and needed a systematic worldwide health strategy to combat it. The main responses included the need to make available, to people everywhere, the medicines essential to save human life and to avoid mother-to-child transmission of HIV. It was considered more important to prevent disease than to cure it, and protecting and promoting health measures should be intensified. It was likewise important to establish adequate health systems and laboratory services, and to ensure adequate financing and training facilities for that purpose; in that connection, the Global Fund to Fight AIDS, Tuberculosis and Malaria must be made accessible to all countries in need of it, the developing countries in particular, enabling measures to be taken corresponding to the situation in each Member State. A global strategy had been outlined, a number of important resolutions had been adopted, and research was continuing into the most effective means of treatment, including an effective vaccine. He supported the proposed draft resolution, as amended. Professor ZELTNER (Switzerland) also expressed support for the draft resolution, as amended. Noting that blood safety was one of the priority areas defined in the global health-sector strategy, he enquired how that subject would be related to the general strategy to combat HIVI AIDS. Regarding the widespread growing concern about the development of strains of viruses which were resistant to the existing antivirals, he asked whether WHO should take a leading role in monitoring that development. He would appreciate a response in that regard. Dr PlOT (Executive Director, UNAIDS), speaking at the invitation of the CHAIRMAN, said that during 2001, the response to AIDS had intensified to a remarkable degree: the fruit of five years' advocacy for that purpose by UNAIDS and its cosponsors. The special session of the United Nations General Assembly on HIVI AIDS in June 2001 had culminated in a global commitment to meet the goals set by the session, which also reflected those of the United Nations Millennium Declaration. Further commitments had been entered into at regional level in the Caribbean region, and the regions of Africa and South-East Asia. However, the hard work was only just beginning. Twenty years' experience of the HIVI AIDS pandemic had shown that the growth of the epidemic was still outpacing efforts to contain it. An effective response was possible, but it was necessary to scale up the extent of that response. New evidence had emerged over the past year of successful prevention, treatment and care, for instance in Brazil, and of the impact of prevention programmes in Cambodia, parts of India, the United Republic of Tanzania and Zambia. During 2002, there must be a shift from planning to resourcing and implementing the strategic plan, and an emphasis on delivery within the community. A realistic appraisal had been made of the resources needed to support the strategic plan on an adequate scale, and those resources should be forthcoming from national budgets, bilateral donors, the World Bank, regional banks and the Global Fund to Fight AIDS, Tuberculosis and Malaria. He welcomed the increased commitment to helping the health sector to step up its response to HIVI AIDS, and the strengthening of WHO activities in that respect. The role of WHO was a key element of the strategic plan. Ms BENCEVIC (International Federation of Medical Students' Associations), speaking at the invitation of the CHAIRMAN, said that the Federation aimed to be a loyal partner to WHO in the

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global fight against HIV I AIDS. A key objective set by the Health Assembly and the United Nations General Assembly at its special session on HIVI AIDS was to reduce HIV infection among young people aged from 15 to 24. The membership ofthe Federation, young people at the upper end of that age range, were affected by the pandemic. She consequently welcomed the commitment of WHO to tackling HIV I AIDS issues among health personnel. Joint work was under way with WHO to improve education and training on HIV I AIDS for medical students, and to empower medical students, the next generation of health professionals, to become role models in their societies. In August 2001, the Federation had adopted a Plan of Action in which HIVIAIDS was given high priority. It had issued two global statements on HIVI AIDS, calling for the active participation of medical students in national efforts to combat HIV I AIDS, and presenting a set of recommendations for the treatment of the topic in medical education curricula. It had worked with UNESCO to produce a resource kit for young people on HIV I AIDS and human rights, resulting in a series of regional training workshops on the topic in Indonesia, Nepal, Panama, South Africa and Tunisia. She requested the Board to consider the inclusion of a component to address HIVI AIDS prevention and the care and psychosocial support of university students in the global strategy. Or TORMEN (Executive Director) welcomed the statements made in favour of a stronger health-sector response to HIVIAIDS and thanked Professor Yunes for his detailed account: there was clearly room for replicating the kind of progress that had been taking place in Brazil. She was grateful to Ms Stavas for pointing out that the global health-sector strategy would be essential for enabling countries to absorb the resources that would become available through the Global Fund. As Or Sadrizadeh had pointed out, all interventions should be available at the primary health care level. The importance of monitoring and evaluating programmes would also be kept in mind. Responding to Or Di Gennaro, she said that WHO would be glad to share the details of the restructuring of its HIVI AIDS department. She was grateful to all the governments that had seconded leading scientists to work with WHO in strengthening its work. As for the question of blood safety, she assured the Board that it would be part of the global health-sector strategy. Work on blood safety was being scaled up through the work of the Health technology and pharmaceuticals cluster and supply services, and the recent decision to open up its bulk procurement to nongovernmental organizations and to HIVI AIDS organizations. As for monitoring resistance to HIVI AIDS antiviral drugs, work was in progress in the Communicable diseases cluster and with the International AIDS Society to keep track of resistance patterns around the globe and to preserve the effectiveness of the drugs, which were a precious commodity. The CHAIRMAN invited the Board to adopt the draft resolution as amended by Sweden. The resolution, as amended, was adopted. 1 (For resumption of discussion of health strategy matters, see section 4.)

Resolution EB 109.R6.

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OTHER MANAGEMENT MATTERS (continued)

Governing body matters: Item 7.4 of the Agenda (continued) • Review of working methods of the Executive Board (Documents EB 109/24 and EB 109/31) (continued from the fifth meeting, section 2) The CHAIRMAN invited the Chair of the ad hoc open-ended intergovernmental working group, Professor Zeltner, to report on the first meeting of the working group, which had taken place on Wednesday, 16 January. Professor ZELTNER (Switzerland) affirmed that the Board would be kept fully informed, in written and oral form, at each of its sessions, of the progress of the working group. Seventy-two participants had attended the first meeting representing 41 countries. The terms of reference of the working group had been discussed with an exchange of views on how the group should function in future. It was felt that the terms of reference should reflect as closely as possible resolution WHA54.22. It was clear from the initial discussion at the meeting that Member States had had two key objectives. Although discussions on the work of the Board had not yet begun, Member States wanted the Board to be as efficient and effective as possible, and had emphasized that its decisions and procedures must be fully transparent. Further, they wanted to ascertain how all Member States could be enabled to participate in the group's work. For Member States with missions located in Geneva, it was relatively easy to enter into discussion between sessions of the Board and the Health Assembly. However, 45 Member States had no such mission. For them, the new interactive technologies and the WHO web site might serve a useful purpose. None of the information reaching WHO from Member States should be filtered in any way; it should all be made available on the web site just as received. Likewise, the conclusions and recommendations of the group should also appear on the web site. The working group at its next meeting before the end of the current session of the Board would discuss a definitive timetable for its work. He said that he expected that it would submit a substantive report to the Board at its 11 Oth and Ill th sessions, and thanked all those who had supported the process thus far. Dr SALLAM (Egypt) emphasized the need for democratic procedure and noted that nominations for the chair should be made at the meetings of the body in question in the interests of transparency as well as democracy. Proper minutes should be kept of meetings, reflecting the discussions which had taken place. The new working group and its chairman should be given adequate time to establish their own formal procedures in a manner acceptable to all. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) said that the meeting of the working group had been extremely constructive, and thanked Professor Zeltner for chairing it so ably. The report was clear and presented a process for continued work in which all countries could participate. A sound basis had been set for the future work of the working group. He proposed that the present debate be discontinued. Dr BODZONGO (Congo) did not agree with Dr Sallam's remarks. All Member States had been given an opportunity to participate in the working group, which was open-ended. It was not feasible or appropriate to report its discussions in full; only the conclusions reached needed to be brought to the Board. Professor ABOUO-N'DORI (Cote d'lvoire) reminded the Board that the meeting had finished very late the previous evening, so a detailed report would not have been possible in any case. He paid

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tribute to Professor Zeltner for his great diligence in providing the Board with the report of the working group, which had been presented in all languages. Dr SALLAM (Egypt) clarified that he was not looking for a detailed report, but for minutes of some kind, so that reference could be made to the group's deliberations. A more detailed report would help the group to formulate the procedures to govern its future work. Professor ZELTNER (Switzerland) assured Dr Sallam that fuller reports of the group's work would be available in future, and would be supplemented by an oral presentation so that any queries could be cleared up. The CHAIRMAN invited the Board to agree the terms of reference of the working group, which would continue its work after the end of the current session. Summary records, and not merely conclusions, would be produced for future meetings.

It was so decided. 1 The CHAIRMAN invited the Board to consider the draft resolution proposed by Brazil on the working methods of the Executive Board, which read: The Executive Board, Taking account of resolution WHA54.22 that requests the Executive Board to conduct a review of its working methods and those of its subsidiary bodies in order to ensure that they are effective, efficient and transparent, and to improve participation of Member States in its proceedings, including working groups and drafting committees; Stressing that the timely distribution of documents would contribute to a more effective participation by Member States in sessions of the Executive Board; Taking note of resolution WHA51.30 which requests the Director-General to ensure that the governing body documents for forthcoming sessions are dispatched and made available on the Internet in the six official languages not less than 30 days before the date fixed for the opening of the session; Recognizing that end-of-year festivities create difficulties for the Secretariat to make these documents available and for Member States to prepare adequately for sessions of the Executive Board; Recalling that Rule 5 of the Rules of Procedure of the Executive Board establishes that the Executive Board shall hold at least two sessions a year, DECIDES that sessions of the Executive Board shall always be convened at the beginning of February each year, and immediately after the Health Assembly. Mr NOGUEIRA VIANA (alternate to Professor Yunes, Brazil), introducing the draft resolution, said that the suggestion to move the session from January to February represented a modest first step in a gradual process. The timely distribution of documents to give the Board adequate preparation time was an important aspect of efficient work. Mr AITKEN (Senior Policy Adviser) said that one difficulty with the proposal was the requirement for budget proposals to be submitted to the Member States 12 weeks before the opening of the Health Assembly, which met normally in May. Naturally the Director-General might wish to revise her proposals in the light of any comments by the Board, which would take time. The difficulty

Decision EB 109(2).

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might be overcome by amending the proposed wording to "late January/early February" to allow a margin of flexibility. Mr TOPPING (Legal Counsel), referring to Rule 5 of the Rules of Procedure, which allowed the Board to determine "at each session" the time and place of its next session, suggested replacing the word "always" in the operative paragraph by "in principle", in order to avoid making the resolution too prescriptive. Professor ABOUO-N'DORI (Cote d'Ivoire) said that a date in February might make it awkward for the documentation for the Health Assembly to be prepared in good time and proposed postponing the dates of both the Executive Board and the Health Assembly by two weeks, thus keeping the interval between the two the same. Mr AITKEN (Senior Policy Adviser) replied that it would be difficult to reserve conference rooms at the Palais des Nations in that case, since ILO traditionally held the International Labour Conference immediately after the Health Assembly. However, he would look into the possibility of postponing the Health Assembly by a few days. Ms WIGZELL (Sweden) said that it would be more appropriate to discuss the issue in the ad hoc intergovernmental working group. There were practical implications as well as issues of principle. For her, the most important point was for the Executive Board to meet at a time that fitted into the process of strategic planning, budgeting, monitoring, evaluation and reporting. Mr TASAKA (alternate to Dr Shinozaki, Japan) said that it would be difficult to change the dates since the availability of each individual member of the Board was bound to be different. For example, Dr Shinozaki was not usually available in February. He was therefore not in favour of the draft resolution. Professor ZELTNER (Switzerland) said that any proposals made by the working group would be adopted in January 2003, meaning that any changes made would apply to the Executive Board held in January 2004. All that needed to be decided at the current session was the date for the Board's first session in 2003. Dr TRIERS (Belgium) said that he feared that the decision was being taken too hastily. He suggested that various alternatives should be considered and submitted to the Board at its next session in May. The Board could then decide whether to come to a decision at that session or whether to refer the matter to the working group for further discussion. Dr BODZONGO (Congo) recalled that under Rule 5 of its Rules of Procedure the Board was entitled to determine at each session the time and place of its next session. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) suggested that, as well as possible dates, the Secretariat could be asked to review its own methods of work to ensure that documents were made available in good time, which as most would agree was the essence of the problem. The CHAIRMAN said that she took it that it was the wish of the Board to return to the issue in May2002. It was so agreed.

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The CHAIRMAN invited the Board to consider a draft resolution proposed by Brazil, Colombia, Ethiopia, India, Philippines and the Republic of Korea on the reimbursement of travel expenses for members of the Executive Board, which read: The Executive Board, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Recalling resolution WHA30.1 0, DECIDES that: ( 1) from May 2002, the maximum reimbursement of travel expenses of members of the Executive Board shall be restricted to the equivalent of one business class or equivalent return ticket for those members whose travel time between the capital city of the Member State to the place of meeting, including necessary stopovers, exceeds six hours; (2) all other provisions of paragraphs 1 and 2 of resolution WHA30.1 0 shall remain applicable, including those for travel of members whose travel time is six hours or less. Dr OM (Republic of Korea) thanked his cosponsors and expressed the hope that the draft resolution would be approved at the Health Assembly. Dt GIRMA (Ethiopia), speaking as one of the cosponsors of the draft resolution, proposed that paragraph 1 be amended to allow business class travel to be provided for all members of the Board regardless of the duration of their flight.

Dr AL KHARABSEH (Jordan) supported that proposal. While he agreed that savings should be made, the administrative costs of calculating in each particular case whether the travel time exceeded six hours would be considerable. Moreover, all members of the Board were senior officials in their own country, where they were treated accordingly, and they deserved similar consideration from WHO. Mr STEIGER (United States of America)/ speaking at the invitation of the CHAIRMAN, said that the Board had done much good work on many important issues that day. However, the proposed draft resolution would send the wrong message to the world. It was extremely disappointing to see members of the Board, as stewards of the fiscal integrity and accountability of WHO, make such a move. Members of the Board already received complimentary air travel, per diem and complimentary accommodation in five-star hotels in Geneva, one of the most expensive cities in the world, and were nevertheless demanding more. How could they justify having the Organization's scarce resources spent on business class travel rather than on WHO's critical normative work on blood safety, cancer control, preventive health or HIV I AIDS? As the provider of nearly one-quarter of the Organization's core budget, the United States objected to the draft resolution. In that country, those who indulged in such conduct were termed "limousine liberals" and he considered that such a draft resolution, submitted by those who claimed to speak on behalf of the down-trodden, was hypocritical.

