REGIONAL COMMITTEE Fifty-eighth Session Colombo, Sri Lanka 6-10 September 2005
Provisional Agenda item 8 SEA/RC58/15 2 August 2005
11 TH GENERAL PROGRAMME OF WORK 2006-2015: REVIEW OF PROCESS AND DRAFT CONTENTS The 42 Meeting of the Consultative Committee for Programme Development and th Management (CCPDM), held in Dhaka, from 5 -7 July 2005, deliberated on the 11 General Programme of Work 2006-2015: Review of process and draft contents. The CCPDM reviewed th the draft Executive S ummary of the 11 General Programme of Work. The preparation of a programme of work covering a specific period is a constitutional th requirement of WHO. The 11 General Programme of Work is for the ten-year period 20062015. The General Programme of Work is being drafted over the cours e of a year through a consultation process that is still actively under way, involving Member States, WHO Secretariat, organizations of the United Nations system and intergovernmental organizations, civil society and major stakeholders. After review by regional governing bodies and further consultation with other partners, the General Programme of Work will be revised and submitted to the Executive th Board at its 117 session, before being presented to the Fifty-ninth World Health Assembly. The draft executive summary is attached. The General Programme of Work is not simply a framework for planning the work of WHO. It has a strategic function i.e. to review and assess the current condition of world health and to propose a global health agenda. Given the recognition that health is a crucial component of th work on development, security, poverty, and justice, among others, the 11 General Programme of Work is outward looking, placing health in the increasingly complex global context. Its duration coincides with that set for achievement of the internationally-agreed development goals contained in the Millennium Declaration, reflecting the close linkages with other development partners in this endeavour. The General Programme of Work proposes a reasoned, strategic perspective on the challenges facing world health, collective action through a global agenda to meet them, and an assessment of what this implies for WHO. Once approved by the governing bodies, it will have direct policy and management implications for the Organization, and will inform preparation of both the medium-term strategic plan for 2008-2013 and biennial programme budgets. The Regional Committee is invited to consider the Executive Summary and to comment on its strategic orientation. Attention is particularly drawn to identified challenges and gaps, and to the proposed global health agenda and its specific implications for the work of WHO. nd
RC/2005/2
TOGETHER TOWARDS A HEALTHIER FUTURE DRAFT ELEVENTH GENERAL PROGRAMME OF WORK 2006-2015: EXECUTIVE SUMMARY
HEALTH IN A CHANGING GLOBAL ENVIRONMENT 1. The Constitution of the World Health Organization, adopted in 1946, defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”. That position is still appropriate for a contemporary global health agenda that reaffirms these principles and adapts them to health work in the coming decade, responding to new questions, new challenges and new forms of responsibility. 2. For all but the very poorest, for whom choices remain highly limited, the world offers a vastly different environment from that of 1946. Advances in technology, supported by more open policies, have made the world more interconnected and interdependent than ever before. However, the fruits of “development” have not necessarily improved the health and well-being of all. Although the potential for good is immense, the current processes of globalization are generating unbalanced outcomes, both between and within countries. The root causes of those imbalances need to be better understood and dealt with.
Health: a defining characteristic of the twenty-first century 3. Health occupies a more prominent place in development debates, being increasingly seen as a fundamental dimension of security at individual, local, national and global levels and a key element of social justice. It remains a strongly scientific and medical field; many of the challe nges to world health can still be traditionally described in terms of their disease burden. However, their solutions usually cannot; they are part of a far more complicated and dynamic picture. 4. Central to a multidimensional understanding of health today is the recognition that health concerns and health actions reach far beyond medical care. Broader social, economic, environmental, political and institutional arrangements determine health opportunities and outcomes, and how health – and vulnerability to ill-health – is distributed across different groups in society. To be most effective, health will need to be tackled from many angles. Progress will be substantial only when it is perceived as a vital dimension in all arenas. The global health community and WHO will need to work differently in the future in response to the creative challenges this target represents.