Participating by virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

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Dr SALLAM (Egypt) objected to that statement. It was not true that members of the Board were "limousine liberals". Experts employed by WHO already travelled in business class. It was difficult to see how treating Board members with the respect they deserved could adversely affect blood safety. He wished to cosponsor the draft resolution, which he found perfectly reasonable. Professor ABOUO-N'DORI (Cote d'Ivoire) observed that Mr Steiger was endeavouring to give lessons in morality to the developing countries. What was unacceptable, in his view, would be to house members of the Board in five-star hotels but to make them travel in economy class. It was obvious that Mr Steiger had never travelled in economy class for more than eight hours, otherwise he would be more tolerant towards the draft resolution. It might be possible to save money in other ways, for example if sessions were to be made shorter. However, the draft resolution, which concerned business class travel for only 30 or so members of the Board, did not warrant such a virulent response. Mr TASAKA (alternate to Dr Shinozaki, Japan) urged the Board to approach the matter with caution, bearing in mind the repercussions on the management of the Organization and the impression that would be given to the public. He asked what the travel arrangements were in other organizations. Ms WIGZELL (Sweden) agreed that it was impossible to decide such a contentious issue without having more information, notably the rules governing the matter in other United Nations bodies and in WHO itself, and of course the cost implications. Dr SADRIZADEH (Islamic Republic of Iran) said that the statement made by the representative of the United States obliged him to defend the decency and integrity of Executive Board members. They had voluntarily participated until late the previous evening in the discussions of the working group, not for the purpose of upgrading their tickets but more important reasons. Executive Board members were senior officials in their own countries and could easily obtain first-class tickets from their Governments. The point was, however, that their position entitled them to respect. He called for the closure of the discussion on the issue of tickets and a return to other aspects of the question of the Board's working methods. Mr CHOWDHURY (India) said that he had been taken aback by Mr Steiger's reaction. Strong language had been used. His own earlier remarks had been a reflection, not of a vested interest but of a general feeling among Board members. The fact that a developing or resource-short country like his own deemed it necessary to have its representative travel to WHO meetings on a first-class ticket and be given an extra day to recover from the journey reflected physical necessity, not profligacy or self-indulgence. WHO was a powerful international organization, which conducted its business on an appropriately large scale. If it wished to make real savings, it could shift its headquarters to a developing country: in New Delhi, facilities could be provided for meetings at a fraction of the cost of those in Geneva. He urged members of the Board to distance themselves from all rhetoric in taking a decision on the draft resolution. Mr BAQUEROT (Executive Director), responding to the questions raised by Ms Wigzell and Mr Tasaka about the practices of WHO and other organizations, said WHO's current policy was that for journeys of more than six hours staff were entitled to business class travel. The draft resolution thus reflected the Organization's policy for its own staff. He did not have full information on other organizations, but knew that at least two in Geneva had a similar policy for journeys of four hours' duration, while the United Nations applied a time limit of nine hours in general, and four hours for high-level staff and delegates. Thus, different organizations applied different policies, but the underlying concept was that business class travel should be authorized above a certain duration of travel time because of the fatigue factor. A precise analysis of cost implications for the travel of current and future members of the Board had not been made, but it should not be assumed that the proposed measure would be unduly

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expensive. WHO had arrangements with airline companies and travel agents through which it could acquire business class tickets at 25% to 35% less than the normal cost, and in some cases at significantly less than the price of a full-fare economy ticket. Dr AL-MAZROU (Saudi Arabia) said that the desire of members of the Board to be treated in the same way as governing body representatives in other organizations did not merit the reaction it had received from the representative of the United States. Executive Board members were acutely aware of the issue of the Organization's costs. He himself had recently put forward a proposal for the programme of work aimed at reducing the amount of per diem that had to be paid. That attested to the conscientious approach of Board members, one that should be met with appreciation, not antagonism. Dr KARAM (Lebanon) said that the issue seemed to have divided members of the Board into two camps: rich countries that liked to act like poor ones, and poor countries that enjoyed acting like rich ones. Board members could not fail to appreciate the pragmatism, frugality and work ethic that prevailed in Japan and the United States. Sometimes, however, too much humility bred contempt. In some cultures, a high government official would be looked down upon for flying economy class, while in others, senators were commonly seen mowing lawns. For an organization like WHO, certain standards had to be upheld, and the idea that its representatives were being pampered must be dispelled. Ms WIGZELL (Sweden) said she would like to see a reference to WHO's Rules and Regulations included in the draft resolution. The CHAIRMAN asked whether the Board agreed to adopt the resolution as presented, but with a reference to WHO's Rules and Regulations included. It was so agreed. 1

(For continuation of discussion of Other management matters, see summary record of the ninth meeting, section 1.)

3. REPORT BY THE DIRECTOR-GENERAL: Item 2 of the Agenda (continued from the second meeting, section 3) Consideration of draft resolutions

The CHAIRMAN drew attention to a draft resolution proposed by Belgium on strengthening mental health, which read: The Executive Board, Bearing in mind World Health Day 2001 and The world health report 2001 on mental health, in addition to heightened activities worldwide, devoted to securing the policy, research and advocacy climate needed for strengthening and protecting the mental health of people in Member States; Recalling resolutions WHA28.84 and EB61.R28 on the promotion of mental health, resolution WHA29.21 on psychosocial factors and health, resolutions WHA32.40, WHA33.27 and EB69.R9 on drug- and alcohol-related problems, resolution WHA30.38 on mental

Resolution EB109.R7.

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retardation and resolution WHA39.25 on prevention of mental, neurological and psychosocial disorders; Recognizing that mental health problems are of major importance to all societies and to all age groups and are significant contributors to the burden of disease and the loss of quality of life; and that they are common to all countries, cause human suffering and disability, increase risk of social exclusion, increase mortality, and have huge economic and social costs; Further recognizing the need to enhance the visibility of mental health and to raise public and professional awareness of the real burden of mental disorders; 1. CALLS on Member States: ( 1) to adopt the recommendations contained in The world health report 2001; (2) to establish mental health policies, programmes and legislation based on current knowledge and considerations regarding human rights, in consultation with all stakeholders in mental health; (3) to invest more in mental health as an integral component of the well-being of populations;

2. REQUESTS the regional committees to discuss ways in which the recommendations of The world health report 2001 could best be implemented at regional level; URGES the Director-General to take appropriate action to enhance collaboration with 3. Member States in order to implement the recommendations of The world health report 2001, including: • support for analysis of the mental health situation based on research and assessment of needs, in order to contribute to greater understanding of mental health issues among policy-makers and other partners and facilitate effective development of policies and programmes to strengthen and protect mental health; • strengthening and diversification of the process of coalition building with civil society and key actions in order to enhance global awareness-raising and advocacy campaigns on mental health; • support for implementation of programmes to repair the psychological damage of war, conflict and natural disasters. Ms WIGZELL (Sweden) said that she fully supported the text, but wished to see the incorporation of two new preambular paragraphs. The first would be inserted between the first and second preambular paragraphs and would read: "Welcoming that, for the first time, The world health report has incorporated the promotion and protection of human rights in its analysis of a global mental health challenge". The second would become another preambular paragraph, and would read: "Underscoring the importance of human rights as an integral dimension to the development of mental health policies, programmes and legislation". Dr DI GENNARO (Italy) supported the proposal by Sweden regarding the reference to human rights. She suggested that in paragraph 1(3) the words "both within countries and in bilateral and multilateral cooperation" be inserted after the words "mental health". The resolution, as amended, was adopted. 1

The CHAIRMAN drew attention to a draft resolution proposed by Brazil, Colombia, Cuba, Grenada, Guatemala and Venezuela on the centenary of PAHO, which read: 1

Resolution EB109.R8.

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The Executive Board, Conscious that the Pan American Health Organization is celebrating its centenary in the year 2002, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Bearing in mind that the Pan American Health Organization is the oldest international health organization in existence, since it was founded by the Republics of the Americas in December 1902, and has worked uninterruptedly on behalf of the health of its peoples since that time; Recalling that since 1949 the Pan American Health Organization has acted as the Regional Office for the Americas of the World Health Organization; Considering the role played by the Pan American Health Organization in the past 100 years in the noteworthy improvement that can be seen in health in the Region of the Americas; Aware of the leadership displayed by the Pan American Health Organization, together with Member States, in the eradication of smallpox and poliomyelitis, and in the significant reduction of cases of measles, almost eliminating it, among other achievements in the Americas in the course of the last 100 years, RESOLVES: ( 1) to congratulate the Pan American Health Organization on attaining the first centenary of its foundation in this year 2002; (2) to congratulate the Member States of the Americas on the results obtained in improvement of its peoples' health during the past century; (3) to encourage the Member States of the Pan American Health Organization to redouble their efforts to achieve equity in health matters, and to promote the spirit of unity as evidence of the Panamericanism characteristic of the Region during the past 100 years; and (4) to thank the Pan American Health Organization and the World Health Organization for their close cooperation, dedication, leadership and contributions to the health of the peoples of the Americas. Dr DOTRES MARTiNEZ (Cuba), introducing the draft resolution on behalf of the Latin American countries, said that PAHO had, over the past 50 years, shown efficient leadership and, with WHO, had made a sustained contribution towards improving the health of the peoples of the region. Dr ROMUALDEZ (Philippines) said that during the first 50 years of PAHO's existence, his country had benefited greatly from its activities. He therefore strongly supported the draft resolution. Dr BODZONGO (Congo) expressed his support for the resolution and congratulated PAHO on reaching its centenary despite all the difficulties it had had to overcome. The resolution was adopted!

Resolution EB109.R9.

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HEALTH STRATEGY MATTERS: Item 3 of the Agenda (resumed)

The role of contractual arrangements in improving health systems' performance: Item 3.3 of the Agenda (Document EB109/5) (continued from the third meeting) Consideration of draft resolutions The CHAIRMAN drew the Board's attention to a draft resolution proposed by Chad and Cote d'Ivoire on the role of contractual arrangements in improving health systems' performance, which read: The Executive Board, Having examined the report on the role of contractual arrangements in improving health systems' performance, 1 RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Noting that the performance of health systems must be strengthened in order to further improve the health of the population, ensure equitable financing of health and meet the legitimate expectations of the population; Considering that the reform of health systems has generally involved institutional restructuring, with a diversification of the agents involved in the field of health (in the public and private sectors and in nongovemmental organizations); Recognizing the important role of government stewardship in regulation of contractual arrangements in the health sector, I. URGES Member States to: (1) ensure that contractual arrangements in the field of health adopt rules and principles that are in harmony with the national health policy; (2) develop contractual policies that maximize impact on the performance of health systems and harmonize the practices of all parties in a transparent way, to avoid adverse effects; (3) share their experiences on contractual arrangements involving the public and private sectors and nongovemmental organizations in the provision of health services; REQUESTS the Director-General to: (1) develop an evidence base so as to permit the evaluation of the impact of differing types of contractual arrangements on the performance of health systems and the identification of best practices, taking account of sociocultural differences; (2) provide, in response to requests from Member States, technical support in developing capacities and expertise in the development of contractual arrangements; (3) develop methods and tools to provide support to Member States in accreditation, licensing and registration of public and private sector and nongovemmental organizations in the health sector, establishing a system of supervision to ensure the provision of high-quality health services;

Document EB109/5.

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(4) report to the Executive Board and the World Health Assembly in 2005 on the ways in which contractual arrangements improve the performance of health systems in the Member States of the Organization. Ms WIGZELL (Sweden) proposed the insertion of "in response to requests from Member States" between "provide" and "support" in paragraph 2(3) of the resolution. With reference to the same subparagraph, she was not clear whether the "system of supervision" referred to would be a global or a national one. Mr AITKEN (Senior Policy Adviser) said the system envisaged would be a national system. The resolution, as amended, was adopted. 1 (For continuation of discussion of Health strategy matters, see summary record of the ninth meeting, section 4.)

HUMAN RESOURCES: Item 6 of the Agenda

Reform of human resources management: Item 6.1 of the Agenda (Document EB 109/25) Dr KARAM (Lebanon), speaking as Chairman of the Administration, Budget and Finance Committee (ABFC), said that the Committee had noted that the main focus in 2001 had been on contract reform and that contractual arrangements had been revised after extensive discussions throughout the Organization. The Committee had expressed appreciation of the progress being made in the different areas of human resources management reform, notably in performance management and development and efforts to improve the geographical and gender balance. ABFC considered that contract reform was fundamental and that the implications, including those in terms of cost and consistency with the United Nations common system, needed to be carefully assessed. The Committee had received clarification about the salient features of contract reform, in particular that the proposed term-limited appointments were similar to appointments in place in several common-system organizations and programmes, notably the United Nations. It had been further noted that the issue had been reviewed by the International Civil Service Commission in 1997, and that the Commission had endorsed principles and guidelines for use of those arrangements in the United Nations common system. ABFC had also received details of the distinguishing features of the revised contractual arrangements and of the service allowance applicable to term-limited appointments. For short-term, fixed-term and service appointments, implementation would be largely cost-neutral. Additional costs would accrue only in respect of the new term-limited appointments which were designed to provide some improvement in employment conditions. The annual financial implications were estimated at about US$ 3 million, almost all of which came under extrabudgetary funds. Dr OM (Republic of Korea) welcomed WHO's efforts to enhance the gender and geographical balance of its workforce. With regard to human resources management, he requested the Organization to formulate a more specific plan of work for submission to the Board, in consultation with the Member States concerned, in order to tackle what had become a chronic problem.

Resolution EB109.Rl0.

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Mr TASAKA (alternate to Or Shinozaki, Japan) urged WHO to build on the progress made so far by making full use of the new programme designed to strengthen efforts to improve markedly the gender and geographical balance of WHO. Mr MACPHEE (Canada),' speaking at the invitation of the CHAIRMAN, said that Canada welcomed the progress made by WHO in the reform of human resources management. He had noted with satisfaction that ABFC had stressed the importance of contractual reform and that, in continuing its efforts in that important aspect of human resource management, it recognized the need to assess carefully its implications, including those relating to cost and consistency with the United Nations common system. Or FEDOROV (Russian Federation), 1 speaking at the invitation of the CHAIRMAN, first expressed appreciation of the work of the staff of the Organization and their contribution to implementation of the decisions of WHO Member States. Over the past few years, at sessions of the Executive Board and the Health Assembly, the Russian Federation had called for concrete proposals from the Secretariat on reform of the Organization's staff policy, which, it was convinced, should include further steps to ensure the non-career character of service in WHO and the filling of vacancies on the basis of equitable competition. During the current session, proposals had been submitted that would be studied most attentively with a view to in-depth discussion at the forthcoming Health Assembly. For the present, as a preliminary reaction, he drew attention only to a few aspects. First, he welcomed the proposal to phase out career service appointments, which at present accounted for a very small proportion of contracts- about 4% for the specialist and higher categories. The new concept of service appointments required further study and needed a precise, straightforward definition of what such contracts would entail. Secondly, a number of proposals concerning elements of staff remuneration would require a ruling by the International Civil Service Commission as to their compliance with the norms of the United Nations common system, in particular in regard to increasing the termination indemnity by 50% and the proposed use of the new increment. Thirdly, concerning the new proposals for staff remuneration and conditions of service, his country would like to see more detailed data on their financial implications, including an explanation of the statement made in ABFC that the improvement of some conditions of service did not require additional expenditure. Fourthly, should the Executive Board organize any form of consultation with Member States before the next session of the Health Assembly, the Russian Federation would wish to participate; if there were to be none, it would be prepared for in-depth discussion at the Health Assembly itself and article-by-article discussion of both existing amendments to the Staff Rules and Staff Regulations and any amendments to those amendments. Any new, more detailed document on the matter produced before the discussions would naturally be welcomed. Mr REN Yisheng (China), 1 speaking at the invitation of the CHAIRMAN, suggested that the Organization should give priority, in its current reform of human resources, to employing more young staff and seeking to achieve a more equal geographical balance. Reward and disciplinary mechanisms were needed to ensure that standards of conduct were adhered to by staff. To that end, he welcomed the revised text of the 1954 report on standards of conduct in the international civil service as adopted by the Commission. Among other requirements, the report stated that international civil servants should avoid any conduct that might harm their status. They also made it plain that international civil servants, either as individuals or as a group, did not have the same freedom as private individuals to take sides on controversial issues. However, he had noted with concern that at the first meeting of the

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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current session of the Board, an officer of the Secretariat had failed to observe that very principle of impartiality. The Organization should therefore be actively promoting implementation ofthe standards of conduct through appropriate and clearly defined supervision and disciplinary mechanisms. Where there had been misconduct, Articles 1 and 10 of the Staff Regulations gave the Director-General authority to deal with the matter, and he urged her to avail herself of that authority in order to safeguard the credibility of the Organization. The CHAIRMAN said that, in the absence of any further comments, she would take it that the Board wished to take cognizance of the note. It was so agreed.

(For resumption of discussion, see section 7.)

MATTERS FOR INFORMATION: Item 8 of the Agenda

Annual report on human resources: Item 8.4 of the Agenda (Documents EB109/37 and EBABFC16/3) Dr KARAM (Lebanon), speaking as Chairman of ABFC, said that the Committee had examined and taken note of document EB109/37, recognizing that the annual report with complete data as at 31 December 2001 would be submitted to the Fifty-fifth World Health Assembly. The CHAIRMAN said that, in the absence of any comments, she would take it that the Board wished to note the annual report on human resources. It was so agreed.