Health actors: a changing world 5. The past decade has witnessed dramatic changes in public -health governance and international cooperation. Health’s position has been charted in a wide range of national and international agreements and affirmed in action by a wide set of stakeholders far beyond ministries of health. A multiplicity of new actors is redefining the boundaries of the health sector, each with its own unique expertise and vision. Groups of individuals united in a certain cause, such as patient or civil society groups, are becoming major players, creating powerful lobbies and raising public awareness of issues. An increasing range of nongovernmental organizations and religiously affiliated providers have stepped in to deliver care and complement the efforts of national health systems. Research and academic institutions are increasingly important in shaping the directions and use of knowledge. The 1
private sector is a powerful driver for research and development, and a massive force behind marketing and production of goods that can be beneficial or harmful. 6. The past five years have seen a dramatic increase in the number of global partnerships in health. This has broadened the traditionally medical confines of public health, and brought a new complexity to relationships, planning, and the need for delineation of responsibilities and harmonization. New mechanisms for health financing, and the scale of resources brought by new partners, are changing the way in which health is funded in many countries, and its relative profile and status. 7. With solidarity between all those engaged in the struggle for better health, great success is possible. However, this will require the resolution of difficult questions about the ways in which to realize the potential of partnerships, to ensure sustainability, and to build country capacity.
The current health situation 8. Over the past 20 years, life expectancy at age 15 has increased by between two and three years for most regions. This overall remarkable improvement in health is generally d ue to socioeconomic development, the wider provision of safe water and sanitation facilities allowing greater personal hygiene, and the expansion of national health services. However, despite this continued improvement in average health status in many developing countries, there are widening health inequities within countries, including between rich and poor, men and women, and different ethnic groups. In some regions, progress in health status has gone into decline, for instance, in some African countries and the former Soviet countries of Eastern Europe, where life expectancy at age 15 has decreased. Some effects of globalization, such as hostile or damaged environments, detrimental urbanization, unfair trading practices, or system failures, have had an increased negative impact on the health of women and vulnerable population groups such as poor people, ethnic minorities, and migrants, and on social and health services. 9. Of the expected total of 58 million deaths in 2005, 17.5 million will be caused by infectious diseases, and perinatal, maternal and nutritional disorders. Three million of these deaths will stem from HIV/AIDS. It is the leading cause of mortality among adults aged 15 to 59, responsible for 2.4 million deaths, representing 15% of global deaths in this age group. This disease is currently the greatest challenge for communicable disease control and cannot be controlled by traditional means such as preventive and curative medicine. It exemplifies the challenge facing the health sector: that the majority of health concerns and health actions reach far beyond medical care. 10. No region of the developing world is currently on track to meet the reduction targeted in the Millennium Development Goals for under-five mortality. Evidence indicates that declines in the maternal mortality ratio have been limited to countries with lower levels of mortality, while those with high maternal mortality are experiencing stagnation or even increased death rates. However, coverage of measles immunization is on the rise in many countries and the proportion of women who have a skilled medical person with them during delivery has increased rapidly in some regions, especially in Asia. 11. Major infectious diseases such as tuberculosis and malaria are still taking a heavy toll in poor countries and tuberculosis is reappearing in certain groups in developed countries. In both cases, traditional curative remedies have encountered antimicrobial resistance. New diseases, such as avian influenza and SARS, regularly appear, adding to difficulties in preventing the spread of epidemics. In addition to this burden of disease, which falls mainly on poor countries, other new epidemics occur, the growing burden of which have the potential to counteract social and economic development and to cripple already stretched health systems. 12. Noncommunicable diseases already represent 60% of the current global disease burden, and account for 35 million deaths, of which 16 million occur under the age of 69 years. These chronic conditions result from years of exposure to risk factors and behaviours such as smoking, alcohol use, lack of physical activity, diets dominated by processed foods, and lack of fresh fruit and vegetables. 2
Four of the 10 leading causes of death in the world are related to smoking, reflecting rising tobacco consumption in low- and middle -income countries. 13. Demographic changes are compounding factors. The world’s popula tion is rapidly ageing, but not becoming wealthier. The obligation to treat the chronic conditions associated with old age – cancers, diabetes mellitus, heart disease, degenerative diseases, and a range of nutritional imbalances – falls squarely on the health services, often involving expensive long-term tertiary care and exerting pressure to divert funding from provision of primary health care. Migration to areas offering better prospects of security and livelihood also disrupts traditional public -health practices. 14. Environmental factors also have a significant impact on health. Mostly associated with indoor and ambient air pollution, they cause over one third of the disease burden attributable to lower respiratory infections. Road traffic injuries, which kill an estimated 1.2 million people annually, are linked with poor urban and transport planning, wider social and behavioural factors such as alcohol use, and failure to fasten seatbelts or observe speed limits. 15. The solutions to such public -health challenges will involve changes in the wider socioeconomic and cultural context of industrial practices, transport systems, agriculture, trade, and legislative decisions on control of products and labelling. It requires a rethinking of the determinants of health, and demands a commitment to greatly increased advocacy and a range of behavioural changes through the whole social strata.
Health systems 16. Where health systems function well, they contribute significantly to maintaining and improving individual, community and population health. In many countries the insufficient generation and inefficient use of public resources has led to health services with a low operative capacity; primary and secondary care with inadequate content; weakened public health programmes; health worker shortages; the absence of reliable supply chains for diagnostics and drugs; and other problems. At the same time, the range of non-State actors providing care and other services is increasing substantially in many countries. The advantages of these services can be considerable for the population, but the challenge remains to align their practices with public health goals and to hold them accountable through coordinated oversight mechanisms and regulatory approaches. This is particularly difficult in countries where the leadership and steering role of the government is weak and where lack of capacity in the competent government agencies prevents them from developing relevant policy frameworks and oversight mechanisms. 17. The health-care sector as a proportion of the global economy has grown enormously over the past 100 years. Industrialized countries continue to increase spending on health in response to growing expectations. Countries with economies in transition face major problems in managing and financing the transformation of their health systems. Few poor countries are spending on health at a level that corresponds to their needs. Economic pressures lead to low or dwindling health budgets and in many countries to very high individual or household out-of-pocket payments for health services. Most countries face major difficulties in extending or sustaining social protection or other mechanisms that will protect individuals and populations from medical expenses and ensure independent ability to pay.
THE CHALLENGES TO HEALTH 18. Significant discrepancies exist between the opportunities for change and growth and the current global realities of widespread deprivation and ill-health. These gaps need to be closed. They relate to situations where there are evidently complex factors causing ill-health, yet it is not clear who is responsible for them, or what kind of authority can be exerted in order to overcome them. They include flaws in implementation and processes, where opportunities to improve health have been missed for lack of adequate systems or links among potential partners. They include shortcomings in 3
the way that ethical and human rights considerations such as equity and gender equality are reflected in public and private attitudes, policies and plans. Lastly, important elements are missing in the way that knowledge is generated and used to promote global well-being.
Gaps in synergy 19. Well-being is influenced by a wide range of factors outside public health. People’s health suffers or benefits not just from their domestic environment and personal choices but also from decisions made at national level, and outside their own countries. The consequences of these complex interactions are clear, but the means of attributing responsibility for them are not. Modern communications and travel have changed the way in which authority can be exercised. Information and microbes can move across the world in ways that are not susceptible to monitoring, control or regulation. The speed of movement around the globe of goods , people and messages is coupled with a vacuum of responsibility for the consequences. This situation calls for renewed or extended advocacy for, and synergy through, intersectoral coordination, awareness-raising to generate demand for change in order to decrease vulnerabilities, and the exertion of leadership.
Gaps in implementation 20. Systems and services are often inefficient or inadequate to the task of delivering what is needed. There is an urgent need to improve coherence in delivery and execution, to scale up interventions, to secure financial and human resources, and to ensure that policies are effectively implemented. These are imperatives not only for health systems, but for the research community, and for policy- and decision-makers at all levels. Similarly, although the structures exist to offer international aid, they are not being well used. Issues of harmonization and alignment have to be resolved in order to increase the uptake of resources and decrease inefficiencies.
Gaps in social justice 21. Crucial components of equity, human rights and gender are often overlooked in policy-making and planning. Limitations in access to essential social services are excluding the poor or other socially vulnerable groups and leading to widening health inequities within countries. For example, the rights and opportunities of individuals to enjoy the living and working conditions and services that enable them to achieve their potential for health are still determined in many settings by the fact of being born male or female. Prejudice, stigma and discrimination persist, affecting people’s abilities to participate in society or business and to achieve their potential. It is imperative to tackle the difference in vulnerabilities, and to institutionalize a positive orie ntation towards social justice.