(For continuation of discussion, see summary record of tenth meeting, section 4.)

HUMAN RESOURCES: Item 6 of the Agenda (resumed from section 5)

Statement by the representative of the WHO staff associations: Item 6.2 of the Agenda (Document EB109/INF.DOC./1) Mr RAJAN (WHO Regional Office for South-East Asia Staff Association), speaking on behalf of the staff associations of WHO, IARC and the Onchocerciasis Control Programme in West Africa, expressed appreciation of the unique juxtaposition of staff associations with administrations at both global and regional level, which gave ample opportunities for consultation and dialogue, facilitating problem-solving and promoting mutual well-being. He also expressed appreciation for mechanisms such as the Global Staff/Management Council and staff management consultative committees at regional level, which made it possible for him to deliver his statement to the Executive Board. The year had seen many developments that affected WHO and its staff, and the Organization's technical ability had been called into play to assist Member States to respond effectively to the global challenges of disease, disaster and biochemical attack. WHO's strength had always resided in the quality and effectiveness of its human resources. Even at the risk of their own personal security and safety, staff members had never failed to uphold WHO's mission and discharge its mandate. Human resources were nevertheless only as good or as bad as the way in which they were managed. They

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needed to be nurtured if enthusiasm and technical skills were to be maintained and improved, and thus transparency and recognition in dealing with service matters were of great importance. The reform of human resources management undertaken at the behest of the Organization's governing bodies had taken a decisive turn towards implementation. The Task Force on Human Resources Management Reform and the Global Staff/Management Council had made great progress on contract-related issues, rotation and mobility issues, and the rewards/recognition regime. He said that the staff associations nevertheless felt that the documents to be discussed by the Council should be made available to representatives at least two weeks in advance to enable them to consult in a satisfactory manner with the staff at large before meetings. It was through relevant training that staff should be able to maintain their efficiency in meeting the Organization's changing mandate and the challenges it faced. Although some progress had been made, much remained to be done, particularly in the regions. Emphasis should be laid on occupational training at mid-career level, in the form of external or internal training or mobility schemes. The staff associations requested that sufficient funds be allocated in the budget for that purpose and that proper training and career development plans be formulated in regional offices for staff members of all categories. While professional excellence, experience and competency were at a premium, the staff associations would nevertheless urge WHO to refrain from re-employing or rehiring retirees. The practice smacked of nepotism, blocked career advancement and undermined staff morale, and it had been brought to the attention of the Executive Board several times. The principle of "nobody is indispensable" should be honestly applied. The staff associations earnestly pressed for fair and equal treatment for general service staff at all levels, since they played an essential role at headquarters, duty stations and country/field offices alike, and deserved better. Dispassionate consideration should be given to the issue of discrimination among professional and general service staff, with a view to waiving geographical criteria up to P-1/P-2 levels. He called for the introduction of a cadre similar to national professional officer in the regional offices, so as to enhance the functional abilities of those offices and provide much needed career development opportunities for general service staff. While professional salaries should be high enough to retain the best talent, there should also be sufficient relevant career development opportunities. The regional administrations should be given authority to classify or reclassify posts up to P-5 level in order to be more responsive to staffs career development needs. The recent brutal killing of the WHO Representative in Burundi had brought the issue of security and safety, particularly of field staff, to the fore. The staff associations appreciated the creation of a post of Director, Security Coordination in Geneva. They would insist, however, that security measures implemented in the field be applied to all WHO staff independently of their type of contract and recruitment. All United Nations staff, whether international or locally recruited, should be treated equally in times of emergency and danger. Medical and evacuation facilities were also of paramount importance to country and field staff. In a medical emergency, there should be an easy and responsive mechanism for approving evacuation. Consideration should also be given to a global staff health insurance card which would ensure easy and quick access to hospital treatment. The staff associations noted the progress made to date on reform of human resources management, as described in document EB I 09/25. They were pleased to see that the Organization was looking into such issues as a staff ethics framework, workforce planning and management accountability, which had long been neglected. The document reflected agreements and promises made by the administration at the Global Staff/Management Council meeting in October 200 I with regard to contract reform and human resources management. However, there were still certain significant issues linked to modifications in the staff rules, a matter the Board would be considering, which were of great concern.

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Dr NUTTALL (WHO Headquarters Staff Association) said there were indeed three major issues linked to modifications in staff rules which merited attention by the Board. The first was contract reform. The administration was proposing to introduce a new type of temporary contract known as a term-limited contract that could be renewed up to a maximum of four years. The staff associations believed that such a contract should in no case apply to "long-term short-term" staff currently employed by WHO. In addition, it was important that rigorous selection procedures should be put in place, and she requested that that be done at the forthcoming Global Staff/Management Council meeting. The headquarters and PAHO staff associations believed that one of the basic principles of reform was to put a stop to the practice of "long-term short-term" contracts. The proposed term-limited contracts, however, would again make it possible to recruit staff without a proper selection procedure and without complying with policy on gender balance and geographical distribution for periods of four years, which seemed very long for a temporary contract. That ran counter to the fundamental principle to which the associations were deeply attached, namely equal pay for equal work. Contract reform could consist in limiting short-term contracts to 11 months, renewable once only. All other contracts would be ordinary contracts, no matter what the source of financing, renewable on the basis of availability of funds, continued need and satisfactory performance. The second issue of concern was the abolition of reduction in force procedures, and the proposals on separation arrangements whereby any post could be abolished without prior discussion or consultation. She was aware that the competition phase of reduction in force as currently practised was not satisfactory, but the rules governing it were an acquired right for every staff member, and it was therefore the responsibility of the staff associations to ensure that the procedures established would protect staff according to their competence and experience. They requested a commitment from the management to safeguard acquired rights, and proposed that satisfactory mechanisms be established. The staff associations strongly urged that the issues of term-limited contracts, acquired rights and the reduction in force mechanism be revisited at an exclusive meeting between the administration and the staff associations before the staff rules were changed. They also noted that the issue of post management was not well described in document EB109/25, and requested further discussion of the matter. With regard to the third issue, employment of "long-term short-term" staff, although negotiations were ongoing and moving in the right direction, it was urgent that decent contracts should be offered to staff who had worked at WHO for many years on temporary contracts, some for as long as 15 or 17 years. In November 1998, the Director-General had declared in a cluster note that the problem would be given priority. In the light of the proposals agreed at the meeting of the Global Staff/Management Council in October 2001, the staff associations requested all administrations globally and regionally to start work immediately on its solution. She invited members of the Board to give careful consideration to the texts submitted to them in the light of the statements just made. Only dispassionate and calm discussion would make it possible to reach a proper agreement before the staff rules were changed. Mr RAJAN (WHO Regional Office for South-East Asia Staff Association) added that the staff associations fully believed in the principle of negotiation and consultation, and noted with satisfaction the efforts made in that direction over the past few years. They would continue to contribute to and promote the enhancement of work culture, accountability and mutual trust, and reaffirmed their commitment to helping to fulfil the Organization's mandate of alleviating human suffering and providing better health for all. Mr BAQUEROT (Executive Director) recalled that the Global Staff/Management Council, for which the staff associations had expressed appreciation, had been established by the Director-General shortly after her appointment in a bid to strengthen dialogue between staff and management. The Council had been operational for over three years and had been a valued part of the consultation process. In October 2001, a series of proposals on contract reform and related matters, including the replacement of the existing reduction in force procedures and the issue of"long-term short-term staff',

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had been reviewed at a special session of the Global Staff/Management Council. On that occasion, a number of changes had been made to the original management proposal at the request of the staff in a spirit of constructive dialogue, and an agreement had been reached to recommend to the Director-General the package of revised arrangements for contract reform, reduction in force procedures and "long-term short-term staff' contained in document EB109/25. A number of loose ends had been tied up in a subsequent videoconference in early November. The final report of the special session had been approved by the Director-General and had been circulated to all Global Staff/Management Council members by mid-December. The proposals contained in document EB 109/25 therefore represented the agreed outcome of the consultation process, and were reasonable and realistic. They struck a balance between WHO's responsibility as an employer, programme responsiveness and evolving funding realities. In such a complex and fundamental matter, it was only natural that some aspects would require fine-tuning. The administration would work to resolve all outstanding points within the framework of the agreed package. The next meeting of the Global Staff/Management Council, in March 2002, would focus on completing work on the existing proposals, in full consultation with staff representatives. (For continuation of discussion, see summary record of the ninth meeting, section 2.)

The meeting rose at 17:40.

NINTH MEETING Friday, 18 January 2002, at 9:10 Chairman: Mrs M. ABEL (Vanuatu)

The meeting was held in private from 9:10 to 9:45 and resumed in public session at 9:50.

1. OTHER MANAGEMENT MATTERS: Item 7 of the Agenda (continued from the eighth meeting, section 2)

Appointment of the Regional Director for the Eastern Mediterranean: Item 7.1 of the Agenda (Document EB 109/28) Dr MODESTE-CURWEN (Grenada), Rapporteur, read out the following resolution adopted by the Board in private session. The Executive Board, Considering the provisions of Article 52 of the WHO Constitution; Considering the nomination made by the Regional Committee for the Eastern Mediterranean Region at its forty-eighth session, 1. REAPPOINTS Dr Hussein A. Gezairy as Regional Director for the Eastern Mediterranean as from I October 2002;

2. AUTHORIZES the Director-General to issue to Dr Hussein A. Gezairy a contract for a period of five years from 1 October 2002, subject to the provisions of the Staff Regulations and Staff Rules. The CHAIRMAN congratulated Dr Gezairy on his reappointment and conveyed the Executive Board's best wishes for continuing success in all his endeavours in the Eastern Mediterranean Region. Dr GEZAIRY (Regional Director for the Eastern Mediterranean) thanked the Board for the confidence placed in him. It gave him great pleasure to accept the reappointment. He also thanked the Member States of the Eastern Mediterranean Region for their vote of confidence, for the trust they had placed in his ability to serve their interests through WHO, and above all for the support they had given him during the previous 20 years, saying that he was deeply touched that, after such a period of time, the Members continued to wish him to represent them. It was also a reflection of tradition in the Eastern Mediterranean Region, which sought to preserve continuity and stability in the face of a changing world. The Region was not averse to change, however, and he had been able to introduce many innovative changes to WHO's dealings with its Members in the Region, some of which had been of influence at the global level. So much of the work in WHO was for the long-term that it was possible to forget what had been achieved. Many of WHO's staff left without seeing their labours come to fruition, and few were as lucky as he to be able to look back on a substantial period and see change in retrospect.

- 151 -

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One of the first innovations he had introduced at the Regional Office had been the concept of joint planning for each biennium in concert with the Member States, through the joint programme review mission. It was surprising to recall that 20 years ago, the idea of asking Members to look at what had been achieved in the previous biennium and what they wanted to do in the coming biennium, and fitting that within WHO's priorities and the available budget was quite new. That had become standard practice throughout the Organization. Later, the Regional Office had developed a computer programme, the regional activity management system, to handle the budgetary detail of what had been agreed, that had subsequently formed the basis for the Organization-wide system. A more recent innovation that had become standard practice in WHO was the Poliofax, a weekly bulletin, contributed to by all Member States and faxed back to them as a comprehensive and concise update on the poliomyelitis situation in the Region. Another early innovation had been the development of a prototype school health curriculum to provide primary school pupils, the parents of the future, with a firm grounding in health education. The curriculum had been widely used and adapted throughout the Region. The Eastern Mediterranean had been the first region, in the late 1980s, to promote leadership development in health in order to develop national capacity in the areas of health policy, strategy and management. Within 10 years, the leadership development courses had been decentralized and institutionalized at regional level. The Eastern Mediterranean Region had been the first to use health as a bridge for peace. Its first experimental period of tranquillity had been in Afghanistan in 1994. Through extensive negotiation, the WHO Representative had managed to secure seven days of peace in which to implement a mass immunization programme, an exercise that had been so successful and so appreciated that it had become a relatively regular event that would sometimes extend to several months as the factions found a valid excuse to stop fighting. In the mid-1980s, the Regional Office had started to work on the basic minimum needs approach, which had already been tried in Thailand, whereby health could be made a bridge for development of the poorest communities and villages. While health for all lay at the heart of the approach, for the first time it took into account the fact that the goal of health could not be achieved in isolation; for some communities that meant empowering people, helping them to help themselves. With community involvement, needs were assessed, priorities put in place and seed money for interest-free loans provided. Those activities had been successful in the most disadvantaged areas of the Region, such as Afghanistan and Sudan, while in Pakistan the Government had institutionalized the approach as a national development programme. Who would have imagined 20 years earlier that WHO could promote health by supporting income-generation schemes, education and literacy projects, agricultural development and the empowerment of women? The Eastern Mediterranean was a turbulent Region, in parts materially rich and in others very poor. Spiritually, it might be said to be the richest Region of all, and that too had provided an entry point to promote health. Through collaboration with the Islamic Organization of Medical Sciences and with the Islamic Educational, Scientific and Cultural Organization forums had been established in which to discuss some of the more difficult areas of health promotion, such as adolescent health, drug abuse, genetics and ethical issues. He was particularly proud of the contribution made by the Regional Office to the debate on tobacco smoking in the Region, where there were so many smokers and where tobacco promotion was becoming increasingly aggressive. The debate had been initiated by the Council of Arab Health Ministers and the Eastern Mediterranean Regional Office had been the first Regional Office to ban smoking. More recently, after involving religious leaders in the debate, not only had an Islamic ruling, or fatwa, been issued against smoking, and proved to be very effective, but the holy cities of Mecca and Medina had been declared tobacco-free. Rapid growth in the Region had led to many unwelcome developments. For example, there had been the sudden trend in the 1990s for private medical schools. Prompt action to raise the warning signals and initiate debate in that regard had resulted in the setting of regional standards. In the course of 20 years he had witnessed a growing self-sufficiency in the production of essential drugs in the Region, and three countries currently produced vaccines. During the previous year's Health Assembly, the Islamic Republic of Iran and Pakistan from the Eastern Mediterranean

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Region and Indonesia from the South-East Asia Region had formally agreed to initiate a collaborative programme to ensure vaccine availability and development in the three countries, an agreement in which the Regional Office had played an important coordinating role. He had also contributed to raising awareness of nutritional issues in the Region, including the importance of micronutrient deficiency diseases. The Region currently had very successful collaborative programmes in flour fortification with iron and iodization of salt. He warmly commended the support, dedication and hard work of his staff which had been essential to the achievements of the Regional Office during his period of tenure, and looked forward to continuing to work with them and Member States in the future. The DIRECTOR-GENERAL, Dr KARAM (Lebanon), Dr SADRIZADEH (Islamic Republic of Iran), Dr MANSOUR (alternate to Dr Sallam, Egypt), Dr AL-MAZROU (Saudi Arabia), Dr AL KHARABSEH (Jordan) and Professor YUNES (Brazil) congratulated Dr Gezairy warmly on his reappointment, drew attention to his many attributes and wished him a successful term of office. Reports of the Executive Board Committees: Item 7.2 of the Agenda • Awards Ihsan Dogramaci Family Health Foundation Prize Decision: The Executive Board, having considered the report of the Ihsan Dogramaci Family Health Foundation Selection Panel, awarded the Ihsan Dogramaci Health Foundation Prize for 1 2002 to Professor Elisabeth Wollast (Belgium) for her service in the field of family health. Sasakawa Health Prize Decision: The Executive Board, having considered the report of the Sasakawa Health Prize Selection Panel, awarded the Sasakawa Health Prize for 2002 to the Programa Nacional de Atenci6n Odontol6gica Integral para Mujeres Trabajadoras de Escasos Recursos of Chile. The laureate will receive an amount of US$ 40 000 for its outstanding work in health development. 2 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 2002 to Medecins sans Frontieres (France) and to Dr Ibrahim Mohamed Yacoub (Bahrain) for their outstanding contribution to health development. The laureates will each receive US$ 20 000. 3

1 2

Decision EB109(5). Decision EB 109(6). Decision EB 109(7).

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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 2002 to Dr Hussein Mirchamsi (Islamic Republic of Iran) for his most significant contribution to the objectives of primary health care in the geographical area in which Dr Shousha served the World Health Organization. 1 Jacques Parisot Foundation Fellowship Decision: The Executive Board, having considered the report of the Jacques Parisot Foundation Selection Panel, awarded the Jacques Parisot Foundation Fellowship for 2002 to Dr Yu Dongbao (China)? (For continuation of discussion, see summary record of tenth meeting, section 3.)

HUMAN RESOURCES: Item 6 of the Agenda (continued from the eighth meeting, section 7)

Statement by the representative of the WHO staff associations: Item 6.2 of the Agenda (Document EB109/INF.DOC./1) (continued) Mr RAJAN (WHO Regional Office for South-East Asia Staff Association) said that his attention had been drawn to discrepancies between sections of document EB109/INF.DOC./1 as presented orally at the previous meeting by the representative of the WHO Headquarters Staff Association and the version contained in document EB109/INF.DOC./1. The version contained in that document remained the official statement. Dr NUTTALL (WHO Headquarters Staff Association) thanked those participants who had stressed the need to observe the principle of equitable geographical distribution. In the view of the Headquarters Staff Association, fixed-term contracts as presented would not allow for the observance of that principle. Secondly, in response to the statement made at the previous meeting by the Executive Director of the General Management cluster, she said that the Headquarters and PAHO Staff Associations had not agreed to some of the points discussed at the Global Staff/Management Council meeting; in particular, they had opposed the contractual reforms and the abolition of the reduction in force procedures on many occasions over the past four years, before, during and after that meeting. She also stressed that the Council was currently only a consultative body, albeit one that was much appreciated. Its report did not have the force of a decision, particularly when some staff associations were not satisfied with its conclusions. Lastly, the Council was one of several forums for discussions between management and staff. The Headquarters Staff Association had had occasion to express its disagreement to the Director-General both orally and in written memoranda. The Association welcomed the possibility of continued discussion at the March 2002 Council meeting, but drew attention to the fact that discussions held in a framework determined by the amended Staff Rules to be considered later by the Board were unlikely to result in an agreement reflecting the interests of all the parties.

1 2

Decision EBI09(3). Decision EBI09(4).

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Mr BAQUEROT (Executive Director) acknowledged that the Global Staff/Management Council was a mechanism for consultation between administration and staff. Decision-making clearly remained with the Director-General, or with the governing bodies for matters under their purview. Thus, the aim of the consultation process was to arrive at a consensus recommendation to the DirectorGeneral or the higher authority, as the case might be. At the October 2001 meeting such a consensus had been reached, once disagreements had been ironed out in the course of the proceedings. The report had then been transmitted to the Director-General for her decision. The Board took note of the statements of the representatives of the WHO staff associations. Amendments to the Staff Rules: Item 6.3 of the Agenda (Documents EB109/27 and EB109/27 Add.l) Dr KARAM (Lebanon), speaking as the Chairman of the Administration, Budget and Finance Committee (ABFC), introduced document EB109/27. With regard to the amendments to the Staff Rules in respect of action taken by the International Civil Service Commission, the Committee had been informed that the 200 1 annual report of that body had contained one recommendation requiring action. It had related to an upward adjustment of 3.87% of the common-system base floor salary scale for professional and higher category staff on a "no-loss-no-gain" basis, with effect from 1 March 2002. The Commission's recommendation had been approved by the United Nations General Assembly and was expected to be implemented in all the other bodies of the common system. Parallel adjustments, also approved by the General Assembly, had been proposed to the salaries of staff in ungraded posts with similar adjustments to the salary of the Director-General. The Committee was recommending to the Board the adoption ofthe draft resolutions contained in document EB109/27. Document EB 109/27 Add.l contained amendments to the Staff Rules in order to implement contractual reform with effect from 1 July 2002 and the system for performance management and development with effect from 1 January 2002 as well as a proposed amendment to Staff Regulation 4.5 concerning appointments of high-level officials. With regard to the latter, the Committee had requested the Director-General to consider an amendment which would reflect past governing body resolutions concerning renewals of appointments of Regional Directors. The Committee was recommending to the Board the adoption of the draft resolutions contained in document EB109/27 Add.1, in the light of the Board's consideration of the Committee's proposal with respect to Staff Regulation 4.5. Mr TASAKA (alternate to Dr Shinozaki, Japan) said that, while accepting that the new contractual arrangements such as fixed-term and service appointments were designed to meet the operational requirements and responsiveness that were being demanded of WHO, Japan remained attached to the principle of zero nominal growth in the regular budget, and could accept the reform only if that principle was not infringed. That, furthermore, was its reading of the second bullet point of paragraph 23 of the report of ABFC (document EBABFC16/3). The CHAIRMAN drew attention to draft resolutions document EB109/27. The resolutions were adopted. 1 and 2, contained in paragraph 9 of

Resolutions EBI09.R!2 and EBI09.Rl3, respectively.

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The CHAIRMAN drew attention to the first draft resolution contained m paragraph 6 of document EB109/27 Add. I. The resolution was adopted. 1 The CHAIRMAN drew attention to the second draft resolution contained in paragraph 6 of document EB109/27 Add. I, on the amendment of Staff Regulation 4.5. ABFC had suggested that the Regulation be further amended to include a reference to the limitation on the eligibility of Regional Directors for reappointment. Mrs McKEOUGH (Office of the Legal Counsel) read out the following revised text of the Regulation: "Appointments of the Deputy Director-General, Assistant Directors-General and Regional Directors shall be for a period not to exceed five years, subject to renewal, and in accordance with conditions determined by the Executive Board concerning eligibility of Regional Directors for reappointment. Other staff members shall be granted appointments of a duration, and under such terms and conditions, consistent with these regulations as the Director-General may prescribe". The resolution was adopted. 2 The DIRECTOR-GENERAL said that a statement made under item 6.1 of the Agenda at the previous meeting had referred to the first meeting of the current session and had called into question the proper conduct and impartiality of what had been referred to as an officer of the Secretariat. She wished to make it clear that in her view there was no reason for such accusations. Ms WIGZELL (Sweden) said that Sweden fully supported the Secretariat, and that it appreciated and supported its interventions during the current session of the Board. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) pointed out that it was the duty of the Secretariat to draw the Board's attention to any statutory or procedural matters that had a bearing on any decision that the Board might take, even when the explanation of the statutory position might not be welcome news for everyone. He expressed full support for the Secretariat, and in particular drew attention to the high-quality advice it had provided during the Board's current session. Professor GRABAUSKAS (Lithuania) said that Lithuania shared the views expressed by the members from Sweden and the United Kingdom. Dr MBAIONG (Chad) said that it was the duty of the Secretariat to guide the Board in its work, and that consequently the Board could not prevent it from performing that task when it proved necessary. The intervention referred to by the Director-General had been more than usually firm in regard to the Secretariat's activities. He joined the previous speakers in supporting the Secretariat's endeavours to ensure the smooth running of the proceedings and endorsed the Director-General's statement. Mr REN Yisheng (China)/ speaking at the invitation of the CHAIRMAN, said that at the previous meeting, he had referred to standards of conduct for the international civil service, citing the events of the Board session's first meeting as an example, in particular the behaviour of certain 1

Resolution EB109.Rl4. Resolution EB109.RIS. Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

2 3

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officials. In her statement just made, the Director-General had referred to "accusations", a term he found surprising and puzzling. Scrupulous observance of neutrality by the Secretariat was an important principle of the activity of any organization, and one proclaimed in the Charter of the United Nations and the constitutions and statutes of all other international organizations. If certain officers of the WHO Secretariat infringed that principle, then Member States had a right to criticize them. A criticism, however, was not the same as an accusation. Memories of the first meeting of the session, at which half a day had been devoted to a single agenda item, were still fresh. If the problem was not dealt with in an appropriate fashion, China would reserve the right to discuss the issue in other forums. Dr MSA MLIVA (Comoros) suggested an enquiry be held to determine whether the officer concerned had indeed failed to act with the necessary impartiality. Dr BODZONGO (Congo) cautioned against confrontation. China had merely expressed an opinion, which as an observer it was perfectly entitled to do. Mr SELIM LABIB (alternate to Dr Sallam, Egypt) said that he preferred to treat the matter as one of principle. His main concern, no doubt shared with all the other members, was to see the principles of transparency and impartiality further strengthened so as to optimize the Organization's performance and results. Mr CICOGNA (alternate to Dr Di Gennaro, Italy) said that the Board should concentrate on bringing the sound work already accomplished at the current session to a successful conclusion.

PRESS COVERAGE OF THE CURRENT SESSION OF THE EXECUTIVE BOARD

Dr KARAM (Lebanon) said that the International Herald Tribune of 18 January 2002 featured an article entitled "Health Agency Waives Date For Destroying Smallpox Virus" which contained a misrepresentation of the position taken by Lebanon during the Board's consideration of that question. He requested that a press release be issued stating the true facts of the case.

4. HEALTH STRATEGY MATTERS: Item 3 of the Agenda (continued from the eighth meeting, section 4) Quality of care: patient safety: Item 3.4 of the Agenda (Document EB 109/9) (continued from the sixth meeting) The CHAIRMAN drew attention to a draft resolution on Quality of care: patient safety, proposed by Belgium, the Islamic Republic of Iran, Italy, Japan and the United Kingdom of Great Britain and Northern Ireland, which read: The Executive Board, Having considered the report on quality of care: patient safety; 1 Concerned that the incidence of adverse events is a challenge to quality of care, a significant avoidable cause of human suffering, and a high toll in financial loss and opportunity cost to health services;

Document EB109/9.

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Noting that significant enhancement of health systems' performance can be achieved in Member States by preventing adverse events in particular, and improving patient safety and health care quality in general; Recognizing the need to promote patient safety as a fundamental principle of all health systems, REQUESTS the Director-General in the context of quality improvement: (I) to determine global norms and standards for the definition, measurement and reporting of adverse events and near misses in health care, and to provide support to countries in developing reporting systems, taking preventive action, and implementing measures to reduce risks; (2) to promote framing of evidence-based policies, including global standards that will improve patient care, with particular emphasis on such aspects as product safety, safe clinical practice in compliance with appropriate guidelines and safe use of medicinal products and medical devices, and creation of a culture of safety within health care organizations; (3) to develop mechanisms, through accreditation and other means, to recognize the characteristics of health care providers that offer a benchmark for excellence in patient safety internationally; (4) to encourage research into patient safety. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland), introducing the draft resolution, said that it had been drafted after the Board's discussion of the item deliberately, so that comments made by members could be reflected. He thanked the cosponsors and other members of the Board for their support. The Executive Board could feel gratified at having placed the important issue of quality and safety of care on the international health agenda. In view of the level of interest shown in the draft resolution, Dr THIERS (Belgium) suggested that the Board recommend it for consideration by the Health Assembly. He therefore proposed inserting, at the beginning of the text, after "The Executive Board," the words "RECOMMENDS to the Fifth-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly,". Ms WIGZELL (Sweden) expressed her appreciation of, and support for the draft resolution. The question of patient safety was a major element in improving the quality of care and enhancing the performance of health care providers and health care systems. In order to underline the fact that the design of health systems was a national responsibility, she proposed: in paragraph I, the replacement of "determine" by "develop", "norms and standards" by "norms, standards and guidelines", and "to provide ... to countries" by "on requests from Member States to provide"; and in paragraph 3, replacement of "through accreditation and other means" by "for example through accreditation". The resolution, as amended, was adopted. 1 WHO medicines strategy: Item 3.6 of the Agenda (continued from the fourth meeting) The CHAIRMAN drew the Executive Board's attention to a draft resolution on WHO medicines strategy, emerging from informal consultations on two draft resolutions, 2 which read:

Resolution EB109.R16. See summary record of the fourth meeting.

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The Executive Board, Having analysed the reports on expanding access to essential drugs, and the revised procedure for updating WHO's Model List of Essential Drugs, and noting with satisfaction the progress made; 1 Stressing the need to promote access to medicines for all, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Welcoming adoption of the "Declaration on the TRIPS agreement and public health" at the Fourth WTO Ministerial Conference (Doha, 14 November 2001), supportive of the rights of countries to protect public health and, in particular, promote access to medicines for all; Recalling discussions and proposals reported by Member States in their regional meetings before the Fifty-fifth World Health Assembly, mainly at the 53rd session of the Regional Committee for the Americas (September 2001)2 and the Forty-eighth session of the Regional Committee for the Eastern Mediterranean (October 2001 )3 and, additionally, the thorough discussion of the Executive Board at its 109th session; Reaffirming resolution WHA54.11, emphasizing the WHO medicines strategy and its requests to Member States and the Director-General of WHO; Aware of the need to assure the continuity of updating the WHO Model List of Essential Drugs, in light of evidence-based, scientific information; Underlining the feasibility of addressing comprehensively the impact of international trade agreements on equitable access to all drugs, particularly essential drugs; Conscious of the responsibility of Member States to support solid scientific evidence, excluding any biased information or external pressures that may be detrimental to public health, 1. URGES Member States: ( 1) to reaffirm their commitment to increasing access to medicines, and to translate such commitment into specific regulation within countries, especially enactment of national drug policies, establishment of lists of essential medicines based on evidence and with reference to WHO's Model List, and into actions designed to promote policy for, access to, and quality and rational use of medicines within national health systems; (2) to establish the necessary mechanisms for essential medicines lists that are science-based, independent of external pressures, and subject to regular reviews; (3) in addition to health policies and actions, to implement complementary measures to ensure that national lists of essential medicines are supported by standard clinical guidelines, preferably national therapeutic formularies, with the aim of promoting rational prescription; (4) to reaffirm, within the national drug policies, WHO's concept of essential medicines as those medicines that satisfy the priority health care needs of the population, reflecting also availability, quality, price and feasibility of delivery, and reemphasizing the evidence base for overall national discussions;

Documents EB I 09/7 and EB I 09/8, respectively. See document CD53/5. See resolution EMIRC48/R.2.

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(5) to continue monitoring the implications on access to medicines of recent patent-protection laws and compliance with WTO's Agreement on Trade-Related Aspects oflntellectual Property Rights (TRIPS); 2. REQUESTS the Director-General: (1) to strengthen the Expert Committee on the Use of Essential Drugs, ensuring its independence from external pressures at all times, the use of science-based criteria for revision and updating, and receipt, when appropriate and as required, of the necessary inputs from all relevant stakeholders; (2) to ensure that the WHO medicines strategy addresses the important issue of the impact of international trade agreements on access to medicines, and to reflect progress in its comprehensive endeavour in the relevant reports to WHO's governing bodies; (3) to advocate the necessary action worldwide to promote differential pricing for essential medicines between high- middle- and low-income countries, and to provide technical support, especially to developing countries, to establish drugpricing policies; (4) to advocate the concept and policies of essential medicines as a tool for implementing rational prescription of medicines; (5) to continue to work on the methodology for computerized databases on reference prices of essential medicines worldwide; (6) to pursue all diplomatic and political opportunities aimed at overcoming barriers to access to essential medicines, collaborating with Member States in order to make these medicines accessible and affordable to the people who need them; (7) to join with and support nongovernmental organizations in the process of implementing initiatives that are compatible with public health priorities.