Gaps in knowledge 22. Lastly, there are gaps in what is known, and between what is known and what is done. Despite advances in science and technology, despite extensive investment in research, the wrong questions are asked or the right ones not asked, and essential answers are missing; divergent interests mean that beneficial information is not shared; education is inadequate or withheld. Research is not yet efficiently translated into delivery of the most urgent interventions to those in greatest need. It is essential to strengthen the generation, translation, dissemination and use of knowledge. 23. The combined result of these gaps is inefficiency, instability, and exclusion from the benefits of progress. An environment is needed in which individuals, civil society, the private sector, governments and international organizations take responsibility for health; where the solutions are delivered; where ethical issues are taken fully into consideration; and where life-saving and lifeenhancing knowledge is shared and used. The novelty – and the difficulty – lies in devising joint action among actors outside the conventional health sector, and in making a commit ment to resolve these issues.
A GLOBAL HEALTH AGENDA 4
24. The global health agenda outlined below identifies 10 priority areas and explores the action needed in each to use available opportunities and overcome obstacles. It is intended to stimulate awareness of how new or revitalized coalitions can better meet global health needs, and to prompt and lead change. In fact, these priority areas are not new: it is the reading of their complexity that is different, requiring more sophisticated responses to the global health problems, such as HIV/AIDS. Action has to be taken differently, at all levels – individual, community, national, regional and global – by all stakeholders and in all sectors. The power to make the necessary changes does not lie solely with governments and international organizations , but with many different bodies in civil society and the private sector, and voluntary groups. Throughout, the agenda reflects the values and principles of WHO’s Constitution and the Declaration of Alma-Ata, and interprets them in the new global context. 25. The actions to be taken to tackle the priority issues include the policies, strategies and mechanisms that need to be enhanced or put in place. These actions, undertaken in combination, will help to close the gaps outlined above.
A.
Ensure access to essential services
26. Preventive activities will continue to increase in importance as noncommunicable diseases become more prevalent, and disease control depends more on environmental and social actions. Immunization and related disease-prevention activities continue to be essential features of routine health services. For example, child health care, reproductive health care, and emergency obstetric care are critical to achieving the health-related Millennium Development Goals. Good primary health-care services (including preventive services) are a fundamental tool in building efficient and effective health systems and ensuring equitable access. 27. It will be vital for all health actors to work together to strengthen integrated primary health care and essential public health functions in order to meet the new challenges and to secure universal access. This means expanding access to essential health services and overcoming financial, managerial, logistic and gender barriers, in support of improved health for the poorest and most needy.
B.
Build individual and global health security
28. Conflicts, natural disasters, disease outbreaks, and zoonotic dangers, such as bovine spongiform encephalopathy and avian influenza , are increasingly in the news. It is important to be prepared for such dangers and to minimize the risks of disease outbreaks. Global response capacity to cope with outbreaks needs to be enhanced. Global and national infectious disease surveillance needs to be improved, public health systems should be strengthened, and the International Health Regulations (2005) should be applied. 29. Crises bring heightened health risks, with violence adding to preventable morbidity and mortality. The instability associated with poverty and poor population health accelerates institutional failure and the proliferation of violence. Social problems such as homelessness, violence, crime and abuse interact with health and environment problems. Strategies are needed which respond to the rapid evolution of such threats to public health, and to new and emerging diseases such as SARS. 30. Nutritional insecurity continues to be a major issue for health care, with malnutrition exacerbating vulnerabilities and acting as a persistent drain on productivity. There are significant external threats to food security. Security of the household , the basic unit of a healthy population, is linked to a predictable, supportive economic, social and physical environment. Areas outside conventional regulation, such as ghettos, indigenous minority zones and areas of civil unrest, can facilitate transmission of disease and deter prevention and cure.
C.
Promote health-related human rights
5
31. International human rights law should be consistently and coherently applied in the relevant national and international policy-making processes. Many different actors can become involved in helping to raise the profile of health in relation to fundamental human rights, calling for research agendas to be made more equitable, for priority to be given to underserved populations and neglected diseases, and for research findings to be made widely available. 32. Critical components of the right to enjoyment of the highest attainable standard of health include the reduction of discrimination and a focus on vulnerable people , such as those with disabilities, displaced and minority populations, and people living with HIV/AIDS. 33. The pursuit of equity includes fostering equal treatment, a response to gender-based discrimination and other social determinants of health, social protection, the fight against stigmatization, and the guarantee of universal access to services, regardless of ability to pay. It highlights the need for community participation, research and development, an integrated health system that is responsive to local priorities, and monitoring and accountability.
D.
Reduce poverty and its effects on health
34. Poverty remains a major impediment to good health. Efforts should continue to be focused on reducing poverty and inequalities of access to social services such as education and health. 35. In all countries, poverty is associated with exposure to infectious diseases, malnutrition and micronutrient deficiency, and childhood and maternal mortality. To tackle these areas of ill-health, action to reduce the vulnerability caused by poverty is essential. In many developing countries it will mean making major efforts to attain the Millennium Development Goals, and to determine pro-poor health strategies. In each country, it will mean developing social protection for all and framing policies that protect people from falling into poverty or help them find ways out of it. 36. In many areas, the need to pay for indispensable health care can drive a family into absolute poverty. Women responsible for families are particularly exposed to poverty caused by health-related expenses. Unemployment and under-employment remain key problems in all societies, and continue to lead to social marginalization, violence, and an increased flow of migrants from poor areas to wealthier ones. 37. Insufficient attention has been paid to the social and health inequalities that exist within and between societies. Life expectancy and virtually all other key health indicators consistently reflect the social gradient in both low- and high-income countries. This poses a major challenge for national and global health policy attuned to social determinants, but it also offers an opportunity for building broad political consensus.
E.
Tackle the social determinants of health
38. Mortality and morbidity patterns can be attributed in large part to socially mediated factors such as wealth, education, gender, ethnicity, access to water and sanitation, food, housing and habitat, transport, employment and working conditions, social support, and the environment. Even in the most affluent countries, people who are socially disadvantaged generally experience more frequent and severe illness and have shorter lives than people in privileged social groups. 39. Unhealthy consumption, together with reduced physical activity, has a significant negative impact on individual and population health. The consequences are placing increasing economic and social burdens on societies. Priority should be given to controlling the well-known and widespread risks, for which effective and acceptable risk-reduction strategies are available. 40. To tackle the determinants of health effectively, the boundaries of public health action have to change. Governments, especially health ministries, need to play a stronger role in formulating riskprevention policies. Stronger efforts are needed to sustain growth with equity, gender equality, social 6
cohesion, social protection and environmental integrity, and to frame public policy that focuses on creating the social conditions to ensure good health for the entire population. Further, the links between determinants and the consequences need to be more cl early defined in order to promote greater responsibility.
F.
Promote a healthier environment
41. Many environmental risks and hazards are shaped by economic, social, political and institutional forces that lie beyond the health sector’s immediate jurisdiction. These include such factors as the loss of biodiversity, and the long-term effects of exposure to chemicals or radiation. 42. Integrated health and environment management strategies are needed to control such hazards as indoor air pollution, unsafe water and sanitation, and malaria in order to achieve sustained reductions in rates of childhood mortality. Proactive policies on climatic change are needed. These include efforts to reduce air pollution, especially in the world’s major urban areas, but with implications for the rapidly growing populations in urban areas globally which are vulnerable to many environmental hazards and deficiencies in urban planning. Climate change can also influence the emergence or re-emergence of certain communicable diseases, such as dengue or other vector-borne diseases. 43. A large and preventable disease burden is related to water. Safe drinking-water and sanitation facilities are important factors in reduc ing the incidence of diarrhoeal disease, and epidemics such as cholera and hepatitis A. Improving the environmental determinants of health should focus on supporting health-sector engagement and partnerships with the sectors that directly manage them.
G.