Mr BERMUDEZ (alternate to Professor Yunes, Brazil) explained that the draft resolution was the result of the work of an informal drafting group which had met for the purpose of merging two earlier draft resolutions; the first proposed by Brazil, and the second, which had been incorporated unamended, by Cuba, Egypt, India, the Islamic Republic of Iran, Jordan, Myanmar, the Philippines and Saudi Arabia. The joint resolution enjoyed the additional support of Colombia and Venezuela. He commended the draft resolution to the Board for adoption. Mr SELIM LABIB (alternate to Dr Sallam, Egypt) and Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba), speaking as cosponsors of one of the original draft resolutions, expressed their support for the new joint resolution. Dr ROMUALDEZ (Philippines) commended the draft resolution as one further step in WHO's efforts to ensure that medicines were accessible to everyone, including the poor. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland), praising the draft resolution, proposed that, in subparagraph 2(3), the words "market-based" be inserted before "differential pricing". Dr GIRMA (Ethiopia) was in favour of adopting the draft resolution as it stood.

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Mr STEIGER (United States of America), 1 speaking at the invitation of the CHAIRMAN, said that he had a few reservations with respect to the draft resolution but supported its spirit and intent. He urged the Board members to support the amendment proposed by the United Kingdom. The resolution, as amended, was adopted. 2 Infant and young child nutrition: Item 3.8 of the Agenda (continued from the seventh meeting) • Global strategy for infant and young child feeding: (Document EB 109/12) (continued from the seventh meeting) The CHAIRMAN invited the Executive Board to consider a draft resolution entitled "Infant and young child nutrition", which incorporated amendments proposed by Brazil, the Islamic Republic of Iran, Saudi Arabia, Sweden and Switzerland to the draft resolution set out in document EB109/12, and which read as follows: The Executive Board, Having considered the draft global strategy for infant and young child feeding, 3 RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Having considered the draft global strategy for infant and young child feeding; Deeply concerned about the vast numbers of infants and young children who are still inappropriately fed and whose nutritional status, growth and development, health and very survival are thereby compromised; Conscious that every year as much as 55% of infant deaths from diarrhoea! disease and acute respiratory infections may be the result of inappropriate feeding practices, that less than 35% of infants worldwide are exclusively breastfed for even the first four months of life, and that complementary feeding practices are frequently ill-timed, inappropriate and unsafe; Alarmed at the degree to which inappropriate infant and young child feeding practices contribute to the global burden of disease, including malnutrition and its consequences such as blindness and mortality due to vitamin A deficiency, impaired psycho-motor development due to iron deficiency and anaemia, irreversible brain damage as a consequence of iodine deficiency, the massive impact on morbidity and mortality of protein-energy malnutrition, and the later-life consequences of childhood obesity; Mindful of the challenges posed by the ever-increasing number of people affected by major emergencies, the HIV/AIDS pandemic, and the complexities of modem lifestyles coupled with continued promulgation of inconsistent messages about infant and young child feeding; Aware that inappropriate feeding practices and their consequences are major obstacles to sustainable socioeconomic development and poverty reduction; Reaffirming that mothers and babies form an inseparable biological and social unit, and that the health and nutrition of one cannot be divorced from the health and nutrition of the other; 1

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board. Resolution EBI09.RI7. Document EBI09/12.

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Recalling the Health Assembly's endorsement (resolution WHA33.32), in their entirety, of the statement and recommendations made by the joint WHO/UNICEF Meeting on Infant and Young Child Feeding in 1979; its adoption of the International Code of Marketing of Breast-milk Substitutes (resolution WHA34.22), in which it stressed that adoption of and adherence to the code were a minimum requirement; its welcoming of the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding as a basis for international health policy and action (resolution WHA44.33); its urging encouragement and support for all public and private health facilities providing maternity services so that they become "baby-friendly" (resolution WHA45 .34 ); its urging ratification and implementation of the Convention on the Rights of the Child as a vehicle for family health development (resolution WHA46.27); and its endorsement, in their entirety, of the World Declaration and Plan of Action for Nutrition adopted by the International Conference on Nutrition (resolution WHA46.7); Recalling also resolutions WHA35.26, WHA37.30, WHA39.28, WHA41.11, WHA43.3, WHA45.34, WHA46.7, WHA47.5, WHA49.15 and WHA54.2 on infant and young child nutrition, appropriate feeding practices and related questions; Recognizing the need for comprehensive national policies on infant and young child feeding, including guidelines on ensuring appropriate feeding of infants and young children in exceptionally difficult circumstances; Convinced that it is time for governments, civil society and the international community to renew their commitment to promoting the optimal feeding of infants and young children and to work together closely for this purpose, 1. 2. ENDORSES the global strategy for infant and young child feeding; URGES Member States, as a matter of urgency: (1) to adopt the global strategy, implementing it as appropriate to national circumstances, taking into account local traditions and values, as part of their overall nutrition and child-health policies and programmes, in order to ensure optimal feeding for all infants and young children; (2) to strengthen existing, or establish new, structures for implementing the global strategy through the health and other concerned sectors, for monitoring and evaluating its effectiveness, and for guiding resource investment and management to improve infant and young child feeding; (3) to define for this purpose, consistent with national circumstances: (a) national goals and objectives, (b) a realistic timeline for their achievement, (c) measurable process and output indicators that will permit an accurate monitoring and evaluation of action taken and a rapid response to identified needs; (4) to mobilize all concerned social and economic resources within civil society, including scientific, professional, nongovernmental, voluntary, and commercial groups and associations, and to engage them actively in implementing the global strategy and achieving its aim and objectives;

3. CALLS UPON other international organizations and bodies, in particular ILO, FAO, UNFPA, UNICEF, UNHCR and UNAIDS, to give high priority, within their respective mandates and programmes, consistent with guidelines on conflict of interest, to support governments in implementing this global strategy, and invites donors to provide adequate funding for the necessary measures;

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4. REQUESTS the Codex Alimentarius Commission to continue to give full consideration, within the framework of its operational mandate, to action it might take to improve the quality standards of processed foods for infants and young children and to promote their safe and proper use at an appropriate age, consistent with the policy of WHO, in particular the International Code of Marketing of Breast-milk Substitutes, resolution WHA54.2 and other relevant resolutions of the Health Assembly; 5. REQUESTS the Director-General: (1) to support Member States, on request, in implementing this strategy and monitoring and evaluating its impact; (2) to continue developing, in the light of the scale and frequency of major emergencies worldwide, specific information and training materials aimed at ensuring that the feeding requirements of infants and young children in exceptionally difficult circumstances are met; (3) to strengthen international cooperation with other organizations of the United Nations system and bilateral development agencies in promoting appropriate infant and young child feeding; (4) to promote continued cooperation with and among all parties concerned with implementing the global strategy.

Mr SELIM LABIB (alternate to Dr Sallam, Egypt) suggested that the third preambular paragraph of the draft resolution be amended to read: "Conscious that every year as much as 55% of infant deaths from diarrhoea! disease and acute respiratory infections may be the result of inappropriate feeding practices, that exclusive breastfeeding for the first six months and continued breastfeeding, with safe and appropriate complementary foods up to the age of two years and beyond, must replace ill-timed, inappropriate and unsafe infant feeding practices in order to reduce infant and young child malnutrition and mortality;" He further suggested that paragraph (4) be amended to read as follows: "REQUESTS the Codex Alimentarius Commission to continue to give full consideration, within the framework of its operational mandate, to the action it might take to ensure the protection of exclusive breastfeeding for six months in its work to improve the quality standards of processed foods for infants and young children and to promote their safe use at an appropriate age, in line with the International Code of Marketing of Breast-milk Substitutes, resolution WHA54.2 and other relevant World Health Assembly resolutions." If those amendments were not acceptable to the Board, he would join the consensus. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) endorsed Egypt's proposals. It would be useful if the draft resolution could be considered in the light of all the proposed amendments, including those which Cuba had submitted. The fourth preambular paragraph should end with the words "protein-energy malnutrition", the rest being deleted, and two new preambular paragraphs should be added, which would read: "Aware that inadequate breastfeeding and poor complementary feeding practices, as well as the marketing of inappropriate foods has been associated with the rising incidence of overweight and the later-life consequences of childhood obesity; Considering that micronutrient interventions should not replace or undermine support for the sustainable practice of exclusive breastfeeding and optimal complementary feeding and

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acknowledging that the marketing of nutritional supplements should be subject to the protective provisions of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions." In paragraph 2(1 ), a new phrase should be added, which would read: "and to reduce the risks associated with obesity and other forms of malnutrition.". Mr CICOGNA (alternate to Dr Di Gennaro, Italy) recalled that, when the global strategy for infant and young child feeding had been discussed, the text of the draft resolution as it stood had been considered well balanced and well structured. Although the content of the proposed amendments was in line with the proposed strategy and the resolution as a whole, they appeared to be unduly long. The text as it stood was preferable. Ms V ALDEZ (United States of America), 1 speaking at the invitation of the CHAIRMAN, welcomed the comprehensive nature of the draft resolution and endorsed the view ofltaly. The CHAIRMAN said she took it that the Board wished to adopt the resolution as it stood.

The resolution was adopted. 2

PROGRAMME AND BUDGET MATTERS: Item 4 of the Agenda

Meeting oflnterested Parties, 2001: Item 4.I of the Agenda (Document EBI09/18) The CHAIRMAN, introducing the item, said that document EBI09/I8 provided background information on the Meeting oflnterested Parties which had taken place in Geneva in June 2001. The Board's attendance at the meeting was referred to in paragraph 8. Dr SADRIZADEH (Islamic Republic of Iran) said that the meeting had been well organized, with excellent documentation and presentations on WHO activities at global, regional and country levels. The two main concerns raised by some of the participants had already been addressed in the context of the proposed actions in paragraph I2 ofthe report, which he fully supported. Mrs BERGER (alternate to Professor Zeltner, Switzerland) said that, following discussions with other members of the Board, she had decided to focus on questions of process rather than content, which would be taken up by other members. The report was a first stage in responding to the desire expressed in 200 I by participants in the Meeting of Interested Parties to keep the Board informed of the matters discussed. It was important that all interested parties - Member States, the Secretariat and the many international health partners such as nongovernmental organizations, scientists, universities, the private sector and industry- be given an opportunity to consider the justification for the meetings, their objectives and the value of participation in the light of the overall cost in terms of human, financial and technical resources and time for all concerned. Together, it should be possible to ensure that the meetings met the expectations of the various partners. Greater attention should be given to increasing the participation of developing countries. To that end, WHO should initiate a process to facilitate an exchange of views and perceptions on the functions of the meetings. The present Board meeting was the first stage in sounding the views of Member States and the Secretariat, and WHO's 1 2

Participating by virtue of Rule 3 of the Rules ofProcedure of the Executive Board. Resolution EBI09.RI8.

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assistance in continuing that process with all the interested parties would be important. It would then be easier to determine the structure of the Meetings of Interested Parties, their optimum duration, the interface with special programmes such as on tropical diseases and reproductive health and the function of the meetings in the strategic and budget planning cycle of the Organization. Although it would be difficult to reconcile all expectations and interests, such consultations would be helpful in clarifying the various positions and facilitating the work of improving the meetings. Dr THIERS (Belgium) said that the two meetings he had attended in 2000, one on food safety and the other on evidence and information for policy had been disappointing. At the latter meeting, which he had chaired, only 17 of the 28 countries that had registered were represented, and only one of those, Indonesia, was a developing country. Representatives of 20 countries had attended the food safety meeting, but most were from the permanent missions in Geneva. It was important therefore to consider the reasons for the poor attendance, the purpose of the meetings, the target audience, which countries attended and which did not. The Belgian representative from the Ministry of Cooperation for Development had found the meetings very useful from the point of view of contacts, and he himself found the content of the meetings excellent. Nevertheless, the Director-General should analyse the situation thoroughly with respect to the effectiveness and cost-effectiveness of the meetings, because, unless they attracted enough participants, they served little purpose. Mr JANG Chun Sik (Democratic People's Republic of Korea) said that the Meeting of Interested Parties 2001 had provided WHO's partners with an opportunity to hold frank, constructive discussions on matters of interest. As the Director-General had stated at the time, securing sufficient funds was essential for successful implementation of the strategic programmes and rational management of the programme budget. In that sense, he supported the proposals set out in paragraph 12 of the report. Mr TASAKA (alternate to Dr Shinozaki, Japan) said that the meetings provided a valuable opportunity to gain insight into many of the Organization's programmes and generate feedback from the various interested parties. The lack of satisfaction of most participants with the meetings was due to two reasons. First, they were time consuming and overlapped with other important meetings and, secondly, they usually followed the Health Assembly. As the information could be obtained at any time through the Internet, there was every reason to reconsider the methods of presentation and discussion. The role of the meetings should be more focused and they should address specific areas of work or specific programmes. Ms WIGZELL (Sweden) said that the Meetings of Interested Parties should be a forum for providing in-depth information and dialogue, in order to increase transparency and provide additional input to the work of WHO. It was particularly important to secure the participation of the developing countries. The meetings should also provide an opportunity for the partners to assess the ongoing work of the Organization at all levels and for WHO to benefit from the technical and policy input of the partners. They should not be designed specifically to elicit voluntary contributions but could also help to strengthen the strategic budget process, thereby contributing to the smooth functioning of the Organization. The documents provided at the meetings should be in the format of and part of the planning, reporting and evaluation cycle of the two-year strategic budget, including voluntary and assessed contributions. They should not take the form of special reports to the meetings, which would put an added burden on the Secretariat. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) said that, judging by the information given in the report, particularly on the format and objectives of the meetings, he wondered whether they might not better be incorporated into the work of the Programme and Development Committee. If they were to continue in their present form, they might be used to analyse the programmes and priorities for the 2004-2005 biennium, with a view to identifying possible donors.

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Mr CICOGNA (alternate to Dr Di Gennaro, Italy) agreed with the member from Switzerland on the need to clarify the scope of the meetings through a process that could start at the present meeting and draw its conclusions in the near future. There should, in particular, be agreement on the management of the meetings, which should be an effective forum for dialogue with and between WHO partners, where the activities of the year and future strategy could be discussed within the framework of the overall budget. The meetings should not constitute a new governing body but a channel for the exchange of information and concerns, or support for ongoing activities. It was therefore important that all interested parties should be represented, since they all had a role to play. Dr NABARRO (Executive Director) said that the comments of the members would help to ensure that the new approach to strategic programme budgeting and management was open and accessible to Member States and other interested parties. Management of the Meetings of Interested Parties had been evolving, and he had noted that many Member States had expressed the wish that such work continue, while stressing the need for a clearer definition of the purpose of the meetings. They were intended to fit into the existing strategic programme management process and to be seen to support the governance of the Organization by the Board, its subcommittees and the Health Assembly, rather than as a separate mechanism. He had also noted the calls for greater consultation on the process and for any documentation to be limited to what was essential and to be part of the planning and reporting cycle. He expressed the hope that some of the specific concerns expressed would be allayed by implementation of the plans referred to in paragraph 12. A more detailed summary report 1 had been prepared for the benefit of Member States who had not attended the 2001 Meeting. The CHAIRMAN took it that the Executive Board wished to take note of the report and to ask the Director-General to take into account the comments made.

It was so agreed. Priorities for the biennium 2004-2005: Item 4.2 of the Agenda (Document EB109/19) Mr BERMUDEZ (alternate to Professor Yunes, Brazil) said that, although countries all over the world sought to improve the health of their populations, it was nevertheless essential to set priorities to enable governments to establish appropriate funding. He therefore welcomed the report contained in document EB 109/19. In relation to the 11 specific priorities for the biennium, which were vital, he proposed that "maternal health" be renamed "maternal and child care", so as to include infant care. One issue that had been considered a priority in all recent forums was access to medicines, which concerned developed and developing countries alike. He referred to the current political and economic crisis in Argentina, where the Government had declared a health emergency as a result of the lack of medicines, to which Brazil had responded with the immediate provision of essential medicines. He formally requested that the issue of access to medicines be included in the list of priorities for the next biennium. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) expressed overall support for the priorities for 2004-2005, but agreed with both proposals made by the member from Brazil. He further proposed adding dengue and dengue haemorrhagic fever, with a regional emphasis on the areas most affected, to the list of global priorities. Dr LOPEZ (Venezuela) endorsed the list of priorities but agreed that the issue of access to medicines was a priority within most of the items on the list. She agreed with the proposal of the member from Brazil that issues relating to a mother and her child could not be dealt with separately.

Meeting oflnterested Parties, Geneva, 18-29 June 2001, Document MIP/01/SUM.

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She also endorsed the proposal of the member from Cuba to include dengue fever in the list of priorities, given that the areas at risk or potentially at risk from dengue were on the increase. Or BODZONGO (Congo), while recognizing that it was not possible to deal with every health problem at the same time, nevertheless supported the proposal to add the important subject of medicines to the list of priorities. Mr SELIM LABIB (alternate to Dr Sallam, Egypt) supported the proposals of the members from Brazil and Cuba and, in particular, the proposal to add access to medicines to the list of priorities, to which he proposed adding the word "affordable", so that the item would read "affordable access to medicines". Mr JANG Chun Sik (Democratic People's Republic of Korea) observed that the priorities had been well selected in view of the health challenges faced by the world but agreed that access to medicines should be added. He welcomed and supported the proposal to allow regional offices to set a limited number of additional region-specific programmes, agreed with other speakers that the health of mother and child were inextricably linked and endorsed the addition proposed by the member from Brazil. Mr TASAKA (alternate to Dr Shinozaki, Japan) observed that "health and environment" was a new item on the 2004-2005 list of priorities and enquired what the grounds for its inclusion were. Mrs BENAVIDES COTES (alternate to Dr Boshell, Colombia) reiterated the request she had made during the discussion on item 3.6, "WHO medicines strategy", namely that access to medicines be included on the list of WHO priorities. That was particularly important because WHO was to lead the way in implementing the Doha Declaration on the TRIPS Agreement and Public Health. Furthermore, the Board had just adopted a resolution on access to medicines.' She too endorsed the proposal made by the member from Cuba to include dengue in WHO's work. Ms WIGZELL (Sweden) applauded the procedure adopted by WHO of first setting long-term priorities and subsequently developing a strategic budget. It was appropriate for the Board to analyse core functions and decide whether, on the basis of a constantly evolving situation, its priorities needed to be reordered. She praised WHO's attempts to obtain greater input from the regions. The inclusion of "health and environment" in the list of priorities was to be welcomed, and the World Summit on Sustainable Development, to be held in Johannesburg later in the year, would be a milestone. Emphasis on health and environment would allow WHO to create an institutional environment for the health sector and promote an effective health dimension for social, economic, environmental and development policy. She supported the proposal put forward by several members of the Board to include child health in the list of priorities. Dr ROMUALDEZ (Philippines) supported the proposal of the members from Brazil and Cuba with regard to access to medicines, which had been a problem for his country for over two decades. Professor KULZHANOV (Kazakhstan) supported the priorities as set out, with the addition of those proposed by the members from Brazil and Cuba. He proposed addition of "sexually transmitted diseases" after "HIV/AIDS", as those conditions often occurred concurrently. He further proposed addition of "alcohol" after "tobacco". The item "health systems" should read "reform of health systems". Referring to the item "cancer, cardiovascular disease and diabetes", he said that "trauma"

Resolution EB109.Rl7.

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was also an important problem in many countries. In order that the item be all-inclusive, it should be changed to read "leading noncommunicable diseases". Professor GRABAUSKAS (Lithuania) welcomed the inclusion of noncommunicable diseases on the list of priorities. The global burden of such diseases consumed an ever-increasing proportion of national health budgets, and a global focus on that important area should remain a priority. Dr MBAIONG (Chad), supporting the proposal to include access to essential medicines among the priorities, stressed that health systems should remain a priority, as strengthening those systems was essential. He noted that WHO's list of priorities included areas of specific interest for Africa, namely malaria, tuberculosis and HIV/AIDS. Dr MOON (alternate to Dr Om, Republic of Korea) agreed in principle with the 11 specific priorities but requested that use of traditional medicine should receive special attention under the item "health systems", as his country's use of such medicine in primary health care had proved to be costeffective. That had become an important consideration for health sectors worldwide. Dr AL-MAZROU (Saudi Arabia) also agreed with the list of priorities and supported the proposals to combine maternal and child health as a single priority and to include access to essential medicines on the list; both of those items had been adopted as priorities for strategic aspects of country programmes at the meeting of the Regional Committee for the Eastern Mediterranean, held in September 2001. Dr DORLER (alternate to Professor Zeltner, Switzerland) said that his country had requested inclusion of "health and environment" as a priority on the grounds that health problems caused by environmental pollution were common in almost all Member States. He supported the proposal to extend the priority of maternal health to include child health. Dr GIRMA (Ethiopia) welcomed the reaffirmation of malaria, tuberculosis and HIV/AIDS as top priorities. He agreed that the subject of access to medicines should be a continued priority and that maternal and child health should be inseparable. Attention should also be devoted to major regional health priorities such as trypanosomiasis, which claimed 100 lives a day and to which 60 million inhabitants of37 countries in Africa were vulnerable. Dr AGGARWAL (alternate to Mr Chowdhury, India) said that strokes were a significant and growing cause of mortality and morbidity and should therefore be added to the noncommunicable diseases listed as a priority, together with accidental injuries, which also represented a burden, especially in developing countries. Dr SADRIZADEH (Islamic Republic of Iran) considered that all leading noncommunicable diseases should be listed as a priority. Mr SELIM LABIB (alternate to Dr Sallam, Egypt) stressed that the Brazilian proposal to add the item "access to medicines" as a priority was consistent with the spirit of the resolution that had just been adopted by the Board, 1 on "essential medicines" and not "essential drugs", a matter on which Egypt's views were already well known. He reiterated his proposal that the item read "affordable access to medicines", as affordability was a crucial prerequisite to accessibility.

Resolution EB 109 .R 17.

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Mr STEIGER (United States of America), 1 speaking at the invitation of the CHAIRMAN, commended the progress of the Board in its work and welcomed the constructive dialogue and friendly spirit of cooperation among its members. In his view, the list of priorities accurately reflected the spectrum of global challenges in the field of health. In regard to the proposal of the member from Brazil and the comments of the member from Chad, he considered that the theme of access to medicines was covered by the priorities malaria, tuberculosis and HIV/AIDS. Although the item "investing in change in WHO" had been removed from the list, he expressed the hope nevertheless that the Director-General would pursue the programme for reform of the Organization. It had been a great honour for his country to participate in the work of the Organization during the past year, and he reiterated its commitment of future support. Mr BERMUDEZ (alternate to Professor Yunes, Brazil) said that, contrary to the opmwn expressed by the previous speaker, the question of access to medicines was not covered by the priority items malaria, tuberculosis and HIVI AIDS. Moreover, it was only partially reflected within the other priorities. He therefore reiterated his proposal to include access to medicines as a priority for the biennium 2004-2005. Mr THINUS (European Commission), speaking at the invitation of the CHAIRMAN, said that the new framework of cooperation established by an exchange of letters between the European Commission and WHO in December 2000 was a useful basis for improving synergy in the work of the two organizations. They had thus been able to launch common activities and coordinate actions, with extremely promising results, while avoiding unnecessary duplication of work. In the context of those letters, regular meetings took place between the Health Commissioner of the European Commission and the Director-General, as well as between officials from the two organizations, with a view to discussing joint work in key areas identified in the letters. Several joint events on areas of common interest to both organizations, such as mental health, young people and alcohol, had been held in 2000, and the European Commission was actively involved in the work of the Intergovernmental Negotiating Body on the WHO framework convention on tobacco control. Today's new challenges in the field of health demanded greater cooperation on health risks in developing countries. In that respect, revision of the International Health Regulations was an immediate priority. The DIRECTOR-GENERAL recalled that the list of priorities presented to the Board formed part of a process of consultation with Member States before her budget proposals for the biennium 2004-2005 were made. No final decisions were envisaged at the current meeting. Although the item "health and environment" had been added as a new priority, the number of priorities had not changed. Given the many key issues and areas in which WHO was involved, she was acutely aware of the difficulty of maintaining a limited number of priorities. Of the numerous areas mentioned by the members, however, the two substantive areas of child health and access to affordable medicines stood out. Means could be explored of combining child health as a priority with maternal health, without any ensuing dilution of either issue. Access to affordable medicines was an extremely important issue that cut across many of the priorities listed and not simply those of malaria, tuberculosis and HIV I AIDS. With a view to ensuring that those two issues received appropriate attention, she would consider how best to incorporate them into the work of the Organization as the process of preparing the programme budget moved forward.

Participating by virtue of Rule 3 of the Rules ofProcedure of the Executive Board.

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The CHAIRMAN said that she took it that the Executive Board wished to request the DirectorGeneral, during her preparation of the budget for the biennium 2004-2005, to take into consideration the comments that had been made.

It was so agreed.

The meeting rose at 12:50.

TENTH MEETING Friday, 18 January 2002, at 14:10 Chairman: Mr J.A. CHOWDHURY (India) Later: Mrs M. ABEL (Vanuatu)

PROGRAMME AND BUDGET MATTERS: Item 4 of the Agenda (continued)

Miscellaneous income: Item 4.3 of the Agenda (Documents EB109/23 and EBABFC16/3) Dr KARAM (Lebanon), speaking as Chairman of the Administration, Budget and Finance Committee (ABFC), recalled that five Member States had responded to the Director-General's appeal and that regular contact had been maintained with Member States in that regard; the total current requirement in miscellaneous income had been reduced from the original figure ofUS$ 52.1 million to US$ 46.9 million. The estimated shortfall of some US$ 13 million for 2002-2003 would be kept under review. The picture would be much clearer by the time of the Fifty-fifth World Health Assembly in May 2002, and further updates would be made, if necessary, for the Board's 111 th session in January 2003. With regard to the Financial Incentive Scheme, the Committee had noted that the arrangement proposed would speed up the transition from the old scheme, governed by resolution WHA41.12, to the new scheme established under the revised Financial Regulations and Financial Rules. The result of the proposal, which did not alter the amount to be credited, would be that the Member States concerned would receive credits due under the old incentive scheme in 2002-2003 rather than in 2004-2005. The Committee recommended that the Executive Board note the report on miscellaneous income (document EB 109/23) and adopt the draft resolution in its paragraph 11. The CHAIRMAN said that, in the absence of comments, he took it that the Board noted the report and wished to adopt the draft resolution. It was so decided and the resolution was adopted. 1

FINANCIAL MATTERS: Item 5 ofthe Agenda

Assessed contributions: Item 5.1 of the Agenda • Status of collection (Documents EB 109/20 and Corr.l, EB 109/20 Add.l and EBABFC 16/3) Dr KARAM (Lebanon), speaking as Chairman of ABFC, said that the Committee had noted the maintenance in 2001 of the improved rate of collection of contributions with, by contrast, a lack of progress in reducing arrears, which had risen slightly since the end of the 1998-1999 biennium. It had also noted that document EB109/20 contained information as at 30 November 2001 and that

Resolution EBI09.RI9.

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US$ 16 million had since been received in respect of assessments for 2001, and US$ 33 million in respect of future year assessments. The Committee had thanked the the Gambia, Italy, the Philippines, Poland, Puerto Rico and the United States of America for payments made in respect of 2001 assessments since 30 November 2001. Noting that US$ 33 million had been received in December 2001 as advance payment on 2002 assessments, the Committee had also thanked Canada, Cuba, the Gambia, Haiti, Latvia, Lithuania, New Zealand, Poland, Sao Tome and Principe, Slovakia and the United Kingdom of Great Britain and Northern Ireland for such payments. It had also noted payments made in January 2002 by Colombia, Indonesia and Uruguay. The Committee would prepare resolutions at its seventeenth meeting in May 2002 for consideration by the Fifty-fifth World Health Assembly in respect of Members so much in arrears as to justify invoking Article 7 of the Constitution. Resolutions would also be prepared at that time in respect of all Member States having made requests by 31 March 2002 for special arrangements regarding payment of arrears, including the Dominican Republic, which had already made such a request, and in regard to the proposal to waive the arrears of Somalia. The Committee recommended that the Board take note of the report contained in documents EB 109/20 and Corr.1 and EB 109/20 Add. I. Mr BAQUEROT (Executive Director) said that since the previous meeting of ABFC Pakistan and Portugal had paid their assessments for 2001 in full, and the Philippines had paid part of its assessment for that year. In addition, Belize, Hungary, Ireland and Singapore had paid their assessments for 2002 in full. The CHAIRMAN said that he took it that the Board wished to take note of the report and to note that the Committee, at its seventeenth meeting, would prepare resolutions, for consideration by the Fifty-fifth World Health Assembly, on the proposals in respect of the arrears of the Dominican Republic and Somalia. It was so agreed. • Assessments for 2003 (Documents EB109/21, EBABFC16/3 and EB109/INF.DOC./2) Mr KARAM (Lebanon), speaking as Chairman of ABFC, said that, with regard to the United Nations methodology relating to its scale of assessment, the Committee had been informed that copies of the report made by the Committee on Contributions to the United Nations General Assembly at its fifty-fifth session were available to Member States. It contained information that might be useful in considering the scale of assessment for 2004-2005. Mr CICOGNA (alternate to Dr Di Gennaro, Italy), speaking on behalf of Member States of the European Union, expressed appreciation of the documentation on financial matters but emphasized that such material should be circulated no later than the first half of December to allow time for extensive consultation between Member States. With regard to miscellaneous income, the estimated shortfall of US$ 13 481 082 for the current year was a cause for concern, since it would affect the countries in greatest need of the Organization's operations. Although the receipt of 83% of Member States' contributions by 30 November 2001 and of an increasing number of payments in full was encouraging, the level of amounts outstanding from earlier periods remained worrying. Countries should meet their obligations by paying arrears and assessed contributions in full, on time and unconditionally, since that was essential to sound WHO finances. He encouraged the Director-General to take steps to enable the Board, at its 111 th session, to adopt appropriate measures to be approved by the Fifty-sixth World Health Assembly for the 2004-2005 biennium. He also understood that the assessment for 2003, as set out in resolution WHA54.17, would be applied. He therefore supported the Board's recommendation to maintain the assessment for 2003 accordingly and recalled resolutions WHA8.5 and WHA24.12, which had

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established and reaffirmed the principle that the latest available United Nations scale of assessment would serve as a basis for determining the scale to be used by WHO. Mr TASAKA (alternate to Dr Shinozaki, Japan) said that he shared the concerns expressed by the previous speaker. Before debating contributions for 2004-2005 at the Health Assembly, all countries should be aware that the assessment method traditionally adopted by WHO was that used by the United Nations. The United Nations scale of contributions was the best basis for calculation, having been designed to ensure the utmost fairness for all Member States in terms of their capacity to pay. Japan did not see how any fairer scale could be proposed after the many months of intensive deliberations and consideration of each country's economic situation. Since no fairer scale seemed possible, he urged the Secretariat to take the initiative in the matter. The CHAIRMAN said that, there being no further comments, he took it that the Board wished to recommend that the Fifty-fifth World Health Assembly should maintain the assessments for 2003 as adopted in resolution WHA54.17, while taking steps to prepare for the following biennium. It was so agreed.