Build well-financed and equitable health systems
44. Without more efficient, effective and equitable health systems, countries will not be able to scale up the disease prevention and control programmes required to achieve the health-related Millennium Development Goals, stop the proliferation of noncommunicable diseases, cope with new epidemics, and meet the needs of ageing populations. Without sustained and serious investment in health, the necessary growth in health systems will not be possible and the gaps in implementation will not be closed. 45. The primary health care strategy needs to be reinvigorated through investments in good-quality public-health and personal-care services, ensuring social protection and equitable financing mechanisms, and making links with other sectors which influence health outcomes, such as education, water and the environment. Social protection is crucial to mitigate the risks of financial ruin due to out-of-pocket spending on health. 46. There is a dramatic shortfall in the resources needed. Many countries, in particular low-income countries with weak infrastructure and poor levels of health and education, could make a much stronger case for rapid increase of public expenditure, but lack capacity in planning, managing and coordinating international cooperation. Decisions on the amount that could be usefully absorbed, and where it should be directed, should be made on a country-by-country basis. Additional resources need to be mobilized using national and international facilities to rebuild local and national public health systems throughout the developing world and pursuing close partnerships between international donors, national authorities and local civil-society organizations. 47. Secondary-level care should not be neglected, in view of the essential role it plays in such prominent and growing problems as perinatal and neonatal morbidity and mortality, and injuries. Better district-level health information systems will make it possible to develop specific strategies and interventions. Improved access to hospitals is needed, with fully functional referral processes. 48. In the health system as a whole, private providers, traditional practitioners, community-based organizations, nongovernmental organizations, and home-based care make essential contributions and 7
should be part of the consultative process for change. Incentives are needed to increase the involvement of users and communities in shaping health policies. Health policies and planning do not currently take sufficient account of gender-based discrimination or inequalities. Policies need to be framed and enforced that allow all actors to provide services within an overall framework set by the government in a consultative process.
H.
Ensure an adequate health workforce
49. Behind every area of vulnerability in health systems nationally and globally is the lack of appropriate staff. Much of the world is facing shortages of skilled public health workers. Realistic and long-term global and regional solutions are needed to manage the outflows of workforces from lower to higher income countries. While meeting the requirements of national health systems, these solutions have to respect the rights of individuals to cross national boundaries. At the same time, measures need to be taken to increase effectiveness, motivation and retention of the workforce at national level. The underlying macroeconomic issues need to be analysed and taken fully into account, together with issues relating to public -sector reform and coordination of human-resources policies. 50. An appropriate mix of health workers, and the training given to the health workforce, are of critical importance. Medical and public -health education should be reoriented consistently to focus on the major determinants of health and related problems. Comprehensive approaches to training of health workers and to support for training institutions are urgently needed. This calls for joint efforts from governments and partners.
I.
Harness knowledge, science and technology
51. In all fields of health there is much evidence and experience that has not been generally applied. Lack of basic health information and ignorance of best practice are critical causes of failure in health systems. Advances in the development of vaccines and delivery systems have already made enormous – and very cost-effective – changes to the extent of protection available to vulnerable groups. A significant proportion of today’s global death and disease burden could be avoided using relatively inexpensive and tested solutions, given more coherent and coordinated preventive and public health measures. It is imperative that best practices should be consistently applied and that inequities in access to such technologies should be eliminated. 52. Innovations in science, agriculture, communication and transport should be made available to benefit the developing world. New tools, technologies and approaches are needed to tackle the double burden of diseases, adverse demographic and epidemiological trends and an ageing population. The system for financing and producing these kinds of public goods for health have not yet been designed. Research is not yet sufficiently applied to achieving delivery of the most urgent interventions to those in greatest need. The research agenda for health needs to be expanded to encompass the multidimensional determinants of health and ensure cross-linkages beyond its traditional boundaries and categories. Country capacity to conduct such essential research needs to be further increased. 53. It is essential to strengthen the translation, dissemination and use of knowledge. The sharing of knowledge may be limited by intellectual property rights, protection of trade secrets, patent laws, and similar measures. Knowledge resulting from research should be made available where it is needed most, and appropriate policies and institutions should be developed to ensure that global public goods are produced, financed and used in an equitable manner.
J.