Revolving and other long-term funds: Item 5.2 of the Agenda (Documents EB109/22 and EBABFC 16/3) Mr KARAM (Lebanon), speaking as Chairman of ABFC, said that the Committee had discussed four different funds. With regard to the Real Estate Fund, it had noted that initial five-year plans had been prepared but had considered that they should be developed more comprehensively, the better to delineate priorities. It had noted that the Director-General's budget proposals for future bienniums would include proposals for funding the Real Estate Fund based on those long-term plans, and that the estimated cost of the plans for the 2002-2003 biennium would be met from appropriations already approved by the Health Assembly. The Committee had also noted that the new building project was well in hand and that the Swiss authorities had continued to provide appreciated support. In that respect, an amendment to the draft resolution in paragraph 31 of document EB 109/22 had been proposed to the effect that, should WHO's share of the estimated construction cost be likely to exceed CHF 27 500 000 by more than 10%, authorization to incur additional expenditure would be sought from the Health Assembly. In discussing the Information Technology Fund, the Committee had noted that replacement of the 25-year-old core administrative systems had become a priority and that the process was entering its operational phase. Although initial funding had been allocated, the estimated project cost of some US$ 50 million would require additional funding through regular budget appropriations and allocations from programme support costs over at least three to four years. The estimated cost would become clearer in the ensuing six months as work progressed. Although it might be desirable to use an IT system common to all United Nations organizations at country level, integration would be impossible if such organizations had different global systems. However, common approaches in the areas of voice and networking communications were being explored with other United Nations bodies. With regard to the Security Fund, the Committee had fully supported the Director-General's decision to establish a fund to ensure WHO staff security and safety worldwide, supporting both the global United Nations Security Management System and the security coordination function within WHO. It had noted that a review of the Revolving Sales Fund's presentation in the Organization's Financial Report had resulted in the draft resolution in paragraph 32 of document EB 109/22, to the effect that all the Fund's operations would be presented under one account. The Committee recommended that the Board note the report contained in document EB 109/22, and adopt the draft decision tabled by the Committee on the Security Fund, the amended version of the

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draft resolution in paragraph 31 of the document in respect of the Real Estate Fund and the draft resolution relating to the Revolving Sales Fund in paragraph 32. The CHAIRMAN drew attention to a draft decision on the establishment of a security fund proposed by the Committee, which read: Decision: The Executive Board, having considered the report on Revolving and other long-term funds, 1 noted the decision of the Director-General to establish a security fund for the purposes outlined in the report and commended the work carried out by WHO staff in difficult circumstances. The decision was adopted. 2

The CHAIRMAN invited the Board to consider a draft resolution entitled "Real Estate Fund", contained in document EB 109/22 and amended by the Committee, which read: The Executive Board, Having considered the Director-General's report on Revolving and other long-term funds; 1 Noting the outline plans for the five-year period 2002-2006 and the estimated cost thereof; Noting the status of negotiations with the Swiss authorities for the construction of a building in Geneva to provide accommodation to UNAIDS and additional office accommodation for WHO; Noting the proposals of the Regional Office for the Western Pacific Region to extend Building 2 and to construct a new four-storey building to provide additional office accommodation and parking, RECOMMENDS to the Fifty-fifth World Health Assembly the adoption of the following resolution: The Fifty-fifth World Health Assembly, Having considered the report of the Director-General on Revolving and other long-term funds, 1. EXPRESSES appreciation to the Swiss Confederation and to the Republic and Canton of Geneva for the continued expression of their hospitality; 2. AUTHORIZES the Director-General to proceed with the construction of a new building at headquarters at a cost currently estimated at CHF 55 000 000, of which WHO's share is estimated at CHF 27 500 000, on the understanding that if WHO's share were likely to exceed more than 10% of the aforementioned amount, further authority would be sought from the Health Assembly; 3. APPROVES the use of the Real Estate Fund for the repayment over a 50-year period of the WHO share of the interest-free loan to be provided by the Swiss authorities with effect from the first year of the completion of the building;

Document EB 109/22. Decision EB109(8).

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4. NOTES that negotiations are under way with the Swiss authorities with a view to reducing WHO's share of the loan to be provided by the Swiss authorities by the value of compensation for the demolition of the V building; 5. REQUESTS the Director-General to report at appropriate intervals to the Executive Board and the Health Assembly on progress in the construction of the new accommodation at headquarters and on related costs; 6. AUTHORIZES the construction of an extension to Building 2 and the construction of a new four-storey building to provide additional office accommodation and car parking in the Regional Office for the Western Pacific, to be financed from the Real Estate Fund. The resolution was adopted. 1 The CHAIRMAN drew attention to the draft resolution on the Revolving Sales Fund m paragraph 32 of document EB 109/22. The resolution was adopted. 2

OTHER MANAGEMENT MATTERS: Item 7 of the Agenda (continued from the ninth meeting, section 1)

Reports of the Executive Board Committees: Item 7.2 of the Agenda (continued from the ninth meeting, section I) • Programme Development Committee (Document EBPDC8/5) Ms WIGZELL (Sweden), speaking as Chair of the Programme Development Committee, said that at its eighth meeting the Committee had reviewed the reports of two thematic evaluations undertaken in 2001, one on the Poliomyelitis Eradication Initiative and one on WHO's strategic budgeting and planning procesS. Dr Salisbury, the head of the evaluation team on poliomyelitis, had described some of the challenges faced during the review, and summarized its main findings and recommendations. He had mentioned the problems of mobilizing resources, the inadequate forecasting of vaccine needs, varying levels of institutional support, and an initial absence of clear leadership. He believed such initiatives could benefit from early and regular reviews by high-level scientific experts. He had also noted the importance of ensuring that major investments in such programmes should leave a legacy of improved infrastructure and skills. The Committee had commended the evaluation team on its frank and comprehensive evaluation, and endorsed its recommendations, urging that the lessons learned be applied to other programmes. It had agreed on the urgency of eradicating poliomyelitis by the target date, and of being able to rely on secure supplies of vaccine. It had also stressed the importance of ensuring that sustainable benefits to the health infrastructure remained once poliomyelitis was eradicated. The Committee had also reviewed a report on the evaluation of WHO's strategic budgeting and planning process, presented by Dr Samlee, a member of the evaluation team. The Committee had endorsed the key recommendations of the evaluation. Its positive aspects included clear policy guidelines, a logical framework and the improved focus provided by the corporate strategy and the identification of a limited number of priorities. More work was needed to enhance the integration of 1 2

Resolution EB109.R20. Resolution EB 109 .R21.

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the budget, in terms of regular budget and extrabudgetary resources, training staff in the principles of results-based budgeting, and strengthening the evaluation phase of the budgetary cycle. Ways should be found to increase country participation, which was not adequate at present. An impact at country level was an obvious indication of success. The Committee had also reviewed a report on the current reporting requirements contained in resolutions ofthe Executive Board and Health Assembly, and had discussed ways of reducing ongoing reporting requirements. The solutions proposed included striking a better balance between reporting on specific items by a fixed date, and other mechanisms such as annual reports by the DirectorGeneral and thematic evaluations. As to the Committee's future meetings, it had noted the framework for global thematic evaluations presented in document EB107/INF.DOC./3, stating that such evaluations would be initiated by the Director-General in consultation with the Committee, and that progress reports would be submitted to the Committee at its annual session. The results of the planned evaluation of integrated management of childhood illness would be reported to a future meeting when complete. Dr AL-MAZROU (Saudi Arabia), observing that no mention had been made of the late arrival of documentation dispatched to Board members, requested that efforts be made to ensure that documents were received by members no later than two weeks before the meeting for which they were intended. The CHAIRMAN said that the request would be noted. He took it that the Board noted with appreciation the report on the work of the eighth meeting of the Programme Development Committee. It was so agreed.

• Administration, Budget and Finance Committee (Document EBABFC16/3) The CHAIRMAN said that, in the absence of comments, he took it that the Board wished to note with appreciation the work ofthe sixteenth meeting of the Committee.

It was so agreed. • Audit Committee (Document EBAC5/5) Dr OM (Republic of Korea), speaking as Chairman of the Audit Committee, said that the Committee had held its fifth meeting on 9 and I 0 January 2002. With a view to seeing how it could best assist WHO in pursuing reform, it had reflected on its mandate and found its terms of reference sufficiently detailed yet broad enough in scope for it to perform such a role. However, members of the Committee had expressed dissatisfaction that most of the documentation had not been dispatched in time to allow proper consultations. They had been assured that in future all documents would be forwarded I5 working days before the date of the meeting and that, if the translations were not ready, advance copies would be sent in English, but had nevertheless suggested that a study be made of the operational difficulties of producing documentation for the governing bodies. The Committee had considered the report of the External Auditor on the status of the implementation of recommendations, and had received an update on the progress of the external audit for 2000-200 I. It had noted the plans for 2002 of the Office of Internal Audit and Oversight but had questioned whether regional operations could be sufficiently covered through one visit a year and suggested other options, stressing the need to focus on major risks. The Committee had also reviewed reports of the Joint Inspection Unit, particularly a major report on the review of WHO management and administration, which had made highly pertinent and important recommendations. It had expressed strong support for the work of the Unit in that regard and had noted WHO's commitment to ensuring full implementation of the recommendations in the

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report. The report of the Committee's fourth meeting, held on 10 and 11 May 2001, had been transmitted to the Board for information and was contained in document EBACS/2. The CHAIRMAN said that, as there were no comments, he took it that the Board wished to note with thanks the report of the Audit Committee on the work of its fifth meeting. It was so agreed. o

Nongovernmental organizations (Document EB 109/29)

Dr SADRIZADEH (Islamic Republic of Iran), speaking as Chairman of the Standing Committee on Nongovernmental Organizations, said the Committee had expressed its appreciation of the work of the applicant organizations, especially those whose activities had been reviewed. The recommendations of the Committee were set out in the proposed draft resolution on relations with nongovernmental organizations and the draft decision on review of nongovernmental organizations in official relations with WHO. The CHAIRMAN invited the Board to consider the draft resolution contained in section IV of document EB109/29. The resolution was adopted. 1 The CHAIRMAN invited the Board to consider the draft decision in section IV of document EB109/29. The decision was adopted. 2 o

WHOIUNICEFIUNFPA Coordinating Committee on Health (Document EB109/38)

The CHAIRMAN invited Professor Yunes, a member of the Coordinating Committee, to comment on the third session of the Committee, held in New York on 19 and 20 April200 1. Professor YUNES (Brazil) said that the third session of the WHO/UNICEF/UNFPA Coordinating Committee on Health had focused on two main items. The first was a report on progress in implementing the numerous recommendations made by the Committee at its second session, which were set out in Annex 3 to document EB 109/3 8 and related for the most part to the outcome of the five-year review in 1999 of the International Conference on Population and Development. Maternal mortality, adolescent health, prevention of mother-to-child transmission of HIV, benchmark indicators and gender came within the category of follow-up to that Conference, for which UNFP A was the lead agency. Immunization, an area of long-standing and productive collaboration between WHO and UNICEF, had been the other subject taken up at the second and third sessions of the Committee. The second main item was sector-wide approaches for health development, characterized by national ownership of the process, cooperation on agreed national health agendas and better management of development assistance. Presentations on national experiences in Cambodia and Uganda had been made by country teams of national experts and agency representatives. The Committee had decided to hold its next biennial meeting in Geneva, when it would review the collaboration in sector-wide approaches in one or two countries, focusing to the extent possible on maternal and newborn health, violence, especially against women and girls, and HIV I AIDS and young people. 1 2

Resolution EB109.R22. Decision EB I 09(9).

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Mr MACDONALD (UNFPA), speaking at the invitation of the CHAIRMAN, said that he was glad to note the enhanced convergence of areas of interest to both WHO and UNFP A. He particularly welcomed progress in the work of the Coordinating Committee on Health. UNFP A was committed to increasing its cooperation with WHO and UNICEF in areas of common interest. Dr EL ABASSI (UNICEF), speaking at the invitation of the CHAIRMAN, said that UNICEF attached great importance to its collaboration with WHO. The Coordinating Committee was a mechanism for reviewing and extending collaboration between UNICEF and both WHO and UNFPA and for defining the specific contribution of each organization to the development of effective new programmes and interventions. It was also a means of supporting interventions aimed at improving the health of women and children, learning lessons from activities at the country level. The CRt\.IRMAN said that he took it that the Board wished to take note of the report of the WHOIUNICEFIUNFPA Coordinating Committee on Health. It was so agreed.

Reports of the Joint Inspection Unit: Item 7.3 of the Agenda (Documents EB109/30, EB109/30 Add.l and EBAC5/5) Dr OM (Republic of Korea), speaking as Chairman of the Audit Committee, said that the Committee had expressed its appreciation of the comprehensive report on the review of management and administration in WHO contained in document EB109/30. The Committee had been reassured that the work of the Joint Inspection Unit was fully in line with initiatives under way at WHO. On the whole, the recommendations contained in the report were welcomed. The recommendation on decentralization was particularly important for WHO. The Audit Committee had expressed some concern that a deadline had not been set for laying down criteria of the desirable type of country representation, and the Board might wish to consider whether it should urge that the time frame proposed by the Joint Inspection Unit be followed. The Committee had also stressed that defining criteria of the type and level of country presence was only one way in which WHO could improve its performance at country level- a key component of the reform process. With regard to the Joint Inspection Unit's recommendations on evaluations, the Committee had agreed that the thematic evaluations carried out in 2001, which had been discussed at the eighth meeting of the Programme Development Committee, were good examples of the type of evaluations that should be made available on the Internet. The Committee had welcomed the Organization's efforts at results-based budgeting and its intent to strengthen programme evaluation. Strategic budgeting should become an integral part of WHO's work at all levels. Some frustration had been expressed about the loss of momentum for change within certain programmes or clusters. Since strategic budgeting entailed a cultural change for the whole Organization, it was expected that further progress would be made in the coming biennium, particularly as a result of the preparations for the programme budget 2004-2005 under way. The Joint Inspection Unit's report gave special attention to the management of human resources. As in many other United Nations agencies, there was a need to rejuvenate and diversify the workforce. An opportunity to achieve that objective and to improve gender and geographical targets would be provided by the large number of WHO staff expected to retire in the coming years. However, a balance had to be struck between the need to bring in new blood and the need to retain reasonable numbers of experienced staff. The Committee had noted that the recommendation dealing with the term of office of the External Auditor was a matter to be considered by the Board and the Health Assembly. The Committee had considered two other reports of relevance to WHO: one on strengthening the investigations function in organizations of the United Nations system, and another on United

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Nations system support for science and technology in Latin America and the Caribbean. Details of the Audit Committee's views on three reports were contained in the report of the fifth meeting of the Audit Committee (document EBAC5/5). Mr KUY AMA (Joint Inspection Unit) in his capacity as Chairman of the Unit presented its report on the review of management and administration in WHO, which had been considered in detail by the Audit Committee and, in part, by ABFC. It had been written not in isolation but as part of a series of similar reports concerning other organizations in the United Nations system. In preparing those reports the Unit had used management practices across the entire system as a benchmark. The conclusions and recommendations of the report were set around several themes in five substantive chapters, as evident in the Annex to document EB I 09/30. The Unit was gratified to note from the comments, included in that document, a significant convergence of views on most issues, resulting, he maintained, from extensive dialogue and consultation between WHO and the Unit. Some differences of opinion remained but they related more to implementation than to the principles of sound management, and, moreover, had been narrowed further in discussions in the Audit Committee. In particular, the Unit welcomed the commitment to engage in discussions with staff associations on institutionalizing consultative mechanisms. It accepted, however, the argument that it would not be possible to prepare and finalize by the 111 th session of the Board a common set of objectives and criteria on, and to determine the nature and extent of, WHO country representation. A timetable for the completion of that important task must, he said, be specified. The Audit Committee had supported the recommendation for increased transparency in the presentation of the findings of evaluation and for the adoption of a disclosure policy in that regard. Explicit support by the Executive Board would facilitate progress. The review of WHO should aid Member States and the Director-General in reforming the Organization and making it more effective. To achieve that goal, the Board would need to endorse the document and in particular to pronounce itself on those recommendations also where the gap between the Unit and the Secretariat's views had not been closed. The Secretariat was expected to implement also those recommendations which had been accepted by the Director-General within her own sphere of competence. He expressed the hope that a status report would be submitted to the Board on the measures taken to implement the approved recommendations and those accepted by the Director-General, as envisaged in the formal follow-up procedure endorsed by the Board in May 2000. Mr TASAKA (alternate to Dr Shinozaki, Japan) requested regular reports on measures taken to respond to the recommendations in the reports of the Audit Committee and the Joint Inspection Unit, so that the Board could better examine follow-up to those reports. Furthermore, as the reports of the Joint Inspection Unit often covered budgetary questions and the management of human resources, they should be considered at the same time as financial matters and, if necessary, human resources. The CHAIRMAN said that he took it that the Board wished to take note of the reports of the Joint Inspection Unit and to request the Director-General to pursue the necessary follow-up as she had indicated in her responses to the reports. It was so agreed. Mrs Abel took the Chair. Governing body matters: Item 7.4 of the Agenda (continued from the eighth meeting, section 2) • Future sessions (Document EB I 09/32) The CHAIRMAN drew members' attention to the draft decision in paragraph 5 of document EB I 09/32. In addition, two corrections should be made to the provisional agenda in Annex I: an item

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on Quality of care: Patient safety should be added to item 13, Technical and health matters; Item 15.4 should read Revolving and other long-term funds. Dr THIERS (Belgium) said that, even though the resolution on strengthening mental health had been adopted, 1 he considered the subject important enough to be submitted to the Health Assembly as well and would like the item to be added to the agenda. Professor YUNES (Brazil) observed that the World Summit on Sustainable Development was to be held in Johannesburg in August 2002. As the host of the 1992 United Nations Conference on Environment and Development and recognizing the close link between subsequent work on sustainable development and health and Dr Brundtland's crucial role as chair of the Commission on Sustainable Development, Brazil recommended that the issue be added as a separate item to the agenda of the Health Assembly. A document on work to date and WHO's input would help Member States to ensure that health featured strongly at the Johannesburg Summit. Recognizing the importance of the Second World Assembly on Ageing, to be held in Madrid in April 2002, he said that the implications of a fast-ageing world had been known for decades. The challenges for developing countries were formidable, as the ageing process was faster in a context of prevailing poverty and unresolved structural problems. Ageing was therefore a development issue, as a healthy older person was a resource for the family, the community and the economy. The World Assembly on Ageing offered WHO a unique opportunity to promote effective policies to ensure healthy, longer lives in all regions of the world. WHO would indeed be expected to take the lead in the health, well-being and care of older persons in the twenty-first century. He therefore requested that a discussion on the outcomes of the Second World Assembly on Ageing, with particular reference to health and the WHO response, be included as an agenda item under Technical and health matters. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) proposed that an information briefing should be held early in the forthcoming Health Assembly on subjects such as bioterrorism. That would enable ministers from developed and developing countries to meet, perhaps for the first time, to hear about the issues and engage in informal discussion. Professor ABOUO-N'DORI (Cote d'Ivoire) recalled that the Heads of Member States ofOAU, in Lome in June 2000 and in Lusaka in June 2001, had adopted resolutions for eradication of the tsetse fly, responsible for human and animal trypanosomiasis. The Pan-African campaign emphasized the epidemiology, the extent and the socioeconomic impact of the disease. Thanking WHO and other partners in the surveillance and control of trypanosomiasis, he called for an item to be placed on the agenda of the forthcoming Health Assembly, entitled "Pan-African campaign for the eradication of the tsetse fly and trypanosomiasis". A draft resolution would be submitted. Mr SELIM LABIB (alternate to Dr Sallam, Egypt) supported the proposal of the member from Brazil to include an item on the Second World Summit on Sustainable Development. He also supported inclusion of an agenda item on eradication of the tsetse fly and trypanosomiasis, as proposed by the member from Cote d'Ivoire. Dr MODESTE-CURWEN (Grenada), recalling that there had been much discussion of the request by some Member States for consideration of observer status for Taiwan at the Health Assembly, said that Chad, Grenada, Guatemala, Nicaragua and Senegal considered that by its decision of 14 January 2002 the Executive Board had disregarded a formal instruction of the sovereign body, the Health Assembly, to the Board as its executive organ, since Rule 5(d) ofthe Rules of Procedure of the World Health Assembly obliged the Board to include in the provisional agenda of each regular

Resolution EB 109.R8.

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session of the Health Assembly any item proposed by a Member. It had consequently deprived Members of their constitutional right to propose to the Health Assembly for its consideration any matter they deemed appropriate, thereby prejudging the decision on the substance that exclusively belonged to the Health Assembly and creating a precedent that called into question the integrity of the Rules of Procedure guiding the functioning of the Board. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) asked whether the suggested discussion of the PAHO centenary would be taking place in plenary or in Committee B. Mr AITKEN (Senior Policy Adviser) replied that such an important item would normally be considered in plenary. Ms BLACKWOOD (United States of America), 1 speaking at the invitation of the CHAIRMAN, said her delegation had listened with surprise and concern to the previous Monday's inappropriate debate following the request by five Member States that an item be included in the provisional agenda of the forthcoming Health Assembly on observer status for Taiwan. That request had been properly submitted, and the Board's responsibility under the Rules of Procedure of the World Health Assembly was to include the item in the provisional agenda and forward the matter for decision to the Health Assembly, where the substance ofthe proposal would be discussed in the General Committee. The United States did not wish to "interpret" the Rules, but simply to point out that Rule 5 of the Rules of Procedure of the World Health Assembly categorically required the Board to include in the Health Assembly's provisional agenda "any item proposed by a Member". That Rule was for the benefit of all Member States, whether those designating Executive Board members or represented by observers. Individual Member States had often proposed agenda items for Health Assembly sessions and, when presented in a proper and timely fashion, they had been accepted and placed on the provisional agenda. The Board had no right to reject them. While recognizing that there were differing opinions on the substance of the proposed item, the United States contended that such opinions should, as in the past, be presented and debated in the General Committee and in the plenary of the forthcoming Health Assembly. Previous Health Assembly decisions on proposed agenda items did not establish any precedent regarding the competence of the Board on that or any matter. The United States wished the normal legal processes of WHO to operate in the way they had done successfully for 50 years. It further wished to protect the integrity of WHO, and for it to be made clear that it was an organization that abided by its own rules. She believed that the Board's vote to exclude the item from the agenda did not have validity. She emphasized that the Secretariat had given clear and professional advice to the Board, which her country had appreciated. Mr REN Yisheng (China)/ speaking at the invitation of the CHAIRMAN, pointed out that, under Rule 40 of the Rules of Procedure of the Executive Board, once a proposal had been adopted or rejected it could not be reconsidered at the same session unless the Board so decided by a two-thirds majority of members present and voting. He expressed surprise that the Board's decision of the previous Monday had been brought up again and challenged by some members. It was clear from Rule 5 of the Rules of Procedure ofthe World Health Assembly and Rule 9 of those ofthe Board that the rules could not be understood in isolation; besides which, the Vienna Convention on the Law of Treaties required that legal provisions of that kind should be interpreted in good faith. China had repeatedly emphasized that the issue of Taiwan as an observer member of WHO was irrelevant to world health. That was what the Director-General had confirmed when interviewed and it was also the opinion of the majority of Member States that designated members of the Executive Board. He

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board.

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reiterated China's stand in view of the constant challenges being made by some Board members and observers. Dr SADRIZADEH (Islamic Republic of Iran) said that it would be useful to know what was the basis of the rights of the Executive Board in the matter, and who should interpret those rights. Ms MAFUBELU (South Africa), 1 speaking at the invitation of the CHAIRMAN, recalled that the Director-General, in her opening address to the Board, had referred to the importance of making planning for health a major focus of the World Summit on Sustainable Development, to be held in Johannesburg (South Africa) in August/September 2002. Supporting the members from Brazil and Egypt, South Africa therefore urged that it be made a separate item on the Health Assembly's agenda. The South African Minister of Health would be hosting with WHO a preparatory meeting for that Summit, starting in Johannesburg the following weekend, which was expected to provide useful input from a health perspective. Dr SADRIZADEH (Islamic Republic oflran) supported that proposal. The CHAIRMAN said that, in the absence of further comment, she took it that the Board wished to approve the decision in paragraph 5 of document EB109/32, the end of the first sentence being amended to read: " ... with the addition of mental health, the World Summit on Sustainable Development, quality of care: patients' safety, ageing, African trypanosomiasis and neurocysticercosis." It was so decided.2

MATTERS FOR INFORMATION: Item 8 of the Agenda (continued from the eighth meeting, section 6)

Report on meetings of expert committees and study groups (and report on appointments to expert advisory panels and committees): Item 8.1 of the Agenda (Documents EB109/33 and EB109/33 Add.l) The CHAIRMAN invited the Board to consider document EB109/33, which summarized two reports on meetings of expert committees: the Fifty-fifth report of the Joint FAO/WHO Expert Committee on Food Additives (WHO Technical Report Series, No. 901, 2001) and the Thirty-second report of the WHO Expert Committee on Drug Dependence (WHO Technical Report Series, No. 903, in press). Noting the absence of comments, she said that she took it that the Board wished to thank the experts who had taken part in the meetings and to request that their recommendations should be followed up, as appropriate, in implementing the Organization's programmes. It was so agreed.

The CHAIRMAN invited comments on the report contained in document EB109/33 Add.l on expert advisory panels and committees and their membership.

1 2

Participating by virtue of Rule 3 of the Rules of Procedure of the Executive Board. Decision EB 109(1 0 ).

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Mr SELIM LABIB (alternate to Dr Sallam, Egypt) noted that, of all the regions, the Eastern Mediterranean accounted for the smallest number of experts on WHO expert advisory panels, only 123. It had no experts on several panels on diseases that were widespread and of great concern to the Eastern Mediterranean, such as parasitic diseases, respiratory infections, acute diarrhoea! diseases and other enteric infections. Countries of the Region had major national projects and expertise in those areas. He requested an explanation for the Region's lack of representation on such panels. He would like to see the names of the chairmen of panels included in the document and endorsed the comments ofDr Sallam on the need to appoint such chairmen as democratically as possible. Dr AL-MAZROU (Saudi Arabia) concurred with the remarks just made. It was true that the Eastern Mediterranean Region was not well represented, but that was something that could be corrected by constructive action. He, too, would like to see a list of names of chairmen provided to Board members. Professor ABOUO-N'DORI (Cote d'lvoire) said that, similarly, he would like to know why several committees had no African experts on them. Dr GONZALEZ FERNANDEZ (alternate to Dr Dotres Martinez, Cuba) drew attention to the long delay in the issuance of reports of expert committees. The meeting of the Joint FAO/WHO Expert Committee on Food Additives had been held in June 2000, while that of the WHO Expert Committee on Drug Dependence had taken place in September 2000. At the Board's previous session, it had received reports on expert committee meetings in 1999 and the first half of 2000. That seemed at variance with paragraph 4.23 of the Regulations for Expert Advisory Panels and Committees, which stated that the Director-General should submit to the Executive Board a report on meetings on expert committees held since the previous session. Perhaps something could be done to accelerate the submission of such reports. Mr AITKEN (Senior Policy Adviser) attributed the disparities in representation of regions on expert advisory panels to some extent to the location of the relevant expertise, but also to the level of interaction between the Secretariat and countries, regions and experts worldwide. It was a responsibility of the Secretariat and Member States to increase that interaction in order to broaden representation on the panels across the regions. Global Alliance for Vaccines and Immunization: Item 8.2 of the Agenda (Document EB109/34) Mr CHOWDHURY (India) expressed appreciation of the service rendered by the Global Alliance for Vaccines and Immunization (GAVI) in maximizing the scale of vaccination of young children worldwide, and of its plans to accelerate efforts to develop new vaccines. India gave top priority to eradicating poliomyelitis, and the dramatic drop in the number of cases each year augured well for achieving that aim in the near future. The country had therefore committed a vast amount of its public health and administrative capacity to the pulse polio campaign despite the possibility that in the short run it could cause a slight drop in routine immunization. It was hoped that by concentrating all the necessary resources on poliomyelitis, the disease would soon be eradicated, allowing attention to be re-focused on routine immunization. To that end, a grant from the Vaccine Fund would provide valuable assistance, and it was disappointing that the Board of GAVI had so far decided not to support the pulse polio campaign, particularly in view of the very real possibility of eradication. He urged the Board of GAVI to reconsider its decision, since the eradication of poliomyelitis might well constitute the greatest public health achievement since smallpox was eradicated. Mr JANG Chun Sik (Democratic People's Republic of Korea) noted with satisfaction that the Vaccine Fund had expanded its resources to about US$ 1000 million for 2001-2005. He expressed the hope that in future those resources would be apportioned equally between the different regions.

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Dr TARANTOLA (Vaccines and Biologicals) commended the Government of India on its immense efforts to eradicate poliomyelitis. GAVI could learn from its pulse polio campaign in terms of building stronger routine immunization programmes and gaining easier access to communities. However, given that the resources available to GA VI were limited, its primary function was to strengthen routine immunization. He had taken note of India's commitment to sustaining a high level of immunization against poliomyelitis, but, in his view, that could best be achieved by combining the pulse polio campaign with a strengthened programme of routine immunization. With regard to ensuring that awards from the Vaccine Fund were equally distributed among the regions, as requested by the Democratic People's Republic of Korea, he explained that any apparent unevenness was due to the decision by the GAVI Board to focus its resources on the 74 poorest countries. The CHAIRMAN, in the absence of any further comments, said that she took it that the Board wished to take note of the report contained in document EB109/34. It was so agreed.

Eradication of poliomyelitis: Item 8.3 of the Agenda (Documents EB 109/35 and Corr.1) Dr AGGARWAL (alternate to Mr Chowdhury, India) said that India aimed to achieve zero transmission by the end of 2002 and to sustain its poliomyelitis-free status up to 2005. During that period, National Immunization Days and acute flaccid paralysis surveillance would have to be continued. In India, oral poliomyelitis vaccine was being procured from indigenous sources that imported it in bulk and then blended and bottled it, and help from WHO and UNICEF was needed to ensure that the supply from the bulk manufacturers was not interrupted. Meeting the targets up to 2005 would require further substantial resources. India hoped that the funding gap of US$ 400 million to the end of 2005 would be met in a timely manner. Dr SADRIZADEH (Islamic Republic of Iran) said that he believed the global poliomyelitis eradication campaign should concentrate on five priorities: assisting countries in conflict, including those with damaged health systems; tackling the problems of refugees and displaced populations through United Nations agencies; strengthening cross-border activities with regard to acute flaccid paralysis surveillance; ensuring that oral polio vaccines were available to the countries concerned; and sustaining political commitment to continuing those efforts. Mr CICOGNA (alternate to Dr Di Gennaro, Italy) expressed satisfaction at the sharp drop in the number of poliomyelitis cases worldwide since 1988. WHO and its many partners in the eradication campaign were to be congratulated on that success. Italy, like other countries, had responded to the call for funding and for technical assistance, but care should be taken to avoid becoming complacent or losing momentum at what was a critical stage. Italy welcomed the reference made in the document to poliomyelitis eradication activities as a crucial part of the humanitarian agenda in countries where the disease was endemic. The CHAIRMAN, in the absence of any further comments, said that she took it that the Board had noted the report contained in document EB109/35. It was so agreed.

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Date and place of the llOth session of the Executive Board Decision: The Executive Board decided that its 11 Oth session should be convened on Monday, 20 May 2002, at WHO headquarters, Geneva, and should close no later than Tuesday, 21 May 2002. 1

CLOSURE OF THE SESSION: Item 9 of the Agenda After the customary exchange of courtesies, the CHAIRMAN declared the session closed.

The meeting rose at 16:45.

Decision EB 109(11 ).

Key facts

Organisation World Health Organization (WHO)

Document type Governing Bodies documents

Adoption date December 31, 2002

Source World Health Organization