Strengthen governance and leadership
54. Appropriate leadership, aware and focused on common goals, is needed to create the positive environment in which the other elements of the health agenda can be managed, and the gaps between
8
potential and reality can be narrowed. The demand for coordination and direction in international health work has never been greater. 55. Globally, there is a new landscape for health, with new actors and new p artnerships. The expanded role envisaged for health, oriented to development through a focus on broad determinants and working in partnership with many other sectors, requires strong advocacy skills and leadership. More inclusive and participatory leadership structures are needed for the multiple stakeholders, which should bring streamlined resource flows and reduced transaction costs. Alignment and harmonization of development policies will be a necessary aspect of a more consolidated and communicative approach to governance. Similarly, health policy-makers and WHO should be fully involved in the international forums in which issues affecting health status are discussed. The respective responsibilities of government, society and the individual for health should be clearly defined and upheld. 56. The health sector needs to exercise leadership and advocacy to promote effective action on health determinants by actors in a variety of sectors and at all relevant policy levels. Priority should be given to collaborative efforts to improve health outcomes. The new global agenda under development needs a strong public -health component able to play a central role in framing of national and international policy, speak out on health issues, and foster people’s participation. It will need to define the various stakeholders and specify the work and approaches needed.
WHO – EVOLVING TO MEET THE CHALLENGES 57. WHO’s mandate specifies concern for the health of all peoples. It has a specialized stewardship role, able to act in neglected or sensitive areas such as control of tropical diseases, improvement of reproductive health, or enhancement of biosafety. In matters such as the preparation of response to health crises, it is developing an unchallenged authority, and its expertise has grown with the negotiation of such international instruments as the WHO Framework Convention on Tobacco Control and the International Health Regulations (2005). 58. Although WHO can stimulate high-level political leadership on issues, it is not always able to influence other ministries and partners outside the health sector. It has the technical ability to draw upon the best scientific advice in the world, and therefore has access to the most perfected technologies and methods that exist. Yet the results do not always match the opportunities. Collaboration with the research community, civil society and organizations of the United Nations system needs a more proactive and dynamic attitude. 59. As the world’s specialized agency for health, WHO cannot select a few health problems, populations, age groups or health-system issues and exclude others. Awareness of the gaps and opportunities outlined above needs to inform every aspect of WHO’s leadership in policy and technical work, and its input to the global health agenda. 60. Changes in the global health context over the p ast two decades have both supported and hindered WHO’s capacity to lead towards improved health. In the next 10 years, WHO’s work will evolve to re-establish solid foundations for action to close gaps in synergy, in implementation, in social justice, and in knowledge. 61. Acting as the coordinating and directing authority in international health work, WHO will work with all actors to confront the challenges set out in the global health agenda, to close gaps, and to decrease the instability associated with them.
9
62. Hence WHO will work to promote engagement and synergy in the common agenda, raising awareness of the ways in which work in sectors outside health affects health outcomes, and guiding those involved to take responsibility. This will involve coordinating the issues, and defining positions and end points to which all should be working, on the assumption of shared information and common goals. Plans will acknowledge greater interdependence, multiple partners and the reality of an uncertain future. The broader approach to health will be based on health determinants, and public health work will be more fully informed by factors outside the medical-care service. 63. Work to close the implementation gap will include improving service delivery, supporting and encouraging legislative action that has a health perspective, tackling trade and commercial issues, connecting at the right time with the negotiation and enactment of multilateral trade agreements, and working with major donors and organizations to align programmes and activities. Health policy should reflect a more disease-preventive and health-promotional approach, with primary health care providing the means to work with people of all ages. WHO will play a greater role in broadening national and international consensus on health policy, strategies, norms and standards, negotiating partnerships, and putting to use the catalytic action of others. 64. Achieving a strong orientation towards social justice entails wholeheartedly adhering to human-rights law, and actively promoting gender equality and fairness of treatment for all, regardless of religion, income group or ethnicity. Frameworks for achieving these ends will formalize the process and include an expanded role for civil society. 65. Work to reduce the science and knowledge gap will focus on ensuring that research is adequately directed towards delivering the most urgent interventions to those in greatest need; promoting, implementing and disseminating the outcomes of health research; creating effective linkages and mechanisms to assure prompt and equitable translation of scientific advances into policy, programmes and practice; and supporting research capacity in developing countries. 66. WHO welcomes and will use these opportunities in order to evolve. It faces the invigorating task of forging a consensus in the wider constituency for health action, and establishing new forms of authority appropriate to the emergence of multiple players and new alliances. These new opportunities illustrate the need for reflection on the future role and scope of the Organization. = = =
10